'.1/
TPIE
MEDICAL Ai\D SURGICAL HISTORY
OF THE
WAR OF THE REBELLIOX.
PAKT III.
VOLUME I.
MEDICAL HISTORY.
BEING THE
THIRD MEDICAL VOLUME.
Prepared under the direction of the Surgeon General, United States Army.
By CHARLES SMART, Major and Surgeon, United States Army.
WASHIIfGTON:
GOVERNMENT PRINTING OFFICE.
1888.
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WAR DEPARTMENT,
Surgeon General's Office,
Washington, D. C, Januanj 17, 1S88.
Brac.ADiER General JOIIX MOORE.
Surgeon General, U. S. Army.
General:
I liave the honor herewith to submit the Third and concludinsf Part of the Medical
History of the AVar of the RebelHon. The First Part, published in 1870, consisted of a
consolidation by departments and regions of the monthly reports of sick and wounded of the
various regimental organizations, with appended extracts from special reports of medical
officers, giving a view from the medical standpoint, of the movements of our armies and the
manv deadly struggles that took place between the opposed forces. The ^Second Part, pub-
lished in 1879, was devoted to a thorough discussion of the alvine fluxes based on tlie mate-
rials, documentary and anatomical, collected by our medical officers during the war. Sur-
geon J. J. Woodward, its distinguished author, brought to his task a comprehensive knowl-
edge of those records of the past, which form the historical basis of the professional opinions
of the present day, on the nature and causation of these important diseases. Moreover, his
intimate familiarity with the materials which had accumulated in the Army ^Medical Museum,
and the enthusiasm with which he prosecuted their study, peculiarly fitted him for the work
of laying before the j^rofession the results of that study. Unfortunately, failing health and
ultimately death, prevented the further progress of the work by the mind and hand that had
conducted it thus far with sucli consummate ability. In July, 1883, the late Surgeon Gen-
eral Crane expressed to me his desire that I should undertake the Third Part of the work ;
and, in view of my reluctance to assume this heavy responsibility, he gave me to understand
that his wish in this instance was intended to carry the weight of an order. No conditions
were imposed as to the matter or manner of the volume to be written, save that the val-
uable plates which Dr. Woodward had prepared, illustrative of the pathological changes
in the intestinal tunics, should be embodied in the work. Since that time I have given my
best endeavor to the fulfilment of this duty; and in presenting the completed results of
these years of labor, I beg that their shortcomings and errors may be attributed to lack of
judgment rather than to a want of careful and earnest consideration.
I have the honor to be. General,
Very respectfully, your obedient servant,
CHARLES SMART,
Major and Surgeon, U. S. A.
TABLE OF CONTENTS
^OLTJIylE XXT OF FJ^-R^T X
MEDICAL AND SURGICAL HISTORY OF THE REBELLION,
EEIXG THE
THIRD MEDICAL VOLUME.
LIST OF ILLUSTKATIOXS _ ix
LIST OF STATISTICAL TABLES AND TABULATED STATEMENTS xi
CHAPTER I. ON THE MEDICAL STATISTICS OF THE WAR.
SECTION I. Sickness and mortalitj' among the H. S.
forces _ 1-2*
-Mortality, actual and reported 1
Mortality-rates 2
Sickness, absolute and reported S
4
4
6
10
Sick-rates
Rates of fatality in specified diseases
General and annual rates of sickness and mor
tality
Sickness and nrortality as caused byTarious
diseases and classes of disease
Sick and mortality-rates of U. S. white troops,
as compared with those of other bodies of men
of the military age 14
Sickness and mortality as influenced by season,
locality, etc 1"
Discharges on account of disability from disease 24
Transfers to the Veteran Reserve Corps. _- 28
SECTION n. Medical statistics of the Confederate
armies 29-33
Page.
SECTION ni. Prevalence and mortality of disease among
U. S. troops in Confederate prisons 33-15
SECTION IV. Prevalence and mortality of disease
among Confederate troops In U. S.
prisons — - 45-71
Prison-camp and hospital at Camp Douglas,
near Chicago, III 48
Pi'ison and hospital at Alton, 111 50
Prison-barracks and hospital at Rock Island, 111 52
Prison and hospital at Camp Morton, near In-
dianapolis, Ind 5:3
Prison-camp and hospital at Johnson's Island,
Sandusk.v, Ohio 51
Prison and hospital at Camp Chase, Columbus,
Ohio 51
Prison-camp and hospital at Elmira, N. Y 56
Prison-depot at Fort Delaware, Del 57
Prison-camp and hospital atPointLookout.Md 59
Prison-camp near .Springfield, 111 CO
CHAPTER II. INTRODUCTORY TO THE PRESENTATION OF THE CAMP FEVERS.
CHAPTER III. ON THE
SECTION I. The statistics of the malarial fevers 77-111
Malarial fevers among the U. S. forces 77
Prevalence and mortality 77
Annual variations in prevalence and
mortality 82
Relative prevalence and mortality
among the white and colored troops— 84
Seasonal variations in prevalence 89
Seasonal variations in mortality 91
Influence of region on prevalence 94
Malarial fevers among the Confederate
troops 102-ias
Prevalence 102
Mortality — 106
Malarial fevers among the prisoners of war
held by the Rebel authorities 103
ilalarial fevers among the prisoners of war
held by the U. S _"_ l<^
SECTION n. Clinical records of malarial disease 111-119
SECTION III. Symptomatology of malarial disease 119-129
Intermittents and remittents 119
PAROXYSMAL FEVERS.
SECTION III. Sy5iPT0M.\T0L0GV, ETC.— [Continued.]
The pernicious fevers 125
Chronic lualarial poisoning 129
SECTION IV. Post-mortem records and pathology of
malarial disease — 129-1-53
Post-mortem records 129
Pathological anatomy and pathology 144
SECTION V. Causation of malarial disease 153-165
Causation of relaiiscs 164
SECTION VI. Prevention of malarial disease — 165-176
General consitierations 165
Prophylactic use of quinine 166
Prophylactic use of other medicinal agents 175
SECTION vn. Treatment of malarial disease 176-190
General considerations 176
Treatment of interuiittents ISl
Treatment of remittents 182
Treatment of congestive fevers 1S3
Treatment of chronic malarial poisoning l&J
Untoward effects of quinine 183
Use of other remedial agents 184
V
i
TABLE OF CO^'TENTS.
CHAPTER IV. ON THE CONTINUED FEVERS.
Page.
SECTION I. Tlie statistics of tbe continued fevers-— 190-210
In the U. S. armies 100
Prevalence and mortality 190
Prevalenceas related to season and locality- 196
In the Confederate armies 20.3
.\mong Union soldiers, prisoners of war 208
.Vmon):; Rebel soldiers, prisoners of war 209
SECTION II. Clinical records of the continued fevers-210-270
Common continued fever 211
Typho-malarial and typhoid fevers 212
Febrile cases at the Seminary Hospital,
Georgetown, D. C 215
Febrile enses from regimental records 249
Febrile cases from various records 257
Typhus fever. __ 268
SECTION III. Symptomatology of the continued fevers -270-3:34
Comiuon contiuued fever 270
Typhoid fever 27.3
Temperature 279
Pulse 2S1
Epistaxis 283
Condition of the skin 28:3
Sudaniina -- 283
Rose-colored spots 285
Petechia; 287
Bedsores 288
Herpetic spots 288
Peculiar odors 288
Condition of the nervous system 288
Iielirium — 288
Dilatation of the pupils 289
Condition of the digestive systeni 201
Anorexia, thirst and gastric irritability. 2',ll
Appearance of the tongue 292
Sordes 292
Diarrhoea 292
Hemorrhage from the bowels 294
Tenderness, tympanites and gurgling— 295
Pulmonary s.vmptoms 297
Other clinical features 297
^Micturition 297
Parotid swelling 298
Pain in the lower extremities 298
Modified typhoid fever 303
Onset — 301
Pulse 301
Epistaxis 302
Condition of the skin - 302
Rose-colored spots 303
Sudami na 304
Petechial and ecchymotic patches 304
Erysipelas 304
Bedsores - 304
Peculiar odors — 304
Cerebral symptoms 304
Delirium - 304
Contraction of the pupils 305
Prostration and muscular tremors 305
Condition of the digestive system 305
Gastric irritability 305
Jaundice 305
Appearance of the tongue, mouth and
throat 300
Diarrhcea 306
Hemorrhage from the bowels 307
Meteorism, abdominal tenderness and
gurgling 307
Splenic enlargement 307
Chest complications 307
Cough 307
Other clinical features 308
Micturition 308
Pai'otid swelling 30S
VI
Page.
SECTION III. Sy.mptomatology, etc.— [Continued.]
Pain in the joints and muscles 308
Gangrene 308
Relapses 308
Fatality 308
Typhoid, modified and unmodified 309
Sequel* - 309
Relapses 312
Second attacks 312
Extracts from reports of medical officers 312
Typhus fever _ 323
SECTION IV. Post-mortem records of the continued
fevers 331-419
Cases ill which the diagnosis, typhoid, is more
or less sustained by the clinical history 335
Cases entered as typho-malarial with or with-
out a record of symptoms to substantiate the
diagnosis 345
Cases entered as typhoid, but with clinical his-
tories suggestive of malarial complications— .351
Cases reported as typhoid, the clinical history
absent or defective 377
Cases variously registered, but typhoid fever
considered present from the symptoms or
post-mortem appearances JOS
Cases illustrative of complications or sequeUe. 416
Cases reported as typhus 418
SECTION V. Pathological anatomy and pathology of the
continued fevers 419-485
The cases and their analysis 419
The alimentary tract and abdominal viscera— 434
Salivary glands 434
Pharynx and cesophagus 434
Stomach — 435
Duodenum 435
Jejunum 435
Intussusception 4;35
Lumbricoid worms 436
Patches of Peyer ^36
Large intestine ^-il
Solitary glands -i-tS
Erosion of tlie intestinal mucous membrane 450
Hemorrhage, perforation and peritoneal
inflammation 450
Reparation of the intestinal ulcerations— 453
Pigmentation of the Intestinal lining 4.55
Mesenteric glands 4.58
Spleen ^ -159
Liver 460
Emphysema of 461
Gall-bladder 463
Pancreas ^03
Kidneys — 46:5
The organs of respiration and circulation 463
Larynx and trachea 463
Bronchial tubes 464
Lungs 464
Pleura; J65
Pericardium 465
Heart J6&
The blood — 471
The brain and its membranes 478
Age of patient; state of nutrition, etc 481
General conclusions 483-
SECTION VI. Etiology of the continued fevers 48.5-5:31
Common continued fever 485-
Typhoid fever 486
Continued malarial fever — 508
Typlio-malarial fever 508
Typhus fever 526
SECTION VII. Treatment of the continued fevers .531-551
TABLE OF CONTENTS.
CHAPTER V. ON THE DISEASES ALLIED TO OR ASSOCIATED WITH THE PAROXYSMAL
AND CONTINUED FEVERS.
Page.
SECTION I. Cerebro-splnal fever 552-5!i0
Clinical nml posl-inortein records.. 5.12
-Vmonj; tlie colored troops !W(t
Among the Confederato troops 5S7
Amonj; the prisoners 590
Symptomatology and pathological anat-
omy bm-cm
Pathology. _ I'M
Prtpo.
Section I. Cerebko-spinal fever— [Continued.]
Prevention and treatment 610-813
Prevention (jio
Trentnicnt - gn
SECTION II. Pneumonic fever C13-fil5
SECTION III. Diarrhoea and dysentery C15-622
SECTION IV. Scurvy 622-024
CHAPTER VI. ON THE ERUPTIVE FEVERS.
SECTION I. Small-pox. C25-C18
Stiitistics •... 62.5
Clinical and post-mortenx records Oiti
Treatnu-iit («j
rniiiwarcl result.s of attempted vaccination 6.'!1
SECTION II. Measles- ! IH9-661
Prevalence and fatality 649
Clinical records 6.5.5
Post-mortem records (i>s
i| Section II. Measles— [Continued.]
Treatment ._ (^9
SECTION III. Scarlet fever— 662
SECTION IV. Erysipelas - 662-4)7.5
Prevalence and fatality 662
Symptoms 061
Clinical reeoi'ds _ 6(W
Post-mortem I'ccords 669
Treatment 67^)
CHAPTER VII. OTHER MIASMATIC DISEASES.
SECTION I. Mumps-
SECTION II. Yellow fever -. — 675
CHAPTER VIII. ON SCURVY.
Prevalence, etc 683
Clinica; records 696
Postrmortem observations 700
Symptoms .._ 70t
Nyctalopia 706
Morbid anatomy 70S
P:itliiilfi._'y, <>:iM^ntion and treatment 709
CHAPTER IX. ON DISEASES ATTRIBUTED TO NON-MIASMATIC EXPOSURES.
SECTION I. Disease of tlie respiratory organs-. 719-818
faturi-h 725
Kpidemic catarrh 725
-Acute bronchitis 726
Chronic bruncbitis 728
.\sthma -. - 729
ItillaiiiiiiatioD of the hirynx 730
Iiinaiiiiiiatioii of tlie tonsils 732
Diphtheritic iutlaiiiination of the fauces, etc. 73.5
Clinical records 742
Post-mortem records 745
Treatment 749
Pneumonia 751
Clinical records 7.52
Post-mortem observations: 759
with ante-mortem notes 760
in cases complicated with laryngitis 763
in patients affected with delirium tre-
mens 763
in cast's in which cerebral lesions were
not associated with recognized cere-
bral symptoms 763
in cases unmarked hy characteristic
pneumonic symptoms 764
in cases of relapse or recurrence 704
in cases complicated by malarial mani-
festations 765
in cases possibly associated with the
poison of typlioid fever 76(1
in cases showing disease of the solitary
follicles 766
in cases having typhoid symptoms but
no typhoid lesion 767
in cases sliowing the maximum weight
of the consolidated lungs 768
in cases associated with pericarditis 768
in cases complicated with peritonitis... 772
in cases complicated with erysipelas... 773
In cases complicated with inflammation
of the parotids 77-1
SECTION I. Diseases OF RESPIRATORY ORGANS— [Cont'd.]
Post-mortem observations:
in cases fatal by hemorrhage into the
pleural cavity. 774
in cases terminated in abscess or cir-
cumscribed disintegration 774
in caseii ending in gangrene 770
in cases ending in liquefaction of the
lungs 777
in cases with coexisting tubei'cle 777
in cases complicated with cerebral le-
sions. 778
Analysis of the post-mortem appearances
in three hundred lobar cases 779
Post-mortem rccordsof catarrhal cases 783
.\nalysis of the post-mortem appearances
in one himdred and thirty-live catarrhal
cases 798
Pathology of pneumonia 801
Treatment 806
SECTION II. Consumption 818-828
Prevalence 818
Clinical records 819
Post-mortem records 825
Treatment 828
SECTION III. Rheumatic affections s.'9-S44
Acute rlieumatisin H29
Statistics 829
Clinical and post-mortem records 829
Chronic rheumatism 8.32
Statistics SS2
Character of the cases — 832
Treatment 843
SECTION IV. Other diseases attributed to expo3ure-.S44-860
Congestion and indaniinatlon of tlie spinal
membranes 844
Ophthalmia 849
Sunstroke 8-53
VII
TABLE OF CONTENTS.
CHAPTER X. ON CERTAIN LOCAL DISEASES.
r;ig-.
SECTION I, Cardiac diseases - 860
860
863
S66
867
868
Orjjuiiif a fleet ions
Fuurtioiial disturbances.
Idiopatliio pericarclitis —
ICiilitiire of the heart
Aneurism
SECTION II. Morbid conditions attributed to the weight
of the accoutrements S69
HaM»ioi>tysis J^IjB
Page.
SECTION ir. Morbid conditions, etc.— [Continued. ]
Hernia S71
Lumbar pains, etc 872
SECTION III. Constipation, headache and neuralgia 873
SECTION IV. Jaundice ..._ 874
Acute inliaramation of the liver 877
SECTION V. Idiopathic peritonitis 870
SECTION VI. Diseases of the kidneys ssi
CHAPTER XI. ON CERTAIN DISEASES NOT HERETOFORE DISCUSSED.
Nostalgia ..
Army itch .
Poisoning-.
. 884
Alooliolisni SOl)
Venereal diseases S91
Systematized efforts at prevention Si^S
CHAPTER Xil. ON THE GENERAL HOSPITALS.
Extemporized hospitals 899
Barrack-buildings converted to hospital uses.. 90S
Pavilion wards 908
Pavilion hospitals 917
Remarks on construction, personnel and man-
ageuieut 9,50
Li.st of hospitals in active service in December,
1S6J 9G9
Medical and hospital supplies 904
LIST OF MEDICAL OFFICERS CITED OR MENTIONED. — 967
LIST OF MEDICAL AUTHORS AND OTHERS CITED OR MENTIONED 972
INDEX __ 975
VIII
LIST OIP ILXjTJSTK/j^TIOnsrS.
■iO
21
94
100
A comparison of the annual mortality-rates caused Ijy certain speeincd diseases in various bodies of men of tlie military
age,— racing page ■ \[
T^ronthly death-rates among white troops from all diseases and from certain specifled diseases,— feeing page
The prevalence of disease and the mortality caused thereby among the Vt-hito and the colored troops of the U. S. armies during
the years of the war and the year following the war, expressed in monthly rates per thousand of slrengtli present,— faci ng
page - -
Chromo-pUite showing'the prison-barracks and hospital at Rock Island, 111.— facing page - 5'-2
The monthly prevalence of malarial fevers among the wliite troops,— facing page 90
Average annual curves of prevalence of the malarial fevers among the white and the colored troops during the war in monthly
rates per thousand of strength,— facing page
Peasoniil prevalence of malarial fevers in the Atlantic, Central and Pacific regions 00
ilap of the United States, showing the prevalence of malarial fevers in the various military departments during the Rebel
lion,— facing page
Lines indicating the prevalence of tlie continued fevers among the white troops,— facing page - 199
Lines indicating the prevalence and mortality of the continued fevers among the colored troops,— facing page 200
Seasonal variations in the mortality and prevalence of typhoid fever among a U. S. civil population of eight millions 200
Seasonal variations in the mortality and prevaleuco of the continued fevers among tlic white and the colored troops 201
Lines indicating the prevalence of the continued fevers In the Atlantic, Central and Pacific regions,— facing page 202
Perforating ulcers of the ileum,— facing pages 313,382,391
Thickened patches of Peyer and enlarged solitary follicles,— facing pages 380, 410, 112, J36
Sloughing patches of Peyer,— facing p.iges 388, -118
Cicatrices of typhoid ulceratlon.-facing pages 401, '104, 151, 450,458
Ulceration of tlie patches of Peyer,— facing pages 43!',410
Perpendicular section of the ileum showing enlargement, softening and ulceration of the solitary glands,— facing page 444
Perpendicular section of the ileum showing a follicular ulcer which has penetrated nearly to the muscular coat,— facing page 44fi
Section of a typhoid patch ulcerateil superficially ''1'
Section ofa typhoid patch showing the lymphoid elements in the glands and stroma 418
Perpendicular section of the ileum sliowing typhoid thickening ofa Peyer's patch,— facing page 448
Section ofa typhoid patch with the lymphoid elements agg^-egated mainly in the glands 449
Perpendicular section of the ileum through an ulcerated patch from wliich the softened contents of several follicles have
escaped,— facing page ^^^
Microscopic appearance of matter from tlie superficial part ofa typhoid patcli - 450
Jlieroscopic appearance of matter from the dceiicr parts of a typhoid patch 450
Pigmentation of the ileum in continued malarial fever,— facing page 460
Showing the relation between the height of the subsoil water-level and the prevalence of typhoid fever in the State of Michi-
gan during the 5 ear 1882 — - 5*"
Hilliard's temperature chart of typho-malarial fever -— - 518
Town's temperature charts of typho-malarial fever olS,519
Coraegy"s temperature charts of typho-malarial fever — - ^'-O
Hotf's temperature charts of mountain fever ~ — 523,5-1
Showing the monthly rates of prevalence of small-pox and erysipelas among the wiiite and the colored troops,— facing page— 021
Showing the monthly rates of prevalence of measles among the white and the colored troops,— facing page — 050
Showing the prevalence of scurvy among the wliite and the colored troops of the U. S. during the war of the Rebellion, and in
the English and French armies during tlie Crimean war,— facing page -— ""1
Showing that In the civil population of the United States pneumonia has seasonal waves of prevaleucc similar to those of ^
acute bronchial inflammation '"
Showing the monthly rates of prevalence, per thousand men of mean strength among the whites, of catarrh, epidemic catarrh, ^
acute bronchitis, pneumonia and pleurisy,— facing page '_—
Showing the monthly prevalence of tonsillitis and diphtheria among the white and the colored troops,— facing page.-- — 738
Showing the monthlv variations in tlie prevalence of acute and chronic rheumatism and consumption among the wliite and
8''8
the colored troops, — facing page *'**^
Showing the regulation weights carried by the soldier and the belts and braces wliich supported them; also, the method of
carrying them generally adopted by veteran troops,— facing page *'''
Showing the monthly rates of prevalence of constipation, headache and neuralgia among the white and the colored troops,—
facing page ; °^
Showing the variations in the monthly prevalence of jaundice among the white and the colored troops in the Atlantic and
the Central regions,— facing page "'
Lines indicating the monthly prevalence of venereal diseases and of alcoholism among the white and the colored troops,—
X LIST OF ILLUSTRATIONS.
Plans, etc., of hospitals:
Seminary Hospital, Georgetovrn, D. C — 90O
01(1 Hallowell house, Alexandria, Va. - 'J02,SIUS
Broad .and Cherry streets, Philadelphia, Pa 904
Good Samaritan, St. Louis, Mo 00.5. 90(>
Marine Hospital, St. Louis, Mo - 907
Clarysville, Md., pavilions at — 90S
McKim's Mansion, Baltimore, Md — 911
Patterson Park Hospital, Baltimore, Md 912
Campbell Hospital, WashinsTton, U. C — 913
Carver Hospital, Washington, D. C 91-1
Emory Hospital, Washington, D. C 91»
Hilton Head Hospital, S. C - — 91«
Details of wards at Mount Pleasant and Judiciary .Square hospitals, Washington, D. C 917
Judiciary Square Hospital, M'ashington, D. C— ground plan 91S
Judiciary Hospital,— side, front and rear elevations 911*
Chester Hospital, Chester, Pa 921
De Camp Hospital, David's Island, N. Y. Harbor,— facing page - 922
Summit House, Delaware Co., Pa 9J:i
Tilton Hospital, Wilmington, Del 925
Cuyler Hospital, Germantown, Pa -— 927
Satterlee Hospital, West Phil.adelphia, Pa.— ground plan 929
Ventilation of the wards of the Satterlee Hospital 9:n
Mower Hospital, Chestnut Hill, Pa 93S
Stanton Hospital, Wasliington, D. C — — 93G
Armory Square Hospital, Washington, D. C 9o7
Hampton Hospital near Fort Monroe, Va 93*
Lovell Hospital, Portsmouth Grove, R. I 9J0
Harewood Hospital, Washington, D. C 941
Hammond Hospital, Point Lookout, Md.— facing page 9J2
Sections of wards and covered-ways of the Hammond Hospital - 942
Plan of wards as given in orders from the War Department 914
Ventilation and heating of wards as directed by orders from the War Department 9J.>
Sedgwicli Hospital, Greenville, La 946
Kitchen of the Sedgwick Hospital 947
Wards, ventilation and heating of the Sedgwick Hcspital 948
Hick's Hospital, Baltimore, Md 9.50
Cross-ventilation of water-closets of pavilion-wards 951
LIST OF STATISTICAL TABLES AND TABULATED STATEMENTS.
Page.
Mortality of the U. S. Armies from May, ISil, to June 30, ISGC — — - 1
Table I, sliowing the annual movement of sickness and death among the white and the colored troops, expressed in ratios
per thousand of mean strength 6
Statement of the mortality from disease in the German army during the war of 1870-71 7
Rates of mortality from disease in the V. S. Army during the years lS10-'.5i) 8
Rates of mortality from disease among the while troops of the V. S. Army during the years 1S67-"S? !)
Table TI, showing the comparative frequency of, and mortality from, the diseases that prevailed among the wliite troops of
the U. S. .\rmy during the period from Jlay 1, lS(iI, to June 30, ISCfi, and among the colored troops during the period from
July 1, ISIJi, to June 30, 1806 — U
Table III, sliowing, by average annual rates per 1,00*1 of mean strength, the comparative frequency of, and mortality from, liie
diseases that prevailed among tlie wliile and thecolored troops of tlie U. iS. Army 13
Table IV. Average annual sick and death-rates perthousand of mean strength in the V. S. Army before, during and since the
war, and in tlie German and French armies, witli the annual death-rate for males of the military age in the United
.States, as ciilculated from the returns of the census year ISSO 10
Table V, showing the annual prevalenceof sickness and the mortality from disease in the several regions, expressed in rivtios
per tliousand of mean strength 18
T^le VI, showing the annual prevalence of sickness from all diseases in the several military departments, expressed in
ratios per tliousand of strength 19
Table VII. Montiily ratio of sickness per thousand of mean strengtli among the white troops of the U. S. Army, by regions,
for the period from June 30, ISiil, to June 30, 1866 21
Table \'III. Monthly ratio of cases of sickness per thousand of mean strength among the colored troops, by regions, for the
period from June 30, 186:), to June 30, 1866 21
Table IX. Montiily ratio of deatlis from disease per thousand of mean strength among tlie wliite troops of the U. S. Army, bv
regions, for tlie period from June 30, 1861, to June 30, 1866 22
Tabic X. Monthly ratio of deaths from sickness per thousand of mean strength among the colored troops, by regions, for tlie
periotl from June 30, 180:1, to June 30, 1866 — 22
Table XI. Discharges for disabilit.v from disease in the V. H. Army from Maj- 1, 1S61. to June 30, 186<i, with ratio per tliousand
of mean strength in the Held, garrisons and general hospitals, ratio per thousand of total discharges, and mean annual
ratio per thousand of strength 27
Table XII. -Vb.stractof the cases of speciflert diseases with recorded terminations, and of deaths among such cases at the Chi m-
borazo liospit^il, Richmond, Va 30
Statement of the sickness, wounds and mortality in the C. S. army, exclusive of the troops in the Trans-Mississippi Depart-
ment, from tlie beginning of tlie war to December 31, 1862 30
Table XIII. A comparison of the prevalence and fatality of disease in the opposing armies from the commencement of the
Table XIV. Cases of sickness and wounds reported from certain of the Confederate armies during portions of the years I86I,
1862 and 18(>l, with the strength present during tlie periods covered by the statistics, and the calculated annual rates per
thousand of strength in juxtaposition witii the corresponding rates of the U. S. Army for the year ending June 30, 180:1— ;12
Tabic XV, summarizing the records of the hospital at Camp Sumter, Andersonville, Ga 31
Talile XVI, giving a general view of the sick and death-rates from prominent diseases and classes of diseases among the Fed-
eral prisoners at .Vndersonville, Ga., for tlie period extending from Mareli 1 to August 31, 1861. Average present, 19,133
prisoners :t5
Table XVII. summarizing the records of the prison hospital at Panville, Va., November23, 1863, to March 27, 1865-- 41
Table XVIII. showing the number of casesof certitin specified diseases and classesof disease, and of deatlis attributed to tliem,
among the Confederate prisoners of war at tlie principal prison depots, for the period covered by the records of eacli
Table XIX, in which the facts of Table XVIH are consolidated and expressed in average annual rates per thousand of strength,
with the ratio of cases of specified diseases to cases of all diseases, of deaths from specified diseases to deaths from ail dis-
eases, and the percentage of fatal cases of specified disease. Average strength present, 10,81.5 men 47
Table XX, contrasting the mortality rates, per thousand of strength, among the wliite and the colored troops of the V. S.
Army and the Union and tlie Confederate prisoners of war 48
Barrack occujianc.v of the Union troops as compared with that of the Confederate prisoners at Camp Chase, Ohio 5-5
Table XXI, comparing the annual sickness and mortality from certain specified diseases at the principal depots for Rebel
prisoners 61
Tabular statement of the ration in kind allowed to Rebel prisoners of waPf with the full ration of the U. S. troops at the same
dales, and the diflerence in the value of the two rations credited to the prison-fund 69
XII LIST OF STATISTICAL TABLES
PagR
Table XXII. Statement of the frequency and mortality of the several forms of malarial fever, giving the totals reported from
May 1, 1S61, to June 30, 1S66, with the ratio of cases to strength and to cases of all diseases, and the ratio of deaths to
strength, to deaths from all diseases, and to cases of malarial fever: White troops 79
Table XXIII. .Statement of the frequency and mortality of the several forms of malarial fever, giving the totals reported from
July 1, ISCJ, to June 30, ISG6, with the ratios of cases to strength and to cases of all diseases, and the ratios of deaths to
strength, to deaths from all diseases, and to cases of malarial fever: Colored troops ^ SO
Table XXIV. Relative frequency of cases of malarial fevers and deaths caused by them, during the several years of the war
and the year following the war, expressed in annual rates per 1,(XI0 of mean strength : White troops 82
Table XXV. Relative frequency of cases of malarial fevers and of deaths caused by them among the colored troops during two
years of the war and the year following the war, expressed in annual rates per 1,00(J of mean strength 83
Table XXVI. Relative frequency among the white and the colored troops of cases of malarial fevers and of deaths caused liy
them, as shown by the average number annually recorded, reduced to ratios per 1,000 of strength 84
Table XXVII. A comparison of the prevalence of malarial fevers among the wiiite and the colored troops serving in the same
localities during the two years from July 1, 1S63, to June 30, 1865, the figures given being the average annual ratios per
1,000 of strength 86
Tabular statement of the death-rate from malarial fevers among the white and the colored population of certain sections of
the United States 87
Comparison of the death-rate from malarial disease among the white and the colored population of certain cities of the United
States ; : 87
Statement of the prevalence of periodic fevers among the white and colored troops serving, since the war, at certain posts in
the Department of Texas 88
Table XXVIII, showing the seasonal variations in the prevalence of malarial fevers among the white troops in the several
regions during the years of the war and the year following the war, expressed in monthly ratios per l,Ouo of mean
strength 89
Table XXIX. Average monthly number of cases of the several varieties of malarial fever among the white troops from July 1,
1861, to June 30, 1866, expressed as ratios per l.OiW of mean strength 93
Table XXX. Average monthly number of cases of the several varieties of malarial fever among the colored troops from July
1, 1863, to June 30, 1866, expressed in ratios per 1,000 of strength • 91
Table XXXI. Average monthly number of cases of the several forms of malarial fever among the white troops in the several
regions, expressed in ratios per 1.000 of strength, calculated from the cases which occurred from July 1, 1861, to June 30, 1806. 95
Table XXXII, showing the prevalence of malarial fevers in the departmentson the Eastern and Southern coasts of the United
States, and in those of the high and low grounds of the Central Region, expressed in annual ratios per 1,000 of strength,
calculated from the statistics of tlie four years ending June 30, 1865 97
Table XXXIII, showing — 1, the relative prevalence of the malarial fevers among the white troops in the several departments
and regions during the four years ending June 30, 1865, expressed as ratios per 1,000 of strength ; 2, the relative frequency
of the forms of these fevers, expressed in percentages of the total number of cases; and 3, the relative frequency of the
varieties of intermittent fever, expressed as percentages of the total number of intermittent cases 98
Tabular statement of the death-rates from malarial disease in the States and Territories of the United .States from the census
returns of 1870 and 1880 102
Table XXXIV. A comparison of the prevalence of intermittent and remittent fevers in the Confederate and Federal Armies
of the Potomac from July 1, 1861, to March 31, 1862 103
Table XXXV. A comparison of the prevalence of intermittent and remittent fevers In the Confederate and United States
Armies of the Tennessee from June 1, 1862, to May 31, 1863 101
Tabulated comparison of the prevalence of intermittent and remittent fevers in the Confederate Army of the Valley of Vir-
ginia and the U. S. Middle Department of the Atlantic Region from July 1 to October 31, 1862 105
Table XXXVI. A comparison of the prevalence of intermittent and remittent fevers in the Confederate Army of the Valley of
Virginia and the U. S. Department of the Shenandoah from January 1, 1862, to June 30, 1862 106
Table XXXVII, showing— 1, the relative frequency of the forms of malarial fever among the Confederate troops as compared
with their frequency among the troops of the United States, expressed in percentages of the total number of malarial
cases; and 2, the frequency of the varieties of the intermittents expressed in percentages of their totals 107
Tabular statement of the relative frequency of the various types of malarial fever among the U. S. and the C. S. troops, with
an approximative comparison of the mortality occasioned by them _ 108
Table XXXVIII. Cases of malarial fever with resulting mortality, reported from the principal prison depots as having
occurred among the Confederate prisoners of war; with the annual ratios per thousand of strength present 110
Table XXXIX. Statement of the frequency and fatality of the continued fevers, giving the totals reported from Jlay 1, 1861, to
June 30, 1866, among the white troops, and from July 1 , 1863, to June 30, 1866, among the colored troops ; with the ratio of
cases to strength and to cases of all diseases, and the ratio of deaths to strength, to deaths from all diseases, and to cases
of the continued fevers 191
Table XL. Expressing the frequency of and mortality from the reported forms of the continued fevers as percentages of the
total cases and deaths caused by such fevers 192
Table XLI. Relative frequency of cases of the continued fevers, and of deaths occasioned by them, during the several years of
the war and the year following the war, expressed in annual rates per thousand of strength present 193
Table XLII, showing the annual percentages of fatality of the continued fevers 191
Table XLIII. Comparison of the frequency of cases of the continued fevers, and of the deaths occasioned by them, among the
white and the colored troops, as shown by the average numbers annually recorded, reduced to ratios per thousand of
strength ; the figures for the white troops based on the statistics of the period May 1, 1861, to June 30, 1866, and those for
*he colored troops on the statistics of the three years July 1, 186:5, to June :iO, 1866 195
Table XLIV, showing the variations in the prevalence of the continued fevers among white troops in the various regions
during the years of the war and the year following the war, expressed in montiily ratios per thousand of mean strength, 196
Table XLV. Seasonal variations in the prevalence and mortality of the continued fevers among the white troops, expressed
in average monthly rates per thousand of strength, obtained by the consolidation of the figures for the corresponding
month of each of the years covered by the statistics 201
Table XLVI. Seasonal variations in the prevalence and mortality of the continued fevers among the colored troops, expressed
as average monthly rates per thousand of strength, obtained by the consolidation of the figures for the corresponding
mouths of each of the years covered by the statistics 202
Table XLVII, showing the relative frequency of the reported forms of the continued fevers among the "white troops in the
several departments and regions during the four years of war service from July 1, 1861, to June 30, 1865 203
AND TABULATED STATEMENTS. XIII
rage.
Table XLVIII. Xiimbcr of cases of the contiiiuoil fovors in the Confederate and IVilonil Armies of tlie Potomac from July 1,
1>^1, to March 31, IStii, with the ratio per tlioiisanil of mean strength for each monlli 206
Table XLIX. A comparison of the prevalence of the eontiniiccl feveisin the Union and Confederate forces during the nineteen
months, January, 18(32, to July, lSti-3, inclusive, expressed in montlily ratios per Ihousaml of strength 207
Tabular statement of the continued fevers at the hospital at Cainji Sumter, Anderson ville, Ga 20S
Tabular statement of the fatality tif the continued fevers in certain of the Conlederate fj:eneral hospitals 203
Table L. Number of cases of the continued fevers, with the resulting mortality, rep<trtetl from the principal prison depots as
having occurred among Conlederate prisoners of war, with the annual rates per tliousand of strength 209
Percentage of men of various stated ages in tlii' ranks of the army . -181
Table LI, showing the ages of four hundred and thirty-one eases of continued fever, and comparing the frequency of these
fevers at certain ages with the relative number of men of those ages in the ranks of the army 482
Tabular statement of the relations of diarrhaal diseases to the nuilarial fevers as shown by the mortality tables of the Tenth
U.S. Census, ISSO 017
Table LII, showing the prevalence and mortality of the eruptive fevers among the U. S. forces during the yeai'S of the war
and the year following the war 624
Table LIII, showing the numbcrof cases of the eruptive fevers and of deaths caused by them among the Confederate prisoners
t)f war at the principal prison depots for the period covered by the records of each prison C29
Table LIV, showing the annual and average annual rates of sickness and deatli from diseases of the respiratory oi'gans, as
also the percentage of fatality of these diseases among the U. S. troops for stated periods, expressed in ratios per thousand
of strength 719
Table LV, contrasting the mortality irom pneumonia in rates per thousand of strength in certain of the Confederate armies
and the white commands of the Union army 720
Table LVI, showing the prevalence and mortality fi'om certain diseases attributed to atmospheric exposures among the Con-
federate prisonei's held at the principal prison depots in the United States. Average period covered by the observations,
two years; average strength present, I0,S1.~) men 721
Tabular statement of the seasonal prevalence of pneumonia in the .Southern armies 723
Table LVII, showing, by ratios per thousand of strength, the relative freiiucncy of catarrh of the respirator)- inucous mem-
brane and pnemuonia ainong the white troops of the several deiiartments.and regions during the four years of war serv-
ice, July 1, 1S61, to June 30, 1S<)5 _ 724
Table I.VIII. Localization and specification of the morbid conditions found in the lungs in 300 eases of acute lobar pneumonia. 7S0
Tabular statement of the pleuritic complications in 300 cases of lobar pneumonia - 781
Tabulation of the stated conditions of the lungs in 1.35 cases of lobular pneumonia 798
Tabulation of the pleuritic complications in 185 cases of lobular imeumonia 799
Tabulation comparing the death-rates from malarial fevers and consumption in some large cities of the U. S 824
Mean of temperature observations taken during the hot mouths of the years of the war 854
List of general hospitals in active service in December, 1864 060
Quantity of certain medical and hospital supplies, etc., issued by the Medical Purveying Bureau during the war 906
Alphabetical list of medical officers cited or mentioned 967
Al])habetieal list of medical authors and others cited or mentioned 972
Index 975
T II E
MEDICAL AND SURGICAL HISTORY
OF THE
WAi; OF Tin; I!1-p.eli,io> nsiii-Tui.
PAET III, VOLUME I.
BEINO THK XHIRD aiEDICA-L VOLUME.
CHAPTER L— OX THE MEDICAL STATISTICS OF THE WAR.
I— SICKNESS AND MORTALITY AMONG THE U. S. FORCES.
The First Part of this Medical Volume of the History of the War is mainly com-
posed of a series of Tables giving the figures reported by various commands as expressing
the facts connected with the occurrence of sickness and deaths from certain specified
diseases among the troops composing them. To derive any information from tbese Tables
other than that borne upon their face, as for instance, to compare their items one with
another, or with similar statistics from other sources, it is necessary to convert their figures
into others expressive of their relation to some common standard. But before deducing
ratios of sickness and mortality in designated diseases from the figures tabulated, it may
be well to recall some points connected with them that definite ideas may be obtained of
their probable value.
1st. As TO MORTALITY ACTUAL AND EEPOETED. — On page XXXVII of the Introduc-
tion to the First Part, it is shown by a comparison of data drawn from various sources that
the actual mortality of our armies from May, 1861, to June 30, 1866, may be assumed to
be closely approximated by the following figures :
Mortality.
White.
Colored.
Total.
Killed in battle - -
42, 724
47,914
157, 004
23,347
1,514
1,817
29 212
44, 238
Died of wounds, etc
Died of disease
49,731
181), 210
24,184
Total . -
270, 989
33,380
304,369'
1
• According to Dr. JOSEPH JOXES (see Jitchmtmd and LouitvilU Mtd. Jour,, Vol. IX, 1870, p. 259), the deaths in.the Cunfederate armies during
the war did not foil short of 200,000, three-fourths of which number were due to disease and onefounh to the casualties of battle. The data from which
these conclusiims were derived are said to have been critically examined and considered correct by the former Adjutant General of the Confederate States,
S. Cooper, of ,\lexaDdria. Virginia.
Med. Hist. Pt. Ill— 1
2 SICKNESS AND MORTALITY
If the deatlis from unknown causes in this statement be distributed anion" the three
causes specified in tlie proportion which the figures of each bear to their total, the deaths
from disease will be found to amount to 171,806 among the white troops, and to 29,963
among the colored troops, giving a total of 201,769 deaths from disease.
Looking now at Table C,'"' which gives a general summary of the sickness and mor-
tality among the white troops during the war, it will be found that, excluding 37,237
deaths attributed to wounds, accidents and injuries, there were reported 123,937 deaths
from diseases that are specified and 449 from diseases that are not specified, making a total
of 129,386 deaths reported as from disease.
But since the total mortality from disease was 171,806, it is evident that 42,420
deaths, or 24.7 per cent, of the total, were not reported, and that 42,869 deaths, or 24.9
per cent, of the total, were not attributed to their special causes. Hence, if it be desired
to obtain from the Tables in the First Part of this work an approximation to the absolute
mortality from any specified disease, we may assume, in the absence of other and accurate
data, a p?'o rata distribution of the 42,869 deaths from unspecified diseases and multiply
the number in the tables by 1.33, since the number of deaths tabulated and reported as
due to specified causes, to wit, 128,937, is to the whole number of deaths attributed to
disease, 171,806, as 1 : 1.33. Thus, taking acute and chronic diarrhoea and dysentery by
way of illustration, it is found tliat the deaths reported as from these diseases numbered
37,794; but the actual mortality caused by them must have been considerably greater,
to-wit, about 50,226.t
Again, looking at Table CXI, J which gives a general summary of the sickness and
mortality of colored troops during the war, it will be found that in the strength represented,
27,499 deaths were reported from specified diseases. This number is less by 2,464 than
the actual mortality, 29,963, in the strength present and absent. The tables, therefore,
embrace 91.8 per cent, of the mortality statistics of the colored troops. If an approxima-
tion to the actual mortality be desired in the case of any given disease, it may be obtained
from the figures in the statistical tables by the use of the factor 1.09. Thus, in the case
of the alvine fluxes, the tables give a mortality of 6,764, but the actual mortality was
probably about 7,373. ||
2d. As to mortality rates. ^ — Although the figures given in the tables constitute
but 75.3 and 91.8 per cent, of the total mortality among the white and colored troops
respectively, it is to be remembered that the strength in which this tabulated mortality
occurred was only a part of that Avhich furnished the total. The tabulated deaths took
place among the men in the field and garrisons, and among the floating population of the
general hospitals in which the sick from the field and garrisons were treated, when, for
military or medical reasons, it was deemed expedient to send them to a distance from their
commands. The untalndated deaths of white aiid colored soldiers, 42,420 and 2,464,
respectively, occurred firstl}', in commands the reports of wdiich were not received, or if
received were not embodied in the tables on account of some defect which rendered them
valueless for the computation of rates; secondly, among men separated from their com-
mands by the fortune of Avar and held as prisoners by the enemy; and thirdly, among
those not borne as- present numerically in the strength of their commands on account of .
temporary absence on furlough or various special duties.
* Part First, p. Ml. I See Dr. Woouwaud'b calculation, p. 3 of Part II, where the actual mortality in this instance is figured as 49,885.
J Part First, p. 712. || Dr. WooinvAun's calculation puts tlie number at 7,380.
AMONG THE U. S. FORCES. 3
With regard to untabiilatcd deaths due to unrendered or rejected reports, the assump-
tion seems warranted tliat, had these reports been received in a condition to admit of tlieir
incorporation in the tables, it is not likely that the rates calculated from the latter would
have been materially altered, since the numbers tabulated were in themselves so large, and
constituted so large a percentage of the deaths that occurred in the field, garrisons, and
general liospitals. Dr. Woodward estimated that, in a general way, the tables covor<>(l
about nine-tenths of the class of facts which they were intended to embrace.
With respect to the deaths that occurred among prisoners of war, they are with pro-
priety excluded from data forming the basis of an inquiry into the mortality rates afl^cting
our armies in the field, since, as is well known, the circumstances surrounding these
unfortunate men were such as predisposed to a higher rate of mortality. Had full returns of
the deaths among them, with a knowledge of the numerical strength present in the iDrisons
during the war, been preserved, they would have served as materials for an interesting
study; but it would not have been advisable to consolidate them witli the mortality
statistics of men under wholly different conditions.
Similarly, it seems proper to exclude from consideration the deaths that occurred
among the large number of men absent from their commands <iu furlough and by reason
of other causes, as this class was for the time being removed from the influence of the
causes and conditions which favored mortality among the men on active service. It is
highly improbable that the deaths among them were relatively as numerous as among men
on field duty. Although many men were furloughed because thcv were sick, and undoubt-
edly many deaths occurred among such cases, the majority of those thus furloughed were
convalescents looking for improvement and return to health during their temporary sojourn
at home. The number of these absent from their commands cannot be obtained; but had
it been possible to have ascertained all the facts, their consolidation with the matter of the
statistical tables of Part First would have introduced an element which would have
recjuircd elimination before the rates affecting the troops on active service could have lieen
deduced.
AVe may therefore accept tlie conclusion that death rates based on the tabulated
figures, notwithstanding the incompleteness of the latter, will furnisli a fair index to the
mortality caused by tlie morbific influences to which tlie army was sulijected during the
years of the war.
3d. As to the cases of sickn'ess, absoja'te akd reported. — Tlie tabulated statis-
tics show the occurrence among white troops of 5,417,360 cases in which the disease is
specified and 7,187 cases of unspecified disease, making a total of 5,424,547 cases of dis-
ease, exclusive of 400,933 cases of wounds, accidents and injuries comprised in Class V
of the ofiicial reports. This number of cases of disease is far from including the whole of
those furnished by the army during the war. The tabulated mortality among the white
troops has been shown to be deficient by 24.7 per cent. The deficiency in the tabulation
of the cases is even greater, as it includes not only cases among prisoners of war and
others absent from their commands as well as those in commands which failed to make the
required reports, but also the many cases that occurred among the floating population of
tiie general hospitals. The strength of these hos2:)itals was reported regularly ; but it was
found impossible, as already explained,'"" to ascertain the number of cases of sickness that
* IntrudiictiuD, Part First, p. XXIV.
SICKNESS AN'D MORTALITY
originated in tliem or the number of cases that were received without having been pre-
viously reported on regimental returns.
The same remarks are applicable to the 605.017 cases of specified diseases which are
reported in the tables as having occurred among the colored troops.
■iTH. As TO SICK BATES. — But altliougli the statistical tables give only an unknown
percentage of the sickness which affected our armies, their application to the calculation
of correct rates is not impaired thereby. They give, we may assume, a fairlv accurate
representation of the attacks of sickness that occurred in those commands in "field and
garrison" from which reports were received. The large number of men, a mean strength
of 431,237 white and 61,132 colored troops, under observation, warrants the belief tliat
the rates deduced from the reports would not be materially altered if to these reports had
been added the mean strength and total cases of sickness of commands which failed to
report, or sent in reports which were valueless in this connection by the omission of needful
data. The remarks already made with regard to mortality rates among prisoners of war
and others absent from their commands are equally applicable here. Supposing the neces-
sary figures for calculating the ratio of cases to strength among them to be available, the
propriety of consolidating these rates with those from trooj-)S in active service would be
subject to question, as tending to complicate the point at issue by the introduction of results
due to other conditions. For similar reasons it would have been proper to have excluded
from the tabulated reports the cases originating in the general hospitals, as the conditions
affecting the inmates of these hospitals were certainly very different from those which
determined attacks of sickness in the field. As it is, those cases were not reported. A
complete medical history of any war necessarily involves the separate presentation of the
facts reported from the various classes of men and their comparison with those gathered
from the men present for duty with tlie flao;; but the difficulties in the way of obtaining
the necessary data are so great that it is doubtful if such a history will ever be written.
While regretting the want of records covering the attacks of sickness in the whole number
of men who were enrolled for service, it suffices at present to point out that this want does
not affect the value of the sick rates deduced from the reports which form the main part
of the First Part of this work.
5th. The kates of fatality in specified diseases. — In comparing the number
of deaths from a given disease with the number of cases of the same disease to ascertain
the percentage of fatal cases caused by it, a point of importance comes up for appreciation.
It has been shown that neither the deaths nor tlie attacks tabulated form the respective
totals of these occurrences, but only an uncertain though comparatively large portion of
them, and it has been argued that this want of absolute figures does not detract from the
value of the death rates and sick rates as deduced respectively from the strength given in
connection with the figures of each, to wit: the strength present in the field and garrison
in connection with the cases, and the strength present in the field, garrisons, and general
hosj^itals in connection with the deaths. But in considering the ratio of deaths to cases
their abnormal relationship, consequent on their derivation from different numbers of men,
must not be forgotten. The cases occurred in the strength present in the field and garri^
sons; the deaths in the strength present in the field, garrisons, and general hospitals.
The strength which furnished the cases, 431,237; in the instance of the white troops,
was smaller than the strength, 468,275, which furnished the deaths. If the cases which
-f—r
AMONG THE U. S. FORCES. O
originated in the hospitals were known, their aJJition to the others would establish a
normal ratio between the cases and deaths. Or, it" the deaths which occurred among
such cases were known, a similar result would be obtainable by deducting them from the
tabulated deaths. But, as it was found impossible to rectify this matter by either of these
methods, there exists this want of relationship between the deaths and cases.
In calculating from the tabulated figures the rate of fatality of a given disease, a
figure of unknown and probably different value for each disease, caused by the unrecorded
cases among the hospital population, tends to increase the percentage of fatal cases.
The fatality of cases originating in the general hospitals was probably greater than
that of those occurring among men in active service, for although the latter had a greater
exposure to many of the causes of disease, they had at the same time a greater power of
resistance against these morbific influences. The exposures of the field may be regarded
also as having tended to multiply cases and to correspondingly lessen the fatality of disease
among the troops as compared with the rates affecting a hospital population. If, therefore,
we assume that the same rates prevailed among the floating population of the hospitals as
in the commands from which their population was derived, we shall ascertain a portion of
the error which is involved in a calculation of rates from the deaths and cases in the tables
already published.
On this assumption the deaths attributable to diseases originating in the hospitals and
those attributable to diseases originating in the field and garrisons would be respectively
proportioned to the number of men present in each; and the factor .921, obtained by
dividing the strength present in the field and garrison by the total strength in the field,
garrison, and general hospitals, when applied to the rates of fatality calculated from the
cases and deaths recorded in the First Part of this work, would reduce these rates by the
elimination of the deaths assumed to have taken place among cases that originated in the-
hospitals. In this way a part of the error is indicated, the true rate of fatality being
lower even than this corrected rate. Thus, in the case of tyj^hoid fever among the white
troops,* where 75,368 cases in the field and garrison are associated with 27,056 deaths in
the field, garrison, and general hospitals a mortality of 35.9 per cent, is obtained; but this,
for the reason given, is certainly higher than the true rate of fatality. Multiplied by the
factor .921 the percentage becomes reduced to 33.0, and this probably expresses the very
highest figure at which we may put the mortality from typhoid fever as deduced from the
tabulated statistics. When we come to consider the continued fevers it will be found that
this corrected percentage is open to question; but the present object is merely an illustra-
tion of an inaccuracy which affects the rates of fatality when deduced from the published
figures.f
The factor .921, based on the mean strength for the whole period of the war, has
necessarily a generic character. The error which it is intended to define varied month by
month and year by year in the same command, and differed in different commands during
the same periods in proportion to the number of men constituting the hospital population.
In the following pages the rates of fatality will be calculated from the figures as reported
in the First Part of this work. Those who desire greater precision in individual cases
• Table C. p. 636, First Part.
tDr. Geokge L. Peabody, in an article on the Trcatmtnt of Tijphoiil Fn-cr. in the Philadelphia Medical Sews, March 29, 1884, tabulates the
typhoid fever cases as reported in llie First I'art of this work, and calculates the fatality among white troops at 33.9 i>er cent, of the cases, without obsen--
ing that the cases and deaths did not occur among the same number of men.
6
SICKNESS AND MORTALITY
may make use of the average factor above stated, or calculate the factor specially appli-
cable to the case in point in accordance with the statement given of the principle involved.
General and annual rates of sickness and mortality. — The number of cases
of disease reported among the vv'hite troops during the period, May 1, 1861, to June 30,
1866, was 5,424,547, and the number among the colored troops during the three years
ending with the latter date was 605,017, making a total of 6,029,564 reported cases of
disease.
During the same period the deaths reported as from disease numbered 129,386 among
the white and 27,499 among the colored troops, making a total of 156,885; but, as has
been already explained, if it be desired to obtain numbers which will express the absolute
mortality from disease in our armies, the factor 1.33 must be used in the case of the white,
and 1.09 in the case of the colored troops, to provide for the addition of 42,420 deaths
among the former and 2,464 deaths among the latter, as the proportion of deaths from
unknown causes which may with propriety be ascribed to disease. There were, therefore,
during the war and the year that followed it 171,806 deaths among the white and 29,963
deaths among the colored troops, making a total in the United States Armies of 201,769
deaths which were attributed to disease.
The cases and deaths available for the calculation of rates of sickness and mortality
are equivalent to 12,579 cases and 276 deaths in every 1,000 of the white troops during
the five and one-sixth years covered by the reports, and 9,897 cases and 430 deaths in
every 1,000 of the coloi'ed troops during the three years similarly covered. Disease among
the latter is thus seen to have been not only of more frequent occurrence but considerably
more fatal than among the former. This may be better seen by presenting the statistics
of the colored troops on a basis of five and one-sixth years of service, when the numbers
are found to be 17,044 cases and 740.6 deaths, equivalent to 135.5 cases and 268.4 deaths
respectively for every 100 cases and every 100 deaths among the white troops. The greater
liability of the colored troops to disease and death is also clearly shown l>y the presentation
of the statistics in the form of annual rates. The average annual numbers among white
soldiers per 1,000 of mean strength were 2,435 cases and 53.4 deaths; in the colored
command the corresponding numbers were 3,299 and 143.4.
Table I.
Shoiclvff tlic Annual Movement of Sickness and Death among the Wliile and the Colored Troops, expressed
in ratios per 1,000 of mean strength.
For the TE.4R ENDISG JUNE 30T1I—
Average
Annual Rate
I'EU 1,000.
1861.
1862.
1863.
1864.
1865.
1866.
Cases.
Deaths.
Cases.
Deaths.
Cases.
Deaths.
Cases.
Deaths.
Cases.
Deaths.
■ Cases.
Deaths.
Cases.
Deaths.
3,82i
10.8
2,983
49.
2, 696
63.
2,210
4,092
• 48.
211.
3,205
56.
140.
2,362
2,797
42.
94.
2,435
3,299
,53. 4
143. 4 1
It may be inquired how these figures compare with the records of other armies. To
institute a satisfactory comparison between the sickness and mortality of armies of difler-
ent nationalities is diificult, especially in dealing with the records of war service.- Besides
differences in nomenclature and in methods of reporting, which interfere with just com-
AMON(i TIIK U. S. KORCES.
parisons in time of peace, tlie war ivcunls are usually more or less inJelinite in certain
items of information, as of strength present, needful tu the calculation of comparative
rates.
There is, however, little to be gained by comparing the statistics of one campaign
with those of others conducted under wholly different conditions. Each may be advan-
tageously studied for the special lessons inculcated, but unless similar general conditions
coincided with particular conditions whirh wre not sinular, there is no [irotit in the com-
parison. The medical histories of the Frt'iich and English armies before Sevastopol present
many fruitful comparisons, but it is of little moment to })lace the 94.9 deaths* per 1,000
of strength which occurred from disease in the English ranks in January, 1855, by the
side of our average annual rate of 53.4, or to note that during that one month diseases of
the stomach and buwi-ls, chiefly diai'rha'a and dysentery, caused among the British troops
as many deaths, 62.7 per 1,000 strength,f as were occasioned by all diseases in our armies
during 1862—3, the year of their liighest mortality, 63 per 1,000. For similar reasons it
is needless to enter into detailed comparisons between the rates above mentioned and the
14.30J deaths per 1,000 of strength, equalling an annual rate of 24.51, which occiu'red
from disease during tiie seven months of war, August, 1870, to Feliruary, 1871, inclusive,
in the Prussian army.
The standard of comparison for each army should be its own average sick and death
rates derived from the records of a series of years during which it was exposed to no
specially unfavorable conditions, or, preferably, the best annual record furnished Ijy its
history, as all deviations from that record indicate, when their causes are investigated, not
only how they may be avoided in the future, but how the standard itself may be improved.
The difference between such a standard and the disastrous experience of the English
dining the first half of the Crimean war was a measure of the virulence of the unusual
morbific agencies to which their array was exposed.
■* MciUcal and Surgical History of the British Arm>/ which served in TurJ.ey and the Crimea during the War agaitist Russia in the years 1P54-G.
Oflicial publicatiun. London. ]SoS, Vol. II, p. 44.
t Op. cit.. last note. Table B.
* Calculated from the figures given by Dr. Enuki. in the ZeUschri/t des Knn J'reussichen Statidesvhen Bureaus Jahrgimg li?, Berlin, ]87,\ p. 250,
The mortality from disease in the German army during the war of 1870-71 was as follows:
Mortality.
Deaths iVoni acute iuternal dl»eases :
Dysentery
Typhus
(lastrie Fever
Sinall-pox
Iiitianimatinn of the air-passugcs ai;d lune;s.
Other diseases ,
Deaths from chronic intenial diseases ;
Consumption
Other internal diseases (chronic)
Sudden death (from disease)
Cnses in which the disease was not given
Cases in which the cause of death was net given
NUlIliEU.
MEAN STKKXGTH.
i.on
...
G, !i:i.')
p. 14
158
0.18
s«
0. Q'J
4IU
0. .->7
515
C. lU
521
0, (il
2-ii;
0. 29
ny
II. HI
53:)
0. i;i
Total.
12, 147
14.30
Tlie strength (^50..">c'.5) fnun which these rates were ealeulated was obtained Iruiu Dr. E.ngkl's statement of the total number cf deatlis (join
disease and injury (40,74:i) and of the rale (47.90) per thousand of mean strcogtli to which this total corresponded.
SICKNESS AND MORTALITY
The difference between the ordinary death rate from disease in the German army,
5.64 in 1868 and 4.76 in 1869/^' and the war rate of 1870, ah'eady instanced, shows
the operation of insanitary causes which might be specified with more or less accuracy by
detailed comparisons. The German record during this war is noteworthy as having pre-
sented a death rate from disease considerably smaller than that resulting from the casualties
of battle. The total death rate, 47.90 per thousand strength, in the seven months of active
operations consisted of 33.60 from violence and 14.30 from disease, the latter being equal
to an annual rate of 24.51 per thou.sand. But when this i-ecord is compared with its
proper standard, the mortality of the German army in time of peace, it will be observed that
a very notable increase took place in the deaths from disease on account of the exposures
incident to the seven months of war. The death rate, in fact, became cjuadrupled.
When our own war statistics, as given above in annual rates per 1,000 of strength, are
compared with similar figures derived from reports covering eighteen years of the history
of the army,"|" it will be found that the morbific influences to which our troops were subjected
were such as to increase the annual deatli rate from disease by 34.50 per 1,000 of mean
strength. The peace rate, 18.98 per 1,000, became nearly tripled by the war influences.
Our war rate does not appear great when viewed in relation to the mortality rates of
previous years and to the English and German figures instanced as expressing the mortality
* These rates were obtained from the Sanitiits Bencht ii. d. Preuss. Jrmee, 1868-69, pp. 40, 142-145, 203, and 298-301. The mean strength during
1868 was 250.376 and the mortality from disease 1,413; the strength durhig 1869 was 248,246 and the mortality 1,183.
tThe records of the .Surgeon General's Olfice show tliat. excluding deaths from wounds, accidents and injuries, and also those from Asiatic cholera
and yellow fever, the annual mortality rate of tlie United States army during eighteen years of peace whicli preceded the outbrealv of the civil war
averaged 18.98 per 1,000 of strengtii, the extremes being 8.4 in 1845 and 39.6 in 1849. The deaths in excess of the minimum were due for the most part
to diarrhcea and dysentery, continued and remittent fevers. Tlie following table has been compiled to show the death rates from disease that prevailed in
the army before the war. The years 1847-48 are not included, as the troops wer^then on active service in Mexico.
YEAR.
Deaths fuoji—
Death Rate fuom—
.Strength.
All Diseases.
Cholera.
Yellow Fever.
All Diseases.
Exclusive of that
from Cholera .and
Yellow Fever.
1840
10,116
9, 748
10, COO
9,863
8,570
8,590
9, 083
9,148
8,970
9, 242
9,203
9,994
8,095
9, 367
14,434
12, 701
14,510
1.3,510
241
367
2S1
156
95
72
175
721
268
280
208
266
224
305
353
107
202
240
10
6
28
12
11
23. 8
37.6
29.1
16.2
11.1
8.4
19.3
78.8
29.9
39.3
22.6
26.6
27.7
33.6
24.7
13.1
13.9
15.5
22. 8
37.0
26.3
14.6
9.8
8.4
19. 3
3X6
22.9
20.5
19.8
16.8
15.2
19.3
20.5
12.0
13.5
10.8
1841
1842
1843
1844
1845
1846
1849
307
60
Ul
26
94
18
104
58
52
3
1850 .
1851
1852
1853
4
83
20
2
14
1854
1855
18.-)6 :....
1857
1858 '.
6
1859
72
10, 3D7
257
24.72
18.98
The figures of this table may be compared, with those fur the years 1866-83, given in note upon page , as well as with those in Table I of
the text.
AMONG THK U. S. FORCES.
9
induced bv war conditions. It is the mortality rate of our army in the years of peace
preceding the war that compares unfavorably with the analogous German rate, and gives
the liigh rate of death from disease when that consequent on the aggregation of our troops
in larsre masses and the exposures incident to field service are superadded. Our army was
scattered at posts in all parts of the countr}^ which afterwards became the theatre of war,
and was exposed to the same miasmatic agencies which subsequently attracted more notice
on account of the large number of men constituting the commands. The peace rate of
IS. 98 shows the insanitary conditions to which our troops were subjected during those
eighteen years. The increase to 53.48 during the war is the measure of the mortality
directly referable to its morbific influences.
But when, instead of tlie average of many years, the best annual record furnished by
the liistorv of our army is accepted as a standard, the influence of the war in giving potency
to the causes of disease becomes very manifest. The rates 8.4 in 1845, 9.8 in 1844, and
10.8 in 1859 are much below the average of the eighteen years. Favorable conditions
conduced to this relatively light mortality. But these favorable conditions were, as will be
shown directly, in great part susceptible of attainment in other years. The average of
these rates, 9.33, may therefore be accepted as indicating the unavoidable mortality frora
disease in a body of men constituted and circumstanced as was our army before the \<ar;
and the large increase of 44.15 deaths per 1,000 of strength annually is necessarily
referred for causation to the war influences.
The war rates assume a larger relative magnitude when the rates which have prevailed
among our troops since the war is made the basis of comparison.* The average annual
*The following table e.vbibits the mortality rates, exclusive cf those from wounds, accijeuts and injuries and also th<;se from Asiatic Cliolera and
Yellow Fever io the army since the war, and may be compared with that given iu the note to page 8, supra.
Table showing the Annual Death Bates aiming the TT7ii7e Troops of the UniUd States Army since the close of the War of the Bebetlion.
Yeak.
Mkan Stkexc.th.
DE.ITIIS FK03I—
DE-ITH R.\TE FR05I—
All Diseases.
CbuletH.
Yellow Fever.
Exclusive of that
All Diseases. fnim Cholera and'
Y'ellow Fever,
16.;6-7
1868-9
1869-70
40, 163
45, 023
37, 197
28, 660
29, 373
24, 116
24, 897
25, 786
21,939
21,718
23, 363
20, 813
21,848
22,096
21, 174
20,723
20,923
1,529
1,168
376
219
355
20-3
247
218
158
169
179
122
162
126
131
141
146
747
139
2
7
437
1
19
46
20
38. 05 19. 29
26.39 ia82
10. 11 10. 03
1
8. 69 ' 8. 03
12. 09 10. 52
10. 91 10. 1'6
9. 93 '.'. 64
8. 45 1 7. 60
:670-!
1872-3
2
1873-4
16
2
30
2
1674-5. .
1875-6-.
7.20
7.78
7.66
5.86
7.41
5.70
7. It
6 40 '
7.57
5. 6i;
6.9i;
5.70
1876-7..
1677-8
1678-9
10
1679-80
1680-1
2
1
C. IJ 6. 0!! 1
1
6.60 1 6.60
6.98 6.83
1681-2
1662-3
3
Annual average
26,462
338.7
517
34.4
12.80 j 9.31
Mku. Hist. Pt. Ill— 2
10 SICKNESS AND MORTALITY
mortality IV.jm disease for the seventeen years, 1866-7 — 1S82-3, was but 9.51 per l.UOU,
although the country occupied by the troops and the unavoidable causes of disease to
Avhicli thev were exposed were the same as in the vears preceding; the war. This rati',
taken as a standard, refers the large annual mortality of 43.9 directly to the exposures
incident to the war. But if the average rate of the ten years, 1873-4 — 1882-3, be made
tl;e basis of comparison, the war influences become correspondingly magnified. This rate,
6.74, is but slightly in excess of the minimum, 5.70. in 1879-80.. The causation of this
great iliminutiou in the death rate of our soldiers of late years is readdy appreciated.
After the war the regular troops were distributed mainly over the undeveloped West to
hold the Indians in check and promote the settlement of the country. The old posts
which had been occupied before the war were in ruins, and the new conditions develojjed
by tl;e advance of civilization westward recjuired the establishment of garrisons in positions
which had formerly been unoccupied. Military policy rather than hygienic considerations
usually dictated the selection of the site, and in many instances the stations were estab-
lished in unhealthy river bottoms for the .sake of being near to a water supplv. The
quarters built b)- tlie troops were of the most primitive character, the materials at com-
mand being only such as the country afforded. Practically, our soldiers during the years
1867 and 1868 were in the field, and hence the high death rate. But in the years that
followed, posts which experience had shown to be unhealthy were abandoned, and monev
was appropriated for the construction of barracks at such stations as appeared likely to
recjuire permanent occupation. The conditions became gradually changed from those
attending a state of war or active field service to those of garrison duty in time of 2:>eace,
although occasional campaigns against hostile Indians kept the mortality rate higher than
a purely peace rate should be. The average rate of the past ten years testifies to the
efforts of the Medical Department on behalf of the soldier, and the earnest and intelligent
co-operative action of mditarv commanders.
The popular idea that our armies suffered severely from disease during the campaigns
of the civil war is thus well sustained by the statistics, in view of the fact that no notable
<?2Didemic of imported ijestilence, as of typhus, cholera, or yellow fever, contributed to their
mortality. Had our camps been unhappily visited by these scourges, our annual mortalitv.
of 53 per 1,000 of strength would have appeared light in comparison with tlie terrible
record which would have formed the text of a medical history of the period.
Sickness and mortality as caused by various diseases and cla.sses of disease. — ■
It has been already stated that among the white troops the cases of disease i-eported during
the five and one-sixth years embraced in the statistical records numbered 12,579 and the
deaths 276 in every 1,000 men of mean strength, these figures being equivalent to the
annual rates of 24.34 and 53.48 respectively. It has also been stated that among the
colored troo])s during three years of service there were recorded 9,897 cases of sickness
and 430 deaths from disease in everv 1,000 men of mean strength, figures ecjual to the
annual rates of 3,299 and 143.4 respectively. The following table is designed to give a
general view of the distribution of these cases and deaths under specific and generic head-
ings. The first two columns of each division of the table rei)resent the sickness and deaths
that occurred during the whole period, the figures being ratios per 1,000 men of mean
strength; the last two columns show to what extent the specified diseases contributed to
the totals of the cases and deaths that were reported as from disease.
Nl
AMONG THE V. S. FORCES.
11
Tablk II.
Sliou-iuff ihc Comparative Frequenci/ of, and }[ortaUtti from, the Diseases that prevailed among the While
Troops of the U. S. Army durinj the period from May 1, 1S61, to June SO, 1SG6, and among the
Colored Troops during the prr/o(? from July 1, 1S63, to June oO, ISGd.
AViUTK Titaoi's.
CoixiKED Troops.
Ciisfs lu.i:l.> t ..>v> jt. r l.)._.t;lts|>er ' Ciiscs ' Deaths I Cnscs per Deaths per
)>crl.lXKlol per l.OiiOof l,000"tl..lal LlHHIof i.,ial per '.l''"' of perl.tHlOof l,(XX)oftolal 1.000. iltulal
tiiean I liienn eases de.ith»froin ^ mean liiean e.l6C8 Ueatlis frum
sTretvj-tli. ' fitreogth. ofdUease. disease. || strength. , strength. ! of disease. , disease.
Coiitiiuied Fevers
Typho-mahiriul Fevers ((t)
Malarial Fevers. .
Diarrhoea and Dysentery
Diphtheria (a)
Eruptive Fevers
Other Miasmatic diseases {h)
Total Miasniatie diseases
-Syphilis, Gonorrluea and Orchitis
Scurvy
Kbeumatism, acute and cbruoic
CunsnmptioQ :.
Itch
Diseases of Nervous System
Diseases of Eye and Ear
Diseases of Circulatory Organs
Acute Bronchitis and Catarrh (b)
loflammation of Lungs and Pleunt . . .
Other diseases of Respiratory Organs.
Total Respiratory Organs
Diseases of the Digestive Organs
I'rino-genital disease
Diseases of Bones and Joints
Boils, .\bscesses and other Integumentarj*
diseases.
Grand Total 12,579.04
as. Ill
11.T.C5
2,(iSa78
3, 673. 93
1G.87
240. 83
404. 60
7, 306. 84
42:!. 8.-.
71.22
590.71
:!I.:i0
74. 39
3.M.33
272.73
.58.22
C01.57
S15.78
235.32
1,352.67
1,306.10
0.28
18.73
440. 17
59.91
P. G7
17.38
80.71
1. .'iS
23.26
5.33
196.79
.29
.82
1.01
ll.-_'.>
9.4!'
a34
2.33
32.73
2. 57
38.23
8.85
. 92 ■
.10
.46
276.30
16.53
9.19
214.55
292.23
1.34
14.85
32.16 I
580. £7
33.69
I
5.66
4G.96
■-•.49 I
3.91
31.34
L'i.i;.<
4.C3
71.67
17. 15
18.71 '
107.53
10a63
&51 j
1.49 j
C4.99 ;
216.82
31.37
6191
292. 10
5. .13
84.19
19.33
712.21
1.05
3.96
3.C7
40.85
12.81 j
9.16 I
118.47 ,
10.74
I3a36|
33.04
132 !
.36
1.67
1,000.00 1,000.00
C8. 98
133. 16
2, 488. 73
2, 51?. 14
12.09
276.86
396.90
5,88*46
23122
205l23
525. 53
21.77
51.63
ail. 53
153.33
23.30
531.91
381.27
131. 03
1,064.22
837.77
43.34
15.54
192.37
37.36
20.33 I
33. CS
103.81
.95
53. C8
8.93
338.62
.50
6.07
aer
13.94
12. 75
.03
7.31
4.07
86.62
6.35
S7.04
15.19
2.05
.23
.43
6.97
12.44
231:47
VA. 43
1.58
•10. 13
5.!4. C8
3.5.56
26.80
53.10
2.20 ^
5.22 :.
39.56
16. CO I
2.58 1
5a 73
38.53
15.36
107.53
60. 7J
4.<:s
1.57
19.44
6C.84
47.31
C9.r.3
I
24.-). S7
2.23
138. C4
20.88
C01.19
1.16
14.11
8. .-)3
41. 1 '4
39.C4
.c; I
16. 98 I
9.46
201.33
14.73
235.57
3.'.. 31
4.76
I
"CO. CO 1,000.00
(a) Cases were reported under this heading only during the period from June 30, 1362.
(h) In the composition of thi.s table the fifrures reported under llie heailing Epidemic Catarrh have been dropped from the class of miiismatie diseases
and consolidated with the diseases of the respir.itorj- organs, as there seems good reason for believing that intluenza was at no time prevalent atiionir the
troops. .See infra, page 725.
Among the white troops diarrhoea and dysentery occurred with great frec^uency and
occasioned a laro-e mortality. These intestinal affections were the cause of more than one-
fourth of all the entries upon the sick reports ; and it is a singular coincidence that their
reported cases bear to the reported cases of all diseases the same ratio, 292 per thousand,
that the deaths occasioned by them bear to the total deaths from disease. Malarial fevers
^followed in order of frequency, haying constituted, if typho-malarial cases are included,
about one-fourth of the whole number of cases of disease. These caused nearly one-tenth
of the total deaths, a mortality almost reached by the eruptiye fevers, which, howfever,
occasioned only 14.8 of every thousand of the cases. But in order of gravity the continued
fevers, consisting mainly of typhoid cases, took the second place, having caused 216 deaths
in every thousand from disease, although contributing only 16.5 cases fo -v ry thousand
12 SICKNESS AXD MORTALITY
cases of all diseases. To the miasmatic diseases as a class were attributed considerably
more than one-half, 581 cases per thousand of all diseases, of the entries on sick reports, and
nearly three-fourths of the mortality, 712 deaths in every thousand. The only other classes
of disease which furnished high rates of prevalence, diseases of the digestive and of the
respiratory organs, agreed closely in their number of cases, 103.8 of the former and lUT.o
of the latter, contributed to every thousand of all diseases ; but the deaths caused by the
diseases of the respiratory organs assumed a higher jiroportion, 138.4 per thousand, on
account of the gravity of the pneumonic cases. Scurvy as an individualized disease caused
less than 6 in every thousand of the cases and less than 3 in every thousand of the deaths.
The second part of the table presents the parallel facts deduced from the medical
statistics o£ the colored troops. Among the colored, as among the white troops, diarrhoea
and dysentery occurred with great frequency and fatality. The ratio of cases of these
intestinal aflfections to the total number of cases of disease was 254:. 4, and of deaths caused
by them to the deaths caused liy all diseases, 245.97 in every thousand of each respectively.
Malarial fevers constituted one-fourth of the whole number of cases of disease, and caused,
if typho-malarial fevers are included, somewhat more than one-tenth of the deaths. But
inflaraniation of the lungs occupied the second place in the order of gravity, the deaths
from this cause having formed 201.3 of every thousand from all diseases. The eruptive
fevers occasioned 128 of every thousand deaths. The continued fevers did not occupy so
prominent a place in the medical, records of the colored troops as in those of the white
regiments ; the cases formed only 6.97 of every thousand cases of all diseases, and the
deaths 86.84 of every thousand deaths from disease, as compared with 16.55 and 216.82,
the corresponding numbers from the records of the white troops. Miasmatic diseases as
a class caused 594.68 of every thousand cases and 601.19 of every thousand deaths.
Scurvy attained a decided prominence among the colored troops as compared with its
prevalence among the whites. It was nearly as frequent as the eruptive fevers, 26.80
cases having been recorded in every thousand cases of disease ; and a comparatively large
number of deaths were attributed to it, 14.11 of every thousand from all cases, as asrainst
2.96 among the white troops.
Incidentally a comparison may be instituted between the sickness and mortality of
the white and the colored troops by noting the figures in the third and fourth columns of
Table II, in connection with the corresponding figures in its seventh and eighth columns.
The first two columns of each division of this table are insusceptible of comparison, as they
do not refer to equal periods of time, but in the following table the average annual rates
of sickness and death in the white and the colored commands are strictly comparable.
From this table the greater sickness and the very much larger death rate among the
colored troops may be appreciated and referred to tlie disease or classes of disease that
occasioned them. There occurred on the average annually in every thousand of the colored
men 143.4 deaths from disease as compared with 53.48 among the white troops ; and as
the sickness of the former, althougli large, was not proportionally increased, the greater
fatality of disease among them is manifested.
Malarial diseases caused 829.58 cases as against 522.34 anaong the white troops, and
10.03 deaths as against 3.36, whilst at the same time cases reported as typho-malarial
were more numerous and very much more fatal among the colored commands. Evidently,
from these figures, the latter did not possess that insusceptibility to the malarial influence that
AMONU THK U. S. FORCES.
13
has been sometimes claimed for them.* Indeed, an insusceptibility to the typhoid poison
rather than to the malarial influence appears suggested, for the average annual number of
Taklk III.
Showing by Average Annual Rales per 1,000 of mean strength the Comparative Frecjuency of, and
Mortality from, the Disea.ses that prevailed among the While and Colored Troops of the r\ .S'. Ainm.
WnnE Troops.
C^*l.^-M:tll i i:"
Diseased
Cases.
Deaths. I Cases. I Deaths.
Average uuniia) mie fur all diseasi-
2,434.04
53. 43 3, 59?. %
14^4
_L
I
Continued Fevers
Tj-pho-malarial Fevers
Malarial Fevers
Diarrhoea and Dysentery
Diphtheria
Eruptive Fevers
Other Miasmatic diseases
Total Miasmatic diseases
Syphilis, Gonorrhcea ami Orchitis .
Seur\'y
Rheumatism, acute and chrunic . . .
ConsuinptioD
Itch
Diseases of Xervoos System -.
Diseases of Eye andEar
Diseases of Circulation
Acute Broacbitis
Inflammation of Lungs and Pleura
Other diseases of Respiratorj' Organs
Total diseases of Respiratory Organs
Diseases of Digestive System
I'rino-^nital diseases
Diseases of Bones and Joints
Boils, .Abscesses and other Integumentary diseases .
40.29 I
22.3?
532. 34
711. 4C
3. sa
4i;. Gi
7S.31
1,414.22
M. 04
13.78
114.33
cot)
11. 40
71). 31
Si 7.1
1 1. i7
174.43
41. 7i;
45. 55
2til.80
252.70
i:i. 41
3.G3
8.5. 19
11.60 1
l.f?
3. 3i;
15.62
.34
4.50
1.03
38.09 |,
.01)
.It) '
.20
2.18
1.84 !
.OtH
. ("9
.4;i
.:. :i4
. !;7
7.40
1.71
. 1.-
.02 ^
.09 i
2a 99
41.05
829. o-
639.38
4.23
92.29
132.30
1,9()1.82
77.74
88.43
178.54
7.26
17.21
130.51 '
52. 7^i
8. .".0
177. :tn
li7. 09
CO. 34
354.74
295. 93 '
1.;. 4.-.
5. 18
C4. 12 '
12. 45
6.7? '
10. 03
35.27
.32
18.36
2.99
86.21
.17
2.02
1.2:)
6.31
4.25
.01
2.44
1. 311
2. 12
32.35
5.96
.i;8
.14
'5^,
cases of the continued fevers was only 22.99 amoncj the colored men, yv\m\; it reached 40.29
among the white troops. Nevertheless, the annual death rate from these fevers, typhoid
mainly, was somewhat larger among the colored men, 12.45, than the white commands,
11.60; thiS indicating the unlikely coincidence of a diminished prevalence and a largely
augrnented virulence. This anomaly is probably due to the aggregation of a larger propor-
tion of true tyjihoid cases in the 41.05 cases reported as typho-raalarial from the colored
commands than in the 22.38 cases similarly reported from the white regiments. Diarrhoea
and dysentery, the eruptive fevers, diseases of the lungs — in fact, with the partial exception
of the continued fevers, all the diseases that were specially i^revalent in our camps occasioned
more sickness and more deaths among the colored troops than among corresponding numbers
of the white troops. Miasmatic diseases as a class caused 1,961.82 cases and 86.21 deaths,
as compared with 1,414.22 cases and 38.09 deaths among the whites. Even those, such as
' See in/ra, page S4, in continuation of this subject.
14 SICKNESS AND MOPITALITY
sypliilisi, gonorrhoea and orchitis, consumption, diseases of the eye and ear, diseases of the
circulation and acute bronchitic attacks, which were not of more frequent occurrence
among the colored troops were, nevertheless, attended with a higher mortality than among
the whites.*
Sick- and mortality-hates of U. S. white troops during the war as compared
WITH THOSE OF OTHER BODIES OF MEN OF THE MILITARY AGE. — Table IV and the plate which
faces this page have been designed to illustrate the A^arious points that appear of interest
under this heading. Special attention may be invited to some of the more prominent of these.
Five of the red lines representing annual mortality rates among our white troops
during the war are projected into the closed-up divisions of the plate. Evidently the dis-
eases indicated by them caused the main portion of the total mortality. The length of
these lines as comjaared with that of the correlated lines of other colors, gives expression
to the influences whicli the conditions of war impressed on the mortality from these affec-
tions. The diseases thus prominently brought into notice are those already recognized
in Table II as having occasioned so many of the deaths among our soldiers. Of the 53.48
deaths that occurred annually in every thousand men of the average strength present,
diarrhoea and dvsenterv caused 15.62; the continued fevers, not includino- those reported
as typho-malarial, 11.60; diseases of the respiration, jjneumonia chiefly, 7.40; the erup-
tive fevers, 4.50; and the malarial fevers, 3. 36. The only other lines that are projected
into the denser portion of the plate are the black line indicating the mortality, 5.32, from
diarrhcea and dysentery among our troops before tlie war, and the green line representing
that from the continued fevers, 3.39, among the French troops. The former was due to
that want of sanitary supervision and care for the health of "the troops which permitted
scurvy to show as a well-defined cause of death among them, while it scarcely appears
among the other bodies of men tabulated, except in our own armies during the war, when
the unusual nature of the conditions suffice to explain, and in a measure to condone, its
appearance. The latter was due to the influence of local epidemics during the years taken
for comj^arison, and especially to the prevalence of continued fevers among the troops in
Algeria.
The increased mortality during the war from what has been called typho-malarial
fever is well marked by comparison with the death rate from tlie same disease since the
war; but, as will be shown hereafter, febrile cases presenting essential differences were
aggregated under this heading.
The large death rate, 11.60 per thousand of sti-ength, from the continued fevers during
the war period, when compared with their relatively insignificant mortality in our army
since the war, 0.61, in the German array, 0.98, or among our civil population of the
military age, 0.49, implies of necessity a vastly increased prevalence as well as fatality.
Both of these facts may be verified from the data in Table IV. A precisely analogous
series of facts delineated under the heading of the eruptive fevers is suggestive of one of
the probable causes of the increased prevalence and fatality of the continued fevers. The
main factor in the development of an epidemic of the eruptive fevers is not so much the
introduction of the contagion, although this of course is essential, but the accumulation in
the population of a sufficient number of susceptible individuals to afford material for the
' This tendency of the colored troops to succumb to morbific iniiuences was brought forcibly to the notice of the writer in ISfA by Assistant .Surgeon
J. T. Calhoun, U. S. Army, then in charge of a field hospital fur their treatment at City Point, Virginia. " I do not know what to do with these colored
men,'' lie said, **I cannot keep them up. They do not have tlie stamica of our wliite men. They just go to their beds and die."'
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AMONG THK U. S. FORCES. 15
operation of tlie morbid agency. This is well recognized by the recurrence of the epidemic
visitation after a certain lapse of time has permitted the conmumity to accumulate a large
proportion of jiersons hitherto unafleeted ; and in the case of small-pox, by the institution
of effective preventive measures based on the destruction of the susceptibility rather than
on the exclusion of the contagion. Keginients recruited in country districts that had been
unvisited by these fevers for a nunib(>r of years, presented material for their rapid spread
on the introduction of the contagious princi[)le. Similarly, regiments from localities that
had lieen free from typlund. were liable to sntlVr severely iVom this disease on account of
the susceptibility of the men composing them.
The mortality lines of our armies during the war period are exceeiKxl by tlioso of other
bodies of men in the two instances, consumption and scurvy. The males of our civil
population have a higlier death rate from the first-mentioned disease as a result of the
selection for service and discharges for disability that tended to free the army from such
cases. Our own troops, before the war, had a higher rate from scurvv, owing to deficient
supplies and their isolation at stations at and beyond tlie frontier of civilization.
Diseases of the digestive system gave a larger mortality among our troops during the
war than among other bodies of men. The records show this to have been mainl\' due fo
the fatality of cholera morbus and dropsy from hepatic disease.
Diseases of the nervous system had also a comparatively large mortality, wiiich, huw-
ever, was equalled in our own army before the war.
Active service during the war slightly increased the mortality from diseases of the
circulatory system; but the records of the French army ascribe to these diseases a nearly
similar death rate.
Rheumatism contributed but little to the mortality in our camps, scarcely more than
was the result of the conditions existing at the military jiosts ol' earlier times.
From Table IV, on the next page, may be gathered sonie interesting points regarding
prevalence not shown by tlie mortality lines.
Thus, according to the figures, the number of cases of sickness among our troops was
relatively greater before the war than during its progress. Certainly, in its early service
in the Indian country, our small army was exposed to many of the influences that subse-
quently contributed to the war rates of sickness. It will be observed, however, that the
number of serious cases, i. e., of diseases yielding a high mortality, was invariably greater
during the war than before it; hence the smaller figures of which our war rates consists,
2,434.64 cases annually per thousand of strength as against 2,886.01 in earlier years,
must be attributed to the failure of our medical officers during the active progress of a
campaign to record cases of trivial ailments rather than to an actuid diminution in tlieir
number.
Again, the frequency of cases of disease in our army since the war appears to have
been more than double that of the German army during corresponding years of peace,
1.474.26 per thousand of strength as compared with 660.78. Here the gravity of the
affection recorded as a case of sickness forms an element of difference. In our service
every man excused from military duty on account of sickness, however trivial, counts as
one case upon the record; but since the mortality rate of the German army is not decreased
in jJroportiou to its sickness, as compared with our rates, it may be inferred that in their
service the trivial cases are not recorded.
1
16
SICKNESS AKD MOBTALITY
Table IV.
Avemffe Annual Sick end Death Rates per thousa7id of mean strength in the U. S. Army before, during
and since the tear, and in the German and French a)-mies, loith the Annual Death Rate for males
of the military age in the United States, as calculated from the returns of the census year 1S80.
o_ be"
^ =^ "3 "a"
= -^ x ^
£ a 3 ■£
" ^.= x
= "!! t.%
Strength represented : 'l, 906, 276
U. S. Array,
White Troops
fur 5J years of
War.
,8,987,358 431,237
Deaths. Deaths.
Average annual rate for all diseases .
C. 97 ! 6.87
Cases. ' Deaths.
a, 434. 64 53. 48
Continued Fevers .'1'.' .54 , 40.29
Typho-malarial Fevers 23.38
Malarial Fevers
Diarrho?a and Dysentery-
Diphtheria
Eruptive Fevers
Other Miasmatic Diseases
Total Miasmatic Diseases
Syphilis. Gonorrhtea and Orchitis
Scurvy
rheumatism, acute and chronic
Consumption ;
Itch
Diseases of Nervous System
(^Diseases of Eye and Ear
Diseases of Circulation
Acute Bronchitis
Inflammation of Luoijs and Pleura
Other Diseases of Respiratory Organs
Total Diseases of Respiratory Organs
Diseases of Digestive System
Uriuo-genital Diseases
Diseases of Bones and Joints
Boils, Abscesses and other Integ-umeutary
Diseases.
.19
.04
.09
.02
.04
■J. 94
.46
.08
.77
.13
.98
.35
.33
.04
.04
.26
.05
.06
.04
2.33
.56
.33
.05
.97
.12
1.14
.33
.18
.03
.05
522. 34'
711.461
3.921
46. 61
78.31
l,414.Sa
82.04
13.78
114.33
1
6.06
14. 40]
76. 31
52.79
11. 27
174. 49
41.76
45. .=55
261. 80
252. 79
13.41
3.63
83.191
11.60
1.68
3.30
15.62
.34
4.50
1.03
38.09
.06
.16
.20
2.18
U. S. Army,
White Troops
for 18 years be-
fore the War (c)
r. S. Army,
White Troo"ps
for 10 years since
the War.
Cases.
2, 886. 01
Deaths. Cases.
18.98 1,474.26
596. 63
4S7. 34
1.29
1.76
5.32
6.74
German Army
for four years,
]874-'3 to
1877- 8. (<2)
? >•
334, 193 1459, 420
Cases. I Deaths.
660. 78 -4. 38
7.48j
1,112.74
67.86
26.37
114.33
3.53
1.84
.004
.69
.49
6.34
.57
7.40
1.71
.18
.02
.09
.19
(/)..
8.56
.08
.£8
.18
1.84
82.26
1.77
."ig.Ol
.01
3.04
.23
299. 59
.19
27.28
1.36
326. 8'
1(8. 46
1.55
.04
129. 91
3.23
2.38
226. 68
S24. 56
.55
2.61
'/)8.48
468.89
87.62
.42
116.54
4.08
.29
lll.S
34.42
7.70
208.83
10.54
11. 42
230.
191. 20
15.44
3.92
118. 09
.61
.34
.32
.47
.02
.06
(/). 13
1.96
.05
.005
.06
.72
.98
24.79
21.88
1.18
4.S6
.009
.10
.04
.07
C7.07 1
41.36
.10
26.21
3.77
1.20
.006
.009
.03
.74
.38
.26
.05
.39 !
.79
4.17
.005
41.08
.67
2.10
.06
43.64
.84
17.61
^n
i.'io
61.25
.69
30.82
.24
6.34'
.21
.03
.06
.03
7.13
43. 78
.75
.009
.08
.06
.006
4.48
.004
I
.004
.09
.48
.004
.18
.18
1.02
.33
1.51
.29
.04
.09
(a) The mortality returns of the Tenth U. S. Census. 1880, were not published at the time this table was calculated; but by the courtesy of the
f5uperintendent the writer was furnished with page proofs of Table XI, Statistics c^f ilortalitij, giving the deaths in certain grand groups by age and sex,
with distinction of color and specification of cause, from which he calculated the rates for his comparative table of annual rates in men of the military age.
The grand groups, Nos. 2, 8 and 11 of tlie topographic.il divisions made by the Census Office, have a population of 1,906.276 white males between and
including the ages of 20 and 44 years. They are: 2, the Middle Atlantic Coast, comprising the District of Columbia, the State of Delaware, and part of
Kew York, >'ew Jersey, jMaryland and \'irginia; 8. tlie Interior Plateau, embracing parts of New Yorl;, Pennsylvania, Virginia and North Carolina;
and 11, the Soutliern Interior Plateau, including parts of South Carolina, Georgia, .\labama, Mississippi and Tennessee.
(I) The figures in this column were calculated from page proofs of Table VII of the Statistics of Mortality of the Tenth Census, which gives the
mortality of the United States from each specified disease and class of diseases, with distiuction of age and sex but not of color.
(c) The average rates in this column are from the statistics of the years 1840 to 1859 inclusive, hut not including the years 1847 and 1 848, during which
•the troops were on active service in Mexico. YeUow fever and cholera prevailed during certain of these years, but the influence of these epidemics
has been excluded in calculating the rates. There were 317 deaths from yellow fever and 764 from cholera, which, if included, would raise the average
annual death rate from 18.98 to 24.73.
((i) These rates were calculated from the Statistischen Sanitiitsbericht iibcr die Kmifflich rrfussische Jrmre. Care was taken in the computation to
so aggregate tl>e figures given under specified diseases as to render thera strictly comparable with the l'nite<i States statistics.
(c) As the French Statistijues Medicales rfe r.-lrmie do not report the number of men excused from duty and treated in quarters, their recorded cases
are not susceptible of comparison with those of the I'nited States or German army. (/) Not including yellow fever.
AMONG THE X'. P. FORCES. 17
Notwithstanding tlie great frequency of malarial attacks during the war, 522.3-4 eases
annually per thousand of strength, it will be observed that these were even of greater
frequency among our troops during the years that preceded it, 596.63 jx-r thousand. TIk'
material reduction of late years in malarial sickness, 226.68 jter thousand, is due to the
abandonment of unhealthy stations."^"
Venereal diseases and those affecting the uriuo-genital organs were nearly as frequent
in our army during the war as in earlier years.
Scurvy during the war gave annually per Ihousand of strength 13.78 cases, or only
about one-lialf of the number, 26.37, recorded by our medical officers before the war.
Tlio war records, co!n{>ared with those of our array before and since the war, do not
show an increased jirevalence of rheumatism, nor of diseases of the nervous svstem, nor of
bronchitic attacks; pneumonic cases, however, were more frequent and liv far more fatal.
Diseases of the circulation were somewhat increased, and those of tlic digestive system
considerably augmented iu number during the period of the war.
Sickness and mortality as influenced by season, locality, etc. — The regimental
monthly reports, compiled from the morning reports of the medical officers on duty, arc the
ultimate elements of which the statistics of sickness and death in our armies were composed;
but these lost their individuality when they were converted into departmental returns. The
data in these departmental tables were intended to show, when converted into comparative
figures, the influence of season, locality and military operations as affecting the prevalence
and fatality of the diseases specified. The influence of season can be determined with
accuracy, but that exercised by locality and military operations is not so well defined.
A series of regimental histories giving in parallel sentences an account of the condi-
tions affecting the health of the men during the progress of their service, and the preva-
lence of disease and death among them, would have been a desirable addition to the
materials for a medical history of the war. The want of these has been in part replaced
by the special reports rendered by medical officers, although generally in these more atten-
tion was given to the details of hostile movements, battle scenes and surgical service, than
to the less exciting contests with the more deadly enemy, disease. By the consolidation
of the regimental into departmental returns the numerical statements lost a great part of
their value. Certain sections of the departments were healthy, others unhealthy, and the
consolidation of the regimental reports obliterated the records of special localities and gave
results for each department depending on the character of that section of it in which the
majority of the regiments were concentrated. Besides this, even the boundary lines of
departments were subject to constant variation consequent on changes in the military policy,
the assignment of new commanders, etc. Departmental reports must therefore be consid-
ered in connection with the localities which were the theatre of military operations, rather
than as figures applying generally to the section of country included in the department.
This renders it difficult to attain to an accurate estimate of the relative value of region as
influencing disease and mortality.
Moreover, military operations carried the troops from one part of a department to
another, and frequently to some other department. They entailed upon the soldier fatigues,
exposures and privations which tended to sickness and death. The pernicious influences of
service in one department came thus in many instances to be credited to a wholly different
locality. A synopsis of the history of the operations in each department precedes the annual
* See svpra, p. 10,
Med. Hist. Pt. 111—3
18
SICKNESS AND MORTALITY
statistical tables in the First Part of this work, and many of the movements and the influ-
ences exercised by them have already been given in free extracts from the reports of the
medical officers who served with the commands. Nevertheless, it will readily be appreciated
that the ratios of disease and death calculated from the figures in the departmental tables
express only in a general way the conjoint influence of locality and military o2)erations.
The following table presents a general view of the annual movement of sickness and
death among the white and the colored troops in the several regions:
Table V.
Showing the Anmud Prevaletux of Sickness and the MortaHty from Disease in the several- Regions,
expressed in ratios per 1,000 of mean strength.
Foe the teab esding Juse SOth-
-
1861.
1862.
1863.
1864.
1865.
1866.
Cases. Deaths.
Cases.
Deaths.
Cases.
Deaths.
Cases.
Deaths.
Cases.
Deaths.
Cases.
Deaths.
White Troops,
Atlantic Region
3,930
3,432
11.4
7.2
2,719
3,495
2,171
32
81
10
2,553
2,841
2,133
42
85
9
2,137
2,262
1,816
33
58
11
2,221
2,328
1,864
53
61
12
2,292
2,549
1,749
42
48
14
3,822
10.8
2,983
49
2,696
63
2i210
48
2,273
56
2,362
42
Colored Troops,
3,461
4,373
83
269
3,122
3,248
HI
156
3,574
2,842
1(H)
93
Total colored
4 092
211
3,205
140
3,797
94
The commencement of service was in all instances characterized by the highest ratio
of sickness.
Among the white troops the first year gave a mortality rate as low as 10.8 per thou-
sand of strength; but this rate is calculated on observations covering only the months of
May and June, as the troops were being hastily called into service. The third year, ending
June 30, 1863, gave the highest death rate, 63 per 1,000. The rate fell to 48 in the fourth
year, and rose to 56 in the fifth year. In the year following the war the sick rate pre-
served its war height, but the mortality fell to 42.
Among the colored troops the sick rate fell from 4,092 during the first year of tlieir
service to 2,797 during the last, and the death rate from 211 to 94.
The rates in the Pacific region corresponded with those in tlie army as a whole since
the war. The troojis in that region were, in fact, during the war exposed to no greater
fatigues or jirivations than the army encountered when at the close of the war it was
distributed over the west.
The high death rate of the troops in the Central region is one of the chief points
developed by this table. In this region during the year of greatest prevalence the deaths
were to the cases as 1 : 43, and during the year of least prevalence as 1 : 39. In the Atlantic
region, omitting the figures for 1861 as representing only a lydrt of a year, the correspond-
ing jorojiortions were 1 : 85 and 1 : 65. The fatality rates or the deaths in a given number
of cases, as well as the mortality rates or the deaths in a given number of men, were
greater in the Central than in the Atlantic region. Unfortunately it is impossible to learn
precisely in which of the departments of the Central region this large excess of deaths
AMONG THE U.
FORCES.
19
took place. The statistical tables in tlio First i'ail of this work record the deaths which
occurred among the troops serving in each department; but the deaths that occurred in the
general hospitals among soldiers of one department are consolidated with those of mei)
belonging to other departments in a series of tables giving the deaths in the general
hospitals of the region. A\'^e must, therefore, endeavor to appreciate the influence of
locality on the mortality by an examination of its influence on the prevalence of disease.
Tlie following table was constructed to facilitate this examination:
Table VI.
Shotcing the Annual Prevalence of Sicknei^s from all Dmases in the several Military Departments,
expressed in ratios of 1,000 strength.
WiiiiK Troops.
Middle Department
DepHrlinent of the .Shenandoah....
Army of tlie Potomac
Departineut of tlic Uappabannock .
Department of Vii^inia
Department of North Carolina
Dei^rtment of Die South
Department of the East
DejtHrtment of AVa.«hing1on
Middle Division
Atlantic Kef^on
Total in Atlantic Jitgion..
I>ei>artinent of We.*.tern Virginia --.-.
Department of the Cumberland
Department of Tennessee
Dei*artment of tlie tliilf
Dei>artinent of the Norlliwe-st
Dei>ar1ment of .Missouri
Northern De(>artnn'iit
Department of the Ohio
Department of Arkansas
Military DiTision of the Mississippi, Part 1 .
Military Division of the Mississippi. Part II
Central ResT'on
jy^al in t.'tntral Retjimi.
l>e|«rtmentof New Mexico .
Dei>artnient of the Pacific. . .
Pa*:ilic Ke^itn
ToUit in racific Region -
Army tif the ITnittd Stales
For the visak knding Ji'nk 30th—
166-2.
Cases.
3,930
3,930
3,83S
3,099
2,aol
2,844
2,204
a, 432
2,410
3,09.'>
2,719
2,802
3,415
3,991
3,85.1
2,889
3,301
3,495
1,738
2,575
2,171
18fi3.
Cases.
■2,609
2,583
2,985
2,249
2,335
2, .'>24
2,002
1,563
2,823
4,012
2,796
2, 217
2.401
.137
2,005
2,936
2,8.')8
3, 996
2,394
2,296
3,383
2,202
2,218
2, 076
2,133
i696
1,293
1,747
2,614
2,923
2,035
2,249
3,029
1,931
2,829
1,693
1,900
1,816
2,210
186.5.
1,363
2,729
3,110
2,395
2, 219
2,273
1,788
2 221
2, 7I>3
2,109
2,494
2,508
3,428
2, 361
1,688
],li58
1,9I>4
1866.
2,292
2,292
2,549
1,749
2^362
20 SICKNESS AND MORTALITY
Perhaps the first point that will attract attention in this table is the gradual diminu-
tion in the sick rates as the war progressed. The years of the war, tliough nominally five,
were in reality but four, that ending June 30, 1861, having embraced only two months of
service. In a general way, as may be seen by the regionic or army totals, the rate of sick-
ness decreased during the first three years and became somewhat increased during the fourth
year. Locality had nothing to do with this except in so far as in some instances to occasion
an exception to the general rule, as in the Departments of Virginia and North Carolina,
where the sickness increased progressively during the three years on account of continued
exposures in malarious sections. The diminished sick rate must be attributed to the
weeding out by death and discharge for disability of the inferior material necessarily present
in all new levies. The term of service of many of the regiments expired during the third
year of the war, when the hardy veterans composing them were in many instances replaced
by raw troops who, in becoming inured to active service, swelled the sick rates during the
fourth year.
The lowest rate, 1,293, was furnished during the third year by the high grounds of
Western Virginia. The low rate of 1 ,563 was given during the same year by the veterans
of the Army of the Potomac. The battle of Gettysburg began the year, and the desperate
struggle that led from the Wilderness to Petersburg during May and June, 1864, ended it;
but the greater portion of this period was spent in what was regarded by the troops as a
picnic in sumiBer quarters on the Rapidan, or hutted during the succeeding winter and
spring in a healthy locality. All the conditions were favorable to a light sick report.
Many of the men were anticipating a sojourn at home on the expiration of their term of
service. Even the exhausting movements which closed the year, the constant skirmishing,
and the battles fought in quick succession at the Wilderness, Spottsylvania, the North
Anna, Cold Arbor and Petersburg, while undoubtedly the cause of much sickness, tended
to reduce the sick rate as preserved on the records which medical officers made up at
intervals from memory or pencilled notes, overlooking the slighter ailments that would
have been recorded in quieter times and noting only those more serious cases that had been
despatched with the wounded to the general hospitals.
The highest rate, 4,012, was furnished during the third year by the continued exposure
of the troops in the malarious regions of the Department of North Carolina.
The high mortality rates in the Central region corresponded with high sick rates which
are jDarticularly displayed in the reports from the Departments of the Tennessee and the
Gulf. The j^revalence as well as the virulence of the morbific influences was greater in the
Central than in the Atlantic region. The influence of locality on the prevalence of
particular diseases will be discussed in the chapters relating to the diseases in question.
To express the relation of season to sickness and mortality in the various regions, and in
the army as a whole, Tables VII, VIII, IX and X have been constructed ; but, as it is a work
of some labor to gather from such tables the relative value of the figures contained in them,
the diagram facing page 24 has been j^repared, and to it accordingly attention is invited.
The sickness is expressed in monthly rates per thousand of strength on the left side of the
jalate and the mortality on the right; but the scales have been so proportioned that the sick
rate may be read as well on the right by appending a cipher to the printed numbers. The
narrow red line represents the sick rate among the white troops of the army, the broader line
the death rate, wliile the yellow lines indicate the correlated figures for the colored troojjs.
Oloi
b
CJt
c
o
5 CJl
b
01
C i OT 1 O
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ui o oi
to t>;
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in
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b
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02
o
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i
Ally.
Sep
Od.
Nov.
Dec.
Jail
Feb.
Mar.
Apr.
Afar
June
1
i
1
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hdy
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Sep.
Oct..
.Vov.
Ilec.
Jon.
Feb.
Mar.
Apr
May
June
-
r 1 , :
: ; 1
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1 1
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k,
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Mar
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July
Aiii/.
Sep.
Oct.
Nov.
Dec.
Jan.
Feb.
Mar.
Apr
Miiy
8
1
r ; 1
1
1
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)tc.
llUI
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m
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July
Aliq.
Sep
Oct.
Nov.
Dec.
■Jan.
feh.
Mar
Apr
May
Jwu
1
^
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- 1 ; 1 1
1
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id.
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r
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July
Aug.
Sep.
Oct.
Nov.
Dec.
Jan.
Feb.
Mar
Apr.
May
i
;
1
T
- ;■ -, -j
1
1
i 1
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L
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i
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far
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1
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1
1
1 ol'-'i'- '1
— -"1 C) ^"1 "
o
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to to
9\'-
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to
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to
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01
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^
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'5
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amoxg t5ik t'. s. forces.
Table YIT.
21
Monthly ratio of Skhiess per 1,000 of nuan strem/th umoiuj the White Troops, C. S. Aniu/, by regionn,
for the period from June SO, 1S61, to June 30, 1SG6.
Vkak exi'Im;—
Kegion.
>
c
b:
i
o
i
>
O
s
9
June3n,18fi2
Atlantic
385
157
370
389
193
2il7
346
200
306
239
263
215
250
268
326
197
285
283
270
172
275
2.17
303
230
271
240
263
181
~251
Central
315
154
Total
324
3li4
257
June 30,1863
311
245
186
235
220
256
238
Central - . . ...
"14
I^'ific . . ...
159
Total
2T9
228
244
268
161
2:15
164
238
178
234
222
175
197
192
186
176
169
190
151
143
158
Central
Pncifio
217
257
226
235
230
145
194
212
195
150
172
189
160
154
Atlautio
269
258
132
260
276
263
143
168
Central
174
Pacifii*
144
265
214
253
160
230
201
172
171
Juii^3l), litK
199
232
149
227
246
166
ffi3
224
183
177
IRi
154
150
Centnil ....
144
Pacific
149
Total
215
233
232
219
177
147
V.
348
128
2:»
222
256
172
238
148
1,1..
153
138
140
113
151
137
1
3
:
2
^
=
X
:••
S
<:
184
167
206
253
261
294
205
194
141
203
195
245
181
180
149
236
240
210
146
152
169
158
165
160
162
113
1,-M
140
146
153
144
124
134
96
113
- — . t
123 I 123
169
142
164
141
179
159
142
154
136
168
138
136
176
183
149
137
141
lye
209
226
192
154
179
147
190
134
174
170
183
162
187 I
--I
239 ;
"iss'i
219 I
181
291
181
213
237
178
206
227
124
218
181
190
166
188
170
155
185
207 I
224
146
199 I
178
188
151
184
183
194
155
191
212
146
Table VIII.
Monthly ratio of cases of Sickness per 1,000 of mean strenf/th amowj the Colored Troops, by regions,
for the period from June SO, 1863, to June 30, 1S66.
1 »
Vkak KNidNi:—
REfilON.
iS
a
«
^
i
a
c
<
517
w
569
0
403
%
'A
294
S
>
<
y.
a:
<
s
1
1
>
1?
0 -
June 30. Ism
-Mhiiilic
292
fVntra!
4-M
441
410
430
3B8
342
333
:tOl
3lA
Ti'tul
:;j;
M ■
J.'il
422
361
333
309
283
328
■ n-
KT
341
Aihinrl.'
Jnoe30. ]8e.>
p
Cfntml . - -
Total
351
359
328
287
.'.>2
311
224
216
267 1
271
262
Juii»* 3(1 iHt;fi
Al!;.i,i;.-
i.".rt
231
264
asi
1 -
1
152
161
122
92
1.'.4
i 215
Central- ... -..
:ii 1
30U
298
282
2T5
2te
lei
.<«
158
137
141
145
.27
i-M
157
237
1 ="
Total
22
SICKNESS AND MORTALITY
Table IX.
Monthly ratio of Deaths from disease j^er J ,000 of mean strength among the White Troops, U. 8. Army,
by regions, for the period from June 30, 1861, to June 30, 1866.
Ykar ending—
Region.
<
i
§
O
>
o
-A
i
i
n
i
2
<
"-3
i
<
a.
I
X
<
<
><
<
o
P
a
§2
1.93
.97
1.33
2.04
2.82
.89
.1.78
3.49
1.26
2.01
4.55
1.21
2.66
6.20
1.60
3.23
6.58
1.00
2.90
8.84
.19
2.40
8.82
.41
2.52
10.24
.88
3.12
6.37
.49
2.85
7.18
.51
3.00
6.42
.77
2.67
6.76
.88
Total
1.49
2.15
2.21
2.82
3.79
4.2r
4.52
4.11
4.79
4.58
4.93
1.44
.5. 17
.70
4.61
1.65
4.79
1.03
4.11
a 47
7.07
.76
5.27
June 30. 1863
3.80
6.63
.72
.5.19
5.55
.55
4.06
5.36
.56
4.52
5.60
.79
4.76
7.48
1.02
4.69
8.00
.81
3.88
8.09
.49
3.08
9.67
1.02
2.74
9.35
.32
2.04
7.09
1.15
Centi-al .
Pacific
4.96
5.25
4. .58
5.01
6.09
6.21
5.93
6.39
6.11
4.76
3.52
3.56
a 45
6.67
.33
2.74
7.53
.65
2.63
5.84
.63
3.02
4.18
.94
2.51
4.06
1.00
2.46
a50
1.28
3.03
3.94
1.25
2.63
4. 25
1.28
a 51
5.51
1.01
2.95
4.98
1.08
1.87
3.92
.71
2.93
4.41
.81
2.73
4.87
.93
Central
Pacific
Total
4.97
5.60
4.51
3.71
3.44
3.10
3.58
3.61
4.71
4.13
3.12
3.82
4.02
5.54
G.8S
.65
6.75
6. 10
.65
5.16
6.05
.53
5.76
5.35
1.08
3.87
3.96
.58
4.90
4.41
1.41
3.80
5.00
.88
3.51
4.75
1.30
4.38
5.89
1.11
3.33
.5. 04
1.63
3.08
3.48
1.17
3.95
3.28
.91
4.44
5.06
.99
Ceutral
Pacific .".
Total
6.17
6.25
5 58
5.46
3.86
4.57
4.41
4.11
5.11
4.15
a 24
1.05
1.06
.77
3.53
4.71
a 52
4.01
1.13
JuneaO, 1866
Atlflntir
5.06
5.07
.98
3.62
4.72
.99
4.26
5.42
1.39
4.42
4.46
1.09
3.05
3.44
1.98
1.84
2.66
1.49
1.24
1.79
.93
1.06
1.38
1.11
1.84
1.66
.83
1.14
1.31
.95
.90
.82
.70
Pacific
Total
4.92
4.10
4.62
4.07
3.07
a. 15
1.43
1.22
1.54
1.19
.99
.82
a 51
T.-VELE X.
Monthly ratio of Deaths from sickness per 1,000 of mean strength among the Colored Troops, by regions,
for the period from June 30, 1803, to June 30, 1866.
Year ending—
Region.
"-a
H
QQ
-<
s
t
w
O
S
>
O
<
•A
i-s
a:
b;
X
<
S
X
<
a
< «
¥
6.90
22.44
2.22
29.19
4.58
31. 40
7.40
31.02
7.08
32.63
4,48
16.84
7.31
15.40
7. .54
18.48
9.03
20.24
9.41
22. 16
6. 33
25.52
5.77
21.38
5.77
20. 75
Central
Total .
24.15
25.31
7.38
18.50
14.79
24.91
8.89
16. 87
14.14
8.59
7. (Ill
25.06
8.62
ia'39
ia22
iai2
15.09
16.41
18.07
19.25
16.54
15.40
17.60
Jiine:tO, 18H5
8.60
20. 7U
16.71
6.67
10. 01
6.76
10.93
9.08
15.24
11.73
12.14
10.35
12. 11
11.45
7.45
8.07
8.36
10.33
11.23
10.70
13.31
9.01
10.04
9.23
12.99
11.66
8.30
7.72
7.82
Total
11.63
12. 09
7. 9l»
8.81
9.33
5.18
7.26
b. 96
12.77
8. 16
6.74
6.91
11.99
6.73
6.62
9.55
4.64
7.57
10.89
Atlantic
11.11
!i. r.ii
7.24
7.15
11. II-..'
4.21
a 00
2.91
a 51
Total
...-,
"■"'
6.63
7.97
6.99
a 18
a 41
AMONG THE U. S. FORCES. 23
The largest monthly ratio of cases among the white troops occurred in August, 1S61,
shortly after the enlargement of the army to meet the military necessities of the time.
This ratio amounted to 364 cases per thousand of strength. The exposures, fatigues, altered
diet and other changes in the conditions afl'ecting the men incident to their new mode of
life as soldiers, coincided at this time with the period of greatest annual prevalence of
malarial disease, and the large amount of sickness indicated by this ratio was the result.
A reference to the diagram showing the prevalence of diarrhoea and dysentery* will mani-
fest the great influence that this class of camp diseases exercised on the general sick rate of
the array at this time. Their extensive prevalence in the Atlantic and Central regions, in
which most of the troops were massed, contributed much to the height of the general sick
wave as shown' on the diagram under present consideration, or more especially on Table
VII, which it illustrates.
The irregular prominence of the line in April, July and October, 1862, appears due
to excess of diarrhoeal cases, — in the Central region during the first-mentioned month, and in
the Atlantic region during the others. As diarrhoea, dysentery and the malarial fevers
occasioned more than one-half of all the cases of disease, 507 of every thousand cases^ that
were reported from the white commands, the concurrence of their periods of maximum
prevalence gives prominence in the autumnal months of subsequent years to the line
indicating the prevalence of disease in general. But in none of these years did the
monthly ratio at all app>roach the height reached during the autumn of the year 1861 : thus
the highest ratio recorded in 1862 was that of July, 279, while August, in the three follow-
ing years, gave the highest monthly rates, respectively 256, 265 and 233 per thousand of
strength.
The minimum as well as the maximum of prevalence in the year ending June 30,
1862, was higher than in the subsequent years. This is attributable mainly to the
frequency of diseases of the respiratory organs and to diarrhoeas, which continued to affect
tlie troops in the Central region, and but little to the malarial influence which in this year,
as will be seen hereafter.^ was at its minimum. The minima of the several years were as
follows: 195 in March of 1862, 179 in May of 1863, and 137, 144 and 123 respectively
in February of the three following years.
Speaking generally, the amount of sickness among the white troops was much less in
the last year than in the first, the average monthly rate of the latter, 249, being greater
than the highest monthly rate of the former, 233 per thousand. A glance at the diagram
will, however, show these variations in the level of the rates more satisfactorily than a
lengthened description. It may be added that the narrow red line, the subject of the fore-
going remarks, corresponds closely in its course with that indicating the prevalence of
disease among the white troops in the Atlantic region. The rates of the Central region,
when plotted diagrammatically, give a line which runs parallel to the red line but on a
somewhat hicrher level. The rates of the Pacific region, wlien delineated in this manner,
occupy a lower level, and fail to manifest in their irregularities the existence of the marked
autumnal elevations which form so striking a feature of the lines for the other regions.
The mortality from all diseases among the wliito troops, represented on the diagram
by the thicker red line, increased from a low rate during the first month to its maximum,
6.39, in February, 1863. After this it fell during March and April to 3.5 in May and
- - _ — . _ _
* Facing pa*fe 22 of the Second Part of this work. t See Table II, supra. X See diagram facing page 90, infra.
24 SICKNESS AND MORTALITY.
June. The line is very irregular in the remainder of its course; but in each of the subse-
quent years there may be distinguished a large autumnal and a smaller spring elevation,
the latter usually occurring during the month of March. Tlie plate facing page 20 affords
a satisfactory explanation of most of these irregularities in the level of the mortality line.
The sudden rise in the rate during the autumn of 1861 was due almost wholly to typhoid
fever, but in November and December of that year and January, 1862, pneumonia and the
eruptive fe\-ers aided considerably in its elevation. The mortality from typhoid fever
continued to augment and uphold the general death rate, although the former allies of this
disease declined in virulence as the spring advanced. Meanwhile diarrhoea, and a little
later the malarial fevers, began to contribute materially to the rate. During the period
from November, 1862, to March, 1863, when the monthly death rate amounted to about 6
per thousand of strength, all the diseases delineated formed notable percentages of the total.
In the subsequent years the autumnal increase corresponded with larger rates from diarrhoea,
typhoid and malarial fevers, while the smaller prominences in the spring months were
caused by a maximum rate among the pneumonic cases and eruptive fevers, with a large
minimum rate among the diarrhoeal diseases and typhoid fever.
But to return to the diagram on the opposite page: The sick rate of the colored troops,
indicated by the thin yellow line, was highest immediately after their enrollment in 1863,
when nearly one-half of the command was reported as having been taken sick during each
of the months July, August and September. Autumnal exacerbations were encountered
dui'ing each of the subsequent years; but on the whole the health of these troops improved
so remarkably that during the last quarter of the year ending June 30, 1866, tlieir sick
rates were somewhat lower than those of the white troops.
Their death rates, indicated b}^ the heavier yellow line, followed a generallv parallel
course — high at first, about 25 per thousand of strength monthlv during the first four munths
of service, and afterwards declining to the minimum of 3.18 per thousand in Mav, 1866;
but at no period of their service did the death rate of these troops fall Itrdow that of the
white commands.
Discharges on account of disability froji disease. — The sick and mortality rates
by no means express the whole of the loss to the armv occasioned, by disease. Large
numbers of men were discharged as unfit for military service on account of disease that in
a majority of instances originated in the line of duty.
The records of the Adjutant General's Office are understood to embrace certificates of
disabilitv on which 275,738 white soldiers of the regular and volunteer armv were dis-
charged, but the Surgeon General's Office has reports of only 215,312 sflch cases. Of these.
48,374 were based on wounds, accidents and injuries; 4,439 on deformities, immaturity
and senility, disabilities which existed prior to enlistment; and 25,915 on causes that were
not specified. Dropping these, there remain 136,584 certificates in which the disease is
stated. But if the cases in which the disease was not stated and those reported to the
Adjutant General, but not to the Surgeon General of the Army, were distributed pro rata
among the discharges occasioned by wounds, by conditions which should have prevented
enlistment, and by disease, the number referred to the last cause would be increased to
198,849, equal to an annual loss of 82.2 men in every thousand of sti-ength.
Tlie files of the Adjutant Generals Office include certificates pertaining to 9,807
colored men, while those in the Surgeon General's Oflice number only 8,223; and of these
s
iiile
AMONG THK U. S. FORCES. 25
1,479 are based on wounrls, 687 on causes which should have rejected the recruit, and
1,226 on unspecified causes. Dropping these, there remain 4,831 certificates iu which the
disease is specified. But if these figures were treatcil as in tlie case of the white troops,
the number of discharges due to disease would be augmented to 6,771. erpud to an annual
h)ss of 35.3 men in every thousand of strength.
These heavy losses were not wholly due to the diseases incident to military service.
Many of the disabilities existed prior to enlistment; for instance, not all of the men dis-
charged for consumption contracted the disease in the service, nor did all of those discharged
for hernia become ruptured in the performance of military duty. Ignorance, carelessness
and intentional iVaud at the recruiting depots were at first responsible for the enrollment
of this worse than valueless material; afterwards liberal bounties induced men to conceal
infirmities in order to secure acceptance. In garrison or winter quarters their disabilities
were in many instances not manifested; but when exposed to the hardships of a campaign
they swelled the sick list, crowded the hospitals, andvvere eventually discharged. L)r.
Tripi.er reported that of 3,939 discharges for disability from the Army of the Potomac
during the last quarter of the year 1861, 2,881 were for disabilities tliat existed at the
time the men were enlisted.* . Medical officers serving in the field had their duties
materially increased by the presence of cases of this character. Some adverted to the fact
apparently to explain the large number of discharges reported from their commands; others
entered a vigorous protest against the gross negligence of the recruiting authorities. A few
extracts are herewith submitted, and as these are by no means exceptional cases, it will I
appreciated that a considerable percentage of the disabilities were not fairlv attribut
to the service of the soldier :
I con.sidpi- the careful iiispeetiou of the voluuteers before acceptance a matter of the greatest importance.
The great uuniUer of discharges for disqualifying defects among the three-months men that have come under my own
notice, convinces me either that the men were not inspected at all, or else that the duty must have been performed
by inexperienced ofiicers. The incumbrance and dead weight of the men of this description with our columns has
been a serious and con.stantly accumulating impediment to its motions. — Surgi'on Chaules S. Triplek, U. S. Armti,
Mi (lira} Dhictoi; Department of Pennsijlruniu, Charhstown, T'a., Jul;) 18, 18GI.
The number of men discharged from service within the last month or two is very large, owing chiefly to the
fact that a great many were .sent here without undergoing a proper physi<'al exaniinatiim al the time of their enlist-
ment. For example, some thirty or forty cases of hernia have lieen sent away, and in ahuost every instance the
disability existed previous to enlistment. I observe, al.so, that a large number of boys may be found among llie
troops who are [diysiially incajiable of enduring the hardships of a soldier's life in tlie fii-ld. — S'kiv/toh .1. M.Crvi.EH,
r. S. Army, Medical llireclor, Portress Monroe, 1'a., August 3, 1861.
In regard to the condition of the companies, they are, with one or two e.v.ic pliuns, conii)osed chielly of men
who hold respectable positions at home as farmers, nu>chanic.s, &c., and who possess some degree of pride concerning
cleanliness and )ir(ii)er behavior. It is to be regretted, however, that in the haste of preparation and departure,
i|uite a number were enlisted whose physical conilition was such that they ought to have lieen rejected. A large
pri>)iortion were examined in the country towns by ]diysicians not regularly ap])oiuted, and .some were not examined
at all. This may liel]) to account for the fact that, while the number of sick in the hospital is not very great, the
list of those in quarters is larger than it should be, — Axuixlnnl .Surgeon J. Foster II.wex, .jr., i'. .S". I'uh., Camp
l-ml.r, roolesrillr. Mil., September 'SO, 1801.
The 28th Pennsylvania ^■olunteers, numbering ten companies, left Philadeliihia July 26, 18til, with orders to
proceed to Harper's Ferry. They had never been regularly examined by .1 surgeon, and a number of disea.sed men
had been enrolled. These have constantly nuide the sick list larger than it otherwise would have been. Eleven
of these men have been discharged, and certificates of disability made out for fifteen others. — Surgeon H. F.ahnest
(iKoi.MAX, 28(/i Pa. 1'oh., Xorrniber 14,18G1.
I joined the regiment after it was mustered into service and found over one hundred enlisted men that should
have been rejected by the Meilical Inspector before their enlistment. As a cousei|Uenre of this I have been com-
pelled to recommend a large number of nu-n for discharge on certificate of disability. There yet remain a few cases
that I doubt not before long will be decided unfit for the duties of a soldier. — Surgeon \Vm. K. Thkai.i., 27(/( Ohio
Foh., December 31, 1861.
* See patfe 47. Ai>i>eii<lix Iu the First Fart of tliis work.
Mei>. Hist. Pt. Ill— 1
2g SICKNESS AND MORTALITY
A. BRADLEY, jr., U. S. A., Cami> Dupoul, Va., December 31, 1861.
''n";r!rofirst ™"2n;:;rr:»^^ ...» .... or . *..». .—.■«... «■«' <-• •-
require no formal expression. ,„ti,oritie8 of vour State be iuvite.l to tl.is matter, aavising that
„e.ic^^^i:S^t t::::^TTZ:'^^X:rZ a .««. in t.e ...ce o. tUe meaiea. o.cer ot the
^^^"^:;z.i";:rr:::r;:c;^I'itS-ionof tueei,utrec^^^^^ .
Z^ e ana tistnia in ano of Ion. etan.in.. . -^f ---^-tl ' es'a "^ .tS Zt^
.ernia!- 5. Mo.^meut of right ^<>^^- l^^^'^^'^l^Z ^T^: ^^^^^^^n^''^^^^^^
siae. 6. Total blinaness of right eye ^-^^^^fj^^Zi general configuratiou iauperfeet. To ,he«. are aaaea
8. Syphilis ana pulmonary trouble; chest baa Ij f"™^';"'' ^'°^^,_^^i„„ ^ 1. Louis Loeb, the butcher, who
the iL nu-n aisapprovea, but retainea tor the ^^^^ ^^^^^^^^^, f,ou. au oUl ana severe injury of the
is too fat ana heavy for a Soulier; 1^- *-* -<\' f;/;^;"*^^^ f " "^"Lt motion of the left elbow, resulting frou. a
2^:;^Uu!:-"rs:^irn:tse^^^^
commanding 1st BrUjadc Xno Jersey Vols., near Alexan,h;u, T a.
of every IhoBswul discharges for disease. Typhoid a„d mala, al 1, ^« •'■''*■■ £^.u,^^(^j
„„, i.^; fo» d-scbarges; Urt ,l,e disaU.Uy „. a ^^^ ^^;,:'J^j^'X^«.
aad the 2,224 dropsical me,, was „u doubt due to tl,e»o u.mb.ho iS*"""-
heart d,sease.d,ich together caused scarcely o,,e deatl, 1- —^ ^ f ™= '.
auuually, coutributed largely ,„ dimm.shiug J" *;'-^,^- It ^i^^uut of
having constituted 8b. 2 and the lattei ,i.^oie\eiy
o
disease
^e relations between death and discharge, as the result of disease, n.ay be ascer-
ihe lelations De w eonnection with that now under consid-
tained by an examination ot tables li and lii ui co
.ration. The white troops lost, annually by death Irom disease 5..4S, ^1- -'-- P
143.4 in every thousand men; but these rates, while correctly expressing the tacts ot
AMONG THR V. S. FORCES.
Table XL
27
Discharges for Disabiliiy from Disease in the United States Arm i/ from May i, ISGI^io June. 30, 1860^
with ratio per IfiOO of mean strength in Field, Gaii^lson, and General Hospitals , ratio per J flOO
of total discharges and niean annual ratio per 1,000 of sirengUu
Specifietl diseases ouly . .
Typhoid Fever
Mularial Fevers
Diarrbuea and Dysentery
Eruptive Fevers
Debility
Syphilis
Rheumatism
Drtii»S3'
CuDSumptiou .
Scrofula
Epilepsy
Instioity
Piimlysis
Ophthalmia
Deafness
Heart disea^se
Varicose Veins
Varicocele
Asthma .,
Bruiichitis
Intlainmatiiiii ut' Lungs . . .
Inrtummatiou uf Pleura. . .
Hsemorrhage from Lung's
Hernia
TnHammation of Liver
Pil.-s
InOammation of Kidneys .
Anehyli'sis
Diseases of Spine
White Titoors.
198, 849
336, 584
2«),
8 = 2
8t
991.7
1.9
1.8
:!7. 1
.9
:ti.o
.1.8
Sf). 1
4.7
4:i.fi
i.n
C.3
1.7
(i. 1
;i. 1
SJ. 7
4.2
3.0
a.fi
8.0
2.3
1. I
1.3
19.9
a. 9
3.3
2.3
3.9
3. '.'.
■I I
B.7
fi.2
127.3
3.1
10i;.2
l:t.o
8C.2
1C.3
149.4
6.fi
28.3
CO
20.8
10.7
8.5
77.9
14.4
10.2
8.9
27.3
8.0
3.6
4.11
65.9
9.9
11.4
7.8
13. .-.
82.2
0OI.ORK11
TliOOl-S.
i
g§
ii,
•o
fM
It
s °
5-s'i-
■~S
-% ?
= s.
•5 QJ
C!«-=
.= £■3
is
s
'A
0,771
IS
K
1 . HOO. 0
10.1. 9
4,831
. 'C
.35
7.19
.18
5.99
.74
4.87
.92
8.43
.37
1.60
.34
1.17
.60
.48
4. 4U
..'1
.57
.50
1.54
.45
.20
.26
3.72
.56
. >il
.44
.■;fi
In
30
.5
3.59
3
:•. 6
540
8.4
86
1.3
874
13.7
109
1.7
592
9.3
147
2.3
174
IJ.7
34
.5
69
1. 1
25
.4
3H
.6
u;i
2.5
69
I. 1
25
.4
42
.7
96
1.5
25
.4
18
.3
4
.1
:i58
.5.6
29
.4
1,1
27
105
;u
46 I
.4
1.6
.5
.7
l>. 2
74.3
.G
111.8
17.8
1KU.9
22.6
122.5
30.4
:i6. 1)
7.0
14.3
5.2
7.9
33. 3
14.3
5.2
8.7
19.9
5.2
3.7
74. 1
6.0
8.9
.5.6
21.7
6.4
. 05
.16
1.87
.02
2.82
.45
4. .50
..57
3. 09
.91
.18
.36
.13
.20
.84
.36
.13
.50
.13
.09
.112
1.87
.13
.22
.14
.55
.16
-•,'4
official records, do not convey with accuracy tlie relations of death to disease. In view of
I he iuniil)er of men discharged for diarrhoea and dysentery it is evident that the mortality
rates for these intestinal affections would have been greatly increased had the undoubtedly
Z8 SICKNESS AND MORTALITY AMONG THE V. S. FORCES.
serious cases that led to tlie issue of these certificates been followed up to their termination.
In view also of the disjiroportiou between the discharges from the white and the colored
commands, the mortality from disease, as above expressed, requires modification. Among
the former 82.2, among the latter only 35.3 men were discharged annually from everv
thousand present. No doubt many of these went liome to die. If it be assumed that
more deaths occurred among tlie 82.2 discharged'white men than among the 35.3 colored
men, the difference between the mortality rates of the two will be lessened. But even if
the whole number of cases in each instance died ultimately of the disease which occasioned
the disability, the greater mortality among the colored troops would still be evident, for the
sum of the deaths and discharges among them numbers 178.7 annually per thousand of
strength as against 135.68 among the white troops.
The infrequency of discharge among the colored troops may be attributed chiefly to
their jieculiar condition at that disturbed period of their history, and to the more rapidly
fatal course Avliich disease certainly ran when these men became its subjects. While 7.19
whites were annually discharged on account of diarrhoea and dysentery, 5.99 on account of
debility and 8.43 on account of consumption from every thousand- men, in the hoj^e that
the change of climate, scene and surroundings consequent on a return to their northern
homes Avould tend to prolong existence, the corresponding figures for the colored troops
were onlv 1.87, 2.82 and 3.09. The cases represented by the difference between these
figures were retained in hospital until the occurrence of ths fatal event, in some instances
because of the imminence of that event, in others because of the homeless condition of the
colored soldier.
Transfers to the veteran reserve corps. — The list of men discharged for disa-
bility would liave been considerably larger but for the establishment of thi^ Veteran
Reserve Corps. This command absorbed a large number of men who would otherwise
have been discharged. From certain tables appended to a report of Surgeon J. H. Baxter,
U. S. Volunteers, Chief Medical Officer, Provost Marshal General's Bureau, dated April
28, 18G4, it is found that among officers the principal disabling cause was wounds received
ill Ijattle. Of 636 officers transferred, 426, or two-thirds of the whole number, were the
subjects of gunshot wounds which prevented their participation in active or field service.
Among the enlisted men, however, disablement by disease was more extensive than by
wounds. Of a total of 25,031 transferred in 1863, 6,067, or 242.3 per thousand, were
occasioned bv gunshot wounds, and 2,037, or 81.4 per thousand, by injuries mainly also,
perhaps, caused by gunshot. Deducting these cases from the total it is found that 16,927
were transferred on account of disease. Chronic diarrhoea and general debility were thf
chief causes of disablement in these cases, the former havina; occasioned the transfer of
2,292 men, or 135.4 per thousand of the total from disease, and the latter 1,916, or.115.0
per tliousand. Consumption, whicli figured so largely in discharges, was found iii (Hil^y
217 of the transfers, or in 12.8 per thousand of those for disease. But disease ol' the
heart, rlieumatism and hernia contributed as largely to the constitution of tlie Tn\'alid
Corps as to the list of discharges. Heart disease occasioned 1,735 transfers, or 102.5 per
thousand of the total from disease, rheumatism 1,363, and lumbago 427, a total of 1,790
cases, or 105.7 per thousand, and hernia 1,017, or 60.1 per thousand.
I .1
29
n.— MEDICAL STATISTICS OF THE CONFEDEUATE ARMIES.
The sources ot" the Httlo inloriiiatinii we posisess coiK-crning the i>rev:ilence and fatuhty
of disease in the Confederate armies have ah-eady been noted in connection witli the subject
of diarrhoea and dysentery.* They consist of the monthly returns of sick and wounded of
tlie Army of the I'otomac for the nine montlis from July, 1861, to ^larch, 1862, the re]>orts
of certain general hosjiitals in Virginia for the four months, September to December, 1862,
the original registers of the Chimborazo Hospitiil, Richmond, Va., extending from October
17, 1861, to March 31, 1865, and the figures published l)y Pr. JosKPH Jones, of New
Orleans, La., as compiled from the records of the Surgeon General of the Confederate
States Army.
The Returns of the Army of the Potomac give 151,237 as the nmnlier taken sick
and wounded during the nine months in an average strength of 49,394 men. The cases
of sickness numbered 148,149, equivalent to three entries per man, 3,019 per thousand,
during the nine months, or to four entries per man, 4,025 per thousand, for the year. The
United States Army of the Potomac during the same nine months had 2,136 cases per
thousand of strength, equivalent to an annual rate of 2,848 cases. The deaths on the
Confederate returns number 2,016, but they arc given only as the total number that
occurred among the sick and wounded; their distribution among the specified diseases and
wounds is not known.
The hospital reports shovu 48,544 admissions, of which 34,890 were for specified
diseases; but the deaths, 1,899, are not distributed.
The registers of the Cliimborazo Hospital, Richmond, Va.,t which have been carefully
examined and freed from duplication of cases originating in transfers from ward to ward,
show a total of 77,889 admissions; 14,661 of these are recorded under the headings of
Class V of the U. S. sick reports, comprising wounds, accidents and injuries, 12,057 have
no entry in the column of diagnosis, 50 are reported as malingerers and 771 as conva-
lescents, without specification of the disease or injury. There remain 50,350 cases of
specified sickness, but the result in 26,501 of these cases is unknown, as 14,464 were
transferred to other hospitals, 5,537 were furloughed, while in 6,500 no disposition is
recorded. Of tlie cases with known results, 23,849 in number, 19,457 were returned to
duty, and to these may be added 998 terminated by desertion; 2,717 died and 677 were
discharged. The mortality was therefore 11.39 per cent., equivalent to one death in every
8.8 terminated cases. An abstract of the cases in this hospital is given on the following
[.age.
Some interesting data bearing on the mortality of disease in general, and of some
specified diseases, may be gathered from the various publications of Dr. Joseph Jones. J
* PaR^afi, Part .Second of this work.
t Rrfi'rence was made in a foot-note on pape 28 of the .Second Part of this work lo a partial statement of tlie statistics of ttiis hospital liy r»r.
J(»Krn JONty {Richmond and Louisville Mai. Jour., June, 1870. p. (i50), and reiustms were assigned for preferring to tliein tlie more complete statistics
oimpiled from the ho.spital registers. Another |>artial statement of the statistics of this hospital w:is published by .S. K. IIabkI{8HA.^I— Ob.^. on Vie
statistic* of Chimborazo Hospital, with remarks upon the treatment of rarioii.-; diseases during the recent ciril war. — Xashcille Jour, of Med. and
Surg., N. .S., Vol. I. l&W,, p, 41t> — but Dr. H.\uei!Sfl.\.M's tabic covers only the periiKl from Octolier. 18t;l. to November. 186;J. while the registers include
the facts np to March 31. 186.'>. The former foots up only 3G.8-1T admissions for all diseases, with 2.96:1 deaths, while the latter give 77,889 ea.M-s and
3.'.M4 deaths.
t JONKS — Obserrations on the losses of the Confederate armies from ttattU, tC-c. — Richmond and Louisville Med. Jour., Oct*>ber and N'oveiiiber,
1869, and March and June. 1870. Essay on tlie prevalence of Pneumonia and Typhoid Fever in the Con feAerate. forces, and on The diseases of the Federal
prisoners confined at Andersonville, published iu the Medical Volmne of the Memoirs of the United States Sanitary Commission, New Vork, 18(i7. Flteu-
mania in the Confederate Army, in Vol. I of bis Medical and Suryical Memoirs, New (Orleans, 1876.
30
SICKNESS AND MORTALITY
Table XII.
All Abstract of the cases of Specified Diseases, with recorded terminations, and of the Deaths among such
cases at the Chimborazo Hospital, Richmond, Va.
Specified Diseases.
Cos
= ? «
■Si %
go c3
■= s-a
Conlinneri Fevers
Malarial Fevers
Eruptive Fevers
Diarrhiea and Dysentery.
Debility and Anemia
Consumption
Rheumatism
Scurvy
Bronchitis and Catarrh
rneurnonia and Pleurisy. .
Otlier specified di.seases. ..
2,15a
1,988
760
4,644
5,780
189
1,!)84
119
1,099
1,568
3,565
885
125
166
455
117
52
80
8
89
583
157
41.11
6.29
21.84
9.80
2.02
27.51
4.03
0.72
8.10
37.18
4.40
325.7
46.0
61.1
167.5
43.1
19.1
29.4
2.9
32.8
214.6
OT.8
Total specified diseases 23,849
11.39
1,000
He states tliat the reports of sick and wounded filed in the Office of the Surgeon General
of the C. S. A., exclusive of those from the Trans-Mississippi department, gave the follow-
ing figures up to December 31, 1862:
On Field Eeturss.
On hospital Reports.
Total
Deaths.
Cases.
Deaths.
Cases.
Deaths.
848, .555
29,569
16,220
1,623
441, 689
47,724
19,359
2,618
35, 579
4,341
Gunshot wounds
818, 986
14,597
393,965
16,741
31,:a8
Dr. Jones has, however, pointed out that, on account of the repeated transfers of
patients from one ho.^pital to another, the number of cases shown by the hospital reports
as admitted for treatment bears no ascertainable relation to the actual number of patients
admitted from the field. This will readily be acknowledged, in view of the fact that
while a total of only 108,068 cases were sent from the field to general hospitals, no less
than 441,689 cases were reported as admitted on the hospital registers.
But since the system of reports in the Confederate army was similar to that employed
in our own service, and since the hospital cases in both services were derived from'" similar
sources, consisting of those from the field, those originating in the liospital population, and
an indefinite number from men and commands on detached or special duties, the number
of cases borne on the field reports of each service may be compared with the corresponding
number of deaths in field and hospital, with the view of contrasting the relative mortality
from disease in the two armies. In accordance with Dr. Jones' figures, 31,338* deaths in
* These numbers should probably be 31,238 and 819,286; see the totals in Table XIII of th"! text. Dr. JONES' statistics are full of inaccnracies,
the result apparently of careless preparation and proof-reading.
AMONG THE CONFEDERATE TROOPS.
51
s coiislifiitini; 2 Der
field and hospital corresponded with 818,986 cases oi' disease and injury other than gunshot
wounds. The deaths constituted 3.82 per cent, of the cases, or in other words, were to the
cases as 1 : 26. In recasting our statistics''" to coni'onn to the classification addph.'d liy i)r.
JoNKS in his statenient tabulated above, it is i'ound that from the coniiuencenuMil ni the
war to December 31, 1862, the total number taken on siek rejiort for all causes except
giuishot wounds was 1,709,416 cases, of which 31,326 died, llie death.'
cent, of the cases, or being to them in the proportion of 1 : 50.
The following table contrasts the ratios calculated from J)r. Jones' figures with those
obtained from the statistics of our army for the same jieriod:
Table XIII.
A Comparison of ihe Prevalence and FataUty of Dheasc in the Opposinr/ Armies from the Commencemetit
of the War to December .?/, /Sf]?.
Continued Fevers
Malarial Fevers
Eruptive Fevere
Diarrhcea and Dysentery
Pulmonary affections . ..
Rheumatism
All other diseases
Total diseases and injuries exclusive only of gun-
shot wounds.
Confederate Fohckb.
36,746
115,415
44,438
226,888
42,204
29,334
324, 321
819,286
12,225
1,333
2,274
3,354
7,972
4,080
■5 -'■■a
45
141
.M
277
51
36
396
1,000
eg
391
43
73
107
255
131
1,000
ft
33.27
1.15
5.12
1.48
18.89
U. S. FOKCES.
3.81
51,923
274,053
38,888
482, 764
196, 567
88, 475
.Wfi, 746
, 7ii'i, III
11, .571
2, 603
2,050
6,040
4, 607
122
7,333
34,326
.So ■
30
160
23
283
115
52
337
1,000
337
76
00
176
131
3
214
1,000
22.88
.95
5.27
1. 2.i
2.34
.14
1.32
2.01
It is greatly to be regretted that Dr. Jones has not published the mean strength for
the period corresponding to his sick reports. He has given, it is true, the mean strength
represented by the field reports of the Confederate Army for each month of 1862 and for
the first six months of 1863,f but as no mean strength for 1861 is tabulated, and as there
is no way of ascertaining what portion of the figures given in his text belongs to that year
and what portion to 1862, it is impossible to compute trustworthy ratios of cases to strength
for either year.J Nevertheless, by making use of the sick report of the Confederate Army
* Published in Tables III, XXIV and XLVII, Part First of this work. t Richmond and Louisville Medical Journal, Vol. VIII, 1869, p. 351.
; Nor can any assistance be obtained in this connection from an inlerestinp article published orif^iimlly in the Xcw York Tribune, and subsc«iuently
reprinted m Xhe Hislnrical Magazinr ' VusUrrolU of Ihe Confederate Army for WW, 18fi3aKrf 1864. The Uislnrical >laga:ine atid Notes ami Queries con-
cerning Ihe Aniiiittilies. llislo-, nnd Iliography of America. Morrisania, .New York, Vol. II, N. S.. 1867, page 1(13. Mr. llENIiY B. DAWSON, Iho editor ol
this magazine, invt'- ..n- attention of Ihe Surgeon General to the article cited, as likely to prove useful in eonneclion with the data collected by Dr. .JoNEb.
I"nf.— ,-iy ine statements in this lu-ticle referring to Ihe year 1861 are too fragmentary to be used in computing ratios. Indeed tliey could not be safely
so \ised were they as complete as the figures for 1862, contained in the same article. This will be readily understood on comparing the strengths reported
for 1862 with those given by Dr. JoNi:..;, Thus, the article in question contains a table jnirporting to give "approximately and in nnuid munbers Ihe
strength and disposition of the different t'onfederate armies at several irn]virtaTit periods during the war." Two of these periods fall withici Ihe year IMlia.
The first, for .July 2(1, 1862, does not include the Trans-Mississippi department, and gives the total strength of the "Armies of East and West" at 289,0011
pivsent, of whom 217.0(.)() are reported " ftir duty," Now the tat)le of Dr. JoNKti, referred to at the commencement of this note, which als<) does not include
Ihe Trans-Mississippi department, gives the " mean strength, officers and men," for July, 1862, at 79,999, The second period for which the total strength of
Ihe "Armies of East and West" are given in Ihe Ilislorical Magazine is Septemljer, 1862; this includes the Trans-Mississippi deparhnent. Deducting
the force reported for that department there still remains, according to the magazine article, a force of 228,000 present, of whom rj.'i.lXtU are reported for
duly. But Dr, Jo.VKS gives (he "mean sln-ngtli, officers and men, ' for September, 18(;2, at 12,5.408. Nor does this eiii>rmous rliscrepancy indicate any
unfailliliilness on the part of eitluT anihority. The magazine writer altemiited to give a correct notion of the whole Confedenite force ; Dr, JONES neccs.
sarily intended only to give Ihe actual mean sirenglh of that part of the Confederate force represented by the sick reports to which ho had access. Ratios
computed fnim Ihe eases and deallis derived from the latter, and the strengths derived from the former source, would understate the sickness and mortality
of the Confederate armies to an indefinite extent.
32
SICKNESS AND MORTALITY
of the Potomac, preserved by Dv Williams, and of certain figures puLlished by Dr. Jones,*
it is possible to calculate sick rates for a part of the Confederate forces during certain periods .
prior to July, 1863, the aggregate monthly strength represented being 123,257 men. In
Table XIV the information gathered concerning these forces is presented and calculated into
ratios pi'r thousand strength, wliirh an- placed for comparison in juxtaposition with the rates
furnished by the white troops of the United States Army during the year 1863.
Table XIV.
CdfiOi of Sickneas and Wounds reported from certain of the Confederate Armies during portions of the
years ISlJl. 1862 and lS6o, tvifh the strength present during the periods covered bij the statistics,
and the calculated annual rates per thoasand of strength, in ju.vtaposition ivith the correspjonding
rates of the United States Arrny for the year ending June 30, 1863_^.
X
6 ^n
» >*
oT
i-B
i S 1
S2S
is =
Srf
> ^
ll
<
^(?;
S2 ■
ss
s -
1-d-?
Sg
c jj.
S-x
g s
l«
.?§2
*s
^s
"cS '1
- <
li
s
til
lb
g<:2
««5
o
-a
li
a) COD
O - Q
cSbO
6
r
ho
S S =
« >* H
^ o '^
< ta
3 a K
'^ y- e*
<
Q
o
n
<:
<
<
9
19
19
12
10
Confeder-
ate Army.
U.S.
Army.
49, 394
25,732
6, 7.^2
40,282
15, 582
123, 257
15] , 237
157, 113
^
58, 453
226, 721
53, 198
646, 722
4,563
159 (o)
2,861
93
4,404
2,768
10, 197
«
10, 197
275
123('0
Malarial Kevers
16, 781
41, .536
13,940
36, 665
3,876
112, 788
796
460
Diarihcea and Dysentery
M, 572
'
987
T>-a{l)
Pneumonia
3,233
2,220
l,l(il-
6, 974
1,0.14
14, 622
103
34
734
231
445
373
135
43
1, 1158
821
211
101
2,683
971
19
7
17
10
Laryngitis ,
Phthisis .
315
1,312
19,455
184
1,428
18, 8ti2
191
408
3,500
902
8,')8
11, 575
85
514
5, 408
1,677
4,520
58,800
12
32
415'
9
30.
192
AtMite BnincIiitisaiHK'atarrh.incliuliiipcHsesiepinted as epidemic
373
251
1,953
176
111
1,189
855
290
4,732
235
36
1,518
1,639
688
9, 392
Ifi
7
90
16
6
76
Artite Rheumiitisni
2,047
854
.5, 195
1,0^0
1
9,136
87
76
(a) See the text tor the derivation i>f this rate.
(fc) To effect an allowable ennipiirisnn between the Union and Confederate fij^nres indicatinfj; pievalenee, this annual rate is based on
the Union .\rniy of the Votoinac for the nine nnmths, July, IStil, to March, 1862, inclusive.
The imperfection of the data here presented is obvious; only in the figure
Confederate Army of the Potomac are the cases of disease separated from those of
received in l.iattle. But as tlie gunshot casualties in tliis army during the nine
covered by the records do not fairly represent tlie frequency ot these injuries,
derived from them cannot with propriety be applied to tlie consolidated figures t
the reports i>f
s of the
wouinls
months
the rate
"rom the
*See pages 571-589 of the Medical Volume of the U. S. Sanitary Commission Memoirs, New York, 1867.
AJIONG THE CONFEDERATE TROOPS. 33
other departments. Fortunately, Dr. Jones has put on record figures which show the rela-
tion of gunshot wounds to cases ot" disease in the greater part of the Confederate forces
during the first year and a half of the war. The total number of cases of wounds and
tlisease reported hy him was 848,555, of gunshot wounds 29,569. These figures authorize
the statement that the tabulated annual rate of disease and wounds, 4,563 per thousand
strength, included about 159 injuries received in battle. The annual rate for disease alone
is thus seen to have been 4,404, which may be compared with the corresponding rate of
2,768 among the Union forces. Continued and malarial fevers, diarrhoea and dysentery,
bronchitis and pneumonia, were apparently the chief causes of the increased rate among
the southern troops. An expression of the mortality rate per thousand of strength cannot
be directly obtained from the data presented. But since the sick rate has been found to
number 1,404 cases annually [ler thousand of .strength, while the fatality rate was 3.8 per
cent., the annual munber ol deaths per thou.'-and strength must luwe been 167.3, a rate
larger even than the average annual mortality among oui- coloi-ed ti'oops. I'^xception may
be taken to this calculation as the sick and fatality rates used are derived from different
sources, but it serves to indicate in a general way the greater relative mortality among the
smaller number of combatants on the southern side.
In brief, so far as coiujiarison can be made with the statistics at command, disease was
nut only more fatal among the Confederate forces, but the number of cases, in proportion
to the strength present was considerably greater among them than among the United States
t roops.
in.— PREVALENCE AND MORTALITY OF DISEASE AMONG THE ONION TROOPS IN
CONFEDERATE PRISONS.
The fragmentary character of the evidence relating to the diseases of the Federal
lirisdner^ in the hands <•{' the Confederates has already been indicated.* The statistics at
command are derived from the original registers of the hospitals attached to the Anderson-
ville and Danville prisons and certain tables prepared by Dr. Joseph Jones from official
records, and publislu'd in ins article nn the diseases o[' the Andersonville prisoners."}" The
records ol' the Atljulaiil (Teneral's ( )fliee, U. S. Army, according to a communication from
that office dat.ed June 22, 187i^, includi' the: cases of 30,564 Federal soldiers who died
whili.' prisoners o( war.
The Andersonville register. e.Ktending from February 21, 18()4, to April 17, 1865,
inclusive, shows the number uf admissions tVom the stockaded prison to have been 17,875,
but as 45cS ot these are re[iorted as having been cases of wounds and injuries, and 1,430
have iiu diagnosis entered against their names, the cases of specified diseases number only
15.'.)>S/. The result in V)46 of these cases is not recorded, so that the number of cases of
specified disease that may be traced to their termination is reduced to 15,(141. Of these
1 1.(1S6 died, or 73.7 per cent, of the whole number. This enormous mortality is an index
*.See jWMje 31. .Seoniid Part of this wcik.
i Ther^ are also in the Otlii;o of the Adjutant Gnneral a list of ] 4"..* deaths that oi-eiiri-ed amuii^ j«irk and woun'Ied prisonerB at Cahawba, Ala., atid ttvo
hospital rejriKtei^;, one from Hospital Xo. 13, and the other from ji ward of Hospital No. "21, Kiehtnond. \'a. But Wwsp. registers are valueless for statistical
puriHtses, as so many of the i^iitients received were speedily sent elsewhere; and in the ease of the register of Hospital No. 21, the disjtoshion of so many
of the eases is unrecorded. The register of Hospital No. 13 extends fnnu June 2, 1863, to February 14, ISti-l. and contains a record of tiS.") admissions
disposed of by tninsfer in tii] eases, by death in (i7, and by desertion, etc., in 7 cases. The register of Hospital ','1 extends from November, 1663, to
F*ebniarj-. 18fi.'i. f>f 1,3."»8 admissions it is not stated what became of the patients in jt»8 instances: 23(1 were transferred, 2i6 paroled. 173 retunied to
•lUarten* and 3 detailetl ; one is siiid to have ewaped and 217 to have died.
Mf.p. Hi.st. I't. III—.-.
34
SICKNESS AND MORTALITY
of the condition to which tlie unfortunate men became reduced before they were admitted
to this so called hospital. The professional mind is shocked in endeavoring to realize the
scenes presented in an establishment the wards of which formed the ])ortals of the grave to
three out of every four soldiers who had the misfortune to enter them. Indeed, it appears
that large numbers died uncared for in the prison and were removed to hospital simply for
record and interment. Sometimes the deaths in the prison outnumbered those in the hos-
pital. The reports for the week ending September 20, 1864, show the occurrence of 336
deaths in the former and 334 in the latter establishment. At this particular time one-half
of the fatal cases were already terminated when taken up on the hospital register. The
average number of deaths that occurred daily during the occupation of the depot was
thirty; but as many as a hundred deaths were recorded in a single day. Certainly the
most fatal field of the war was that enclosed within the stockade at Andersonville, Georgia.
Ratios calculated from the hospital register have a melancholy interest as indicating
the manner in which these men were cut down in the flower of their manhood. They
have no bearing on the fatality of the specified diseases as the number of those sick within
the stockade is not known; but the information yielded concerning the relative prevalence
of certain grave diseases is as definite as if complete records of the sickness were at com-
mand. The accompanying table gives a summary of the facts gathered from the register:
Table XV.
Summarizing the Records of the Hospital at' Camp Sumter, Andersonville, Georgia.
All diseases and injuries.
Wounds and injuries .
Not specified
Specified diseases .
Continued Fevers
Malarial Fevers
Eruptive Fevers
Diarrliwa and Dysentery .
Dobility
Dropsy
Consumption
Khenmatism
Scurvy
BronchHis
Pneumonia and Pleurisy .
Other diseases
Total specified diseases 15, 987
458
1,430
15, 987
883
254
lli4
', 35-1
333
498
35
202
i, 6fia
205
.553
446
47
8
941!
376
3i;
19
30
377
4
64
S3
946
~ CO
'Eg
•3 '2
16, 874
4U
1,422
15,041
281
241
162
6,976
897
479
35
173
5,S85
201
489
423
15, 041
12,541
163
1,292
241
163
82
5,605
193
3B3
26
83
3,614
141
322
234
11,086
11^
17.
15.
10.
4.19.
20.1
31.;
12.1
3.54. 1
12.1
34.1
27.!
S3 ^ -^
t: t; ■«
.2" E $
21.7
14.7
7.4
505. 6
17.3
34.5
2.3
7.5
336. n
13.7
29.0
21.0
li
73.7
1,000
85.8
67.6
50.6
80.3
64.6
80.0
74.3
48.2
68.4
70. 1
65.8
55. 3
73.7
Diarrhoea and dysentery caused somewhat less than one-half, and scurvy somewhat
more than one-third of the total number of cases. Under these two headings were entered
AMOiS'G UNIOK TROOPS IN lOKl-KDEK.\rE PRISONS.
35
814.1 of every thousand cases, leaving only 185.9 cases in the thousand tor distribution
among all other diseases. These cases also occasioned the greater part of the mortality.
Diarrhoea and dysentery caused 505.6 and scurvy 326.0 deaths in every thousand deaths from
all diseases, leaving only 168.4 in the thousand for distribution among other fatal diseases.
l>r. .foNKS has fortunately j)r('served a monthly return of the cases and deaths in the
t^tockade and hospital for the si.x; months from March 1 to August 31, 1864, giving also
the mean monthly stiengih dui-ing the j)eriod.* From this paper annual rates of sickness
and mortality per thousand of strength ma}' be calculated. Some idea of the relative
prevalence of specified diseases and of the mortality caused by them may likewise be
obtained from the information thus preserved. In the following table the facts gathered
from the paper in question are so arranged as to admit of comparison with the analogous
facts from the records of our troops in the field, the Confederate forces and other bodies of
men already submitted in Tables II, III, IV, XIII and XIV.
T.Vl^LE XVI.
Giring a (jeneral view of the Sick and Death Rates from prominent disecises and classes of diseases anwng
the Federal prisoners at AndersonviUc for the period extending from March 1 to August 31, 186 i.
Average present 19,j^53 prisoners.
'
c
1
*
1
1:5
11
Anriuul rates of deaths
per 1,00() strength.
il
■s- «
iij
(- = •3
Hi
nil
11
1
42,686
7,718
4,388.6
792.8
1
238
■174
21
.565
24.4
48.8
9.2
sao
Not si>etn(it*(l
; Specifiwl diseases
■1 , '.'74
T.V!
a,!(66
236
16,772
955
1,556
114
iJ66
9,501
2,eo«
97!)
7,126
4,315.4
732.6
1,000
i.noo
17.2
■
199
11''
til
4, .>2!(
170
319
33
20
999
90
266
302
77.4
■mr-,. 0
1,724.4
98.9
160.0
11.8
89.0
976.8
988.6
100.6
4.59. 4
90.5
12.2
8.2
465.6
17.5
39.8
3.4
2.0
102.8
9.9
27.4
31.0
17.9
70.7
5.6
399.6
22. 8
37.1
2.7
9a6
996.4
66.9
93.3
106.4
27.9
16.7
11.2
635.6
23.9
44.8
• 4.6
2.8
140.2
19.6
37.3
42.4
26.4
4.0
3a9
27.0
17.8
20.5
28.9
2.3
las
a2
27. a
6.8
Debility .
Dropsv ...
I
Consumption
Rheumatism
Scurvy
Pneumonia and Pleurisy _
4, :■: ;
7, I'JN
■1. :il5. 4
732.6
1,000
1,000
17.9
The annual sick rate per thousand ot* prisoners was 4:,o6t:>.5, or nearly double that oF
our white troops. Nevertheless, it was not so high as the rate which, according to Table
* Memoirt «/" VniUd StaUs Saniuxry CtnnmUtion, p. 5-34. Dr. JOXES. «;>. cit., \\. 5fi7, speetfies the strength fur each nf the six months and gives
the average >trengih iis "^1,120 men. There is an error either in the items nr in ihe rulculate*! average. ISut as the items art- expressed by the same
numbers in another part of his article, p. 502, it seems probable that the error is in the oaleiilation, the correct strenKlh for the six moDtfas being 19.453.
36 SIOKNE!<S ANJI MORTALITY
XIV, prevailed in certain purtioiis (if the L'ont'ederate forces. Tliis demoiistrates merely
that the methods adopted in reporting sick men in the Confederate ranks was not observed
m the case of the Andersonvdle prisoners. The number of sick was certainly vastly in
excess of the number of recorded cases. AVhen Dr. Jonks inspected the stockade in Sep-
tember, 18(34, he found two thousand sick exclusive of those admitted into the prison
hospital, and as there was but one medical officer to attend to this enormous number of
patients/'' and to the cases brought dady to his iK^ice among the mass uf the prisoners, the
impossibility of preserving an accurate record of the cases is manifest. Large numbei's of
the prisoners who had never been entered on the sick list were sufi'ering from severe and
incurable diarrlujea, dysentery and scurvy, f^lighter ailments, such as dictated the relief
of a soldier on active service from military duty and his entry on sick re[)ort, were of
necessity unnoticed. Hence the annual ratio of sick per thousand persons present, and
the ratio of deaths to cases, as represented in the table, are certainly far from accurate,
and are not admissible for comparison with the records of the Confederate troops on active
service. Nevertheless Dr. Jones instituted the comparison and concluded that the diseases
referable to exposure without jn'oper clothing and shelter were as prevalent among the
Confederate troops as among the Federal prisoners. The following by Dr. J. C. B.\TEs,
who was on duty at the prisun hospital from April 22, LS64, to March 26, 1865, is of
interest in this connection:
"I it-fjit-t to say tliat the sTiiiplj' of wood was uot sufficieut to keep the prisouers from what we term freezing
to death. They would not, perhaps, actually freeze to death, hut a patient wliose lilood is thin, and hi.s system worn
down, is very susceptible to the intlueuce of cold. In the aliseuce uf sufWcieut food, sutticieut stimulus, and especially
in the absence of fuel, numy of the patients (I speak now of what I saw in my own ward) would, duriu;; the iiiglit,
become so chilled that in the morning, passing round, I would remark to my steward, ' Last night did the work for
(hat poor fellow — he will die:' or 'This one will die; I cannot resuscitate him with the means iu my hands, his s.vs-
tem is so reduced.' Lying upon the ground during tho.se chilly nights (the weather was not freezing, but sufficient
to thoroughly chill the whole system), the jiatient would reach a conditiiui in which resuscitation was a matter of
iuLpossibility after he commenced going down hill from this (exposure. I have seen a number die in that way." —
]\iport OH tin: Trail incut «/' I'rimmrx of fViir hij thi- llihrl Juthoritiis, 2d St-n/i., iOth ('oiiij., p. IIX.
The Hgures expressing the relations of individual diseases to the total cases of specified
diseases are modihed by the exclusion of the inanv cases of slight ailments which were
unnoted, and by the errors iu diagnosis consequent on the disposition of so many cases by
one medical officer. On September 18, 1864, y(J6 new cases were reported as taken on
sick rejiort; but as none were so reported on the two following days, it may be assumed
that these three days were spent in the transfer of the men in question to the sick report.
Ten hours daily of uninterrupted labor on the part of the medical officer would have
afforded about two minutes for the diagnosis and treatment of each case; but this officer
was not at liberty to allow so much time to the new cases, for the 1,1U2 cases carried
forward from the previous day claimed some share of his attention. Naturally, under such
conditions, the diagnosis and management of a. majority of the cases devolved upon the
intelligence (jf the probably unskilled men who, having gi\'en their parole, were granted
the freedom of the post and tilled subordinate offices in its domestic economy.
Overlooking the influeiice of inaccurate diagnosis, the annual death rate tabulated
may be accepted as a close approximation to the actual mortality. In this consists the
chief value of the extracts made li\' Dr. Jo^'KS from the records. During the six months
7,712 deaths occurred in the average strength of 19,453 prisoners present, equaling an
* "Al till!, time uuly uii« tneiiital ofticer was in atlfmlaDct', wliereas at least twenty iiitUital ullicers should liHvi.- been einliloyed."'— JO.NliS, op. cit., i«. JlL'.
AMONC, UNION TROOPS IN OONFKDEUATK PRISONS. A,
annual rate of 792.8 por thou.sainl, or tlh' I'Xtiuftion ul' ili.' whole I9,45;> in about litU'cii
months. By comparing thost- colnnms ol' Tahlfs X\' an<l X\'I wliu-li iriv.' ixprcssinn 1r.
th<' total nunilier ot deaths, it will he found that tln' nioitalitv was much i;rcat('i- iluiinu
tht^ first six months than dtn-im^ the last eight months, 7.712 deaths haviuif heen recorded
during the former ]>eriod. which number was increased (k Imt 12,")41 by ihc addiliou o|'
those tiiat occurreil later. This might indicate that ilisea<e became less prevalent or less
fatal as time progressed, or that the number of men in confinement became consideral)ly
reduced. In the absence of a knowledge of the strength present this point cannot be
.settled: but it is of interest to observe that while the greater number of the specified
diseases |iarticipated in this diminished mortalitv thei-e was one verv marked exception.
Tlius: deaths from continued fevers, numbering 199 in ihe first six months. l)ecarae
increased to 2-H during the whole period, an addition of only 42 fatal cases for the last
eight months, ^falarial fevers, numbering 119. boM^imi- correspondingly increased by 44.
Onlv 2 deaths tVom the eruptive fevers occurred in the last eight months, as against 80 in
tl arlier period. l)iarrh(ea and dysentery ended fatally in 4.529 cases during the first
six months, and in 5, 605 cases during the whole period, an addition of only 1.07<) deaths
for the last I'ight months. And so of most of the diseases specified. But scurvy, which
occasioned 999 deaths in the first period, had bv the end of the second period increased
the number of its victims to 3,614 bv an addition of 2,01.3 cases.
The aggravation of the scorbutic element, as time progressed, is manifested by these
figures. Of the 7.712 deaths that took place in the first jieriod, diarrluea and dysentery
caused 4.529, or fi36 of every thousand, and scurvy 999, or 140 of every thou.sand. Of
the 4.S29 deaths that occurred during the second period, diarrhrea and dysentery caused
1.07(). or 223 in every thousand, while scurvy caused 2,(U3, or 541 in i/very tli<iusand.
At first more than one4ialf of the victims tell before the causes of diarrhoea and dysentery,
but later scurvy assumed the" role of chief (-xecutioner. Together thev occasioned more
than three-fourtiis of the total mortalitv.
Dr. .Ii«\ES says: Tlif effect of scurvy was manifest iiii every liainl, ami in all its variiins stages, fioni the
nuiildy (lalf riini]ilexion. pale uunis. feelile. languid, iiiiiscular motions, lowness of spirits, ami fetid lireatli, to the
dusky, dirty. leaden complexion. sw<dleu features, sponj^y, purple, liviil. fungoid, bleeding gums, loose teeth, o'de-
niatous liiulis. covered with liviil vihices and petechia-, spasmodically llexed. ]>aiuful and hardened extremities,
sjionlaneoiis li.emorrliages from mucous lauirls, and large, ill-conditioue(t, spreading nlceis covered with a dark
piirpUsli fungons growth.
Ill souM- of the cases of .scurvy the parotid glands were greatly swollen, and iu some instances to such an
extent as to preclude entirely the power of articulation. In several cases of dropsy of the abdomen and lower
extremities supervening n|ion .siurvy. the patients affirmed that previous to the a])pearauce of the dropsy they had
sntlered with jirofuse and obstinate diarrlxea: and that when this was checked by a change of diet from Indian-corn
bread, cooked with the husk, to rice, the <lro))sy appeared. The .severe pains and livid patches were freiiuentlv
associated with swellings in various parts, ami I'specially in the lower extremities, accompanied with stiffness ami
contractions of the knee-joints and ankles, and often with a brawny feel of the parts, as if lymph had lieeu effused
between the integuments and aponeurosis. |)reventiug the motiiui of the skin <iver the swollen parts. • » •
The scorbutic ulcers iiresented a ilark. ]iur))le. fungoid. I'levated surface, with livid, swollen edges, and exuded
a thin, fetid, sanimis tiuid instead of ])us. Many ulcers which originated from the scorbutic' condition of the system
a)ipeared to liecome truly gangn-nous. a.ssuming all the characteristics of hospital gangrene.
Frinu ihi- crowdi'd condition, lilthy habits, bad diet. dejecte<l and depres.sed condition of the prisoners, their
systems had becoiue so disordered that Ihe smallest abrasii>n of the skin, from the rubbing of a shoe, or from the
effects of the li«t sun. <ir frtmi the prick of a sjdinter. or fr»uu scratching a mosipiito's bite, in some cases took on a
rapid and frightful nlceralion and gaugreue.
Dr. JoNfJs was surprised at the comparative absence of typhoid and typhus fevers,
notwithstanding the prevalence of the conditions that are suppo.sed to -produce them, and
attributes this to the immunity derived from a previous attack, or to an insusceptibility
<3»
38 SICKNESS AND MORTALITY
resulting from continued exposure. According to the records continued fevers constituted
only 17.9 of every thousand cases. They were thus comparatively rare, but this arose
from the increased prevalence of diarrhoeal and scorbutic cases rather than from the actual
infrequency of typhoid. An annual rate of 77.4 cases of the continued fevers per thousand
of strength was recorded; and, as has been already shown, the figures representing the
prevalence of disease within the stockade greatly understate the facts. This rate is con-
siderably higher than the average annual rate among our white or colored troops ; although,
as might be expected, it falls below that shown on Table XIV, as prevailing in the camps
of the Federal and Confederate Armies of the Potomac when typhoid was epidemic in
many of the new regiments. Continued fevers caused 26.4 deaths annually in every
thousand prisoners, as compared with 11.6 deaths among our white troops.
Malarial fevers were infrequent among the prisoners; but as their percentage of fatal
cases was much larger than among the United States or Confederate troops, 4 per cent, as
against 1.15 and .95 respectively,* it is probable that numbers of intermittent and remittent
attacks were not recoi'ded.f
The other diseases specified were presumably of more common occurrence among the
prisoners than among our troops in active service; certainly they were more fatal.
Bronchitis, which in the field gave an annual death rate of .49 per thousand of
strength, caused a rate of 9.2 among the prisoners, while the corresponding rates for inflanr-
mation of the lungs and pleura were 6.3 and 27.4.
This extensive prevalence and terrible fatality of disease among the Andersonville
prisoners creates no surprise when the unsanitary conditions aflfecting them are taken into
consideration. These were officially investigated by Dr. Jones, and are fully developed in
the report of tlie Committee of the House of Representatives on the treatment of prisoners
of war by the rebel authorities during the War of the Rebellion. J
The Andersonville stockade and prison hospital were established on a naturally healthy
site in the highlands of Sumter County, Ga. The former enclosed twenty-seven acres,
consisting of the northern and southern exposures of two rising grounds, between which lay
some swampy bottom and a stream running from west to east. In August, 1864, nearly
33,000 prisoners, were crowded together on this area, wliich afforded but little more than
35 square feet for each. But even this limited space was not wholly available, as six acres
of the bottom land had by this time become unfit for occupation. Each prisoner had there-
fore scarcely 28 square feet of surface on which to conduct all the operations of nature.
The Confederate guard occupied the fortified exterior of tlie stockade.
No shelter from the sun, wind or rain, the dews of night or the frosts of winter, was
furnished by the Confederate government. Fresh arrivals of prisoners were driven into the
stockade and left to find so many feet of foul surface for their occupancy among the army
of ragged, vermin-covered, emaciated and dying men already there. The pines and other
small trees that had originally sparsely covered the enclosure had been cut down. Frag-
ments of tent-canvas, blankets, oil-cloth and clothing were stretched upon sticks as a
protection from the hot sun. Some of the men burrowed in the ground and others built
huts of the mud removed from these burrows.
The sinks were built over the lower portion of the stream, but the volume and flow of
the water was insufficient to carry off the excreta. Heavy rainfalls causing the stream to
* See Table XIII sM^ra p. ,31. t See in/ra, note *, page 109.
ISeport Nt>. 4.'), IJousf of Rfprfsmtaiivfs, 3d Sfss., 40th Conr/ress, fVnvernment Printing Otfire. Washington, D. C, 1869.
AMONG UNION TROOPS IN CONFEDERATE PRISONS. 39
overflow spread the foul accumulations over the adjoining bottom lands, converting them
into a quagmire of fermenting filth the stench from which has been represented as horrible,
sickening and indescribable. Speaking of the stream as it issued from the stockade, Jones
says :
As tliesf wati'is, UiuiIimI witli tillli :uh1 liiuiian fXiTi'incnt , How slnj;^islily tlHciiij;li I lie swani]) liclinv, filled with
trees and reeds routed with a tiltliy deposit, they emit an iiitoleialde and most sickeninfj; stench. Standing as I did
over these waters in the middle of a hot day in Septemlier, as they rolled slugf^ishly forth from the stockade, after
having received the filth and excrement of twenty thousand men, the stench was disgusting and overpowering: and
if it was surpassed in unpleasantness by anything, it was only in the disgusting appearance of the filthy, almost
stagnant, waters UM)ving slowly between the stum))s and roots and fallen trunks of trees aud thick branches of reeds,
with inuunu-rable long-tailed, large white maggots, sw dlen peas, and termenting excrement, and fragments of
bread and meat .
But the pollution of the soil was not confined to the bottom-lands. Many of the men
were so prostrated by diarrhoea and scurvy that they were unable to reach the low-grounds
on every call of nature, and the general surface of the enclosure became covered with their
morbid dejections. Tlie ground was honey-combed with small pits a foot or two in depth,
which were used as latrines and emitted an intolerable stench. Later, the tattered clothes
of these men became the receptacle for their involuntary discharges; and ultimately the
foul and wasted forms were carried out for burial. In the vicious atmosphere of this
prison-pen myriads of flies and mosquitoes were developed, which would have made life a
misery even to healthy men.
There is one form of disease which is almost too horrible to l)e witnessed, yet we cannot understand the wretch-
edness rf the prison without looking upon it. This is not a solitary case, but we shall find numerous ones before we
leave this living charnel-house. We instinctively pause as we reach the awful sight before us, holding our breath
lest we inhale the terrible stench that arises from it. Here is a living being who has become so exhausted froiu
exposure that he is unable to rise from the ground, suffering from diarrhoea in its last form. He is covered with his
own fteces: the vermin crawl and riot upon his flesh, tuml)ling undisturbed into his eyes and ears and open mouth;
the worms are feeding beneath his skiu, burying themselves where his limbs, swollen with scurvy, have burst open
in running sores: they have even found their way into his intestines and form a living, writhing mass within him.
His case has been represented to the surgeons, but they have pronounced him incurable, and he is left here in his
misery, in which he will linger for three or four days more.*
But all the sick in the stockade were not left thus to die when their strength had
failed them. The 1 ,292 fatal cases in which no diagnosis was made may be supposed to
represent those exceptional cases in which the medical officers on duty became first aware
of the sickness by a knowledge of the death. It will be observed that such exceptions
constituted one-tenth of the total mortality.")"
In fact, an eflPort was made to aggregate the sick of the stockade, nearly 2,000 in
number at the period of Jones' visit, in four long sheds open on all sides and situated at
the north end of the enclosure. Here the haggard, helpless, hopeless miserables lay side
by side on the boards or upon such ragged and vermin-covered blankets as they possessed,
witliout bedding — without even straw — while foul emanations and swarms of flies consti-
tuted their atmosphere.
The Confederate Congress in May, 1861, passed a bill providing that the rations
furnished to prisoners of war should be the same in quantity and qnlity as those issued
to the enlisted men in the Army of the Confederacy. The daily ration per man officially
consisted of one pound of beef or three-quarters of a pound of bacon, and one and one-
* Op. cit,. last note, page 40.
t It appears that Andereonville, Ga., was not the only prisun iii which the sick were left to die in quarters without the care or knowledge of the
surgeon. A letter to this olfiee from the Adjutant General's Office, dated June 2:2, 1878, states that for the month of December, 1864, alone, the Confed-
erate " burial rei»ort" at Salisbury, N. C, shows that out of 1,115 deaths, 223 or 20 per cent, died in prison quarters and were not accounted for in the
report of the surgeon.
40 SICKNESS AND MORTALITY
quarter pounds of corn-meal, with an occasional issue of beans, rice, raolasses and vinegar.
Although this may have been the issue at first, there is no doubt that it was diminished at a
later period. Isaiah H. White, chief surgeon of the prison, in a re|iort dated August 6,
1864, speaks thus of the diet of the prisoners :
The ration consists of one-third pound of bacon and one and a quarter pounds of meal. The meal is unbolted,
and when baked the bread is coarse and irritating, producing diseases of the organs of the digestive system [diar
rhoea and dysentery]. The absence of vegetable diet has produced scurvy to an alarming extent, especially among
the old prisoners.
It is also well established that this miserable diet was generally not onlv of an inferior
but of a dangerous quality.. The beef was often tainted, the bacon decomposing, and tlie
meal musty, innutritions and irritant, the cob having been ground up with the grains.
Moreover, the ration was frequently issued to the prisoners imperfectly cooked. Nearly
three months after the establishment of the prison the surgeon in charge reported to the
commanding officer that —
The bakery and other culinary arrangements have just been completed, up to which time there had been an
inadequate supply of cooking utensils, and in consequence thereof the articles of 4liet have been insntticiently cooked.
Frequently the food was issued in the raw state. Those of the prisoners who had
the strength and energy to cook their allowance, lacked the necessary fuel and kitchen
utensils, while many were incapable of the effort had all the facilities been afltirded. The
issue had, therefore, to be devoured in this condition, if tlie pangs of hunger were acute
and the individual had not as yet reached the stage of apathy that preceded deatli. Many
also were incapable of eating the ration even if properly cooked, on account of tlie condi-
tion of their teeth and gums. Lieutenant-Colonel D. T. Chandler, Assistant Adjutant
and Inspector General, in his report of an inspection of the prison on August 5, 1864, says
of the rations and their preparation:
The sanitary condition of the prisoners is as wretched as can be, the principal cause of mortality being scurvy
and chronic diarrhcea, the percentage of the former being disproportionately large among those brought from Belle
Isle. Nothing seems to have been done, and but little if any effort made, to arrest it by procuring proper food. The
ration is k pound of bacon and If pounds of unbolted corn-meal, with beef at rare intervals, and occasionally rice.
When to be obtained — very seldom — a small quantity of molasses is substituted for the meat ration. A little weak
vinegar, unfit for use, has sometimes been issued. The arrangements for cooking and baking have been wholly
inadequate, and though additions are now being completed, it will still be impossible to cook for the whole number
of jirisoners. Raw rations have to be issued to a very large proportion, who are entirely unprovideil with proper
utensils, and furnished so limited a supply of fuel they are compelled to dig with their haiuis in the filthy marsh
before mentioned for roots, &e.
But as this monotonous diet, inferior in equality, insufficient m quantity, and having
its intrinsic harmful properties aggravated by the absence of facilities for its proper prepa-
ration was undoubtedly the cause of the diarrhcea, scurvy and starvation, which killed
three-fourths of the prisoners who were buried at Andersonville, and contributed largely
to the fatal event in the remainder of the cases, all details concerning it have a high
etiological value. The following is therefore submitted from the Report of the Committee
of the House of Representatives, already cited:
The rations consisted of corn-meal, bacon, fresh beef, peas, rice, salt and sorghum molasses. The corn-meal
was unbolted, some of it ground with the cob, and often filled with sand and gravel. Much of it had apparently
Ijeen put up while warm, and had become sour and musty either during transportation or while in store. The liacon
was lean, yellow, very salt and maggoty; it had been brought to us unpacked, and was covered with dirt and
cinders; it was so soft with rust that it could easily be pulled in pieces with the fingers. The beef was slaughtered
near the prison, to which it was brought and thrown down in a pile in the north cook-house, where it lay until it
was issued to the prisoners. Here, in the hot climate, it was soon infested with ilies and maggots, and rapidly
changed into a greenish color, emitting an oft'ensive odor peculiar to decaying flesh; it was very lean, but the heat
AMOXtl UXIOX TROOPS IN COXFKDKRATE PRISONS. 41
i-endeieil it (|uite tciiiler beloie it was si'ive<l ii]). The article ilenoniiiiated lilu(^k peas, or cow-peas, was bioiiglit in
sacks, apparently Just as it liad left the ihieshing groniiil ol' tlii' |ii'oiliicer. haviiijr never heeii winnoweil or cleansed
of the line pmls or ilirt which natiuallv mingles with all le^nniinons plants while ^jrowins; in the lielil: hesiiles, they
weri' filled with lmj;s, and many of them were so eaten as to leave nolliini; Iml 1 he thick, loii;rh sUin of the ))ea in
its natural shape. The rice was sonr or mnsty, and had :i|i|i,nciit ly I n |ml up in :i hull' ilricd stale, when il liecame
healed anil wholly nntitted for nsi.
'I'here wel'i* two cook-houses used in eoniu'ction with the prison. The lirst of these was in process of erection
« hen the detachment to whic h I helonged entered the pen. and went into opi-ration ahont the middle of .May. II
was located on the north side of and near the swamp west id' the prison, anil was Kiilisei|neiitly enclosed hy the
defeii.sive stockades. Al the time it was hnilt il was supposed to he of sullicicnt capacity to perform all the cooUin;;
necessary for the jirisoiiors, and contained three laijje lirick ovens, and .several kettles sel in hriek-work, for holling
the meat and peas or rice: hut il lieiiij; found inadeiiiiatc to sni>ply the wants of ihe men. aiiolhcr linildin<; was
constructed .some time in the latter Jiart of August. 1 1 w;is local cil iilioiii :i hi mil led \ aids iioi lli of 1 he defences, on
a line with the west wall of the prison. This was desif;iieil and iisi-d exclusively for lioiliii;; ihc peas and the moat,
and contained perhaps a do/en larye ]iotasli kettles set in hrick-work. The old cook-house was thereafter used for
liakiii;; the corn-meal. A stron-; foice of paroled piisoueis was ap]>ointed to perform I he work in these look-houses,
lil'.t with constant lahor was iinahle In siqiply our wants, and ahoiit one-half of Ihc rations were issued riiw.
The meal was |)iepared for hakin<; hy lirst pourin;; it in iinautity into a lar-ie trough made for the (uirpose. A
little salt was then added, when water euoiij;h was giimred in to make it of the proper consistency, and the whole
stiried with sticks to mix il thoroiifjlily. The doiij;h was hakeil in slieel-irou jians twenty-four hy sixiceii inches
in surface and I wo and one-half inches deep. The whole was divided into )iones i'ontainin<j; alioiil a |iounil. and each
of these poucs constituted a day's ration of hread for one iiiuii. lln- iiliiiost cleanliness could iml In- iiliscr\ .d in
luixing this "slutf:" the meal, as ahove stated, was partl.v <oiii and )iailly coli,and often contained materials ihal
were neither of these: the water was <lipi)ed in i|nantity from the creek, and no means of cleaiisinjj it were furnished;
and these, with the haste lu-ecssary to he made in inep.iriiii; the doii!;h, conspired to make the mixluie unpahitable
and sickeiiiu;;, particularly when cold. The prisoners \\\\t< had charge of the cook-house undoiiliicdly tried to prtv
paie the food as well as they could, hut all of their etforts were in \ aiii wilh sui-li limited facilities as they had.
Ihe peas and rice were hidlcd in the north cook-lionse: they wcii' turned from the liai;s as they were brought
to the prison, without cleansing or .separating from the chatf and dirt, into the large giotash kettles lonlaiuiug the
water in which the meal had been boiled: the cooks here, as in the south cook-hou.se, had no means of cleansing the
raw material, and had they posses.sed the faiilities they had no lime to devote to the purpose. 'I'o winnow, semi-
weekly, a sntfieieiit amount of peas for lli.OdO rations, allowing a third of a i>int to each, ref|uires a long time even
with the aid of the best machines: hut for twenty men to jiick over by hand this vast amount is simply impossible.
Of these cooked rations there were daily issued lo each ]iiisoner about a pound of bread, a fourth of a ])Oiind of
bacon, or four or six oiinees of beef (including the hone) in )ilacc of the bacon, and ;i Icaspoonfiil of salt ; twice a
week a pint of peas or rice were issued iii addilion. and occasionally a coii|ilc of tahles]ioonfnl8 of .sorghum molasses.
Sometimes a sort of mnsli was made to lake the place of the pone, but. although il was a change from the monoto-
nous corn-bread, it w:is so un])alatable that Ihe bread was preferred. About half of the rations were issued raw;
one-half of the jirisoners rei'eiving raw food one day :ind cooked the next. 1 have here given the iiuantily
issued during t he early part of the season : but as the hot weather advanced and tin- number conlliicil here increa.sed,
the daily allowance diminished until it heeaiue but a mere morsel to each iiuiii. ' '
Sometime in the afternoon the ration-wagoii drove into the stockaih' laden with corn-meal, haooii and salt,
which were thrown down into a heap in an open sjiace about midway the emlosiire. It was a horrible sight to wit-
nesa the haggard crowd gathered about this ]irecioiis Jiile, while Ihe commissary su))erinlcnded its division among
the squad sergi-auts: ga/ing, meauwhih'. with wolfish eyes upon the little heaji as it diminished, or following their
sergeanl-commissary back lo his iiuarteis, as famishi'd swine follow clamorously the footsteps of their master as he
carries their food to Ihe accustomed trough. The rations were distiihuted by the division-sergeant to t lie mess-
sergeant, who then divided them among the men. To avoid i|iKirrclliug during the last distribution, it was the
custom aiuoug all the messes for the me.ss-.sergeani lo sepaialc the nitions into as many small parcels as there were
men in the mess: one man of the mess was placed a short distance olf, with his back towards the parcels, in such a
position that he could not see them: the mess-sergeant I hen ]iointed to one, with the words, "Who has this?" to
wliicli the man replied announcing the name of the recipiciil. whin il was given to him. In this manner the w hole
number was gone through with, with salisfaclion to all.
Iron hake-pans, like tlio.se used by the ('onfederate sohlieiN. had been issued to the prisoners who lirst arrived
at this |dace, in which to bake their own meal and fry their bacon: but nothing of the kind was ever given out
afterwarils, to my knowledge. The I'nited Stales soldiers, as is well known, were never provided with other cook-
ing utensils than niess-kellles and mess-pans, both too large to be transported in any other way than ii|ioii army
wagons. Aftlie lime of our ia]iture, in niimeriMis instances, the tin cups anil plates which we had were taken from
us; our knives, il will be remembered, were confiscated at IJanville; nothing, therefore, was left in our possession
with which to cook our raw food after il was given us. How to accomplish this necessary feat was a grave i|iiestion.
\\ c made shift, however, with chips, half canteens, tin cups that had escaped confiscation, ami ])icccs of sheel-iron,
lo hake one side of Ihe stiilf, while the other was scarcely warmed Ihrough. The solder of the tin, melting and
mingling with the Inead, added another to our almost innumerable hardships. Hut with all our care and labor, the
rations were at last devoured in a halt-cooked state — a f;ict which aided in the increase of the frightful misery that
subsequently occurred, quite as much as the small quantity that was issued.
Med. Hi.st., Pt. Ill— 6
42 SICKNESS AND MORTALITY
The prison hospital covered about five acres of ground. It was established in a grove
of forest trees which afforded a grateful shade to the unhappy and suffering men. Its
atmosphere was polluted by the foul effluvia from the stockade; but irrespective of this,
its own emanations rendered it as unfit for occupation as was the general pen. The men
were crowded together in old and ragged tents; neither beds nor straw were furnished, and
the patients lay in bunks or on the ground, often witliout even a blanket over them. Sick
men, unable to visit the latrines, made use of small wooden boxes in the lanes behind the
tents.
Millions of flies swarniod over everything and covered the faces of the sleeping jiatients, and crawled down
their open mouths, and deposited their maggots iu the gangrenous wounds of the living and in the mouths of the
dead. Myriads of mosquitoes also infested the tents, and many of the patients were so stung by these pestiferous
insects that they appeared as if they were suffering from a slight attack of measles. * ♦ » » -
The cooking arrangements were of the most miserable and defective character. Two large iron pots similar
to those used for boiling sugar-cane were the only cooking utensils furnished by the hospital for the cooking of near
two thousand men ; and the patients were dependent in great measure upon their own miserable utensils. They
were allowed to cook in the tent-doors and in the lanes, and this was another source of iilth and another favorable
condition for the generation of flies and other vermin.*
The rations of the hospital appear to have differed from those of the stockade only in
having an occasional addition of potatoes. Indeed, it would seem that but for the shelter
of the ragged tents, the shade of the trees and the increased area, the hospital joatient had
little advantage over the prisoner in the stockade. The supply of medicines was generally
deficient, often exhausted, and medical comforts were unknown.
At the time of Dr. Jones' visit one medical officer attended to the sick in the stockade
while three were on hospital duty. Generally, however, the medical staff consisted of six
or eight for the prison and four or five for the hospital. These officers labored faithfully
to alleviate the misery and suffering by which they were surrounded, but unfortunately
they were powerless to effect a change in the methods of the establishment.
Day after day, for weeks and months, those surgeons labored, breathing the unwholesome air, and iu constant
contact with those horrible diseases ; but they were patient, faithful men, and their sympathy with the victims often
benefited them as much as the medicines they prescribed. » » » j gladly record the little acts of kindness
performed by them, for they were verdant spots in that vast Sahara of misery. Dis. Watkixs, Eowzib, Thokxburn,
Eeeves, Williams, James, Thompson, Pilott and Sanders deserve, and will receive, the lasting gratitude of the
prisoners who received medical treatment at their hands during that memorable summer at Audersouville.t
The medical profession owes a debt of gratitude to the gentlemen mentioned in the
above extract, and to their colleagues on duty in the prison hospital, in that their labors,
however fruitless on behalf of the unfortunate men confined at Anderson ville, have jDermitted
one unsullied paragraph to appear on that foulest page of American or any other history.
The papers published by Dr. Jones, and by the Committee of the House of Representatives,
show that Dr. I. H. White, the surgeon in charge of the prison camp, repeatedly called the
attention of his superiors to the deplorable condition of the prisoners, appealing for medical and
hospital supplies, additional medical officers, an adequate supply of cooking utensils, hospital
tents and even for straw for bedding. It is true his requisitions and recommendations
should have been put in stronger language; but he probably recognized how utterly fruitless
and unprofitable would be appeals to the humanity of an authority whose inhumanity
rendered such appeals necessary. The following extract from his report, dated August 6,
1864, to General Jno. H. Winder, the Commandant of the prison, shows him neither
insensible to the suffering around him nor ignorant of the causes that made the prison-pen
a charnel-house.
• Jones, page .")20, f H. M. D.4Vlli.>iO\, 1st ' llii.. LiKlit Aitilleiy. page 4;i c.f tlic n-pcil ..f tin. Committee alvea.ly liteil.
AMONrt UNION TROOPS IN CONFEDERATE PRISONS. 43
The evils within the power of the iiiopci' autlioiities to (■onci-i :
I. The crowded roiidilioii of the prisonem. — The numher within tlie stockade shonhi not exceed fifteen thousand.
This wouhl allow ami)U' room for the remainder to be camped in order, with streets of sutlicient width to allow free
cirenlation of air and enforcement of police regulations. All that portion of the cam)) on the north side of the stream
conUl then lu' used for exercise, where roll-call could al>o lie held, thereby malcrially iiidinj; the commandant <d' llie
interior.
II. Construction of barracks and hosj'if'il aceommiutalinu. — There should be no delay in the construction of
barracks; with the greatest amount of energy it will be dillicult to complete them before the cold weather comes on,
when they will bo reiiuired more than at present. Too great stress cannot be placed on the necessity for the con-
struction of proper accommodations for the sick. There are at present two thousand two hundred and eight in hospital,
all poorly provided for, and some three hundred without any shelter whatever. There are also at least one thousand
men now in stockade who are helpless, and should be at once removed to hospital. Their ren)oval is prevented by the
absence of accomnu)dations. The construction of hospitals should be at once begun, and in the meantiu\e the sick
should be at once transferred to some point where they can be properly jjrovided for. An oftieer should be employed
to arrange the stream i)assing through the stockade. The bottom-land should be covered over with sand, the stream
be made deeper and wider, the walls and Ijottom covere<l with |)lank: the same arrangements to continue outside,
conducting the ilrainage freely to the creek beyond, ami if necessary, liuild a dairi to prevent the overflow of the
liauks. The stream from stockade to the railroad should also be improved, and the use of it by the troops outside
should be prohibited. Sinks should beat once arranged over the stream of such a nature as to render them i,;iviting;
at present, those; who have an inclination to use them have to wade through mud and faeces to use them. At the u]>per
part of the stream proper bathing arrangements should l)e constructed.
III. Enforcing utringent jiolice retiulations. — Some stringent rules of police should be established, and scavenger
wagons should be sent in every day to remove the collections of filth. A large quantity of mouldy bread and other
decomposing matter scattered through the camp and beyond the dead-line should be removed at once. If necessary,
sentinels .should be instructed to fire on any one committing a nuisance in other places than the sinks.
IV. Kslahlishmeni of regulations in regard to cleiinliness. — It should be the duty of Confederate sergeants, attending
roll-calls, or others, to see that all the men of their command bathe at stated intervals, and that their clothes are
washed at least once a week. For this purpose soaj) should be issued to the prisoners.
V. Tmproremciit in rations. — The meal should be bolted and sifted before being used. Arrangenu^nts should be
speedily made by which rice, beans and other anti-scorbutics should be issued during the present season ; green corn
might be issued in lieu of bread ration, if not regularly, at least three times a week. If possible, the jjrlsoners should
bo supplied with vinegar, and with an occasional issue of molasses in lieu of the meat ration, which would tend
greatly to correct the scurvy which prevails to a great extent.
The deaths at Camp Sumter, Andersonville, Ga., durnig the fourteen month.s of its
occupation numbered about 13,000, when the unrecorded cases are taken into consideration.
But these figures greatly underrate the mortality consequent on the treatment to wliich tlie
prisoners were subjected. Thousands of men died after their hberation iVom thi.s and other
southern prisons. There are no records on file showing the subsequent history of the
Andersonville captives; but the following communication indicates the probabilities with
respect to them, in detailing the condition of those exchanged from Richmond, Va.:
I have the honor to make the following general report of the condition of patients (sick and wounded) who
arrived at and were admitted to this hospital from "Belle Islan<l," Va., per flag-of-truce steamer "New York," via
City Point, Va., on the 29th instant :
This vessel left City Point with one hundred and eighty-nine sick and wounded. Hefore she arrived at Fortress
Monroe four men died; on the trip from Fortress Monroe to this place four more died — leaving one hundred and
eighty-one to be admitted.
Language is inadequate to express fully the condition of this number, and none but those who saw them can
have any apjjreciable idea of their condition. I do not pretend to particularize, for every lase presented eviih'iices
of ill-treatment : every one wore the visage of hunger, the expression of despair, and exhibited the ravages of some
preying di-sease or the wreck of a once athletic frame.
I only generalize, therefore, when I say their external appearance was wretched in the extreme. Many had
neither hats nor shoes, few had a whole garment; many were clothed merely with a tattered blouse or the remnant
of a coat, and a poor apology for a shirt. Some had no under-clothing, and, I believe, none had a blanket. Their
hair was dishevelled, their beards long and caked with the most loathsome filth, and their bodies and clothing
swarmed with vermin.
Their frames were in most instances all that was left of them. A majority had scarcely vitality to enable
them to stand. Their dangling, bony, attenuated arms and legs, sharp, ]iinchcd features, cadaveric countenances,
deep, sepulchral eyes, and voices that could hardly be distinguished (some, indeed, were unable to articulate) pre-
sented a picture which could not be looked upon without calling forth the strongest emotions of pity.
Upon those who had no wounds, as well as on the woundi'd, were large foul ulcers and sores, principally on their
shoulders aiul hips, produced by lying on the hard ground ; and those that were wounded had received no attention,
their wounds being in a filthy, otfensive condition. One man, who died on the trip from Fortress Monroe, told the
44
SICIvNKSR AND MORTALITY
surgeon previous to death that his wouud hail not been dressed since tlie hattle of (iett.vshur.i;-, Pa., where lie was
wounded in the liead. having both tables of the posterior part of the skull fractured.
Most of the cases were suffering with diarrhiea — some of them with involuutar.v evacuations — their clothes
being the onl.v receptacle for them, and the.v too weak to remedy the ditticult.v. This being the case, you can, of
course, ima.sine the stench emitted from them. Many had pneumonia ; some in the advanced stages were gasping
for breath. Delirious with fever, many knew not their destination or were not conscious of their arrival nearer
home; or racked with paiu, many cared not whither they went or considered whether life was dear or not; in some
life was slowly ebbing, from mere exhaustion and the gradual wasting of the system. How great must be the
mortality, then, of these men, and how dreadful among those still suffering the horrors of imprisonment. Every
man wlio could, rejoiced over his escape, deplored the scenes through which he had i)assed, and mourned the lot ol'
I hose he had left liehiud. Weak aiul debilitated, they wished but to die auunig their friends, a wish which, unfortu-
nately, will be realized in too many instances. — Letter of Aet'imi Amiatiint Surgeon J^. .1. R.vnci.lKFE, V. .S. A., Meil'irnl
Officer (if the diiy, iit the C S, General Hospitii!, Dirwion Xn. 1, JninqjoliK, Mil., repitrtiiKj In the Suriienii in ehnrije the rnn-
ilitioii of the nick irnd leoiniiJed aihnitted October 29, 1863,. /'I'om Belle Me, ri<i City Point, Va.
Tlu.' ivcord.< of tlie prison lio.spital at Danville, Va., extending from Noveiulxn- '2'A.
l(S6o, to March 27. 1865, furnish a total of 4,332 oases admitted. As l.")7 of these were
cases of wounds and injuries and 7 cases in which no diagnosis was recorded, thi> numher
remainin.i!: us due to specified diseases is 4,168. But since there is no recoi'd ni' what
liiH-ame of 429 of these cases, the numl)er of terminated cases of specified disease is reduced
to 3,739. (if whieh, l,l>74 or 28.7 per cent, were fatal. An exammaliim uf the following:
table will discowr the aljsolute and rcdative mortality of the lunmment diseases for com
parison with tlie Audersonville record, already presented, and with the i-ecords of our
Nortliern prisons, to be subruitted hereafter.
Tablk XVIL
Summarizinf/ the Records of the Priwn Hospit<il at Danville^ Va., Xof\ ?o, ISGo, to March :27, 1SG5,
Total oas«^s .
Wouixls and injuries.
Nut sitecified
Speritied iliseases
(.'iilltiimfd l'V\rl- . .
Malariiil l-'eviM-
Ernptivfr l''ev<MS
IJianlio-a and Dysi'iitery.
Debilitv
l>rnpsy
('oiiSUIllptloii .
Kheiiliialisin
Sdurvy
Uroiif^liitis
Piietltiiiiiiia ami I'leiinsy.
Other diseases
1!
IB
"A
:=£
i. .
■? i
a ?-.
Died.
■0%
°0 -SB
HI
m
III
<2
{
\ 'X\-^
4:)7
3, 89.-.
1.1184
l.',7
(i
131
10
o
(1
28.7
1 4, lfi8
42'J
:), 73>l
1,1174
12
1,000
l(i.7
1,000
i:><
la
.57
n.i
21.1
■.';r.
ISI
■>\6
17
oil. 4
1...8
7. 1>
HSU
i.W
1 ;•,»■_'
lli.-i
211.1
I.-.3. <;
2ti. .1
1,41S
51
l,:iii7
4.-.l(")
340. 2
4211.0
32. 8
]:h
18
ii;o
13
42.7
12. 1
8.1
fi-,'
ti
."iti
24
14.9
22.4
42.9
1.
1
17
7
4.3
li. 3
41.2
■M»
17
:t3l
18
83. .-.
Hi. 8
...4
111
i
89
6
21.8
5.11
tl. 7
SftI
12
2.i7
31
f.4.5
28. 9
12.1
;U4
19
a!i.i
88
75.3
81.9
29.8
;;sil
14
•J72
342
(».6
225. :l
80, (t
(<() l>r. WonDWAKIi, on \kii^^ Mfi, Fart II ol this work, jfivi-s the nninber of deaths fnmi diarrlupa and tly.'feiiterv as ;ii»-J instead nf 1.11. I \,f i.-. ..rd
shows that wliile ill l,3tJ7 tenniiiated cases there iM-eiirred t.'d tlealhs, hy lollt.wiiiif mit the histories i.J' iIh- ta.st-s ntlier than diurrliceu ami dysenteiy 141 «.f
these are found to have proved falid by the supervenlion i>f the prevailiuij; intei^linal Hux. This accounts, for instance, fur the high death-rate attai'hi;ig
to the cases tabulated under the caption of "'other diseases."
AMONG UNIOX TROOPS IN CONFEDERATE PRISONS. 45
DiarrlifBii ;iii(l tln' (rn|)tive fevers, sraall-pux ohiefly, occasioned the largest number of
admissions us will as of deaths. Diarrhoeas constituted 340.2 of every tliousand cases of
disease, and causeil 420 of every thousand deaths from disease. JUit scurvv. whicii
exercised so fatal an influence at Andersonville, was less manifest here, as it occasioned
only 21.8 of every thousand cases and 5.6 of every thousand deaths. The i^cncral |>er-
centaii,!' of fatal cases of disease in this prison was only 28.7, as compared with 73.7, the
Andersonville percentage. Evidently the prisoners at Danville were treated with i-oin
parative humanity, although the mortality among tin; cases was nearly three-fold that
reported among the Confederate soldiers treated in the Chiinhorazo Hospital at Richmond,
Xa." The ratios of sickness and deaths to the strength present were no doubt correspoml-
ingly augmented among the prisoners, although in the absence oi data it is impossible to
give any other than this vague expression of the facts.
IV.— PREVALENCE OF DISEASE, AND MORTALITY THEREFROM, AMONG THE CONFEDERATE
TROOPS IN UNITED STATES PRISONS.
The rebel soldiers that died in oin- Northern prisons numbered, according to the
monthly reports on file in the iSurgeon General's Office, 30,716. Death in 5,569 of these
cases was the result of wounds; in 404 the cause was unknown, and in 1,1 02 unstated.
There remain, therefore, 23,591 deaths reported as from specified diseases.
The Confederate prisoners were contined in a number of prison camps, many of which
have already been mentioned."}" The statistics of nine of these camps iiave been exam-
ined, consolidated and tabulated to uidicate the diseases and classes of disease that were
the principal causes of the sickness and mortality among the prisoners. The records of
these nine camps include 18,808 deaths from specified disease, or about 80 per cent. o{ the
whole number of d(uiths reported as caused by disease. The statistics of the smaller
camps might readilv have been added to these, but their addit;ion would have materially
increased the size of the tabular .statements without adding correspondingly to their value.
Everything of interest susceptible of illustration by mere figures relative to the diseases of
the prisoners may be gathered from the tigures given below. Table XVIII consolidates
the data of each prison; Table XIX consolidates the data of the whole, and deduces ratios
I'v which compiarisons mav be in.stituted.
( )n comparing the latter consolidation with Table XIII it will be fouuii that the items
making up the total immber of cases of disease among the prisonei's did not differ nuu'h
iVom those constituting the total among the Confederate troops in the field. Thus the two
classes of disease, diarrhoea and dysentery and the malarial fevers, which caused the largest
miniber of cases among both these bodies of men, have their prevalence expressed by very
similar Hgures. Among the Confederate forces cases of diarrhcea and dysentery constituted
277 of every thousand cases of disease, while the malarial fevers numbered 111 in the
thousand. Aniung the prisoners the corresponding tigures were 268 and 157. Tlie
eruptive fevers formed 54 of every tliousand among the troops on service, and 6S among
the prisoners; pulmonary aft'ectious 51 among the former, 58 among the latter; and
rheumatism 36 and 34 re.spectively.
• Sto Tabic XII. f Pages a«i-40, Part II, of this work.
46
SICKNESS AND MORTALITY
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AMONG CONFEDERATE TROOPS IN U. S. PRISONS.
Table XIX.
47
In which (he fads of Tnhk XVIII are consoli doled and ewpi^essed in average annual 7'aies i^a^ thousand
of strem/fhy with the ratio of cases of i<jH'cifial diseases to cases of all dij^easesy of deaths from
specified, diseases to <leaths from all diseases, and the percentage of fatal cases of sprcified disease.
Average strength present ^DjSto men.
Continued Fevers
MHlttriH) Fevers
Eruptive Fevers
Diarrliopa and Dysentery.
Auieiniti and Debility . . . .
Coni»auiptiun
KheiiniHtigm
Scurvy
Broncliitis
Pneiiinnnin umi I'li-iiiisy .
(.Mher diseases
Total specified diseases.
Ti.tnl
number of
cases.
2,5.59
Total
number of
deaths.
Annual ratio per thousand
of averugu strength.
Cases per
thousHiid
citses of nil
diseases.
10. 5
Deaths per
thnnsand
ileiitlis from
all illsou»ieN.
.59. 1)
Percentage
of fatal
eases.
43 3
Cases.
Deaths.
13.6
1,109
31.4
38,5g7
),fl2li
472.7
12. 6
1.57. 7
54. 6
2.7
le, 667
3,453
204.2
42.3
68.1
183.1)
20.7
er,, .580
5, 965
803.4
73.0
268.1
317.1
"I. 1
3,209
156
39.3
1.9
13.1
8.3
4.9
53.5
331
6.6
4.1
2.2
1 7. r.
61.9
8,340
95
102.2
1.2
34.1
1.1
16, 257
351
199.1
4.3
66.4
18.7
2.S
4,488
133
.5.5. 0
1.6
18.3
7. I
3.0
14,319
5, 043
17.5. 4
61.7
.58. 5
268. 1
3.5. 2
74, 151
1,147
908.3
14.1
303. I
61.0
1.5
344,692
18,808
2, 997. 6
2.30. 4
1,000
1,000
7.7
i>ul although this similarity existed among the cases, showing that the diseases prevail-
ing in the prisons were precisely tliose that were at the same time affecting the Confederate
soldiers wiio were not prisoners, the fatality in the cases of the confined men was 7.7 per
cent, as against 3.8 per cent, in the Confederate ranks. No doubt the relative mortality
was considerably greater among the prisoners than among the men on service, but the
increase shown by the statistics is in the main due to a failure to take up certain cases on
tiie sick report, the deaths consequently forming a larger percentage of those that were
taken up. The annual number of cases of disease entered on the surgeons' reports per
thousand prisoners was 2,997.6: the annual number among the troops in the Hold per
thousand of strength was 4,404. The apparently greater prevalence of disease in the field
was obviously due to the entry of men on sick report for slight ailments necessitating
temporary excuse from military dutv; and the greater fatality of disease, as figured by the
statistics of the prisons, resulti'J in part from the absence of such cases from the reconls.
Prisoners with slight ailments did not require the surgeon's signature to excuse them from
duty, as in general they had none to perform.
On the assumption that as many trivial cases occurred among the prisoners as among
the Confederate ranks — and it can hardly be supposed that there were fewer — the per-
centage of fatal cases would be 5.2 instead of 7.7. On the assumption that the trivial
cases outnumbered those occurring in the ranks, the prison rate of fatality would be pro-
portionately lessened.
The actual increase in the percentage of fatality was occasioned by the greater
prominence of diarrhoea and dy;;entery, the enqjtive fevers and pneumonia as death causes.
The continued fevers constituted a larger proportion of the mortality among the troops on
service than among the prisoners. This is explained by the greater prevalence of these
fevers in the regiments, where they contributed 45 to every thousand cases of disease,
48
.SICKNESS AXD MOETALITY
instead of 10.5 as among the prisoners. Nevertheless, the fatahty of the prison cases was
greater, 43.3 per cent., tiian that of those occurring in the ranks, 33.27 per cent.
The ternljlr prouunent'e nf diarrhoea, dysentery and scurvy as causes of sickness and
death at Andersonvdle''' is not manifested on the records of our northern prisons. Diar-
rhoea and dysentery, which occasioned 505.6, and scurvy, which occasioned 326.0 of every
thousand deaths at Andersonville, are seen by the above tabulation to have caused in our
prisons only 317.1 and 1.S.7 respectively. The large number uf deaths from these diseases
among the unfortunate Federal [)risoners reduced the pro[iortion caused by other diseases;
thus, according to tlieir records, the continued fevers are held re.sponsible for but 21.7 and
the malarial fevers for only 14.7 of every thousand deaths, as against 50.0 and 54.6 among
the captured Confederates. iS^ot that these and manv other diseases were more }>revalent
or more fatal in the northern prisons; tin; deaths were merely more generally distributed
among the various causes.
But the deatli rates per thousand of strengtli atlord a more ready means ot a.j)precia-
ting the relative mortality among these men. The inmates of the nine prisons tabulated
lost annuallv bv disease 230.4 out of every thousand [irc.-^ent, as contrasted with 53.48
among our white troops; 143.4 among iiur rolured troops; 167. o'j" in the rebel armies,
and 732.6 among the Andersonville prisoners. Tlie chief causes <.if these stated n\ortalities
are shown in —
Table XX.
Contrastiny the MortuUttj Ratex, per thoiniand of strenf/fh, among the White mid the Colored Troops of
(he U. S. Aniii/ and tlic Union find the Confedemte Prisoners of War.
ilortalily lalf pri l.Oini strfii,i;tli I'miiL —
All diseases.
Diarrbd'a ami Pv.si'iiterv.
J^iieuiiiiiiiia
Eruptive Fevers
('oiitiuuc'rt Fevers
Malarial Ff\ ci.s
Seurvv -
Northern
prisous.
L'30. 4
Anderson- White
ville. troops.
732.fi
53. 48
Colored
troops.
143.4
Tiill
tt;.">. t)
1.5. 82
35. 27
HI. 7
27. I
(i. :u
28.87
10. 5
x.-J'
I.. 50
18. 36
i:!.H
2(1. '-,
ll.liO
12.45
lli.K
12.2
5.04
1H.81
1.3
102. X
0. It)
2. 02
The cause.^ of the large mortalitv from diarrlu.ea and dyMMittTV. pneumonia, and the
eruptive fevers, will be better understood by investigating the sanitary surroundings of the
captives as described in the monthly reports of the Medical Inspectors. From these
d(_)cumeuts the following accounts have been compiled:
Pki.son-ca.mp anii Hospital at Camp iJortiLAS, nk.vk CmcAciO, Illinois. — 'riiis camp was estalilislied in
.laimary, 1862, and closed in .September, 1865. Its situation was within oue-fourth uf a mile of the shore of Lake
Michigan, and ahout one and a lialf miles from the southeastern snhurlis of the city of Chicago. The site was a Mat
and treeless prairie ahout fifteen feet higher than the level of the lake. It had been iireviously used as a fair-ground.
The enclosed area measured 80 acres, nearly one-half of which was set apart for prisoners, the remainder for the
garrison and hoS]>ita]. The soil was a sandy loam on a substratiuu of blue clay. As the surface of the camp was
not favorable to drainage it was often, in the wet weather of its earlier history, .-softened and nniddy, unpleasant
* .See T.ihle .\V, page 34.
t See stiprn, p.ige 'Xi.
AMONrj CONFEDERATK TROOPS IN V. S. PRISONS. 49
and iinlicaltliy. The Imildiugs Wfic at first poorly coiiKtructed wooden shanties arranged in |)aranel lines, east and
west, with avenues between. The whole camp was in form a paralleloj^ram. one long and one short side being used
for prisoners, the other short side for ottieers and the other long side for oftices. The average size of these buildings
was 48 X 25 x 10 feet, with kitchen in the rear 8 feet distant. These kitohens were small and were used also as mess-
rooms. The whole camp was surrounded by a high wooden fence, and the barracks being in close proximity to it,
very little fresh air, according to Dr. Keesey'S report for 8ei>tember, 1«62, fiuind its way into the dark, dingy and
poorly ventilated quarters. In the month mentioned 7,7it8 prisoners of war were conlined in this camp.
.\n extensive tire which o<curred shortly after this destroyed a large number of the barracks: the buildings by
whicli they were replaced were of a much l)etter character in all particulars. The insi>ection report for December,
!8li2, says of this: "Some of the barracks have been burnt and others more substantial have been built in their places.
The recent contiagrations have been attende<l with one salutary effect, in the immensi- destruction of animal life, in
the form of lice, and had less of the tilthy an<l rickety quarters been sj)ared still greater salutary cH'ects would have
been the result."
The report for .lune, 18t>l, says that these quarters were "onestory high, frame, illy constructed, floors raised
four feet from the ground, ridge ventilation and openings at .side and ends ample in number.'' Their condition was
further improved subsequently, for the report for October, 181>1, says of them: "Fifty-two in number, each
70 X 24 X 7.8 feet, with kitchens 20 x 24 X 7.8, attached, in good order ; eight new ones in course of construction."
In .lanuary, 1865, they were described by Dr. Coolidge as follows: " The prisoners of war are confined within
an ;irea of about forty acres, surrounded by a strong oaken barricade twelve feet in height, surnu)unted by a railed
platform for sentinels. The prison barracks are one-storied, ridge-ventilated buildings erecteil on posts four to six
feet from the grounil, to prevent escape by burrowing. These barracks are sixly-four In niiniber. four of which ape
for convalescents exclusively: thirty-one have been built since .January, 18(U. I'liey are arranged in streets of suit-
able width, and are all of the same dimensions, viz: !H1 feet long, 24 feet wide and about 12 feet to eaves. • • •
Kacli barrack is subdivided iuto a kitchen and dormitory, the former 21) X 24, the latter 70 x 24, the dormitories fitted
up with wooden bunks three tiers in height. In several of the barracks at the time of my inspection there were
1(;,"> men, each having a cubic space of 142 and a superficial area of 10 square feet. The laisoners of war confined in
this camp, ,Taunary, 18tVl, numbered "),I>-I9, and 7,ti")2 were received during the year, making a total of 13,301. The
eases of sickness treated during the year amounted to 23,037, and the deaths to l,15ti, of which 41() were from small-
pox. The number of prisoners present December 31, 1864, was 11,780, of whom 577 were sick in hospital and 1,547
in quarters."'
The prison hospital building, in common with that of the post, was described, in September, 1862, by Dr.
Keeney as follows : "The hospitals are pretty nmch the same as the men's barracks; though isolated from them
they occupy grounds in the square. They are more thoroughly ventilated, but still are very defective in this partic-
ular: on an average 23 patients occupy ."v ward where 7 should be, allowing 1,000 cubic feet of air to each patient."
In the report for the following month Dr. Kekney says: "The hospital accomnu>dations of this camp have
reached their utmost limit, * * sickness is on the increase.'' He recounnended that the serious ca.ses be transferred
from the camp hosjiitals to the general hospitals at Chicago, and this ai)pears to have been done.
The building is described in the inspection rei)ort for .June, 1861, as follows: "One building, two stories high,
with two wings, newly built, well-constructed frame, enclosed by a high board fence, well ventilated by the ridge
and base, windows and high stories; 180 beds, and 117 in ])est hospital ; air-space, 800 cubic feet in hospital and 1,200
in pest hospital: total beds, 297."
The pest hospital was composed of two buildings, isolated and comfortable in every way.
The report for October, 1864, says: "Buildings, two two-8tor.y pavilions, two one-story pavilions, and one
barrack for convalescents, all in good condition ; six wards, 325 beds ; air-space, 6.50 cubic feet ; superficial feet, 54
each; overcrowded." At this date there were 7,361 prisoners of war in camp, 397 in hospital and 860 in quarters.
In .January, 1865, Dr. Cooi.ipoe described the buildings as follows: "The prison hospital is within the garrison
grounds but outside the prison square, enclosed with a strong oak fence. It consists of a central building with two
wings, all two stories in height: four wards in each wing: the lower are 99 feet long, 27 feet wide and 12 feet high,
well lighted and ventilated by cold-air shafts opening in the floor and vertical shafts in the walls, opening some near
the floor, others near the ceilings. The upper wards are 99x27x11 feet, well lighted and ventilated by shafts
opening at the ridge. .\t time of inspection each of these wards had 60 l)eds occnjiied, so that each bed had 500 feet
of air-space and 45 feet of area. • • » In addition to the hospital proper there was a single barrack ward 80 X 20
feet, with 30 beds for erysipelas."
The pest hos]iital was about one mile from the camp, and consisted of two ridge-ventilated frame buildings,
204 x28 and 10 feet to eaves: divided into three wards, 1.50 beds. During the year 186-1 1,519 of the ])risoners were
admitted with small-pox or varioloid, and 416 of these died. During the same period 144 cases were admitted from
the I'niou troops at the post, and of these 24 were fatal.
Few alterations were made in these hospitals after this date except in minor jioints, all of which tei:ded to
improvement.
The diet of the prison-cani]) was the ordinary army ration with vegetables added. Some complaint was made
of a scarcity of these by Dr. Keexey, who said in September, 1862, — " I am inclined to believe the prisoners have
been stinted in vegetable matter. The best indication of this is the appearance of the scurvy lurking about the
command. There are many cases of incipient scurvy in camp." But the Luspection reports of later dates speak of
the rations .as good and suthcient.
The diet in the prison hospital was rendered superior to that of the prison by the addition of delicaciea pur*
Med. Hist., Pt. Ill— 7
50 SICKNESS AND MORTALITY
cha«ed by the hospital fund, which appears to have heen expended in this inauuer as fast as it accrued. Dr. C'OOLIDGE
reports for .lanuary, 1865, as follows: "The purchases by the hospital fund were as follows: (Some items only.)
Milk, 1,2:^7 gallons; potatoes, 167 bushels; dried apples, 427 pounds; butter, 994 pounds; chickens, 20 dozen; oysters
(cans), 5 dozen — a great contrast to the treatment of our men in rebel prisons." Excellent soft bread was issued from
the post bakery at all times to the prisoners in camp and hospital.
An abundant water-supply was brought from the lake to the camp by the city water-pipes.
The drainage of the camp was at first imperfect. Dr. Keexey speaks of it thus : "The drainage is exceedingly
bad. The commanding officer and the surgeon have repeatedly submitted plans of drainage to the department, urging
the necessity of such as a means for preserving the health of the camp. As yet, nothing has been done but to permit
long open sewers, extending for nearly a (juarter of a mile, lioth in front and rear of the quarters, containing the
garbage and other refuse of the kitchens of months' standing, to add their miasms to the already noxious air jiervading
the camp." Again, in October, 1862 : "The grounds are so low that no drainage, without much expense, can be had.
Every rain converts the camp into a mud-hole, and in consequence of the flatness of the ground ami the want of
drainage, all the filth and refuse of the company quarters, of the men's sinks, and of the hospital, are to be removed
only l)y the process of evaporation. Already there exists in and around the company iiuarters and hospital sufficient
animal and vegetable matter to contaminate the whole camp and generate fevers of the most uuilignant type.''
This condition of aflairs appears, however, to have been remedied, for the report for Jiine, 1864, speaks of the drain-
age as "naturally bad, liut artificially good." The camp was well graded, and a system of sewers built which
could be flushed into the lake.
The sinks at early dates were shallow pits, many of them merely surrounded by a few poles and brush insuffi-
cient to afford privacy. Dr. Kee>-ey, in his report for September, 1862, says: "The sinks are numerous, near the
men's quarters and badly constructed ; they are not sufficiently deep, nor are they filled up often enough and renewed. ■
The wood-work is not close enough, consequently the mephitic gases are wafted to the quarters, hospitals and over
the parade grounds. This stench is intolerable." At a later period these privies were built over a large sewer and
the excreta effectually removed by flushing.
Prison and Hospital at Alton, Illinois. — The priscm at Alton, 111., was opened in .January, 1862, and
closed in June, 186.'). Its site was that of the Illinois State Penitentiary, on the hillside at the northern end of the
city of Alton, overlooking the Mississippi river, high, dry, well-drained and considered healthy, though subject to
malaria from the river bottom at certain seasons of the year.
The buildings, nearly all of limestone, formed a square which was surrounded by a high wall. Many of the
smaller buildings, used as executive offices, etc., were isolated. The north side of the prison was formed by a building
containing 2r,f) cells, arranged in four tiers in the interior, each tier consisting of two rows facing the north and
south walls respectively. The cells were each 7x7x3+ feet = 171.5 cubic feet; they were ventilated and lighted by
the gratings which formed their doors. They were used only for refractory prisoners or when the prison was crowded,
which the inspection reports show to have often been the case, particularly in the earlier months of its occupation.
Bunks were erected along the corridors, between the central cell structure and the walls of the building. In addition
to this there were two large rooms, each 45 X 15x10, occupied as quarters, one of them at one time exclusively by
Confederate officers.
Dr. Le Conte in his report for May, 1863, says: " In the main building many of the cella are occupied by men
who are not confined therein, but sleep there for want of better place.' He recommended that "the capacity of the
prison should be considered as not greater than 1,000, and that not more than that number should be confined within
it at one time." The prison had been built to accommodate 300 convicts, and at the time of Dr. Le Coxte's visit it
contained 1,500 prisoners. Dr. Keenev in his report for July, 1863, says: • * * "Fifteen hundred prisoners,
both Federals and Rebels, have each about 100 cubic feet of impure air for respiratory purposes. This deficiency of
pure air alone is a sufficient cause to explain the great mortality within its enclosure." In August, 1863, there were
1,200 prisoners; in October, 1863, 1,446; and in November, 1863, 1,800.
In order to afford increased accommodations for the prisoners, tents were at times erected, and the prison hospital
was removed from the permanent stone building to one specially erected of wood, thus giving additional space for
the inmates of the prison.
The reports at first speak of the hospital as consisting of one large ward in the basement of the penitentiary.
In April, 1863, the hospital department was removed into a separate brick building in the prison yard, having room
for 70 beds. An additional building was used as a pest-house.
In August, 1863, out of 117 sick in the hospital 60 were small-pox patients, and to properly isolate these a new
building was erected at " Sickleyville,'' on an island in the river about three-quarters of a mile from the town of
Alton. This building was of wood, well built and comfortably arranged; capacity, 100 beds with 670 cubic feet of
air-space per bed.
In order to afford increased accommodations for the relief of the over-crowding in the prison quarters, a new
two-story wooden pavilion buUding was erected inside the prison enclosure as a hospital, and all the permanent
buildings were henceforth used as quarters. This new prison hospital was divided into two wards, 183+ X40 Xl3 =
95,420 cubic feet each, the lower story being used for executive purposes, the upper only for the sick. A fine and
well-appointed bath-room was attached to this ward ; in fact the hospital arrangements were complete in every par-
ticular. The small-pox ward on the island was 200 X26x 13 feet clear = 67,000 cubic feet, and had 67 beds. It was
well constructed, one story, with roof and side ventilation. Thus the hospital accommodations at this place were
at length made comfortable and complete.
The rations of the prisoners in quarters and hospital are reported as abundant and good. The hospital ftind,
AMONO CONFEDERATE TROOPS IN U. S. PRISONS. 51
as it accrued, was liberally expeiulcd in the purchase of delicacies for the use of the sick, the siinouudiiif; funiw
furnishing vegetables in abundance.
The water-supply was at tirst hauled from the river to the prison by teams; later a steam force-pump was
employed and an abundant supply was ol)tained.
The sinks were at tirst shallow pits situated too near the quarters, ofti'n over full and fiml-smelliiif;. At this
time no water-closet was attached to the hospital, and the excreta had to be removed by hand. But these defects
were remedied. The report for April, 18B5, says of those attached to the hosiiital — '■ Wuti-r-closets clean and build-
ings good. ' The remarks on those of the prison are less satisfactory; "Water-closets .and sinks ample l>n1i as foul
as possible." In fact the condition of t!\e sinks in the prison was generally severely criticised by the medical
inspectors. The bathing facilities were characterizeil as ''ample and good, with good furniture and lixtures.'"
The drainage was naturally good and the sewerage satisfactory during the early occupation of the prison ; but;
in -Vpril, 18t>'i — "most of the .sewers having been clogged with trash, have been opened their entire length, and are
open gutters of fieces, slops and all kinds of tilth. The sewers not thus opened are choked ; con.se(|uently the whole
establishment stinks intolerably and the stench extends to the private residences in the vicinity of the prison walls.
It is proposed to put earthen sewers here, and the work should be done at once."
The following extracts show the condition of this prison when at its worst:
Dr. Kkexey, November, 1862: "The quarters are poorly ventilated, and some have no ventilation at all.
The grounds and quarters are in a shocking condition. The prisoners are permitted to lounge about in their
tilth, with no other duty to perform seemingly than to amuse themselves by slaughtering the vermin crawling about
their filthy persons. This seems to be their general avocation and amusement.
The kitchens are shining with grease, the floors seldom washed, the tables and otln-r kitchen furniture also
filthy.
The cooking arrangements are good; the ranges large and ample for all purposes.
The rations furnished are of the best <iuality, excepting tlour, which is bad. lint there is a great dispropor-
tion between animal and vegetable matter, a deficiency of the latter. Unless more vegetable matter is furnished
scurvy will soon make its aj)pearance.
The grounds around the company quarters and kitchens are I he comuiou receptacles for bones, damaged meat,
mouldy bread, etc.
The prisoners do their washing on a slope where all the soajiy water runs ui)ou the ground and dries uji
under their feet.
The sinks are located in their midst and are exceedingly foul: the pits but tlirei- or four feet deep. There
is no drainage to them, consequently they soon become filled up, and if not often removed they become an intol-
erable nuisance; such is the case now. I have called the attention of the commanding otticer to this, and have
recommended them to be filled up and new pits dug twenty feet deep and walled ii]i.
I also find prisoners occupying the cells where the air is cold and damp and without ventilation, and where
pneunu)nia and rheumatisni were fast increasing. As the.se occui)ants were not condemned to the cells, I recinn-
mendcd the commanding ofticer to remove them immediately to a large open room where tlu; sun's rays might
occasionally brighten their dingy walls.
As above stated, there are 1,040 prisoners inside these walls. Sick in hospital till; in ((uarters 70; total IHO.
The prevailing diseases are erysipelas, pneumonia, dysentery, typhoid fever and diarrhtea. The prevalence of the
last disease arises fiom the sour bread furnished by dishonest contractors, under the administration of an inetJicient
commanding officer.
The hospital accommodations consist of one open ward with low ceiling and bailly ventilated. The walls are
dingy, the floors dirty, the Ix^dding filthy, and the patients unwashed and alive with vermin.
The medical attendants, four in number, are Confederate pris<mers of no account as medical practitioners.
Dr. Hakdex has not time to give his attention to individual cases. The ward is now crowded, one bed riding
another. In this loathsome ward each patient has about 200 cubic feet of foul air for respiratory purposes.
Among the sick I found some eight or ten cases of erysipelas fast running into a contagious form. It is on the
increase."
Dr. Keexey, .Jtily, IStiS: "The percentage of deaths h,as been as high as SO. Through the ald(5 administration
of its ])resent commander. Major IIexdkicksos, l^. S. .Vrmy, and its present medical officer, Assistant Surgeon Wall,
77th Ohio Volunteers, the mortality has been re<luced to 12 or 1.5 per cent.
The general state of police of the entire prison is now almost faultless, including the two wards used for
hospital purposes. The rations are issued in abundance and of the best quality, and the cooking is both well
done and served. The patients in hospital, some 85, are well provided with underclothing from the Government,
and are amply supplied with everything to make them comfortable as far as the present capacity of room will
permit. In this there is a sad deficiency, and humanity demands an immediate change for the better. In one ward,
in the very midst of these 1,-500 prisoners, there are 20 or more cases of small-pox under treatment; in the other and
only ward are typhoiil and malarious fevers, erysiiielas, scabies, pneumonia, etc., etc.
Erysipelas often makes its appearance, assuming a contagious form from the vitiated air and animal poi.sons
constantly being eliminated from the body. In fact , all forms of disease that would be mild with i>lenty of pure air,
have in these <lingy and loathsome rooms assumed the most virulent forms and batilcd medical treatment.
In oriler to check in a measure this great and unnecessary mortality from disease, I have recommended the
commanding ollicer to jirocurc immediately a suitable buildiog a mije or so from the pri.sou aud city, and have it
fitted up for the accoiuuiodation of the small-pox cases.
.')^ SICKNESS AND MORTALITY
- As this loathsome disease seems a eoustaut iumate of the prison iu sjiite of vacoiuation, it will he necessary to
keep up the small-ixix hospital continually, and to employ an able physician to attend to this hospital alone. The
persistence of small-pox iu the ]irison is due to constant importations of the disease.
1 have also recommended tluit the best ventilated and most isolated rooms now occupied by the well inisoners
be approiiriali'd to the erysipelatous and other contajfious di.seases, and the room now occupied by tlie small-pox
cases be turned over to the well prisoners as soon as it is in proper condition to receive them.
I would also call your attention to the great necessity of innncdiately authorizing Major Hkndrickson to
cuiiiiiiy two able physicians, one to attend to the small-pox hospital as soon as opened, and tlio other to assist Dr.
VVai.i, to attend tlu' prison hospital. The duties in this hospital are too much for one num to do Justice to the
numerous bad ca.ses of disease.
If tliese suggestions are carried out the condition of the sick will be ameliorated and tlie percentage of deatli
lessened."
Pi!isoN'-i!.\Ki!ACK.s AND HOSPITAL, RocK ISLAND, ILLINOIS. — This prison was established November 13, 1863,
and discontinued about August, 1865; the prison hospital was opened in December, 1863, and closed in .June, 186.5.
Ruck Island, embracing about 1,000 acres, is situated in the Mississippi river between the cities of Rock Island,
Illinois, and Davenj)ort, Iowa. The .soil is a stiff loam on a limestone foundation. Its well-wooded and undulating
surface was considered to offer a healthy site for a i)rison-camp.
The barracks consisted of eighty-four one-story wooden pavilions, each of which was considered suitable for
the accommodation of one hundred men. They were well built and comfortably arranged, ventilated by the ridge
and well lighted; their floors were raised from the ground, and were comfortalily bunked. They were built in streets
1(10 feet wide, crossing each other at right angles, and there was a central avenue 200 feet wide. Each barrack was
100 feet long, 22 feet wide and 10 feet high, but 20 feet of each was partitioned otf to form a kitchen and mess-room.
The whole area, 1,200 x 850 feet, was enclosed by a strong wooden fence 12 feet high, with a railed platform near the
lop on which the guard patrolled.
Dr. ToWN.SHEND reports the result of his inspection in January, 1864, thus: " The prisoners on the island num-
ber 6,.500. They are comfortably quartered in barracks well built and well arranged for comfort and security. The
appearance of the men is highly creditable to themselves and to the officers having them in charge. In good weather
the prisoners are emjiloyed iu various duties, which secure to them the benefits of out-door exercise; these duties
are therefore regarded by them as a privilege. The discipline of the prison is admirable, being efficient without
being harsh."
The prison-hospital buildings, from January to Ajiril, 1864, consisted of a number of the barrack pavilions
inside the prison enclosure. At the last-mentioned date ten of these barracks were used as hospital wards; but in
May a new prison hospital was opened for the reception of patients. The buildings consisted of seven one-story
frame pavilions arranged en echelon, tolerably well constructed, with ridge ventilation along the entire length of the
roof. Each ward contained 50 beds and had a lavatory, bath and water-closet attached.
The increasing necessity for additional hospital accommodations caused seven additional pavilions of the same
pattern to be erected, and the inspection report of January, 1865, describes them as follows: "The prison hospital
is situated on elevated ground near the centre of the island. It consists of an administrative building two stories
in height, 60 X 40 feet, and fourteen pavilion wards, each 140 x 24, 10 feet high at the eaves and 14 feet to the
ridge, a small space being partitioned off for nurses and attendants; 50 beds to e.ach ward, giving a cubic space of
645 feet to each bed." A kitchen and mess-hall was also erected, 112 X 40 feet, situated between the two rows of
wards; to this building was also attached a well-supplied laundry.
In addition to the above tliere was a small-pox hospital consisting of six pavilion wards, each 150 x 24 aiid 12
feet high to the ea^■C8. Each ward contained 50 beds, and gave 864 cubic feet and 72 square feet per bed. These
buildings were isolated from the liospital luoiier, being situated on the Illinois side of the island. They were well
drained and supplied with every convenience.
Notwithstanding the natural advantages of the site and the substantial and complete character of the
buildings at this place the rates of sickness and mortality appear to have been high, chiefly due to an outbreak
of small-pox. Dr. Townsiiend's report, already quoted, says: "The present condition of the hospital may be con-
sidered good; but much suffering has occurred, and many deaths during the present month from causes beyond the
control of the officers in charge. Many of the prisoners arrived during the extreme cold weather, a large proportion
of whom were subsequently attacked with pneumonia. The same cold weather interfered with railway communica-
tions and prevented the receipt of hospital stores and medicines. In addition to the above, many of the prisoners
were found to have small-pox, and, of course, had subjected many others to exposure. These unforeseen difficulties
appear to have l>een met with the utmost promptitude liy the medical officers and the post commander."
The diet of both the prison and the hospital was always of good quality, ample means being afforded for
cooking the rations. No complaints appear under these headings in any of the inspection reports. In the hospital
the fund was liberally expended in the purchase of delicacies for the use of the sick. Good light bread and corn
bread, with potatoes three times a week, were issued to the prisoners.
The water-supply was abundant and of fair quality. It was pumped from the Mississippi river into a reservoir
and distributed to the camp and hospital by pipes. An artesian and three ordinary wells inside the prison enclosure
furnished a good supply in addition to that from the river.
The sinks were at first simply pits, from which the accumulations were removed by carts and thrown into the
river. At later dates these were abandoned and a large latrine was constructed in the prison, conmiunicating with
the river by means of a trench. Daily flushing swept the deposits into the river. The sinks in the hospital were
provided with ziuc buckets, which were emptied twice daily.
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AMONG CONFEBEEATR TROOPS IN U. S. PRISONS. 58
The (liaiiiaijo of tlio cauip ami hosiiital was iiatiually goud ou acoouiit of llic rolliii}; Kuifacc of the gKuiiid;
and this was improved from time to time until the drainage system was considered exeollent. ISetween (lie prison
and the hospital there was a sUiugli or hayou of some extent which was partly tilled tip and drained. ('oin[dainl
was Kometinics made in the inspection reports of the unsatisfactory character of tln^ drainajje in cold weather
when the drains were frozen up.
The following, hy Assistant Surgeon M. King Moxi.ey, U.S. Vols., is datcil February, 18lil:
" The prevalence of snmll-pox and its iiroiiorlioiuilly great mortality is a sniiject of serious eonsi<leration. 'I'lie
disease made its apjiearanco about the lust of December. The number of those alTected increased so rapidly thai
men had to be allowed to remain in barracks after the eruption appeared, thus infecting the whole )>rison. Three
small houses were used as a pest hospital. Each was capable of containing ten patients, but three times as many
were crowded into them. Two large buildings were erected soon after I assumed charge, .January IS, IKOI. 'J'li<>se
lield .lO ])atients each, allowiug over WR) cubic feet of air per man. liut as the number of cases augmented to an
alarming extent, I asked the commanding oflicer for the erection of another similar building. Five days elapsed
before the order was given to build. Meanwhile the cases increased on my hands; there was no place to ])ut theui
but in one of the barracks used for hospital jiurposes in the prison enclosure; this was filled in two days. Surgeon
A. M. Ci-.vHKE, U. S. Vols., Acting Medical Inspector, found me with 38 cases in the barracks, the accnnnilatiou of
two days, although I was removing them at the rate of twenty a day and crowding the pest-hospital in ho])es of
soon getting into the new building. Had this building been erected when asked for, no case would have been left
in the barracks an hour after being reported. Another of the prison-barrack buildings was then taken, and then
another, and one more barrack used as a ward in the hospital, making four used as small-pox wards within the
enclosure. About February 22, for several days as many as thirty-live new cases were reported daily, and during tlu^
latit two weeks of February there was an average of 20 cases each day. Three new barracks at the pest-house were
erected, making six in all. One of the small houses previously used is now used as ;i kitchen. The foftr barracks in
the Imspital and prison are now cleared of the small-pox; all I ho patients ixri'. in the six barracks anil two small
houses. There are at this time, February 29, 130 casiw; each building, intended for 50 men, contains 70, including
the nurses. A house is lieiug erected as a dormitory for nurses; this will leave more room for the patients daily
reported. There has lieen a scarcity of clothing for convalescents returning to prison, although 1 iiuido a timely
api)lication for a supply. Hence, many had to be retained who could have made way for new cases. The great
mortality results from several causes: Ist. Over-crowding, which could not be avoided. 2d. Want of proper bed-
ding, rough cots with straw being the only beds that could be procured, though now there are in n.se aliout two
hundred bed-sacks which were obtained from the iiuartermaster. 3d. Want of clothing to give the ])atients a change
on coming into hospital, in view- of their previous want of cleanliness. 4th. Insufficient vaccination. Nearly every
prisoner had a large ugly scar on his arm, the result of impure virus imposed on him while in the Southern army.
This did not jirotect him in the least. Prisoners have been received on whom the eruption a])pear(ul the ui^xt day
following their arrival, thus showing that they had contracted the disease befon! coming her(\''
Piusox AND Hospital at C'ami' JIoktox, X'Eak Ixdiaxai'Oi.is, Indiana. — This (h^pot, uscil as a camp for
t'nion troops from Apiil, 1861, was opened as a prison for rebels .lanuary 2(), lXt)2, and closcsd in August, I8(ir>. It
was establishi'd on the State fair-ground, one mile and a half northwest of Indianapolis, Indiana. The site was a
level plain, undulating but slightly in some parts, and hence possessing very poor natural drainage. The soil was
an alluvial clay ou a subsoil of gravel. The area enclosed for prison purposes was at first about twenty acres,
suliseiiuently increased to thirty, and was abundantly shaded by fine forest trees. The great objection to the site
was the absence of running water, which deficiency was repeatedly noted by the various medical olliccrs wlio
inspected the post.
The prison barracks at first consisted of a number of poorly constructed wooilen buililings which bad lieen
erected and used by Union troops. They are described in July, 18(11, as "nine dilapidated barracks, each I'lU x 24
and 10 feet high."' The ventilation of these was by ridge openings running along the entire huigth of the roofs
and by openiugs in the walls and doors at the ends and sides. They were fitted with three tiers of bunks. At
this date there were also 210 condemned tents in use for the accounuodation of the prisoners. Nevertheless these
nuarters were much crowded, there being only (JO to 80 cubic feet ]n-v man in the barracks, whili! five nuui were
crowded in each "A" tent and nine men in each bell tent. \ small isolated building within the enclosure was used
for a few cases of variola that occurred. This crowded condition continued until Sei>tember, 181)4, when the prison
area was increased by adding to it about ten additional acres of ground. In November, 18l>4, six men were crowded
into each "A" tent w hile m-w pavilion barracks were in process of erection. In May, ISfi.'), the barracks were stated
as thirteen in number, each 1.50X18 feet and 9 feet high, giving "sufficient space." Little change appears to have
occurred after this date.
Ho.spital buildings were at first extemporized by the occupancy of some of the prison-barrack buildings already
described. It ajipears that at this time many of thi^ sick and wounded were sent to the Indianapolis City IIosi)ital
for treatment. In Jnne, 18(>3, the stated capacity of these buildings was 83 beds, occupied by 100 men, many of whom
were <Mi double beds. The report for .July, 18(>:i, says: " Enlarged hospital accomnujdations are much needed at this
phne. The present facilities are too limiti'd and are often crowded beyond tlnrir capiicify." In these buildings the
air-space was often reduced to 3.50 feet per num. Few facilities wen- aflV)rded for bathing; bath-tubs were in position,
but as water had to be c;irried a distance of one hundred yards in buckets, they were seldom used. To expatid the
hospital a number of tents were pitched, but these also soon became crowded.
In December, 18(i3, the hospital department was much improveil by the erection of two new pavii.„n buililiugs,
by which the air-space was increasi'd to ooO cubic feet. In .July, 1804, these buildings were described as follows:
64 SICKNESS AND MORTALITY
"The hospital bnildings are four in numljer, one 114x20 and 12 feet high; one 100x20 and 12 feet high; one 40x20
and 11 feet 3 inches high : and one 99x24 and 14 feet high. Furniture good and sutificient. In addition a mess-room
30x24 feet, 12 feet high, and good kitchen accommodations."
The diet in both prison and hospital was good and sufficient; vegetables were freelj" used and tlie hospital
fund libei-ally expended in the inirchase of delicacies for the sick. Soft bread of excellent quality was issued daily
from the post bakery.
The water-supply, derived from wells, was sufficient for the requirements of the camp. Drainage at first was
imperfect. A ditch of irregular depth ran through the camp and carried off the rainfiill. In dry weather stagnant
water collected here and there in the deeper parts of its irregular bottom. These were repeatedly denounced by
inspecting officers, and as a result the ditch was ultimately straightened deepened and converted into a main drain
with which laterals from the area of the camp were connected.
The sinks were simply pits in the ground within the enclosure, and often so near the quarters of the prisoners
as to be oftensive. Lime was used daily as a disinfectant.
The condition of the camp during the last year of its occupation is not known, as no detailed accounts of a
later date than July, 18&4, have been found on file.
The figures for Camp Morton, presented in Table XVIII, do not include the statistics anterior to June, 1863.
An estimate of the mortality previous to that date is contained in the rejiort of Dr. Humphreys for September, 1864,
as follows: "There have been treated in the City Hospital of Indianapolis 846 rebel sick and wounded. Tliey were
all of the Fort Donelson prisoners; out of this number 7.5 died. The men were broken down in health by previous
hardships and exposure. The limbs of many were frosted while working in the trenches at Fort Donelson. The
prevalent diseases amongst them were typhoid fever and typhoid pneumonia, occurring in persons in whom the vital
forces had been reduced to the lowest possible degree; many 'dropped dead' while walking about their quarters,
without having manifested any disease, organic or functional, except great general debility. In persons of tliis
class, while moving about looking apparently in medium health, the action of the heart and arteries would be so
feeble as to be scarcely perceptible in pulsations at the wrist. These men were subsisted and treated medicinally
and surgically in the same manner as the sick and wounded of the United States forces ; the same air-si)ace in
hospital, and every facility afforded our own troops were given to the rebels. The records of the nunilier of rebel
prisoners received at Camp Morton since the commencement of the war are incomplete. Colonel Biddle of the
71st Indiana Infantry has been in command of the camp since the 28th of January, 1863. This officer reports the
number of prisoners of war in this camp since the above date to June 10, 1863, to be 4,604. The sick in hospital out
of this number were 591; of whom 43 died. About one-half of the 591 treated were wounded, among whom were
many cases of hospital gangrene. The total number of rebel prisoners brought to Camp Morton since the war began
exceeds 10,000. From the undertaker who personally superintended all the interments of the rebel dead at this
post, I learned that the total number of deaths up to May 8, 1863, amounted to 3.53; total number of hosjjital cases
treated in the period referred to 1,685."
Prison-camp and Hospit.vl at Jouxson's Island, near Saxdu.sky, Ohio. — The inspection reports of tliis
prison-camp present a most gratifying picture of its sanitary condition. It was opened some time in 1862 and closed
in October, 1865.
The island, three and one-eighth miles from Sandusky. Ohio, has an area of 360 acres. Its natural advantages
as a depot for prisoners of war were very great; the soil was aUuvial on a limestone basis; the drainage excellent;
water from the lake abundant and of good quality, and the salubrity of the site unsurpassed.
The buildings in the camp, frame structures two stories higli, with bunks along the sides, were well lighted
and ventilated by doors and windows, and at a later date by artificial openings. They accommodated 2,000 men,
giving an air-space of 300 feet per man. Their capacity was largely increased in 1864. The prison-camp was
surrounded by a high board fence, enclosing an area of 15 acres. Officers were mainly confined in this prison.
Tlie prison hospital was a two-story frame building, giving 700 feet of air-space to each of 80 beds. It was
divided into four wards with lavatories in each. Bathing facilities were afforded by the abundant water-supply
from the lake. The supply of bedding was abundant. The diet was similar to that furnished to the Union soldiers
in the post hospital. Ice was furnished in abundance. Vegetables and delicacies were freely used. The medical
officer in charge was assisted by Confederate surgeons confined in the prison.
The sinks at first were excavations in the ground, but later box-sinks, capable of being drawn out and emptied
into the lake, were substituted for the old vaults.
The natural advantages of the site rendered but little artificial aid necessary to perfect the drainage. Garbage
was stored in barrels and carted daily from the camp.
The following extract from the report of Surgeon T. Woodbridge, 128th Ohio, in charge of the hospital, sums
up the conditions affecting the prisoners under his care in a few words. The report is that for June, 1863: ''The
rations are of good quality and the cooking exceUeut. We have plenty of vegetables and an abundance of fresh
fish; pure air; pure water; plenty of wood; a police system rigidly enforced; a natural salubrity unsurpassed.
We are as perfect in what pertains to hygiene as possible."
Prison-c.*^mp and Hospital at Camp Chase, xe.\r Columbus, Ohio. — The precise date of the establishment
of this camp and hospital is not shown by the records of the Surgeon General's Office. It was used as a prison-camp
for political and military prisoners early in 1862, but the reports on file antedating January, 1863, are valueless.
The hospital was not closed until December, 1865, although few prisoners remained after July of that year.
Camp Chase prison was situated in the southeastern part of the enclosed camp, four nnles from Columbus, Ohio,
on the National road. The site had previously been a race-course and fair-ground; it was treeless and nearly fiat or
AMONG CONFEDERATE TROOPS IN TJ. S. PRISONS.
65
Somewhat basin-like, and surrounded by forests, which made it close .iiid warm in sunwner. Tlie soil was stifV,
clayey and watcr-lioldiiif;, poorly drained and destitute of runninp; water.
The buildings in the prisou-canip at early dates were poorly constructed wooden barracks, ue<rding constant
repairs to render them habitable. Dr. UrMrilUEYS considered them little better than the huts ordinarily in use for
the juoteetion of iloniestic aninuils. They were divided into three sets, known as prison No. 1, for otiicers, and Nos.
2 and 3 for enlisted men. Each prison was separated from the other, and th(> whole was surrounded by a close board
fence, fifteen feet high, with an elevated platform for the guard. These old barracks were fitted with three tiers of
bunks, and the space per uum was very small. To accommodate the largo numbers of prisoners received, tents were
pitched in the avenues between the barrack buildings, and the crowding was great. The dinu»nsions of these
buildings and the particulars of their construction are not clearly stated. At the inspection in .September, 1863,
the quarters were crowded; at this time there were confined 1,703 prisoners, of whom only 27 were sick — 25 in
hospital and 2 in quarters.
During 18(>4 the prison underwent a radical change: its area was increased, its buildings remodelled, and some
of a better character erected. Division No. 1 of the prison consisted of two barracks, No. 2 of seventeen barracks
and No. 3 of twenty-seven, making a total of forty-six barracks. Each was 100x22x12 feet, and was intended
to a<'commodate i;i2 men, giving 137 cubic feet per man. They were all of the i)avilion pattern, with door and
windows at the sides, floors well removed from the ground, ridges ventilated, and the tiers of bunks reduced to two.
Tlu^ jirisou-hospital building in 1862 and the early part of 1863 consisted of a small one-story wooden barrack,
79 X 20 X 12 feet, divided into two wards, having 600 feet of air for each of 36 beds. It was situated within the
enclosure and too near the high close fence for good ventilation. It was well sup])lii'd with furniture and cooking
apparatus, lavatories and sponge-baths. The capacity of the hospital was increased about December. 1863, by the
erection of a new pavilion, which, however, was of an inferior character. It was built of old lumber preserved
from some condemned buildings. Its size was 84 X 12 feet and only 8 feet high, allowing a little over 400 cubic
feet of air per bed. lioth of these buildings were afterwards condemned and abandoned. Now and superior hospital
pavilions were erected outside the prison enclosure. They consisted of six wards each 100 X 25 x 12 feet, affording
8.50 feet of air-space to each of 216 beds.
In additiim to these, three isolated buildings south of the prison enclosure constituted the |)e8t-hospital. Two
were used for .small-pox and one for erysipelatous patients. The small-pox hospital was 240 x 24 x 12 feet, having
a capacity of 120 beds, to each of which it afibrded a cubic space of 576 feet. These buildings were of the pavilion
pattern, well ccuistructed and .su))plied with everything needful for the comfort and well-being of the ])atieiits. The
attendance was good and careful and the supplies ample and of gooil i|uality.
In a special report dated March 14, 1865, Dr. Co()Lin(;E compared the barrack occupancy of the I'niou troops
and Confederate prisoners.
Barracks for —
No.
Length.
Width.
Height.
Bunks.
No. of
men to
each.
Air-
space.
Area.
United States paroled
18
20
Fttt.
100
60
60
100
Fut.
24
24
24
22
Put.
12
14
14
12
48
48
48
48
192
96
96
192
Fett.
150
210
210
137
Put.
12. 5
1.5.0
1.5.0
11.4
United States garrison
United States recruits _
Confederate prisoners
20
46
The diet in the prison-camp was the army ration with the addition of vegetables, potatoes, onions, etc., the
po.st bakery at all times furnishing a good supply of light bread. There appears to have been a prisoners' fund, but
no account of its expenditure is on record. The kitchens of the prison-barracks were furnished with brick furnaces
having cast-iron tops with holes for kettles. There were few complaints made by the inspectors under this head,
the whole appearing to be quite satisfactory.
The prison-hospital diet was of the same quality as that of the prison, with the addition of such delicacies as
were purchased by the hospital fund, which was expended as fast as it accrued, ,ind, according to the inspection
re|iorrs, it a])pears to have been ample for the purpose.
The supplies in both prison-cami) and hospital are spoken of throughout as having been good and sutiicicnt.
The water-supply was derived from wells, which in the early months of the occupation were not commended,
although they were regarded at a later period as capable of yielding an abundant supply of good but somewhat hard
water for drinking and cooking; it was, however, never sufficient for bathing or washing purposes, and on a few-
occasions, after prolonged dry weather, the low w.ater in the wells rendered some precautionary economy advisable.
In consequence of the nearly level surface of the camp great difficulty was experienced in eflccting a satisfac-
tory drainage. The system consisted of a main drain or ditch running through the prison-camp from west to east,
with lateral branches opening into it. But, as in the absence of running water these drains could not lie satisfactorily
flushed, they became foul and emitted disagreeable odors. On the remodelling of the camp and hospital buildings
the drains were planked or boxed, and provision was made for flushing the system by means of water from a cistern.
The defective drainage of this camp, arising from its physical conformation, was noted in almost every inspection
report, and the advisability of removing the prisoners to another and healthier site was frequently suggested.
56 SICKNESS AND MORTALITY
The sinks at first were merely pits in wliich lime a:id ashes were used as deodorizers. Much difiieulty was
experienced in keeping them in good condition. They were afterwards filled up lest they should contaminate the
water-supply, and new sinks were constructed over the drains, which were flushed periodically. Gar"bage was col-
lected in barrels and carted ofl" regularly.
Prison-cajip aIs'D Hospit.vl .\t Elmira, N. Y. — Elmira barracks were built at the beginning of the war as
a general recruiting dep6t; but in July, 1864, Division No. 3, of the barracks, called afterwards Camp Chemung,
was converted into a prison-camp. This division was situated on the river-bank a mile and a quarter west of the
town. The site was believed to be healthy; it was level, and having a sandy soil resting on a stratum of coarse
gravel a few feet below the surface, aft'orded good underground drainage. At the date mentioned twenty of the
old barrack buildings were considered fit for the occupation of the prisoners and ten new ones were constructed.
The former, 88 X 18 X 8 feet, were intended to accommodate each one hundred men. The latter, 80 X 25 X 12 feet,
were each fitted with bunks for one hundred and forty-eight men. Mess-halls and kitchens were suitably furnished.
The barracks were built of pine; they were well lighted, warmed by stoves and provided with ridge-ventilation.
The bakery could turn out six or seven thousand rations per day. Good water was obtained from two wells, and
any deficiency was supplied from the river. Lavatories and baths were not at first specially provided. Drainage waa
by means of pits dug to the porous subsoil. The sinks were covered pits, which were filled up when necessary.
The grounds of the camp, comprising thirty-five acres, were surrounded by a fence twelve feet high with a
platfornr four feet from the top. In August, over a thousand tents were pitched, each to accommodate five persons.
In one inspection report the drainage is said to have been into an open pond within the camp, thus forming what
was called a perfect pest-hole ; Vint on the recommendation of the inspector this pond was afterwards drained and au
underground sewer constructed, while defects in the surface drainage were remedied from time to time. Nevertheless
the grounds were frequently reported as in a muddy condition during wet seasons.
The prisoners were insutfieiently clothed, there being at the same time a great want of blaukets, especially
among the prisoners in quarters. A supply is said to have Ijeen received on one occasion from the Confederate
authorities. Sometimes the want of clothing was incompatible with the nuiinteuance of health, and hospital
patients, after having sufficiently recovered to be up, were obliged to keep their beds for w;iut of pantaloons.
Needs of this kind, and others less urgent, on becoming known, were relieved by the issue of hospital clothing.
Bedding was supplied in quarters only to the sick, and cousisted of sacks of straw and a Idanket. The men in con-
finement here had the full prison ration as supplied at the other prison depots. They had also a fair supply of veg-
etables purchased by the prison fund. Desiccated \egetables were at first furnished, but as they were not acceptable
to the prisoners, fresh onions and potatoes were substituted. Inspector Lymax reports on November 11, 1864, that
onions and potatoes were supplied on three days out of five, and in each of his subsequent reports speaks of the supply
of vegetables as sufficient. On one occasion he reported the beef as of inferior quality, but generally the diet is rep-
resented as good and well cooked, the kitchen being under the supervision of a special officer.
On the arrival of the prisoners, and while the hospital was in course of erection, the sick were treated in a
pavilion set apart for their recejition. Medical supplies and accommodations were deficient at this time. An inspec-
tion report dated .July 1.5, 1864, says: ''They are absolutely without the necessary medical and hospital supplies.
Requisitions were made three weeks ago. Until the day of my inspection the sick were laid on the naked liunks
from the inability to o})taiu straAv, Tliis was finally procured by the commaniliug officer after considerable difficulty,
and arrived during my inspection. When the reiiuisition for medicine and hospital supplies is filled they will be in
every respect suitably provided in a sanitary view." In August, medicines were reported al)uudant: but the sick-
ness was large and the mortality great. " This,"' said the inspector, "is due to the broken-down condition of the
prisoners on their arrival." There were at this time 9,170 prisoners, of whom 553 received hospital attendance and
558 were prescribed for at sick-call.
The medical staff consisted of a surgeon in charge and eleven or twelve assistants. Confederate surgeons
sometimes assisted in attending to the sick. Visits by the medical officer were made twice a day, and in special cases
oftener; and any complaint against a medical attendant of inattention or harshness was promptly investigated.
Competent persons were selected from among the prisoners to compound prescriptions and to act as nurses and cooks.
In August the hospital consisted of three wards of seventy beds each, and one of eighty-two beds, with 624
cubic feet of space per bed. On October 4th there were 9,063 prisoners, of whom 3,873 slept in the l)arracks and
5,190 in 1,038 tents. The air-space in the larger barrack buildings was 111 cubic feet per man, in the smaller build-
ings 92.5 cubic feet. There were 1,560 men on the sick report. The hospital had been extended, consisting now of
six new wards averaging 62 beds each, with 654 feet of air-space per bed, and four barrack-buildings averaging 70
beds, with 342 cubic feet per bed.
On November 11, an additional hospital ward of 62 beds, with 654 feet of space per bed, had been completed,
and one of the old 70-bed wards was vacated for use as quarters.
In January, 1865, with a view to diminish the sickness and lessen the mortality, the Medical Inspector made
the following recommendations: "1st. That additional wards be constructed and provision be made for hot-water
bathing of the sick. It is impracticable to give this thoroughly in the wards, and it is very much needed. 2d. That
hospital clothing be allowed, which would aflbrd an opportunity for cleansing the woollen and underclothing of the
patients. 3d. That all the old barracks be provided with additional windows. In the winter season the men con-
fine themselves to the wards as much as possible for warmth, and the closing of the doors and windows renders these
barracks too dark. 4th. That more cubic and superficial space be allowed by the erection of additional barracks.
The type of disease among the prisoners is that which results from over-crowding : there is no acute disease,
everything assumes a typhoid type."
AMOXG CONFEDERATE TROOPS IN V. S. PRISONS. 57
Tlio condition of the camp at tlic date nientioneil is tluis descrilicd: "The whole appearance of this cam)) is
greatly iminovcd since the last inspection. The sick in hospital and (|uartcrs are now vigilantly watclicd; the food
is good and well I'ooked: coal stoves have heen sulistitnted for wood, and the police of the barracks is ipiite as good,
and. I think, hetter than in most regimental liarracks." Small-pox hrokc ont anmng the prisoners about this time.
From December I, 18t>4, to .lannary 21, IStio, there had been 397 cases. To isolate these properly a small-pox hospital
liad been improvised with tents: lint a new pavilion was being coustnictcd to replace it. Dnriug .January ."ijiKK)
vaccinations and revaccinatious were performed. To replace, and ati'ord better shelter than the tents, twenty-four
new barracks, each 10() X 2-1 X 12 and 3 feet pitch of roof, had been completed by the midille of March, and six
more were in course of construction. These are .said to have given 180 cubic feet of air-space per man. At this
period there were 1,738 on the sick-list in a total of 5,934 prisoners, and nniny of those iu (jnarters were very sick
and stood aa much in need of suitable ward-accommodation as those in hospital, into which, for want of room,
they could not be received. "The condition of the patients is pitiable," says the inspector; "the diseases are
nearly all of the typhoid type, and much of the sickness is justly attributable to crowd-poisoning. In addition to
this, the clothing during the winter was insuflicient. The deep mud prevents the exercise of the jirisoners in the
ojicn air. and there is no occupation for most of them to relieve, in a measure, the depressing intluencc of prison-life.
The Fort Kisher prisoners, especially, arrived in cold weather very much di'])ressed. poorly clad, and great numliers
were soon taken sick with pneumonia and diarrluca, rajiidly assniuing a typhoid character. The surgeon was
recommended to press constantly upon the commandant the necessity fur ai)iiropriating some of the best barra<^ks
for additional wards, the immnliatc completion of the Hoor-ventilalion, thi' alteration already connnenceil in the
hos))ital latriiR's. and the free use of permanganate of potash throughout the barracks and of bromine in the wards.
1 would renew the recommendation, made iu my .January rcjiort, that additional light be given to the old barracks,
and greater fiicilities for warm and cold bathing as prophylactic measures."' Subse(|uently, up to .June 22, 181S,
the date of the last report, the sanitary condition of the camp and buildings is reported as having been good. The
number of prisoners continued to diminish and the ratio of mortality grew steadily less.
Prlsox Dei'At .\t Fort Delaware, Delaware. — This fort assumed importance as a prison depot in June, 1803,
when 8,400 men captured by (ieneral Urant in his operations against Vicksburg were sent to it for confinement. On
.June 3. Medical Inspector E. 1'. Voi.l.f.M, T. 8. Army, inspected the post in accordance with instructions from the
Surgeon (icneral, to determine the character and extent of the hospital acconunodations to be provided. At this
time barracks for 8,lW)0 men were in course of erection. The coiulitiou of the post and prisoners when at its worst,
that is, shortly after the arrival of this large body of men, is fully depicted in the following report by Assistant Sur-
geon C. H. Al-DEX. r. S. Army, dated July 11, 18(!3, on the causes of the sickness and mortality in the canij) :
"Fort Delaware is situated on an island iu the Delaware river, below Philadelphia and nearly opposite Dela-
ware City. The island has an area of about 90 acres and the soil is of a low marshy nature. Fort Delaware proper
is a large casemated work of granite and brick, which accommodates but a small i>art of the inhabitants of the
post. It has within it the different oflices of the post, officers' quarters, rooms where the officers, prisoners of war,
are confined, and guard-house for the prisoners of the U. S. troops. Outside the fort are numerous wooden build-
ings of more or less recent date, accommodating the rank and file of the prisoners of war, workmen, the hospitals,
sutler's store, etc., with a few cottages for officers' quarters, and a number of tents occupied by the troops composing
the guard. There are now some 7,100 prisoners confined on the island, including about 3(lO officers. The guard
numbers about 8t)0 men.
The barracks for the prisoners of war are two in number, the old and the new, each composed of one-story
wooden builitings enclosing a rectangular piece of ground. They are ordinary shed-buildings with shingle roofs.
The ventilation of these buildings is very defective. The old barrack has small windows along the side at consid-
eralde intervals, and a ridge ventilator along the whole length of the building. The new barrack, though some-
what higher, is still worse in its facilities for ventilation, the ventilators at the ridge being only occasional and placed
at considerable intervals. The interior is arranged with a central aisle and on either side three tiers of bunks or
rather shelves, inclining towards the centre. The prisoners lie on these shelves with their heads directed to the
exterior of the building. In the old barrack are confined 3,500 men, a number, it seems to me, far too great for its
capacity. A rough estimate, but I believe a tolerably correct one, shows that each occupant has less than 100 cubic
feet of air, iu connection with which should be remembered the small opportunity offered for the renewal of the air.
The new barrack is not yet entirely occupied, owing to a portion of the building having given away and re(|uir-
ing repair. This will in a measure account for the crowding of the old barrack, which will, I was assured, be
relieved as .soon as the new is in condition to be occupied. There are also attached to the barracks mess-halls
and kitchens. The mess-halls have long narrow tables at which the prisoners stand at meals. The barracks,
mess-halls, kitchens and the prisoners themselves were in a very dirty condition : some portions of the buildings much
more so than others.
The island is intersected by several ditches and inlets, but the drainage is very imperfect, and the grounds
insiile the prisoners' barracks were rendered very muddy by the recent rains. The water is now excluded from the
moat around the fort to enable the workmen to Iiuild the counterscarp. The filth received into this moat from the
drains and privies of the fort is therefore not removed by the water and lies exposed and decomposing, causing most
disagreeable effluvia on a warm day. The water-closets for the prisoners, as well as for all those living outside of the
fort, are on the edge of the island projecting over the water.
The water on the island is chiefly rain-water of good quality. At intervals along the outside of the liar-
racks are tanks for the collection and storage of the rain-water. Of the.se there are a large number, and many of
them appeared pretty full from the recent rains. There are also tanks connected with the hospitals and other build-
Med. Hist., Pt. Ill— 8
58 SICKNESS AND MORTALITY
ings aiovind tbe fort. Under the casemates of tlie inain work are a series of large cisterns which are designed to
be filled hy the rain-fall on the parapets percolating through the earth, sand and gravel (forming a filtering
arrangement), down into them. They are of large capacity, hnt at present have a small supply in them. AVhcn
rain-water is scarce it has been the practice to send for water by vessel to the Brandy wine; some of the water now
on the island is from this source. The water of the Delaware river, which surrounds the island, is, I learn from
credible persons who have lived there some years, considered entirely fit for drinking in the winter and early spring.
At other .seasons it is soniewliat brackish. If taken at low-water, however, it is not even in summer considered
decidedly injurious. As far as I could learn, and I took the statements of several officers and of the prisoners them-
selves, the supply of rain-water has as yet been sufficient for the garrison, and has been enough also to aftbrd drink-
ing water to the prisoners. The latter use the river water in part, if not entirely, for cooking purposes. With the
present number of persons on the island the supply of water on hand would certainly fall short soon. Measures are,
however, being taken, by bringing water from the Brandywine and by pumping up (by steam apparatus) water from
the river, throwing it over the parapets and allowing it to filter through into the cisterns beneath, to obtain a
good supply. A condensing apparatus has also been ordered.
The ration issued to the prisoners is the ration issued to the U. 8. Army before the late increase in quantity.
The meat is brought, already butchered, from the main land, and appears to be of good quality. The bread is partly
baked on the spot and partly procured from Delaware City. The latter is very good, but the former, though of
tolerable quality generally, appeared in one or two instances a little sour. Besides this, hard bread is also supplie<l
to the prisoners.
There are five hospitals on the island, one for the garrison and four for the prisoners of war, all outside the
fort. They are frame buildings. Two are old, badly ventilated and poorly adapted for the purpose; the three
others are mere sheds, which have, however, the advantage of being tolerably ventilated through the chmks of the
rough boarding. One of the wards of the post-hospital was particularly small, and though it had but 17 men in it,
they had an allowance of less than 300 cubic feet of air per man; it was besides liadly ventilated. Two hospital
tents are also occupied by sick prisoners of war. All the hospitals, but more particularly those of the prisoners,
were in poor police; the grounds around them particularly so. There was a great deficiency, or rather an almost entire
want of stores, clothing and medical supplies of all kinds; bedding was also ^ery insufficient. There were no bed-
steads for most of the sick prisoners of war. A sufficiency of stimulants for immediate use is, I was informed,
obtained through the Quartermaster's department.
Assistant Surgeon H. E. Sillimak, V. S. Army, is in charge. It is due to him to say that he was assigned to
this post but a few days ago. I have no doubt he will immediately make efforts to have the defects above mentioned
corrected. He informs me that four days since he made requisition for all necessary supplies on the Medical Director
at Baltimore. The books and records of the hospital were in much confusion, or rather none were, I believe, kept
except a register of the sick of the garrison and a morning re'port.
This want of correct records makes it difficult to obtain exactly the number of sick, deaths, etc., but the fol-
lowing data are believed to be tolerably accurate: There are 210 sick prisoners of war, among whom are included a
few wounded .iu.st received from tbe battlefields in Pennsylvania. The morning report shows that there are 69 of the
garrison sick, 24 being in hospital and 45 in quarters. The chief, and I may say almost exclusive, disease is chronic
diarrhiea. Hospital reports reveal the fact that the disease and the incident mortality is almost entirely confined
to the members of the rebel regiments from Alabama, Mississippi, and other southern states, taken prisoners by Gen-
eral Grant's army around Vicksburg. A large part of these men came hither broken down, emaciated and already
the subjects, for some weeks or months, of this disease. The long journey from Vicksburg to this place seems to
have exhausted all their vital powers, and many died soon after their arrival. There is very little sickness and
hardly any mortality among the prisoners of war brought from General Lee's army, or "any other source than the
army around Vicksburg. All are equally exposed of course to any imperfect hygienic influences existing on the
island; but the fact that the sickness and mortality are almost entirely confined to the prisoners from Vicksburg,
shows, I think, that the conditions under which they are now placed are chargeable neither with their sickness nor
mortality.
It is important to bear in mind that the majority of the prisoners have been upon the island but a few days.
The want of ventilation, the over-crowding and bad ])olice of the pri.soners' barracks, which I have mentioned, have
not as yet had time to produce any marked effect on their health. I cannot but conceive, however, that serious
results will ensue, if these causes are allowed to operate for any length of time, especially at this season.
I deem it my duty, in view of the pressing necessity of the sulyect, to call the attention of the commanding gen-
eral to the want of ventilation of the barracks, the over-crowding and the want of police. The iirospect of a deficient
Bupjily of water had fully engaged his attention, and he was using his liest efforts to provide for it. He requested
nie to point out the fact that the tanks attached to the barracks should have been double the size, also the need of
a water-tank boat for bringing water, and suggested that the new hospital for 600 beds, now in progress of contruc-
tion, should have tanks twice the size of those contracted for.
The attention of the medical officer in charge was called to the urgent necessity of taking measures to provide
hospital stores and medical supplies. He was advised to make an immediate special requisition on Surgeon MURRAT,
the Medical Purveyor at Philadelphia, for such articles as were most needed, stating the emergency. He was also
advised to have the hospitals and the grounds around them thoroughly policed, applying for a detail of men, if
necessary, and to have the buildings wliitewashed inside. It was recommended to oljtain additional hospital tents
and remove into them the sick from the crowded wards of the garrison hospital, and also to have a pig-sty near one
of the hospitals taken away. Several benevolent individuals having oft'ered contributions, he was advised to accept
AMONG CONFEDERATE TROOPS IN V. S. PRISONS.
59
and invite tliem, e.s))f(iall.v of uncU'relotliiiij; anil liospital stores. This seems to be the more neoesHiiiy, as at presiMit
there is no husi)ital fnnil with which to ])iii'(hase extras.
The snhject ofalhnving the ]>risoiiers to hathe unfortunately escajjeii my attention. I was informed, however,
liy one of the oltieers of the ))ost, that it had not l)een i>erniitted for the othcers, and tin; coiulitiou of the men eer-
tainly indieated tliat tliey have not enjoyed an.v greater privihiges in tliis respect. If occasional bathing could not
onl.v he allowed hut conii)elled, it would of course contribute materially to tlio health of tho prisoners, and there
seems to be no good reason why, umh'r proper and sutlicicnt regulations, this could not safely be provided for."
Prisox-C'.\m1" and Hospitai. at Point Lookott, Makyi.and. — This camp was establishi-d in August, 1K68, on
the eastern side of the point at some distance north of the site of the Hammond (ieneral Hospital. In his re)iort for
.Tuly of that year Medical Inspector (ieneral .1. K. Baunks, V. S. Army, mentioned the j)roposed settlement of ten
thousand prisoners in the vicinity of the liospital, and called the attention of the Surgeon (leneral to the i\irt that
at least 700 of the beds of this establishment would be reiiuired for the use of tlie sick among this nunilier of pris-
oners. The point was sandy and sparsely dotted with shrubby vegetation. The site was considered liealthy, Tho
prison-area was surrounded on three sides by a stockade; on the east side it opi-ned on Chesapeake Bay. One or two
gun-boats guarded the water-front of the camp. The prisoners were sheltered in Sibley and A tents, which were
pitched in regular lines separated by well-graded streets. One divisicm of tho prisoners occupied cracker-bo.v huts,
built by themselves out of such timber as was obtainable on the point and shingle-like fragments of the empty hard-
bread boxes. At first the sick were sent to the Hammond Hos|)ital, but after a time a prison hospital, in which cases
of a less severe character were treated, was established w ithin the stockade. The water-supply was from a nnnrber
of wells which yielded each from utM) to 1,000 gallons daily, liut diarrlnea was sometimes attributed to its use. The
soil of the camii-site was kept unusually free from excreiiu^ntal taint, as the sinks were built over the waters of the
bay, which promptly carried off the depositeil filth.
The first, and perhaps the only, report of special interest from this camp contains a protest against over-
crowding. It was written by Surgeon Jas. II. Thomi-son. U. S. Vols., Surgeon in charge, .lune 30, 18&1 : "Several
thousand prisoners captured during the present campaign have been received into c.iniii during the month of .June.
Many of these wen^ suft'ering from exhaustion and diseases incident to an active campaign. It will he perceived by
a reference to the mortuary report that most of the deaths during the month occurred anu)ng these new arrivals.
The types of all diseases occurring in camp have been nmre aggravated than during previous months. Wounds,
though generally progressing favorably, have in several instances proved troublesome from gangrene and proneness
to secondary ha-morrhages. Only one case of variola has occurred and fifty-five cases of measles; the latter disease
is increasing, the former nearly extinct. Requisition has been made for vaccine lymph to protect the new arrivals.
Subjoined is an extract from a report forwarded to the commanding officer of the Post June 2S, 1864 : —
' I have the honor to call the attention of the commanding officer to the already crowded condition of the pris-
<niers' camp at this post, and as sanitary officer of the camp to respectfully protest against the reception of additional
numtiers of prisoners, there being now fully fourteen thousand persons within the camp, and nearly twenty thousand
on the point, including the I'. S. Hammond General Hospital with one thousand three hundred wounded men, the
contraband cam]) of indefinite numbers, the Qnartermast<'r's department and troops of the garrison. In addition to
tliese are the Quartermaster's stables with, I suppose, two hundred and lift.v horses and mules.
The reasons why I am urged to make this protest are:
1st. The limited area of the camp and of the occupied surface of the point.
2d. The already insufficient and injurious quality of the water. According to the results of analysis th<^ water
of some of the wells is unfit for use, and to this I attribute largely the increased prevalence ami fatalit.y of disease
during the past month.
3d. Though the police of the camp is, and has been for several months past, most excellent, still every precau-
tion against epidemic disease, -with this over-crowding of the camp not only continued but rumor says yet to bo
increased, will, I fear, prove futile, and we may see ere the summer is past an e))idemic that will decimate not only
the ranks of the iirisiiners, but affect alike all the inhabitants of the point, —
I therefore recommeu<l to the consideration of the commanding officer:
1st. That no greater number of prisoners or troops than at present oecujiy the ground be allowed upon the point.
2d. That condensers be at once j>ut nj) to furnish a sufficient quantity of pure water.
3d. The diminished issueof salt pork and the largely increased issue of fresh vegetables; this in consideration
(d' the scorbutic tendency and character exhibited in the majority of diseases oci-urring in the camj).
4th. The immcdiale construction of barrack-hospitals for the accommodation of two hundred sick.' ''
The condensers were not furnished, but to supply the increased necessit.v for water a numlier of new wells
were dug. Free issues of vegetable food were made to the prisoners and a post-hospital of six wards was commenced
outside the stockade. Large numbers of the prisoners were employed under guard on this and other work in the
vicinity of the camp. The details for such duty were eagerly coveted as furnishing occupation and change of scene,
and entitling the laborer to extra rations or special issues of tobacco, as might be desired.
By orders datc<l .\ugust 31, 18f)4, fron\ headquarters of the military district in which the cami) was situated,
the jirovost marshal was charged with the duty of inspecting the camp and hospital of the prisoners of war. Daily
inspections were enjoined, and weekly reports required, covering such points as personal ideanliness, clothing and
bedding, (juarters, kitchen and messing, police, sinks and drainage, hospital wards and attendants, etc.
From a perusal of these rejmrts, now on tile in the office of the Adjutant (Jeneral of the Army, it is evident
that few prison-camps were in better condition than this depot at Point Lookout. During the warm months tho
prisoners were required to liathe and change their underclothing once a week. In fact, many took frequent .idvantage
60 SICKNESS AND MORTALITY
of the general permission to 1)athe in the waters of Chesapeake Bay. During the winter the facilities for personal
cleanliness were not so satisfactory. The water-supply from welhs, twelve to twenty feet deep, was at first sufficient
for all the needs of the camp; hut as fresh coniraituients were made new wells had to be diig, and on a few occasions
of large and unexpected increments of the population, as for instance, on April IG, 186.5, when over 5,00(1 were
received, iirecaiitions had to be taken against waste of water until new sources of supply became available.
Besides the ordinary body-clothing, every prisoner was furnished with an overcoat and blanket and a change
of underclothing. On each of th(^ weekly reports are noted the number of prisoners received and the articles of
clothing, etc., Issued. Sometimes, when ,a large commitment was made, the clothing on hand was insufficient for the
supply of the new arrivajs. Thus, although during the week ending October 16, 1864, 1,000 overcoats, 1,800 blankets,
402 blouses, 202 pairs of drawers, 168 pants, 650 shirts, 6,50 pairs of shoes and 380 pairs of socks were issued, it is stated
that to make the prisoners comfortable and provide each with a blanket, further issues of 4,000 shirts, 3,000 pants,
2,500 pairs of shoes and 1,500 blankets were imperatively recjuired. Requisitions for needful articles were as a rule
promptly honored. The quartei-ma.ster had on hand at this time a large number of pants, but as they were of the
regulation blue color it was deemed inadvisable to distribute them. The similarity in the dress of the guard and
prisoners would have facilitated cscajie, particularly as over 900 of the prisoners were daily employed on the public
works outside the stockade. During the winter some of the prisoners received extra articles of clothing from their
friends in the south, and on February IS), 1864, twelve bales of blankets and one case of socks arrived from New York
through the Confederate Agency for the supply of prisimers. These, and suUsec^uent supplies from the same source,
were distributed by a committee of prisoners to whom this duty was assigned. The report of March 5 states that
two other lots of clothing had been received from General Bk.\le, the rebel agent in New York, and that of March
26 has the further statement that "the supplies of clothing furnished by the Reliel authorities are quite liberal
and timely."
The quarters consisted of Sibley tents, twelve men to a tent, and A tents with four men in each. No descrip-
tion is given of the character of the make-shift shelters constrncted of cracker-boxes and fragments of old lumber,
but as permission to build was regarded as a favor, it seems as if these compared favorably in point of comfort with
the tents, one-third of which, towards the end of the occupation of the camp, were reported as unserviceable.
.Six kitchens, with large mess-halls attached, were used in the preparation and consumption of food. The
rations were uniformly of good quality and well cooked. At the time these inspections were instituted vegetables
were issued freely to counteract the tendency to scorbutic manifestations among the prisoners, and these issues
appear to have lieen kept up to the end.
The camp was jireserved in an excellent state of police. All cleaning was completed before 9 A. M., at which
time the iirisouers formed line in their respective divisions and were inspected by the provost marshal. To supple-
ment the sinks, boxes were in use for the convenience of the prisoners during the night. These were removed in the
early morning by the police parties.
At the suggestion of Surgeon Thompson nine hospital wards of sixty beds each were built outside the stock-
ade; they were reported finished on October 30. There were in addition one hundred and twenty hospital tents
floored with lumber and fitted up with hospital beds. Wards were set apart for the treatment of measles, small-pox
and erysipelas. These, with a full stall' of medical oHicers and attendants and ample supplies of medicines and medical
comforts, were provided for the cure of the prisoners when sick and as a relief to the wards of the Hammond Hospital,
which, however, continued to keep its doors open for the reception of prisoners when, as was usu.ally the case, the
prison-hospital failed to accommodate their number. On December 18 Surgeon Tho.mp.son insisted lui the necessity
for increased hospital facilities, but no action was taken on this recommendation as the Hammond Hospital at all
times acted the part of a prison-hospital.
Occasional remarks on the reports of the provost marshal by Brigadier General James Bitrne.s, cununandiug
the prison-camp, testify to the existence of a uniformly satisfactory condition of affairs. "I have," he s.ays on the
report of November 6, "nothing particular to add to the statement of the inspecting officer except my general
testimony to the kindness manifested by the different officers connected with the duties of the government and
discipline of the camp. Fortunately the general good conduct of the prisoners renders unnecessary any act of
severity towards them, and is at the same time sufficient testimony as to the mode of their treatment."
The following extract from a report of Assistant Surgeon J. C. McKee, U. S. Array, dated .July 1, 18ti2, shows
the insanitary conditions at one of the minor or temporary prison-camps — that established near Springfield, Illinois:
" Camp Butler, Ii.unols, is situated on the Great Western Railroad, six miles from the town of Si)ringfield.
The camp is established on a rather high and rolling piece of ground, surrounded by a high board fence, enclosing
some fifteen acres of land. It was originally intended as a camp of instruction for volunteers. The barracks were
built for two regiments. They are mere shells, single boards forming the sides and roofs; the sides very low, about
eight feet in height ; the roofs covered with tarred paper. Erected by contract they afford protection neither
from storms nor heat. During this month the thermometer has been steady at 102° for days in my own room. The
effect of such intense and continued heat on the sick and well in these miserably constructed barracks has been
prostrating in the extreme. Tho prisoners of war, over two thousand in number, occupy the rows of barracks on
the right ; in front of these there are two rows of tents on a main street also occupied by them. Four of the bar-
racks in this row are used as hospitals, part of another as a drug store. A line of sentinels surrounds all, leaving
ample room for the prisoners to exercise; but they are generally indifferent to this and to their personal cleanliness.
Two other hospitals outside of these lines are now allotted to convalescents on account of the shade. On my
arrival here in May I found the hospitals, six in number, in a miserable sanitary condition. No one had taken
the authority or trouble to better this. The floors were filthy; deodorizing agents were not thought of; slops and
AMONG CONFEDERATE TROOPS IN U. S. PRISONS.
61
liltli wore thrown imli8crimiuately around. Tho sick were crowded in wooden bunks; some on tlie tloor, many
without blankets, and nearly all without straw, either new or old. No attentiou was paid to ventilation or drain-
age. Tho stench of the wards was horrid and siekeninj;. Food was abundant but badly prepared; niedioiues were
delieient. The stewards were ignorant ami negligent of their business; the nurses and cooks insubordinate and
inattentive to the wants of their sick companions. The condition of the prisoners, many of whom had been brokeu
down in service prior to their capture, ojjened a favorable and unlimited (ield for the develoi>meiit of low types of dis-
ea.se. and accordingly typhus aud typhoid fevers, pneumonia, erysipelas, etc., raged, with violence and great fatality.
To carry out my ))lans of improvement reciuired much explanation and persuasion. I was successful in what
1 undertook for the comfort of these unfortunate sick. Floors were scrubbed; lime applied freely on the walls and
Hoors; ventilation aud drainage attended to. A fever hospital (making seven) was established; another hospital
was used for pneumonia ; another for erysipelas. The surgeons (i)risoner8 of war) were assigned to their own
hospitals : stewards and nurses were encouraged to emulate each other in the cleanliness of their wards — all
with tlie happiest etfects. Cooks were supplied with necessary kitchen furnifuro; barrels were procured for slops;
water was furnished in abundance for the sick: wards were limited to the number of 30 patients. The hospital
fund procured many necessary articles such as ice. The Medical Purveyor at Chicago sent nu' a full supjdy, according
to the Standard Supply Table, for six months. A drugstore, under an excellent druggist, was established. A(iuantity,
surticient for a change, of shirts, drawers and sheets was obtained from the Quartermaster; fresh straw and lied-sacks
were also secured. Ihider these changes the ditl'erence in the mortality of my hospitals was remarkable and exceed-
ingly gratifying. During the month of May one hundred and twenty-three died, whilst in June only thirty died.
Of twenty-four ea.ses of camp fevers (typhus) four died ; of fourteen cases of tyjihoid two died; of thirty-
three cases of coninion continued fever two died. In two cases 1 was unable to diagnose whether they were typhus
or typhoid until after a post-morteni examination. The former disease was sudden in its attacks; in two cases
the patients died on tho third day. Ammonia, tonics and stimulants had to be used in large quantities. One case
(I thought of fatal relapse) was saved by blistering the whole length of the spine with ammonia and liiustard.
Typhoid or enteric fever was treated much in the same way, with the addition of oil of turpentine, of which I cannot
sjieak too highly. Quinia had to be employed freely among these nu>n in nearly all diseases. They generally come
from miasmatic districts. I can speak with the highest satisfaction of the use of muriated tincture of iron in the
treatment of erysipelas; alternated with quinia it-coutrolled the disease in all its forms. I found local ap))lications,
as of iodine and nitrate of silver, unsatisfactory in their results, not controlling the spread of the di.sease. I
abandoned their use and applied emulsion of flaxseed, saving pain and trouble to my patients. The two fatal cases
reported were complicated with other diseases."
Having obtained from this investigation of the reports of the medical inspectors some
idea of the unhygienic surroundings of the prisoners at these dep6ts, the following table,
contrasting their mortality-rates from all diseases and from certain prominent classes of
disease, may be consulted with advantage:
Table XXI.
Comparing the Annual Sichiess and Mortalily from certain Specified Diseases at the Principal Depots
for Rebel prisoners.
Name of Prison.
Camp
Douglas,
Alton,
111.
Rock
Island,
IlL
Camp
Morton,
Ind.
Johnson's
Island,
Ohio.
g^»P Elmira,
Fort
Delaware.
Del.
Point
Lookout.
Md.
All these
depots.
Anonal sick-rate per 1,000 strength . . .
3,757
lo.ora
1,575
1,485
811
i, ■. .. 1.544
3,549
2,471
2, 997. 6
Annual death-rate from —
Continued Fevere
19.2
12.7
36.7
3ai
2.1
70.7
24.5
62.0
188.0
80.2
2.1
96.6
6.4
6.1
51.0
42.5
1.6
46.4
7.0
19.9
14.3
52.8
1.0
82.5
5.9
2.3
3.8
10.5
0.0
5.7
10.4
6.7
71.6
44.6
1.0
188.6
21.2
9.9
58.9
211.5
3.0
117.3
12.7
14.2
38.5
32.4
7.7
32.7
12.3
9.2
18.9
116.3
9.5
23.7
13.6
12.6
42.3
rj.0
4.3
61.7
Diarrhtea and Dysentery
Scurvy '.
AU diseases
314.5
509.4
186.1
196.8
35.4
34a a
444.1
179 1
snfi. fi
o-ui 4
[ Percentage of &tal cases
5.7
5.0
11.8
13.2
4.4
7.2
sas
.5.0
8.4
7.7
Annual death-rate from disease per
1 1,000 men admitted.
44.1
55.0
98.0
46.7
9.8
75.2
241.0
45.4
46.4
6a 7
62 SICKNESS AKD MORTALITY
The average death-rate from disease, 230.4 annually per thousand prisoners present,
was exceeded at the three depots, Alton, 111., Elmira, N. Y., and Camp Chase, Ohio. At the
first named of these prisons the high rate of 509.4 annually per thousand, calls for special
inquiry into the conditions that produced it. Excepting scurvy, every one of the diseases
mentioned in the above table had at this post a death-rate higher than among the prisoners
generally. The exception suggests that here the inmates had a better and more varied
diet than was served at prisons where the death-rate from disease was below the average,
as at Fort Delaware and Point Lookout; the diet, at least, was apparently not responsible
for the great mortality. This large death-rate seems at first sight an argument against the
use of permanent brick or stone buildings, like this convict prison, as depots for the safe-
keeping of prisoners of war. The annual rate from the eruptive fevers, 188, as against 42.3,
the average among the prisoners in all the depots, miglit be held as illustrating the ravages
of small-pox when such close ill-ventilated buildings become infected. The death-rate for
the continued fevers, 24.5, nearly double that of the same fevers among the prisoners as a
whole, might be regarded as further testimony to the influence of crowd-poisoning within
substantial walls as compared witb the influences developed by similar crowding in tents and
cheaply constructed wooden pavilions. But when it is observed that malarial fevers also
were largely more fatal than at any of the other depots, although the penitentiary was on a
high, di-y and well-drained site, it must be concluded that the facts, so far as presented, do not
include everything bearing upon the mortality-rate per thousand of strength at this post.
The vast number of cases, 10,072, taken sick annually at Alton in an average strength of
1,008 men, equivalent to ten entries on sick report per man during the year, also requires
explanation. This is found in the fact that the strength present was not a settled population ;
it consisted of constantly varying elements. Detachments of prisoners were receiv^ed, bring-
ing with them their sick to augment the sick report, while generally only the well men,
those fit to travel, were exchanged, released on oath or enlisted into the service, the sick
remaining to swell the mortality lists of the post. The number of persons committed to
this depot was 9,330, and as the average strength was only 1,008, the stay of each prisoner
must have been of comparatively short duration. Practically the strength present was
changed 9.2 times during the period of its occupation as a military prison, or 3.2 times
annually. When the deaths are viewed in connection with these facts, Alton will be found to
have been by no means the terrible pest-hole suggested by the enormous rate of its cases to the
average of its strength, or bj- the annual demise of more than one-half of its population.
All the other depots except Fort Delaware and Johnson's Island had a larger percent-
age of fatal cases of disease than the Alton jienitentiary. The Fort Delaware rate of 5.0
per cent, equalled that of Alton; only at Johnson's Island was the rate of fatality smaller,
4.4 per cent. The ratio of deaths to cases among prisoners is, however, not of much value,
as uncertain numbers of slight cases were not taken upon the report. But when the deaths
are considered in relation to the number of persons who entered the penitentiary, the annual
rate of 55.0 per thousand will be found less than the average rate of all the prisons, 65.7 .
per thousand.
Alton may not, therefore, be considered as having been the worst specimen of our
northern prisons. On the contrary, but for the heavy mortality of its sraall-pox epidemic,
it would have compared favorably with any of the others except the depot at Johnson's
Island, Ohio.
AMONG CONFEDERATE TROOPS IN U. K. PRISONS. 63
Similar changes, to some extent, took place at all the other prisons; and their influence
must be considered in estimating the unhealthiness of these depots from the death-rates
expressed as ratios of the average strength present. A statistical table contained in a
report of the Adjutant General of the Army, appended to the Report of tlie Committee
on the Treatment of Prisoners of War, gives the total number of commitments to eai-h
of the prison depots: Gamp Douglas, 111., received 26,060 men; Alton, III, as already
stated, *9,330; Rock Island, III, 11,458; Camp Morton, Ind., 12,082; Jolinson's Island,
Ohio, 7,627; Camp Chase, Ohio, 16,335; Elraira, N. Y., 12,147; Fort Delaware, Del.,
25,275; and Point Lookout, Md., 42,762.*
When the deaths are calculated as annual ratios per thousand of these commitments,
the depot at Elmira, N. Y., and not that at Alton, 111., stands forth as the most insalubri-
ous of these prison-camps. Not only had it a high mortality-rate, 444.1 annually per
thousand of strength, but the percentage of fatal cases, 28.8, was more than double that of
any other depot. The latter rate, like the corresponding figures from tlic Audersonvillc
prison, gives no true expression to the ratio of deaths to cases, but it indicates sucii an
extensive prevalence of disease that only the serious cases, too often destined to be fatal,
were taken up on the registers of sick. The death-rate was equally high when viewed in
relation to the commitments, 241.0 annually per thousand, as compared with 55.0 at Alton,
or 65.7, the average of the prison-camps. Diarrlupa and dysentery, which caused more
deaths at this depot, in proportion to the strength present, than were occasioned by all dis-
eases at some of the other camps, and pneumonia, which produced a rate nearly double
that of the average of the prisons, were the diseases which gave Elmira its unenviable
notoriety. From the reports of the medical inspectors it is evident that while a large
mortality was undoubtedly referable to over-crowding, insufficient hospital accommodation
and insufficient protection from the cold of a northern climate in the earlier history of the
depot, the main influence underlying all these and raising them into strong relief, was the
broken-down condition of the men at the time of their commitment: most of them suflPered
from diarrhoea of a chronic character. Of the 1,394 deaths attributed to diarrlioja and
dysentery on the records of this camp, 1,376 were reported as from chronic diarrhoea and
only 6 from acute diarrhoea, 7 for acute dysentery and 5 for chronic dysentery.
Turning from the high rates prevalent at Elmira, it is a pleasure to point out the 35.4
per thousand of strength which constituted the annual niortalitj^-rate at Johnson's Island,
Ohio, its fatality rate of 4.4 per cent, of the cases and its 9.8 deaths annually for every
thousand commitments.
The absence of Confederate records showing the general condition of the mun on active
service deprives us of the ability of learning from that source their probable state of health
at the time of their capture. The few statistics presented in Table XIV indicate that the
Confederate sick-rate was considerably greater than that of the Union forces, and that
diarrhoea, dysentery and pulmonary affections, exceedingly prevalent in both armies, were
more prevalent among the southern troops. In Table XIII these diseases were observed
to yield at the same time a much larger percentage of fatal cases in the rebel ranks, the
deaths from pulmonary disease constituting as much as 18.89 per cent, of the cases as
compared with the federal rate of 2.34 per cent. The unbolted corn-meal, which formed
the farinaceous staple of the Confederate ration, was certainly a prolific cause of intestinal
* Op. cit., page 760 U seq.
64 SICKNESS AND MOKTALITY
irritation, especially in troops subject to the influence of strong predisposing conditions.
The high rates in pulmonary affections may readily be referred to the exposures of the
poorly clad and imperfectly protected southern soldiers during service in a northern and less
genial climate than that to which they were accustomed. No information is on file con-
cerning the prevalence of scurvy in their ranks; but that it was present to a greater extent
than among the federal troops may be taken for granted, in view of the liberal ration of
the latter, the efficiency of their sup}ily system and their greater facilities for purchasing
by j>rivate funds. It seems, indeed, highly probable that much of the scurvy reported on
the sick lists of the prison-camps affected the prisoners at the time of their capture. At
Johnson's Island, Ohio, where no death from scurvy took place, and where the abundance
and variety of the diet negatived the idea of its development in the prison, there were,
nevertlieless, fifty-eight cases reported among the inmates, most of whom were officers of
the rebel army. These cases must liave reached the island in the scorbutic condition
which necessitated their appearance on the sick list. And if scurvy affected the officers,
its presence to a greater extent among the men cannot be doubted.* To the better condi-
tion of the officers of the Southern army, as compared with that of their men when the
fortune of war consigned them to Johnson's Island, Ohio, must' be in great part attributed
the slight amount of sickness and mortality that affected them during tlieir detention.
They were subject to the same rules and regulations, and had the same ration as the pris-
oners in other camps. They had 300 feet of air-space in quarters, a more liberal allow-
ance than was commonly furnished; but, as will be seen directly, the niortality among the
prisoners generally cannot be ascribed to the limitation of bed-space.
The presumption is that, at the time of their capture, many of the prisoners were
suffering from diseases resulting from insufficient diet and from the exposures and continued
fatigues incident to the military movements preceding the disaster that brought about their
captivity.
But no doubt exists as to their condition on their arrival at the prison. This is recorded
by many of the inspecting oificers. In fact, "the debilitated condition of the men from pre-
vious hardships and exposures," or words of similar tenor are of frequent occurrence in all
reports relating to the sickness and mortality of the prisoners, as in those from Elmira already
noted. To this is sometimes added a reference to the depressed mental condition consequent
on their status as prisoners of war. Dr. Alben states very decidedly that the mortality from
diarrhoea and dysentery among the prisoners at Fort Delaware in July, 18G3, was almost
entirely confined to the men from Alabama, Mississippi and other southern states taken
by General Grant's army around Vicksburg. Most of these men arrived in a broken-
down condition, emaciated, and already the subjects of the disease for some weeks or
months, while at that time the prisoners from General Lee's army, also confined at Fort
Delaware, were in good condition. Dr. Alden's inference that the influences to which the
prisoners were subjected at Fort Delaware were not to be charged with the sickness and
mortality tlien occurring among them seems thoroughly sustained.
The following extract from a report on the sanitary condition of the depot at Hart's
Island, New York Harbor, dated June 21, 1865, by Geokge H. Lyman, Medical Inspector,
* Dr. JONES says : " Tlie large armies of the Confederacy suffered more than once from scurvy ; and as the war progressed, secondary haemon-hage
and hosi>ital gangrene increased to a great extent from tlie deteriorated condition of tiie blood, dependent on the prolonged use of salt meat; and bat for
the extra supplies received from home, and from the various benevolent State institutions, scurvy, diarrhtea and dysentery would have committed still
greater ravages." — TT. S, San. Com. Memoirs, p. 481,
AMONG CONFKBERATE TROOPS IN U. S. PRISONS. 65
U. S. Armv, is submitted as a special illustration of the point in question, while showing at the
same time that the insanitary influences affecting the prisoners at the smaller depots were
similar in character to those already described as characteristic of the larger prison-camps:
The chief cause of the mortality is to bo found in the fact that large numbers of the prisoners arrived at the
depot broken down, in advanced stages of disease, some in fact moribund, and others past all hope for treatment.
The New l!erne detachment, cajiturcd chiefly in the C'arolinas, were nearly all broken down on arrival. It is
said that less than IdO of them lould he considered as well men or even in fair health. The surgeon then in attcnil-
aiuc having been relieved, more preci.se information on this point is not now available: but it is certain that the
largest percentage of sickness and mortality occurred in that (letachment.
The largest proportion of deaths occurred from chronic diarrhcea brought with them, and pneumonia, which
began to apjiear a few days after their arrival. The men being poorly clad, the weather wet and cold, and the bar-
racks provided with no other bedding than such as the prisoners brought with them, the pneumonic cases developed
rapidly, and the reduced vitality of the patients favored a typhoid type of that disease, increased probably to some
extent by the crowded and unventilated condition of the barracks. These appear b_\'measurcment to have alforded
102 cubic feet of air-space to each man, and with no other ventilation than that allbrdcd by the doors and windows
on one side. Quite recently openings for ventilation have becii made upon the other side of the barracks, it consti-
tuting the outer wall of the prison enclosure.
The rations have been good and in the quantity ordered by the Connnissary General of Prisoners, which is
sufljcienlly liberal. The hospital r.ition has lu'cn such as is used in our own hospitals.
The drainage from the barracks is superficial but good. The sinks are outside the camp and over tiile-water.
The water for cooking and drinking is :vbundant and of excellent quality; it is derived from wells.
The prisoners have had access, under guard, to the beach, and have availed themselves of it freely for salt-
water bathing. They have also been rvquired to take daily exercise.
Over-crowding was regarded by the inspectors as the most serious of the insani-
tary conditions bearing on the prisoners during the period of their detention. But this
comprehended more than the mere limitation to so much dormitory space. Under it
were gathered all the evil consequences of suddenly assigning a large number of men to a
camp which had not been systematically arranged for their reception. The prisoners were
generally destitute of clothing and blankets, and one-tenth of them on arrival required
hospital treatment. The exposures consequent on their destitute condition speedily
increased the disparity between the hospital accommodations and the requirements of the
sick. The wards became crowded, and the more recently developed cases had to remain
in the still more crowded general quarters of the prisoners, lacking the comforts which tlie
hospital provided for its less unfortunate inmates, and adding grievously to the harmful
influences of the quarters containing them. Generally, also, healthful exercise was pre-
vented by the mud and dust begotten of the surface-soil by the tramping of many feet in
the ordiuaiy occupations of prison life. Defective police and inadequate arrangements for
the disposition of excreta rendered tKe external air in many places foul and sickening. A
hastily dug series of pits often emitted their polluted exhalations in close proximity to the
quarters, because if placed at a greater distance the sick men, especially at night, would
fail 1o reach them. The prisoners had foul air without and fouler air within their quarter.-*.
Under these circumstances the extension and aggravation of diarrhoeal cases, and the typhoid
type assumed bj' febrile diseases such as pneumonia,. naturally followed. The evils directly
referable to the commitment of an excess of depressed, debilitated and destitute men to a
given camp were the causes of the large sick and mortality rates that prevailed. Over-
crowding, as restricted to a limitation of bed-space, was a concomitant but minor evil, as it
alone would have required some time to produce its typhous effects.
Without exception, the officers in charge of these camps and hospitals, and the medical
inspectors in their monthly rounds, recognized the conditions in fault; and their earnest
efforts at improvement are worthy of all commendation, since they saved many lives to our
re-united country and preserved our annals stainless.
Med. Hist., Pt. Ill— 9
66 SICKNESS AND MORTALITY
The history of each of these camps shows at first a jieriod of overwork, anxiety and
grave responsibility on tlie part of the officers in charge when their failure to provide for
the urgent necessities of the occasion would have been attended with disastrous results.
In no instance does it appear that the food-supply was at any time deficient; but clothing,
bedding, shelter and kitchen utensils for those who were well, and hospital accommodation,
supplies and comforts for tliose who were sick, had often to be provided at short notice and
under various difficulties. Hospital clothing was issued to the destitute until the arrival of
authorized su2;iplies. Tents were obtained for use until barracks were built. Barracks
were used as hospitals until special buildings were erected. Sinks were dug for the excreta
until some less objectionable method of disposal was planned and carried into effect.
Trendies were opened for drainage until a covered system was provided. Nor did the
improvements end when all were sheltered and fitted out with comparative comfort. New
barrack buildings were constructed after improved plans, and the old were destroyed or
retained to increase the available air-space. New hospitals with better conveniences
replaced the old, which became converted into increased barrack-room. Lavatories and
baths and the accessibility and abundance of the water-supply for flushing and other pur-
poses received attention. In fact, from the establishment of the prison-camp until its disuse
at the close of the war, the improvement of its sanitary condition was progressive and
uninterrupted.
The sites selected were usually such as were considered healthy; that at Elmira liad
been used from the beginning of the war as a recruiting depot, and the twenty barrack
buildings formerly occupied by the recruits formed the nucleus of the prison-camp, — nor was
this a solitary instance of the kind. The bed-space allotted to each man in c^uarters was
sometimes less than one hundred cubic feet, as at Fort Delaware where three tiers of bunks
ran along each wall of the pavilion separated by a central or median aisle. Over-crowding
to this extent was, however, not confined to the prison-barrack buildings. The wooden
shelters built for the Union regiments at depots which were considered permanent were
fitted up with similar shelves. The experiences of the war educated our people in sanitary
matters. At an early period of its progress medical inspectors urged, with some hope of
success, a reduction of the bunks to two tiers in the prisoners' quarters as well as in those of
our own troops. Their request must not be esteemed a measure of what these officers con-
sidered needful. They did not ask for all they wanted, but only for what they might be
likely to get.*
That the mortality among the Confederate prisoners was due, as suggested above, to
other causes than the mere limitation of barrack-space, is shown conclusively by some of
the reports. In the summary of the sanitary history of Camp Chase a tabular state-
ment is given of the occupancy of the barrack buildings by the Confederate prisoners
and their Union guard, showing that the latter had an air-space of 150 to 210 feet and an
area of 12 to 15 feet per man, while the former had 137 cubic feet and 11.4 of superficies.
There occurred in January, 1865, while the buildings were thus occupied, 8 deaths among
1,683 Union troops, or 1 in 210, and 283 deaths among 7,583 prisoners, or 1 in 26.79; in
the following month the deaths among 6,414 Union soldiers numbered 36, or 1 in 178,
while of 8,259 prisoners 495 died, or 1 in 16.68. These enormous differences in the death-
rates cannot be attributed to the comparatively trivial differences in the air-space.
* The double-tiered buuk was not finally expelled from its last retreat in a western military pust until ten years after the war.
AMONG COKFEDKllATE TROOPP TN IT. s. PRISONS.
67
Small-pox followcJ diarrhoea, dysentery and jincuinonia in order of importance as a
cause of death among tiie prisoners, having occasioned 32.1* of the 230.4 deaths that
occurred annually from disease in every thousand of the average strength presunt. Nothing
is on record concerning the prevalence of this disease in the southern armies. Table XITT
shows that among the unknown number of the Confederate forces there were up to Decem-
ber, 1862, 44,438 cases and 2,274 deaths from the eruptive fevers, as compared with lowrr
figures amonof the certainly larger number of the Union troops. But these statistics iiudude
measles, etc., as well as small-pox. Nevertheless its frequent occurrence among them
may be inferred in view of the fact demonstrated by its ravages in the prisons, — the
insufficiency of their protection by vaccination. Certainly in some instances it was appar-
ently introduced into the prisons from the Confederate ranks. The eruption is reported
as having broken out on some of the prisoners within a day or two after their arrival at
the depot.
Our medical officers appear to have faced the emergency with spirit, isolating, some-
times with difliculty, as at Rock Island, and protecting by vaccination, also with difficulty
sometimes, as at Camp Douglas and Alton, until the scourge was controlled. In reporting
the condition of Camp Douglas in June, 1864, Dr. HrMPiiREYS says:
Of tlKi.se prisoners who have heen vaccinated in inison with vims tlial prcxliiced no liad cllectH in Ignited States
tr<»i]>s, l)()8 have healed tardil.v, while 912 vaccinated are surteiing fiom jiliagedenic or indolent or irrital)lo ulcers.
This ditt'erence in the results from the use of the same virus in federals and rebels must be attributed to the cachectic
aiul scorbutic condition of the latter.
In a report for January, 1863, Dr. AVall, the surgeon in charge at Alton, remarks as
follows :
Epidemics both of small-pox and erysipelas visited us, the former with fearful violence, and what rendered it
very unfortunate for us, the vaccine virus that we obtained from St. Louis, Mo., proved worthless, — thus rendering
abortive for a while our attempts to stay its progress by vaccination. I am confident that if we had been successful
in procuring good virus we would have modified the epidemic to a ver.y great extent.
Tlie probability of a marked scorbutic taint in the southern troops has already been
suggested as accounting for much of the sickness and mortality directly charged against
scurvy by the prison records. The ration furnished by our Government to its prisoners of
war was more liberal in its quantity and variety than that issued by'the Confederate Gov-
ernment to its soldiers on active service. Other things being equal, scurvy was therefore
more likely to affect them before than after their capture.
The Confederate ration, in accordance with Army Regulations, consisted of;
Three-fourths of a pound of pork or bacon, or one and one-fourth pounds of fresh or salt beef; eighteen ounces
of bread or flour, or twelve ounces of hard hread, or one and one-fourth pounds of corn-meal ; and at the rate, to one
hundred rations, of eight quarts of peas or beans, or in lieu thereof ten pounds of rice, six pounds of coffee, twelve
pounds of sugar, four quarts of vinegar, one and one-half pounds tallow, or one and one-fourth pounds adamantine,
o. one ]K)und of sperm candles; four pounds of soap, and two quarts of salt. On a campaign or on marches, or on
hoard transports, the ration of hard bread is one pound. * ' * When the officers of the medical department find
anti-.scorliutics necessary for the health of the troops the commanding ofiicer may order issues of fresh vegetables,
pickled onions, sour-krout, or molasses, with an extra i|uantity of rice and vinegar. (Potatoes are usually issued at
the rate of one pound per ration, and onions at thc^ rate of three bushels in lieu of one of beans.) Occasional issues
(extra) of niola.sses are made — two quarts to one hundred rations — and of dried apples of from one to one and one-
half bushels to one hundred rations.
During the early period of the war, when the full ration was issued, scurvy was com-
paratively rare. At later dates the supply department became unable to furnish coffee;
corn-meal had to be largely substituted for wheaten bread or flour; fresh beef was irregu-
* See Table LIII, p. 02'J, infra.
68 SICKNESS AND MORTALITY
larly supplied, and the issues of rice, beans, molasses, vinegar, potatoes, dried apples and
vegetables generally were diminished in frequency and in quantity. Scurvy appeared in
consequence, manifested, according to Dr. Jones :
In the frequency of night-blindness, in the numerous accidents after vaccination, in the increase of secondary
haemorrhage and liospital gangrene after ■nounds, as well as in the actual manifestations of tlie disease, indisjjosition
to exertion, spongy gums, uncertain and ill-defined muscular pains, and obstinate diarrhu>a and dysentery.*
The Subsistence Department of the United States Army allowed the same money
value for the subsistence of the Confederate prisoner of war as for the Federal soldier.
In other words, the ration allowed to the prisoner was the same in all its parts as that
allowed fo the United States volunteer. But the experience of our army had demonstrated
that the troops seldom consumed the whole of their ration. Arrangements were therefore
made by which the money value of the unconsumed portion accumulated in the hands of
the subsistence officers, forming a fund by which the diet of the men might be varied by
the purchase of articles not kept for issue by the subsistence department as a formal part
of the ration. A surplus of bacon or coffee could by this means become converted into
fresh vegetables if needful for the health of the command. Cooking utensils and articles
of mess-furniture for the comfort and convenience of the men were also authorized to be
purchased with this fund. A similar system was adopted at the hospitals, and milk, eggs,
chickens, oysters, fruit, vegetables or other articles not issued by the subsistence or medical
departments of the army, and needful for the use of the sick, were obtained by means of
the money value of the bacon, flour, coffee or other articles of issue which they did not
consume.
This system, in use in the forts and garrisons of the United States, was extended to
the prison-camps and their hospitals. The Commissary General of Prisoners published
from time to time the articles and quantities to be issued for consumption by the prisoners,
and the difference between the money value of the ration thus issued and that of the full
ration allowed by law to the United States soldier was set aside as a prison fund for the
purchase of such articles as were necessary for the health and comfort of the prisoners, and
not expressly provided for by the Army Regulations.
The saving on the ration was the chief but not the only source of the prison fund.
The sutler or camp-trader was taxed a small amount for his privilege of trade, and this tax
made a part of the general fund, as did also all current money left by deceased prisoners
of war or accruing from the sale of their effects, and all current money clandestinely for-
warded to prisoners or found concealed by them.
The following table shows the ration in kind allowed to the prisoners by circulars of
the dates mentioned from the olBce of the Commissary General of Prisoners, together with
the full ration of the United States troops at the same dates, and the difference in the
value of the two rations credited to the prison fund. Prior to April 20, 186-4, no specific
instructions were published limiting the quantities of the constituents of the ration to be
issued, but commanding officers of prison-camps were directed to withhold from the ration
all that could be spared without inconvenience to the prisoners, as a basis of a fund for
their benefit. After the establishment of a special prison-issue, commanding ofiicers were
authorized to report to the Commissary Genei'al of Prisoners, if at any time it seemed
advisable to them to make any change in the scale :
*jilein. V, 5. SanUani Oymmimon^ p. 624.
AMONG CONFEDERATE TROOPS IN U. S. PRISONS.
09
Pork or biicon, or
Fresh or Milt beef
FU<iir or bn-ail (soft ), »ir
Iliircl brenti, nnd
Com-ineal
To eacli 100 mt'ions : —
Beans or peas, and i.
Rice or hominy
(■olTee. preen, or
Coffee, roasted nnd ground, or...
Tea
Sugar
Vinepir
CandU'S. udaninntino
Soap
Salt
Molasses
Potatws (fresh)
Pepper
PmsoxKiis OF War.
April 20,
1864.
10 oz.
1-1 oz.
18 oi.
14 oz.
l.« ciZ.
6qt8.
^• Ib.-^.
7 lbs.
.5 lbs.
18 02.
14 lbs.
June 1,
1864.
10 oz.
14 oz.
16 oz.
14 oz.
ir. oz.
19i lbs.
H lbs.
...(*)..
...(♦) .
'.! <|ts.
Employed on
public works.
Juno 13, 18li4.f
Average cost price cts . .
Credit i>€r ration to prison fund ots. .
') candles.
4 lbs.
2qts.
Iqt.
30 lbs.
16.48
9.76
4 lbs.
3} lbs.
13.63
12.61
12 oz.
16 oz.
18 oz.
16 oz.
ll^OZ.
14 lbs.
10 lbs.
7 lbs.
5 lbs.
16 oz.
12 lbs.
3 qts.
PKISONKKS 01' Wau.
U. S. Troops, 1864.
4 lbs.
3} lbs.
Iqt.
30 lbs.
90.31
5.93
ISoz.
20 oz.
23 oz.
16 i.z.
20 uz.
8. Its. (!,•, Ibs.l
in lbs.
II) lbs.
.- lbs.
i; U.S.
1.') U.S.
4 qts.
14 lbs.
4 lbs.
33 lbs.
1 gall.
100 11)8. three times
a week.
January 13,
1865.
10 oz.
14 or..
It;../..
Ill oz.
I(i c.Z.
12J lbs.
8 lbs.
. () .
.. I*) . ..
. I )
...(•)..,
2 qts.
2 lbs.
2 lbs.
16.81
10.92
Employed
on public
works.
19 o«.
ir.uz.
llioZ.
12 oz.
18 oz.
l."i lbs.
Ill lbs.
7 lbs.
.1 lbs.
1 II.,
12 lbs.
3 qts.
4 lbs.
3% lbs.
24. 90
3.53
1-. S.
Troops,
I8li5.
12 oz.
2(1 oz.
18 o/..
12 oz.
20 oz.
l.'i lbs.
10 lbs.
10 lbs.
8 lbs.
li lbs.
15 lbs.
4 qts.
IJlbs.
4 lbs.
3] lbs.
* .Sugar and coffee or tea were issue<i to the sick and wounded only, every other day, on the recommendation of the surgeon in charge, at the rate
of twelve jH.unds of sugar, five pounds of gnnuid or seven pounds of green colTee or one pound of tea, to every hundred rations.
t Prisoners employed on public works other than the proper police duties of their camps were allowed, if mechanics, ten cents per day, anil if
laborers five cents per day, from the prison fund, which allowance was authorized to be paiil in tobacco to those who preferred its expenditure in that way.
Dislmi-.scments cliarf^i'd against tlie prLson fund were made l)y the Commissary of Subsistence on the order of
the eoiimiaiiiliiif; orticcr, and all siuh ex]ienditiuvs of funds were accounted for liy the commissary on his monthl,y
statement of the prison fund, showing the issues made and the articles and (jnantities purchased, the prices ])aid,
the services rendered, etc. .\inong the articles authorized to be purchased by this fund were all table furnidire and
cooking utensils, articles for iiolicing puri>oses, lied-ticks and straw, and the means of improving or enlarging the
liarrack accommodatioiis. F'.xtra pay was allowed from it to clerks who had (charge of the camp post oltice, who
ke]it tlie accounts of moneys deposited by tlu' prisoners with the commanding otiicer or who wen' otherwise engaged
in lal)or8 connected with the ]>risoners.
The hospital fund accumulated from tlie savings of the ration of the sick men was disbursed on the recom-
mendation or rei|nisition of the surgeon in charge, approved by the commanding officer. It was kept .separate from
the fund of the hospital for the troops. Disbursements from it were cliiefly for the purchase of articles of diet, but
when the fund was sutticiently large, it was permitted to bo expended for shirts and drawers for the sick, the expense
of washing clothes, articles for policing pnrposes and all articles and objects indispensably necessary to promote the
sanitary condition of the hospital.
Clothing was not charged against the prison fund. The commanding otficer. through his (inartermaster, made
re(|nisition on the nearest depot for such clothing as was absolutely necessary for the prisoners, and the papers wore
submitted for the approval of the Commissary (ieneral of Prisoners. The articles when furnished were issued by
the quartermaster under the supervision of an oHicer detailed for the purpose, whose certificate that the issue had
liecii made in his presence was the (|iiartermaster's voucher for the clothing issued. From Ajjril .SO to October!
neither draw<'rs nor socks were allowed except to the sick. When army clothing was issued the buttons and trim-
mings were removed and the skirts cut short to prevent those wearing such articles from being mistaken for United
States soldiers.
The efficiency of the ration allowed the prisoners of war deiieiidecl, as in the case of
United States troops, on the method of its management, and on the market price of vege-
tables in the neighborhood of the camp. The portions of the ration issued were certainly
70 SICKNESS AND MORTALITY
insufficient to prevent the appearance of scur-vy, for that disease was manifested among our
own troops on the full ration during the war, and has been observed since the war at west-
ern posts where vegetables were scarce and correspondingly high-priced. Assuming the
ration as issued to have contained a sufficiency of the nutritive elements to repair the
waste generated by the internal work of the body and the slight amount of outward mani-
festations of force exerted by the prisoners in their enforced confinement, the want of variety
in the diet would in time have produced a distaste for the food and developed the scorbutic
condition. Their protection from this depended on the proper application of the prison
fund. Every guard was apparently placed on the expenditure of this fund. The subsist-
ence officers purchased only on the approval of the commanding officer, and their action
was reported in detail at monthly intervals to superior authority. Inspecting officers
usually devoted particular attention to the condition of the prison and hospital funds and
the details of their expenditure. In many of the reports the extra articles of diet pur-
chased during the month are itemized; in others, when a scorbutic tendency was detected,
larger purchases of such articles were recommended. Generally, however, the issued
rations supplemented by the purchases were considered by these able and impartial officers
as an ample provision against the scorbutic taint. It may therefore be concluded that had
the prisoners been healthy on their arrival, instead of broken down physically by previous
hardships and depressed mentally by present conditions and anxieties, their sick and mor-
tality lists would have been no more burdened with scorbutic cases than were those of our
own men who underwent the strain of active' service upon the same allowances.
In summing up the results of this study of the inspection reports of the prison depots,
it may be said that the hardships and exposures entailed on the men by the military events
that ended in their capture were the main causes of the disease and mortality with which
they were afflicted during tlieir subsequent confinement. The hurried marches, want of
sleep, deficient rations and exposures in all kinds of weather, by night and by day, that pre-
cede and attend the hostile meeting of armies result in larger losses by disease than those
that are directly attributed to the engagement. And as the wounded of a defeated army
are more exposed to capture than the uninjured, so the exhausted and debilitated rather
than the vigorous become included in the li.^ts of prisoners of war.
Fatigues and exposures en route to the prison depots supplemented those already
endured in exhausting their strength and producing sickness. The prisoners seldom caj-ried
from the field a sufficiency of clothing and blankets to protect them from ordinary weather-
changes, and to tljese the journey frequently added changes of a climatic character.
The depression of spirits consequent on defeat and capture, the home-sickness of the
prisoners, the despondency caused by scenes of suffering around them, the gloomy and
vacuous present, and the uncertainty of the future, conspired to render every cause of
disease more potent in its action.
The sudden aggregation of these men at camps unprepared for their reception devel-
oped many insanitary conditions which combined with pre-existing causes in evolving sick-
ness and stamping it with a greater virulence. The most prominent of these were: the
temporarily defective police of the camp, which contributed to the spread of diarrhoea
and dysentery; the insufficient protection in quarters, which induced inflammations of the
respiratory organs and gave them a tvphoid character by the over-crowding; and the
insufficient hospital accommodation, which, in leaving the sick in quarters, tended to the
AMONG CONFEDERATE TROOPS IN U. t?. PRISONS. 71
development of new cases, or, in taking them into hospital, lessened the chances of recovery
of those already there.
But the evil intlaences exercised by the camp conditions would not have been followed
by the same sickness and mortality had the ground and shelters been crowded to the same
extent with well-disciplined troops awaiting the opening of a campaign. The broken
health and broken spirits of the inmates were the main factors in the production of disease
and death.
CHAPTER II. — INTRODUCTORY TO THE PRESENTATION OF THE CAMP
FEVERS.
The fevers which prevailed in our armies were reported at the beginning of the war
under the respective headings of ii/phus, typhoid and common continued fevers, remittent
fever and quotidian, tertian, quartan and congestive intermittent fevers. Each of these
names indicated, with more or less precision, a particular series of morbid phenomena. The
aggregation of symptoms which gave the disease in each instance its individuality might
be stated from an extensive personal knowledge of the clinical and pathological views held
by the medical men who dealt with these febrile cases, but this would be admissible only
in the absence of general and more trustworthy data. The lines dehning each of these
specially reported fevers might be drawn from the clinical records of the regimental and
general hospitals of the time; but the presentation and study of these must be made later
and in other connections. Nor is it necessary that this study should be attempted at the
present time, for the clinical and other facts implied by the titular diagnoses of our medical
men in 1861, in febrile cases, may be gathered from a brief reference to the important dis-
coveries concerning the non-identity of certain fevers which had been made some years
before, to the character of the fevers prevalent in this country at the outbreak of the war,
and to the volumes on practice of medicine which were furnished by the Medical Depart-
ment of the Army to its officers as books of reference.
Typhus and Typhoid Fevers. — Many observers from the time of Willis and Syden-
ham described epidemics of fever 'differing notably in their characteristics from those of
the typhus, which, under such names as pestilent, malignant, putrid, contagious, camp,
ship, jail and hospital fevers, prevailed from generation to generation as a well-known
scourge. These anomalous cases were afterwards named sloiu, mild, nervous fevers, or low
continued fevers; and their occurrence was considered due to some peculiarity of the
epidemic constitution from meteorological or other alterations in the condition of the
atmosphere.*
At the beginning of the present century it was stated by Frost, on the authority of
autopsical observations, that these fevers had their seat in the mucous membrane of the
•Sydenham suggested this peculiarity of the epidemic constitution as arising " from some certain secret and hidden alterations takinj^ place
within the bowels of the earth and pen-ading the atmosphere; or that, l>erhaps. it might chiefly depend upon some influence of the heavenly bodies."
Sydenham Sorictyt Sydtnliam, London, 1851), Vol. II, p. 191.
72 KEMARKS IXTKODUCTORY
intestine; and foi" some years afterward it was taught in the French schools that they were
essentially an enteritis. In 1813 Petit and Serres showed that the lower part of the
ileum was specially affected, and that the disease, thus differing in its site from an ordinary
inflammation, must be of a specific character. Bketonkeatj's observations in 1818-27
localized the inflaramation in the solitary and agminated glands, and demonstrated a want
of correspondence between the severity of the local lesion and the gravity of the general
symptoms. He regarded the disease as an internal exanthem, — dothienenterite.
Two years later, in 1829, the observations of Louis recognized the lesion of the
intestinal glands as the essential or characteristic of the specific fever which he described
as the typhoid affection. The profession in America became familiar with Louis' work
through Dr. Bowditch's translation published in 1836.
Meanwhile pathologists in England failed to discover the glandular lesions in their
fever cases except occasionally in such as presented some variations from the type of true
typhus. Bright in London, and Alison in Edinburgh, in 1827, reported cases in which
were found the intestinal lesions of the French observers. Thus, while the French
pathologists considered the glandular lesions essential to typhus as it occurred under their
observation, the British regarded them only as a comparatively rare and accidental com-
plication. These opposing views were reconciled by a demonstration, made in Philadelphia,
of the non-identity of the British and French fevers. At this time the continued fevers of
the United States were neither so contagious nor so deadly as those of Britain. In the pre-
face to his translation of HiLDEiSfBKAND on Contagious Typhus, published in 1-828, Prof.
S. D. Gross said of our so-called typhus: "Nor is it perhaps precisely of the same nature
and characterized by the same symptoms as the typhus of Europe." But Drs. Gerhard
and Penhock of Philadelphia, who had studied the typhoid affection under Louis, and seen
British typhus in London, recognized in the former the prevailing continued fever of their
own country, and were able to identify the latter when it appeared in an epidemic form in
Philadelphia during their service at the hospital Blockley. Their experience of this out-
break* established its identity with the contagious typhus of Britain, and showed the charac-
teristics which distinguished it from the familiar typhoid or dothienenterite. These were
the activity of its contagion, the suffusion of the eyes, the dusky-red color of the counte-
nance, the stupor, the petechial eruption and the absence of special abdominal symptoms,
together with the general progress of the individual case as manifested in the succession of
the symjitoms. In 1839 Dr. Shattuck of Boston insisted on the existence of two fevers
in London similar to those described in Philadelphia by Gerhard. His paper, read before
the Medical Society of Observation of Paris, was made the basis of an argument by M.
Valleix on the error of the English in confounding their fevers, one of which was identical
with the Parisian typhoid.
As a result of these investigations Louis, in the second edition of his work issued in
1841, recognized that the typhoid afll'ection of Paris was a different disease from the con-
tagious typhus of Britain; and in our country Bartlett in 1842 and Wood in 1847,
described typhus and typhoid as distinct affections. Some opposition was raised to these
new doctrines, but its influence was slight. Professor Dickson of Charleston, S. C, in his
Elements of Medicine jiublished in 1855, adhered to the view that fever had but a single
cause, and that the variations in its manifestations, which had given rise to such names as
* American Journal Medical Sciences, February and August, 1837.
TO THE CAMP FEVERS. 73
typhus (jrarior and mitior, putrid and nervous fevers, vcrcbral and abdominal f>/])J>us, were
due to variations in the intensity or concenti'ation of the poison and to influences exerted
on the condition or jiredisposition of the subject; as, for instance, where ochlesis gave to each
of the forms the character of putridity or malignancy. Tie quoted approvingly from
Campbell:* "It is undeniable that the two diseases are inseparabl}^ bound together in ties
of the strongest and most indissoluble, though mysterious affinity; the necessity which any
theory may involve of separating them is enough of itself to declare its absurdity."
Nevertheless he was constrained to treat of typhus and typhoid in his Elements under two
separate heads, in deference to the almost universal usage in America at the time.
Dr. Bartlett had already shown, in discussing the locality of typhoid fever, that it
was the common continued fever of our Easteru States, and that it occurred, although
{lerhaps with less frequency, in the West and Soutli, where interraittents and remittents
prevailed; but most of the instances cited by him were of epidemics occurring in towns.
Some years later Dr. Jas. E. Reeves brought prominently to the notice of the profession
the fact that enteric fever was of common occurrence iii sparsely settled rural districts as
well as among urban populations.^
The works on Practice of Medicine supplied to the Medical Department of the Army
in 1861 were those by Wood, J Watson|| and Bennett.§ In the first the distinction
between typhus and typhoid was clearly given, and the name enteric fever was suggested
in place of typhoid to era])hasize the distinction. Dr. Watson, influenced by Dr. .Tenner's
presentation of the arguments,^[ had recently subscribed to the doctrine of non-identity; and
in the volume under consideration be taught the notable differences which existed in the
symptoms and course of the two diseases, as well as in their comparative fatality and
exciting causes, regretting that the affinity of the names imputed a similarity in the dis-
eases, and approving Dr. Budd's suggestion to replace the name typhoid by intestinal fever .
In Dr. Bennett's lectures the views of .Tenner were given, but the author did not support
them. He recognized typhoid and typhus clinically, but considered them as "evidently
]iroduced by vajciations in tlie intensity or the nature of the exciting cause. "
It appears evident from these considerations that our medical officers, in identifying a
case of idiopathic fever ast}-plioid, liad well-deHned ideas concerning the aggregation and
sequence of symptoms to whicli this term should be applied. Of typhus they had practi-
cally no knowledge; but they had such conceptions of this disease and of the characteristics
which distinguished it from typhoid that, when a diagnosis of typhus was given, it neces-
sarily meant that the disease differed so materially in some points from the familiar typhoid
fever as to suggest that the unfamiliar typhus of Britain was under observation.
Common Continued Fever. — Many medical officers no doubt looked upon this a|)pella-
tive on the s-ick reports as an obsolete term. The studies and observations which developed
a knowledge of typlioid fever as a separate disease sliowed so many instances of obscurely
marked fever in connection with well-marked epidemics, that these lighter cases were con-
sidered due to the prevailing typhoid cause, peculiarities in its manifestations being
referred to variations in the individual constitution. Thus, while separating a specific
■ p. 28.'; (if bis KkmenU.
t In ih._' UufTalo MeUical Journal^ l&oG, and in a Practical TrealtM on Enteric Fever, Philadelphia, Pa., IS.'iD.
; .1 Treatise on the Practice of Medicine, by flEORGE B. Wool>, M. D., Philadclpliia, 1847.
II Vecturrx nn the Prinriplai awl Praclicr of Physic, by Tnn.MAS W.VTSOS, >I. !>., <di<«l by I>. F. CONIiIE, M. D.. I'liiludelphia, 1858.
§ Clinical lectures on lite Principles and Practice of Medicine, by J. HL'UI1C8 HEXNKrr, M. !»,, F. R. S. E. AniPnrun edition. Xpvv York, 1860.
U In Ihe Edinburgh Monthly Journal of Medical Science, Vols. IX and X, IB49-50.
Med. Hist., Pt. HI— 10
74 REMARKS INTRODUCTORY
typhoid from a specific typhus because individual or epidemic constitutional peculiarities
seemed insufficient to account for the notable differences in the average cases of each, they
liesitated to push the argument and thereby separate fevers of short duration, unaccom-
panied by typhoid symptoms, from the cases of fully developed typhoid fever. Others, on
the contrary, recognized in these febriculse or ephemeral fevers a distinct clinical entity, and
reported them as common continued fever irrespective of etiological considerations. The
unknown or suspected cause, whether conceived to bf the poison of typhoid or of typhus
modified in some way, a specific poison differing from these, or a non-specific irritant, had
no weight in the formation of the diagnosis. Dr. Wood recogni?ed an idiopathic fever
resulting from causes of irritation having nothing specific or peculiar in their mode of
operation — an inflammatory fever, tlie synocha of Cullen, but without any local lesion
other than an occasional slight inflammation of the fauces wholly insufficient to account
for the intensity of the general symptoms. Bennett and Jenner also recognized a febri-
cula, though differing in opinion as to its nature, the former considering it a modified
typhus and the latter an essential fever due to a specific cause. The clinical features of
the cases reported under the name of common continued fever may therefore be readily
appreciated.
Remittent Fever. — The paroxysmal fevers of the West and South were well known at
the outbreak of the war, even to those of the profession whose practice anterior to their
Tiiilitary service had been in non-malarious localities. The importance of these fevers, and
the national character of the great medical schools of the North, called for as thorough a
discussion of the malarial fevers as of those which constituted the common fever of the
North and East. The text-books gave prominence to the endemic fevers. The Amei'ican
edition of Watsons Practice contained an article by Dr. Condie on remittent fever to fit
the work for its new sphere of usefulness. The medical journals showed that the energies
of the profession were as much engaged on malarial disease as on typhus and typhoid.
The medical oflicer from the North was therefore well prepared to recognize malarial remit-
tents when presented to him, and perhaps better qualified than the southern practitioner to
recognize tlie to him familiar typhoid fever when occurring in the habitat of malaria.
Bartlett had shown that typhoid fever was to be found in such localities, and Wood, in
speaking of the diagnosis of enteric fever, called special attention to the miasmatic
remittent as one of the diseases liable to be confounded with it, especially when the remit-
tent was protracted or attended with 'typhus' symptoms. The figures, reported by our
medical officers during the war under the heading remittent fever, may therefore be
accepted as giving a fair expression of the prevalence of this form of fever. Mistakes in
diagnosis no doubt occurred, — remittent fever may have been recorded as typhoid,
especially when it assumed an adynamic form, and, on the other hand, typhoid may have
been set down as remittent in localities where the latter was endemic; this will be con-
sidered hereafter. It is sufficient for the present to know that the name remittent fever
was given to a definite and generally appreciated clinical picture.
hitermitting Fevers. — The intermittent^, including the congestive form, were usually
characterized by such marked and well-known j^eculiarities that the conditions indicated
by the diagnosis are easily understood.
On June 30, 1862, two changes affecting the method of reporting idiopathic febrile
diseases were made in the sick reports. The first involved the disuse of the term common
TO THE CAMP KEVKRS. 75
continued fever. No instructions were issued regarding the disposition to be made of such
cases as had heretofore been reported under this designation; but from what lias been
stated above concerning the tendency developed by the study of typhoid fever, it may be
assumed that many of the cases were thereafter reported under that heading while the
remainder may have found place under Other Miasmatic Diseases. During the year
endinc; June 30, 1862, when the term common continued fever was in use, there were
reported under it, per thousand of strength, 42 cases, 1.25 per cent, of which were fatal,
while under the term other miasmatic diseases there were reported only 27 cases, with .41
per cent, fatal. During the following year, when no special provision was made for the
classification of the cases formerly reported as common continued fever, the cases returned
as other miasmatic diseases rose to 50 per thousand and their fatality to 2.84 ]>er cent. A
lar^e number of the common continued cases may, therefore, iiave been returned under this
indehnite heading.
The second change consisted of the insertion in the reports of a new term, Tijpho-
malarial. The writer has not been able to find the report of the Board that recommended
these changes, and is, therefore, ignorant of the arguments which led to the abolition of
the one term, but Dr. Woodw.\rd has detailed the circumstances attending the introduc-
tion of the other.* In the autumn and early winter of 1861 the medical officers of the
army called attention to the fact that the camp fevers then coming under observation dif-
fered in many particulars from the enteric fevers which they had treated in civil practice
before the war.f A Board consisting of Surgeon A. N. McL.'VREN, U. 8. A., Surgeon G. H.
Lym.\n, U. S. Vols., and Assistant Surgeon M. J. AscH, U. S. A., was convened, December
16, to investigate and determine whether the fever then prevailing in the army was to be
considered an intermittent or bilious remittent fever in its inception, assuming in its course
a typhoid type, or a typhoid fever primarily. The board examined the fever in several of
the division hospitals of the Army of the Potomac. It communicated by circular letter
with many medical officers whose commands could not be conveniently reached. The
replies received, in their general tenor, confirmed the opinion which the board had formed
on the basis of its personal observation, that while a certain number of cases of ordinary
typhoid existed in the army, the large majority of the febrile cases were bilious remittent
fevers which, not having been controlled in their primary stage, had assumed that adynamic
type which is present in enteric fever. This officially pronounced adynamic remittent pre-
vailed extensively during the Peninsular campaign of the following year and was familiarly
known as Chickahominy fever. Dr. Woodward had served with the army in this cam-
paign, and had formed the opinion that these fevers were hybrid forms resulting from the
combined influence of malarial poisoning and the causes of typhoid fever, modified in
individual instances in accordance with the preponderance of one or tlie other of these
influences and occasionally by the presence of a scorbutic taint. At this time he was
detailed a member of a board to revise the form of sick report in use in the army, and
actuated by the strength of his opinions, he induced the board to recommend the insertion
of the term typho-malarial in the blank form for the monthly sick report as a suitable
designation for the complex conditions which he believed to be present in these cases. He
afterwards regretted that he had nt)t also urged upon the board the preparation of a circular
• Tuphomatarial Frrer : ft it a Special lyp< of Ferer } Philadelphia. 1876, pp. 10-12.
t Fur an illustration of the rhara<:ters uf the fevers occurring at Ih« time specified, refer infra, p.21G</ so]., to the admirable clinical records of the
Seminar}- Hospital, (leorgetown, D. C.
76 REMAKKS INTRODUCTORY
lettei' to accompany the new sick report, explaining why this term had been adopted, and
calling for special reports with regard to the cases whicli it was intended to designate.
This omission was indeed unfortunate, as it left the medical officers without a guide for the
use of a term not only of indefinite meaning but absolutely of double meaning. These
fevers, in accordance with the views then current, were either remittents with low or
typhous symptoms, or they were cases of enteric fever with accidental malarial complica-
tions. The uncertainty attaching, in the absence of the necessary instructions, to the value
of the first part of the compound word, permitted it to be used as a diagnostic title for both
of these series of cases. Indeed it was perhaps better suited to meet acceptance as a
designation for low remittents than for cases of true typhoid marked by malarial symptoms,
for tlie compound term tyj)hoid-pneumonia was familiar as a household word at the time,
and no meaning was conveyed by it involving the presence of the specific poison of enteric
fever. Nevertheless Dr. Woodward subsequently claimed that the prompt acceptance of
the term typho-malarial showed how widely the opinions he had formed were shared by
the medical officers of the army. But the sense of the profession cannot be thus construed
in sup})ort of the viev>^ of a 'specific enteric essential in the typho-malarial cases reported at
that time. During the month of July, 1862, the first month of the use of .the new term,
2,283 cases were reported, while Dr. Woodward's opinions were unknown except to a few
personal friends. Indeed his views were not published until the issuance, on September 8,
1863, of Circular No. 15, Surgeon General's Office, Washington, D. G. In this the mean-
ing designed to be attached to the term typho-malarial was for the first time made known
in the following words:
Moreover, while a certain amount of nnconiplicated enteric and remittent fevers certainly did occur, especially
at the commencement of the war, the vast majority of the camp fevers of the army were of a mixed character,
exhibiting undoubted enteric iihcnomena variously combined with the periodicity and other peculiarities of malarial
disease, and still further modified by the tendency to incipient scurvy, which is the ordinary concomitant of camp
diet. To indicate this mixed nature, the term typho-malarial fever, which I had the honor to suggest to the Depart-
ment in June, 1862, aj)pears appropriate, and, at the present time, is coming into very general use.
Up to the close of the month of August, 1863, shortly before the publication of this
circular, 27,399 cases of typho-malarial fever had been reported in a total of 49,871 such
cases during the war. In other words, more than one half of the cases were reported during
the fourteen months which intervened between the appearance of the term on the reports
and the publication of a casual reference to the meaning designed to be attached to it.
The nomenclature of the fevers as officially given in the army sick reports at the
lieginning of the war gave expression to species witli marked clinical distinctions. Uncer-
tainties attached to the etiology of the small percentage reported as common continued
fever, but the nature of the uncertainties was fully appreciated — and the segregatinu o(
the cases rendered them available for special study. The removal of this term from the
sick report complicated the statistics thereafter furnished by doubts as to the disposition
made of ephemeral and other febrile cases not distinctly typhoid. What proportion of
these were sent to swell the lists of typhoid, how many complicated with the eft'ects of
malaria were added to the typho-malarial list, and how many were dropped out of consid-
eration altogether by being placed among other miasmatic diseases, are questions wliich
constantly recur in studying the statistics of fever furnished after June 30, 1862. The
insertion of the term typho-malarial was also a grievous complication. The true value of
the statistics given under this heading can never be known in the absence of a complete
record of all the cases. Such cases as were reported with more or less of detail will be
TO THE CAMP FEVEKS. 77
presented hereafter, and tlie figures themselves, and tliose allied to them, will be examined
in this connection. In the meantime a consideration of the conditions under which the
diagnoses were made will show that clinically typho-malai-ial cases may have presented
great diversity, from the severe and jjrotracted remittent ending fatally with great prostra-
tion, low delirium, stupor and coma, and the equally severe cases .of typhoid fever ending
fatally in like manner, but with some modification in their progress from concurrent
malarial poisoning, to the mild enteric and abortive cases viewed doubtfully as typhoid,
and diagnosticated, when such diagnosis was officially admissible, as common continued
fever, yet recorded with propriety, in accordance with the views of Dr. Woodward, as cases
of typho-malarial fever, in the presence of indications calling for the exhibition of quinine
as an autiperiodic.
CHAPTER III.— ON THE PAROXYSMAL FEVERS.
I. — THE STATISTICS OF THE MALARIAL FEVERS.
I.— MALARIAL FEVERS AMONG THE U. S. FORCES.
Prevalence and Mortality. — During and immediately after the war, one-fourth
of all the reported cases of disease among the white troops was of a malarial character.
There were 224 cases of malarial fever in every thousand cases of reported disease. Typho-
malarial fever is included in this statement, as, irrespective of the views entertained con-
cerniug its typhoid element, its malarial factor was definitely recognized by all parties. It
seems proper, therefore, to consider it in a discussion of the prevalence of malarial disease,
although it may be needful to know more about it before its mortality can with propriety be
admitted to weigh in the scale with that due to the purely malarial fevers.
The simple intermittent constituted by far the greater proportion of these febrile cases,
2,003 cases per 1,000 of mean strength having been reported in a total of 2,814 of malarial
disease; in other words, a distinct peril "1 of intej'mission was recognized in five-sevenths of
the paroxysmal fevers. These figures represent only the number of cases in which inter-
mittent fever was the most obvious abnormal condition present. They by no means express
the extent to which this disease prevailed, even in that part of the army represented in the
statistical tables. As the system of reporting provided no method of recording complica-
tions, it very generally happened that cases of intermittent fever complicated with serious
diarrhoea, dysentery, pneumonia or other grave affections, were reported under the head of
these disorders without any mention of a co-existing malarial affection. But, although under-
stating the facts, the statistics convey a clear idea of the extensive prevalence of this form
of malarial disease. Out of 1,213,685 cases of malarial fever 863,651 were cases of
simple intermittent. How many of these were first attacks, and how many recurrences in
individuals already affected by the malarial influence, cannot be determined. It is probable
78 MALARIAL FEVERS
that the majority of the primary attacks are included in the number, for a soldier
who experienced an ague-fit for the first time was usually disposed to be alarmed at the
violence of tlie symptoms, and to seek medical assistance, even if the nature of the duties
required of him at the time was such as to render it needless for him to report for the pur-
pose of being relieved from their performance. On the other hand, it is certain that many
of the recurrences which took place were not reported. Men became accustomed to attacks
of this kind, and visited the dispensary after the paroxysm, not to report as sick, but
to procure a supply of quinine to prevent a return; even when on important duty which
they were incapable of performing during the attack, such men would he temporarily
excused by their company officers, the medical officer of the command remaining in igno-
rance of the recurrence.
In more than one-half of the agues the cycle of morbid j)henomena was completed in
twenty-four hours. Tertians folkiwed closely in order of iVecpiency. Quartans were com-
paratively rare, forming only one-twentietli of the whole number. Of the 2,003 cases of
simple interraittents occurring per 1,000 of mean strength among the white troops during
the five and one-sixth years covered by the statistics, 1,037 were quotidians, 870 tertians
and 96 quartans.
Congestive fever was fortunately of infrequent occurrence, it having furnished but 32
cases per thousand of strength, constituting 3 of the 224 cases of malarial disease which
were recorded in eveiy thousand cases of all diseases.*
Remittent fever gave 664 of the total of 2,814 cases of malarial disease wliich occurred
per thousand of mean strength, or 53 of the 224' malarial cases recorded per thousand cases
of all diseases. Excluding the typho-malarial cases, the 664 remittents formed part of
2,699 cases of pure malarial fevers which occurred in every thousand men of the command,
or 53 of the 215 pure malarial fevers recorded in every thousand cases of disease. In
simjjler figures, the remittents formed one-fourth or 24.6 per cent, of the purely malarial
fevers, and a little less than this, or 23.7 per cent, of all malarial fevers, including the cases
recorded as typho-malarial.f These typho-malarial cases, 115 per thousand of strength,
formed only 9 of the 224 malarial cases which occurred in every thousand cases of disease.
The deaths reported among the white troops as occasioned by malarial fevers num-
bered 12.199; but if to these be added a due proportion of the 42,869 deaths from
unspecified diseases, the number becomes augmented to 16,225. Of the 12,199 deaths
specially referred to malarial fevers, 4,059 were considered due to typho-malarial mani-
festations, 3,853 to remittent, 3,370 to congestive and 917 to simple intermittent fevers.
Although congestive fevers were infrequent and remittents formed only one-fourth of the
purely malarial fevers, the deaths from these forms of malarial aftection were in striking
contrast with those from the simple intermittents. The latter numbered less than 2 per
thousand of strength, and the former somewhat over 7 and 8 per thousand respectively.
Of 1,000 deaths from all diseases, 94 were caused by malarial fever, 31 of these being
due to typho-rnalarial, 30 to remittent, 26 to congestive and 7 to simple intermittent fevers.
In the last column of the table which follows is shown the light rate of mortality in
the intermittents, one death in every thousand cases of quotidian or tertian ague, and one
* The relative frequency of t}ie types of intermittent fever expressed as perrentu^es of tlie total number of intermittent cases which occurred in
each of the military departments will be found in Table XXXIII itifra, p. 98.
tTbe table mentioned in last note gives also the relative frequency of the forms of malarial fever expressed as percentages of the total number of
malarial cases which occurred in each of the departments.
AMONG THE V. ?. FORCES.
79
death in every five hundred of the quartans. The greater mortality in the last-mentioned
form is at variance with the opinion which regards the quotidian as an expression of a
higher degree of the malarial poisoning than is present in the tertian or quartan. Man}'
of these deaths might be passed to the credit of congestive fever, as the fatal result was
due to the occurrence of a paroxysm of an aggravated type; while others with equal pro-
priety might be transferred to remittent fever, as, although the case was intermittent
originally, and so reported, the fatal issue did not take place until after the fever had
assumed the remitting type.
Kemittent fever gave a fatality-rate of 1.31 per cent., or one death in 76 cases, and
congestive fever 24.65 per cent., or one death in 4 cases. But notwithstanding this high
rate of the congestive fevers, such was their infrequency as compared with the less dan-
goix)Us forms of the disease, that the deaths from the purely malarial diseases amounted
oidy to seven-tenths of one per cent., or, including the deaths from typho-malarial fever,
to one death in every hundred cases.
Table XXTI.
Statevient of the Frequency and Mortality of the several forms of Malarial Fever, giving the totals repoi-ted
from May 1, ISGl. to June 30, ISUG, with the ratio of eases to strength and to cases of all diseases,
and the ratio of deaths to strength, to deaths from all diseases and to cases of Malarial Fever.
WHITE TROOPS.
1
Dl.SEASE.
Xnmber reported
during the period
from May 1, 1861, to
June 30, 1866.
1 11 "3.2
Ratios per 1,000 ] §^
of strength. _-'3
't "3
^ X X
Deaths i)er 1,000
of deaths from
all diseases.
Percentage of
fatal cases.
1
Cases.
Deaths.
Cases.
1, 037
870
96
1
1
Deaths.
X X ^
» 2 5
2 S -~
O
Quotidian Intermittent
Tertian Intermittent
Quartan Intermittent
447,258
375, 170
41,223
452
381
84
.96
.81
.18
82
69
8
3.49
2.95
.64
.10
.10
.20
.16
24.65
1.31
Total simple Intermittent '.
Congestive Fever .
863,651
13,673
286, 490
917
3,370
3, 853
1
2,003
32
664
1.95
7.20
8.23
159
3
53
7.08
26.05
29.78
Remittent Fever
Total j)ure Malarial Fevers
1,163,814
49,871
8,140
4,059
2,699
! 115
i
17.38
8.67
215
3
62.91
:ii.:i7
.70
8.14
Typho-malarial Fever
Total Malarial Fever.s
1,213,685
12, 199
2,814
26.05
224
94.28
1.00
But although the mortality from these fevers was comparatively light, their influence
in detracting Trom the efficiency of the array must have been very great. We have no
means of ascertaining how manv men constantly on sick report would represent this loss,
nor can we learn how many were permanently removed from active service by discharge
on account of the pernicious influence of the fever-poison on the constitution. The statis-
tics show that 373 men were discharged for remittent fever and 480 for intermittent fever;
80
MALARIAL FEVERS
but when it is recognized that there were 2,224 cases in which dropsy figured as the cause
of disability necessitating discharge, 14,500 having debility as the nominal cause, and
25,915 in which tlie cause was not stated, we are left to speculate upon the influence whirh
these fevers may have exercised in the production of temporary and permanent disable-
ment to our armies.
The malarial fevers as they affected the colored troops are shown in the following table:
Table XXIII.
Statement of the Frequency and Mortality of the several forms of Malarial Fever, giving the totals reported
from July 1, 1S63, to June 30, 1866, toith the ratios of cases to strength and to cases of all diseases,
and the ratios of deaths to strength, to deaths from all diseases and to cases of Malarial Fever.
COLORED TROOPS.
Disease.
Number reported
during the period
from July 1,1863, to
June 30, 186G.
Rates per 1,000
of strength.
Cases per 1,000 of
. cases of all dis-
eases.
Deaths per 1,000
of deaths from
all diseases.
Percentage of
fatal cases.
Oases.
Deaths.
Cases.
Deaths.
Quotidian Intermittent
63, 992
51, 045
3,923
58
54
15
1,047
835
64
.91
.85
.23
106
84
7
2.11
1.96
.55
.09
.10
.30
Tertian Intermittent
Quartan Intermittent
Total simple Intermittent
118,960
2,536
30,645
127
794
1,002
1,946
42
501
1.99
12.42
15.67
197
4
50
4.62
28.88
36.43
.10
31.31
3.27
Congestive Fever
Remittent Fever
Total pure Malarial Fevers ...
152, 141
7, 529
1,923
1,301
2,489
123
30.08
20.35
251
12
69.93
47.31
1.26
17.27
Tvpho-malarial Fever
Total Malarial Fevers . .
159, 670
3,224
2,612
50.43
263
117.24
2.02
In comparing this table with that given for the white troops, it must be remembered
that while the latter includes the statistics of five and one-sixth years the former embodies
the records of onlv three years of service. If it be assumed that the rates of prevalence
and mortality which were found in these three years among the colored troops would have
prevailed liad the observations been continued for five and one-sixth years, the ratio of
cases per thousand of strength would have been 4,498 as compared with 2,814 among the
whites, and the deaths 86.88 as compared with 26.05, or, in other words, for every 100
cases occurring among a given number of white soldiers in a certain time, 160 cases would
have occui'red among the same number of colored troops in the same period, and for 1()(J
deaths from malarial fever occurring among the white, 334 deaths would have been recorded
in the same time among the same number of colored troops. This is definitely shown in
Table XXVI, where the sickness and deaths for lioth races are tabulated as annual averages.
But the element of time does not affect the comparative value of the figures in the
last three columns of the table at present under consideration. Thus the increased mor-
AMONG THE U. S. FORCES. 81
tality wliicli has just been indicated is in the last riiliuiin distrilnilcd among the various
forms of lever. Of 100 cases of congestive fever among tlie colored troops 31.31 died, or
1 in 3.2 cases, as against 1 in 4 among the whites; of the same numlier of remittent cases
3.27 died, or 1 in 30, as against 1 in 76 among the whites; of 100 typho-malarial cases
17.27 died, or 1 in 5.8, as against 1 in 12 among llie whites. The intiuencc of this
increased mortality in the more dangerous forms of malarial fever among the colored troops
was such that the percentage of fatality of the malarial fevers as a class among the colored
men is found to be as large again as that which obtained among the white soldiers: thus,
the purely malarial fevers gave a mortality of 0.7 per cent., or 1 in 1 13 cases among the
latter, and 1.26 per cent., or 1 in 79 among the former; while, if tvplm-malarial fever is
taken into consideration, its greater fatality among the blacks will be found to raise their
percentage of fatal cases to 2.02 as compared with 1.00 among the white troops. But
it may not be inferred from these facts that negro troops ai-e more liable t-o malarial
seizures, and more prone to succumb to the uialarial influence thai) white troops, until it has
been shown that both bodies of men were exposed to similar influences.
The tabulated statistics of malarial disease have reference solely to the fevers. It is
not possible to ascertain the actual number of men who suffered from chronic malarial
poisoning during the civil war. ]\[ost of them were undoubtedly reported under the head
of the intercurrent diseases which were developed iluring the progress lA' the cachexia.
Large numbers were registered as cases of general debility or other diseases of the mias-
matic order. Under these headings 101,892 cases with 1,981 deaths were reported among
the white troops, and 11,887 cases with 535 deaths among the colored troops; moreover,
there were 14.500 white, and 540 colored, soldiers discharged tlie service for debility.
Under the head of anaemia 21,892 cases, 438 deaths and 317 dis(-liarges on certificates
of disability were reported among the white troops ; 2,771 cases, 258 deaths and 35
discharges among the colored. Men broken down by the most diverse morbid condi-
tions were included in these figures; and although all who had opportunity of observing
large numbers of such (!ases during the war will testify to the frequeimy with which the
malarial cachexia occurred among them either as the chief morbid condition or as a com-
plication, there is no possibility of giving even an appro.ximate numerical expression of the
fact. It may be added that, according to the tables in the l/^rst Medical Volume, 1,977
cases, 17 deaths and 171 discharges on account of diseases of the spleen were reported
among the white troops, and 55 cases, 3 deaths and 3 discharges among the colored men ;
and although the majority of these cases were instances of malarial enlargement of the
organ, it cannot be supposed that the numbers represent any very considerable proportion
of the actual cases, which were usually recorded under other heads, such as intermittent
fever, debility and ansemia. Xur is it possible to determine the number of cases of malarial
cachexia that terminated in dropsy, though it must be believed that a large number recorded
as i/eneral dropsy, ahdominal dropsy, and dropsy from hepatic disease had this origin.
Under these headings 7,337 cases and 398 deaths were reporti.'d among the white troops;
and 2,224 men are said to have been discharged for dropsy. Under the same headings
1.127 cases, 272 deaths and 109 discharges were reported among the colored troops.
(.)f neuralgia, another manifestation of malarial poisoning, 58,774 cases were noted
among the white, and 0,018 among the colori'd troops. .\ number of these cases may have
Med. Hist., Pt. Ill— U
82
MALAEIAL FEVERS!
been due to malaria, but it i.s difficult to believe that the majority were so, for neither in
their geographical distribution nor in the season at which tliey were most pi-evalent do the
figures reported agree with the distribution of the reported cases of intermittent fever.*
The occurrence of malarial fever in connection with diarrhoea and dysentery has
already been shown.f
Annual variations in prevalence and mortality. — Turning now to Table XXIY, illus-
trating the relative frequency and mortality of these febrile affections among white troops
during the several years covered by the statistics, it is found that their prevalence increased
gradually to the fourth year, or that ending June 30, 1864, when the war maximum was
attained, diminished somewhat during the fifth year, and experienced a marked increase
during the sixth, or year succeeding the war. This marked advance to the fourth year,
and slight diminution during the fifth year, was due to the influence of the mass of the
intermittents on the figures representing the prevalence of the other forms; for both con-
gestive and remittent fevers were slightly more prevalent during the second year than
during any other of the years of the war.
Table XXIV.
Relative Frequeticy of cases of Malarial Fevers, and Deaths caused by them, during the several years of
the war and the year following the ivar, expressed in annual rates per 1,000 of mean strength.
WHITE TROOPS.
Diseases.
1860-1.
1861-2.
1862-3.
1863-1.
1864-5.
1865-6.
Cases.
Deaths.
Cases.
Deaths.
Cases.
Deaths.
Cases.
Deaths.
Cases.
Deaths.
Cases.
Deaths.
56.17
:>'). 63
10.25
144. 36
95.81
.11
.11
.01
les. 01
134. 23
16.07
.21
.18
.06
330. .51
210. 44
22.67
.17
.19
.03
221. 93
184.38
19.39
.21
.12
.03
364. 92
295.58
24.70
.32
.26
.01
Tertian Intermittent
1S6. 05
5.20
•>.=i-T 7q
.24
1.25
313. 31
6.45
.45
^ J. 55
463.82
6.16
.39
1.53
425.70
4.90
.36
1.12
685.20
8.20
.39
2 26
.Oi? 7 !':'
Total
131. 25
43.60
.02
260.78
143.26
1.49
1.28
319. 76
140. 38
2.00
1.76
469.98
114. 12
1.92
1.27
43a 60
127.84
1.48
1.86
693.40
159. 70
a. 85
2.57
174. 85
. 02 404. 04
2.77
460.14
38.00
3.76
1.78
584.16
18.93
a 19
1.71
558.44
22.91
3. -34
a. 27
853.10
16.62
5.42
254
Total Malarial Fevers
174.85
.02
404.04
2.77
498.14
5.54
60a03
4.90
581.35
. 5.61
869.72
7.96
The increased prevalence of malarial fever during the year succeeding the war was
probably due to the occupation of Southern and malarious territory by the army, and
the concurrent discharge from service of troops stationed in Xorthern and less malarious
sections. Although this increase is observable in all the forms of malarial fever, each
reaching a higher figure per thousand of strength than in any of the previous years, the
intermittents constituted absolutely and relatively its greater portion. As will be seen
hereafter in Table XXXII, the troops in the Department of Arkansas had the highest
malarial record, and among them intermittents Were relatively more frequent and remittents
less frequent than among troops in less malarious localities.
* See article on Neuralgia, infra, page 874.
tin the secoiui jiari ol tlii.s worli, pp. S87, 398, 495 and 637.
AMONG THE U. >s. FORCES.
83
Typlio-inalarial I'ewr, howrvcr, (liu-iag these years did uol follow tliu course of ihe
uiunodified malarial fevers. Its presence was not reported during the hrst two years,
einbrai't'd in Table XXIV. During the year-ending Juno 30, 1863, there were 38 cases
per thousand of strength. In the following j^ear, when malarial fevers were at their war
ma.ximum, typho-malarial fever fell off one-half, to 18.93, increasing slightly during the last
year of the war, and subsiding to its minimum when the pure malarial fevers were at tln'ir
maximum during the year succeeding the war.
In general the mortality of the malarial fevers increased with their increased frequency :
thus, in the year after the war, with 853 cases per thousand of strength thcrt^ were 5.42
deaths, while in 1861-2, with 404 cases the deaths were 2.77. J5ut in the typho malarial
fevers an increased mortality was associated with a diminished prevalence: in the year
1862-3, with 38 cases per thou.sand of strength, the corresponding death-rate was 1.78,
while in 1865-6, with 16.62 cases, the ratio of deaths rose to 2.54.
Similar results are obtained by an examination of the statistics from the colored
commands, as given in —
Table XXV.
Relative Frequency of Cases of Ilalarial Fevers and of Deaths caused by them among the Colored Troops
during tiro years of the tvar and the year following the icar, expressed in annual rates per 1,000
of mean strength.
DiSE.VSES.
1863-4.
1864-
-5.
1865-6.
Cases.
Deaths.
Cases.
Deaths.
Cases.
Deaths.
Quotidian Intermittent
362.60
276.50
23.96
.46
.41
.13
308.67
235. 19
21.57
.29
.26
.08
398.94
345. 34
19.02
.19
.21
.04
Tertian Intermittent
Quartan Intermittent
Total .sinij)lo Intermittent
Congestive Fever
663. 06
23.62
1.00
7.76
565.43
11.12
.63
3.42
763.30
9.97
.44
2.33
Total
686.68
147.04
8.76
(i. 13
576.55
173.48
4.05
4.72
773.27
173.73
2.77
5.04
7.81
5.49
Rrniittcnt Fever
Total pnin Malarial Fevers .
833. 72
56.15
15. 19
10.85
750. 03
37.47
8.77
5.51
947. 00
34.21
Tvpho-nialarial Fever _. .
Total Malarial Fevers
889.87-
26. 04
787. 50
14.28
981.21.
13.30
These figures cover only the last two years of the war and the year succeeding the
war. The year ending June 30, 1864, yielded a higher ratio of cases than that which
followed it, but, as in the case of the white troops, not so high a rate as was attained after
the cessation of hostilities. Here also the preponderance of the intermittents is tlie cause
of the varying tides in the annual progress of these fevers; for, while the congestive
cases were most prominent during the first year, corresponding in this respect with tlu'
intermittents generally, the remittents were least prominent during that year.
84
MALARIAL FEVERS
. Typlio-malarial cases were most prevalent, 56 jier thousand of mean strengtli, during
tlie first year of tlie service of the colored troops, diminishing to 37 and 34 per thousand
during the two following years.
Relative prevalence and mortaUty amo/i'j the white and the colored troops. — The fol-
lowing table consolidates the data of the last two tables, giving the annual average ratios
per thousand of strength as deduced from the experience of five and one-sixth years of
service by the white troops and of three years of service by the colored troops:
Table XXVI.
Relative Frequency among the White and the Colored Troops of Cases of Maternal Fevers and of Deaths
caused by them, as shown by the average number annually recorded, reduced to ratios per 1,000 of
strength.
Diseases.
WiuTE Troops.
Colored Troops.
Cases.
Deaths.
Cases.
Deaths.
Quotidian III teriuitteiit -
200. 73
18. 50
.19
.16
.03
348. 93
278. 33
21.40
.30
.28
.08
Tertian Intermit tent _ _- . __. ,-
Quartciu Intermittent . ---
Total sininle Intermittent - - _
1
387.62
6.U
.38
1.39
648. 66
13.82
.66
4.14
393. 76
128. 58
1.77
1.59
662.48
167. 10
4.80
5.23
Remittent Fever 1 -
522. 31
(a) 26. 15
3.36
(«)1.95
829. 58 10. 03
Typho-malarial F'e\'er _ - - - -
41.04
6.79
Total Malarial Kevei'H _ .-._ ._- __.
(.0 544.72
(o)5.04
870. 62
16.82
(a) As the aDtiual rates of typho-malarial fever atnon^ the white troops are derived from the statistics of four years while the rates of the totality
of the malarial fevers cover five aurt one-sixth years of observation, the latter dilVer somewhat from the sum i»f the rates of the purely malarial and
t3'pho-.nalarial fevers.
The greater prevalence of all forms of malarial fever among the colored troops is as
well shown in the various items of this table as in the totals of 544.72 cases per thousand
of mean strength among the white, and 870.62 among the colored men. These figures
are as 100 to 160. The greater mortality among the negroes is equally well shown, and is
especially marked in the more serious forms, giving an average annual total of 16.82
deaths per thousand of strength as compared with 5.04 among the white troops; figures
whicl) are in the ratio of 334 to 100. As has already been seen,* the deaths formed 1.00
per cent, of the cases in the white and 2.02 per cent, in the colored regiments.
These statistics indicate that the colored race exhibited a greater susceptibility to
the malarial poison than was shown by the white commands, or that the colored troops
•Tables XXII and XXIII, pp. 79 and 80, supra.
AMONG THK V. ?. FORGES. 85
were exposed to influences of a more deleterious nature.'^' It would, however, be injudi-
cious to attach weight to a comparison of the annual averages given in Table XXVf
as bearing on the relative liability of the white and the colored troops to the malarial
influence. Large numbers of the white troops served in departments which were com-
iiarativelv salubrious, and the influence of their records is felt in diminishiuii; the average
annual rate for the white commands as a whole. The black men, on the contrary, were
agaregated in malarious districts. Those servincj in the Atlantic region were mainly
distributed in the Departments of the South, of North Carolina and of Virginia, and tliosc
on duty in the Central region held fortresses along the Mississippi bottom and in the
Department of the Gulf. Manifestly, in making a comparison to determine relative preva-
lence, locality must be taken into consideration. The records do not enter with sufficient
minuteness into the conditions of service of the white and the colored commands to enable
their relative susceptibility to be determined. In fact the question was seldom touched
upon by our medical officers. The writer is aware that the officers on duty at the Fitdd
Hospital for colored troops at City Point, Va., were of the opinion that although the
colored people under similar conditions of exposure might be less liable to seizure than the
whites, tliey were assuredly much less able to resist the febrile influence when the attack
was developed. Surgeon John Fish, 17th regiment Corps d'Afrique, appears to have enter-
tained the belief that the negro was as liable to Jiialarial attacks as the white soldier.f
The 17th re^inu'Ut Curjis (VAtVitiuf was rt'cruitcd at Jintoii Kou^c aiul tirst luustcivd August 10, I«t)3. Its
stren^tli at that time wuh 510 ineu. We left Baton Koiige on steamer for Port Hudson, Septenihcr IS, iHCy'A, and have
l)een ou dnty here over sinee. Tlie most fVejinent diseases have lieen diarrlnea and dysentery, intermittent lever,
typhoid fever, seurvy, pneumonia and rheumatism.
I had supposed the bhiek man to be peculiarly exempt from diseases due to malarial intlueuees; hut I should
not expect to have encountered a greater number of cases of intermittent fever in a body of white troops equalling
(»nr8 in number than we have actually had. — Port Hudson^ La., Feb. 25, 18t>4.
* Some writers hare clainied for the negro race an immunity from malarial disease. Thus FEKGUsoS in his article Oil the Nature and History
tif the Marsh Poison, Trans. Royal Society, Kdinbiirgh, Vol. IX. says : — '" The adaptation of the ne^ro t<» live in the unwholesome localities of the
lorrid xone, that prove so fatal to Europeans, is most happy and singular. From peculiarity of idiosyncrasy lie appears to be proof aj^ainst fevew; for
to him marsh iiiia.'imata are in fact no poison, and hence his incalculable value as a soldier, for field service in the West Indies. TJie warm, m()ist, l()W,
and leeward situations, where these i>ernicious exhalations are generated and concentrated, prove to him congenial in every respect- Me delights in
them, for he there enjoys life and health, as much as his feelings are abhorrent to the currents of wind that sweep the iiKuintain tops; where alone the
whites finil security against endemic fevers. One of the most obvious peculiarities of the negro as compared with the European is his thick oily skin,
mnk tt> a degree ; and from this circumstance the theorist, when he speculates upon the mode of reception of the marsh poison into the c<)nslituti(m,
whether by lungs, stomach, or skin, may draw a plausible conjecture in favor of the hist."
t Dr. E. AXUKKWS, in a letter published in the Chicago Med. Examiner, Vol. Ill, ]8t>2, p. 481, — speaks of the prevalence of intermittent and
'remittent fevers among the troops near Memphis, Tennessee, during the summer of 186"2, and remarks that he constantly observes these fevers among the
negroes, whose powers of resistance he conceives to have been greatly over-estimated. See also an interesting paper by Dr. .Sa\F0KI) H. Huxt — The
ytgro as a Soldier, The Quarterly Jour, of Psychological Medicine, Vol. I, 1863. p. 161 H seq. These fevers were, moreover, exceedingly common
among the colored people who received medical assistance frtuu ihe Kreedman's bureau. In an article entitled Uemarks concerning some of the diseases
prevailing among the freed peopU in the District of Columbia (Bureau Refugees, Freedmen and Abandoned Lands), American Journal of the Medical
Sciences, 18fi6. p. 366, Dr. R. UkvbL'RN, Surgeon V. S. Volunteers, cites the occurrence among these colored people of 2,776 eases of remittent and inter-
mittent fevers in a total of 7,949 cases of sickness and wounds, or about 35 per cent, of the whole, as a sufficient answer to and refutation of the statement
fio often reiterated id our text-bofiks. that the negroes are not subject to, and do not sulVer from, malarial disease. *' Now it may be that in Africa, and
in the West Indies they do not suffer to the same extent as unacclimated whites do. but they certainly are not exempt from these diseases in this c<tuntry ;
and as far as our own opinion goes, we are strongly inclined to the belief that this socalletl exemption has no foundation in fact and is unworthy of cre-
dence.'' The only testimony in favor of any supposed immunity of the colored troops from tliese diseases during any . :ir; of the war is contained in a
report by Medical Inspector N. S. TowxeiiEXO, L'. S. A., cited in the American Med. Times, Vol. VII. 1863, p. 65. This report is on file in the oHlce of
Ihe Surgeon General and is dated May 19, 1863. It relates to an inspectii>n of Fi»rts St. Philip and Jackson, near the mouth of the Mifisissipjti river, and
I'ontains the following paragraph: "Of the troops at Ihe forts four-fifths are of the 13th Maine, and one-fifth Louisiana negroes. The comparative
fxemption of the latter fnun diseases of malarial origin is most marked. Of the entire white force 10.8 per cent, had intermittent or remittent fever, while
of the colored troops only . 8 per cent, suffered from those diseases. In respect to other dise^ises their liability appeared nearly equal." This statement
ii no doubt true so far as the time and place referred to are concerned, though it cannot be verified because in the report <it" sick and wounded at this post
for the month of May. 1863, by Surgeon Jas. M. Bates of the 13th Maine, the figures for the white and colored troops of the garrison, viz: eight com-
imnies of the I3th Maine and one battery of Louisiana heavy artillery, are unfortunately consolidated. But whatever may have been the cause of the
temi>omry condiii<m reiwrted. Ihe subse<iuent separate reports of the colored troops at this post show no such immunity from intennittent or remittent
fevers. In this connection reference may be made to the statement of A. G. Temaiu^T with regard to ti.c Negroes of Virginia," as cited by T. P.
.\TKJXS*)X — Rep'trt on the anatomical, physiological and pathological difference* hetv:een the white and the black races, etc., Trans, of Ihe Third Animal
session of the Med. Sirt;. of Virginia, held at Staunton. Nov.. 1873, Richmond, 1873, Appendix E, p. 112, "Cases of intra<;tahle intermittent are rarely
seen aamng them, and never of chronic enlargement of the spleen, or the quartan ague."
86
MALARIAL FEVEES
But this is an opinion based upon one-sided experience. To ascertain the fact, statis-
tics are required from white and colored commands camped or operating in the same locah-
ties at the same time. In their absence, the following table may be of interest as pre-
senting the rate of prevalence among the colored troops during the fourth and fifth years
of the war in juxtaposition with the rates prevailing among the whites during the same
period in the same departments or sections of the country.*
Table XXVII.
A Comparison of the Prevalence of Malarial Fevers among the White and the Colored Troops serving in
the same localities during the tioo years from July 1, 1863, to June 30, 1865, the figures given
being the average annual ratios per 1,000 of strength.
Whitb Tkoops.
Colored Troops.
'si
1^
Typho-
malarial.
Total
Malarial.
Remit-
tents.
liitermit-
teuts.
Typho-
malarial.
o rt
Department of Virginia
88
244
'l08
676
1,364
497
25 789
.. (a) (a) (a\ ..
Department of Nortli C'arolin.a
33
46
1,641
651
Department of the South
■
1
The above Depts. of the Atlantic Region
129
786
33
948
140
412
44
596 '
Department of the Gulf . .
147
144
779
542
1,107
24 950
16 j 702
18 1,291
1
..(a)..
..(«)..
..CO)..
..(0)..
Division of Mississippi and Department of
Tennessee
Department of Arkansas
166
The above Departments of the Central Region
Total in these sections of the Atlantic and
Central Regions
147
664
18 , 829
176 715
44
935
143
692
1
22 857
164 615
44
823
(a) The statistics of the Colored Troops having- been consolidated by regions, it is impossible now to distribute the cases among the several Departments.
From this table it appears that in those departments of the Atlantic region in which
white and colored troops served during the period stated, malarial fevers prevailed more
extensively among the white men, they having presented 948 cases per thousand of mean
strength annually as compared with 596 among the colored troops. In the departments
of the Central region, however, the colored men suffered more than the whites. The
aggregate rates in these various sections show the fevers as somewhat more prevalent
among tlie white troops — 857 per thousand annually as against 823 among the colored
men.
* The Murtality Tables of the Tenth IT. S. Census, 1880, do not furnish satis fact oi-j' information concerning the relative prevalence and fatality of
malarial fevers among- the white and colored i>opn]atii>n. The returns are known to be very incomplete. A comparison with the tleatli records of the leg^is-
tration offices of the States of Massachusetts and New Jersey sliowed a deficiency on the part of the census tables of 2tl.42 per cent, of the whole number
retuiTied by them in the former, and of 34.45 per cent, in the latter. State. This would not affect a calculatiim intended to give expression to the relative
frequency of death fi-om any specified cause in the two races were the deficiency equally distributed ; but it is recognized by Dr. BlLLINGS, p. 1706, Com-
pendium of the. Tenth Census of (he United States, 1880, that in the sections of country having the largest colored population the greatest deficiencies were
found, and that these were probably greater among the colored than among the wliite population. With tiie knowledge that the ratios for the colored
people were in all likelihood greater than is represented by the figures, the foIli>winer table may be examined:
AMONG THE U. 8. FORCES.
87
The statistics do not furnish the necessary data for determining the relative mortality
among white and colored commands operating in the same departments.
V
1'OPUI.ATIOX.
il
ll
ce'3
OS
if
flnnip 2
(f Census Tables Middle \tlantic Const
(Wliile
3,857,003
518, 633
1,284
338
33
46
( Colored
C White ....
4, 990, 587
72-t, nw!
791
374
16
51
( C.lcireil . . . .
C Wliile
rtroun 1 1 of Census Tables. .Suutlieni Interior Plateau <
(Colored
l,iai,0'.l6
1,972,449
1,410
1,784
I
The second ffixiup comprises Delaware, the District of Columbia and parts of New York, Kew Jersey, Maryland and Virfifinia; the eighth includes
parts of New York. Pennsylvania, Virginia and North Carolina; and the eleventh, parts of South Carolina, Georgia, Alabama, Mississippi and Tennessee.
.Aecurding to this tabulation lite colored race is more liable to death from malarial fevers in these sections of the United States; but that this does not
depend on distinctions ff mee seems indicated by the fuel that although in the mure malarious regions the death-rate of both races is increased, the relative
increase is uuieh greater among the whites. l*ntil proved otherwise it may be assumed that the higher death.rate among the negroes is due to greater
ex|t<«ures.
The mortality figures returned by the health oifioers of certain cities have been tabulated below as bearing on the point nt issue. These figures
having tieen obtained by a regular system of registration, based in most instances on the requirement of burial permits, are probably very nearly accurate ;
anti as they represent deaths which occurred within certain restricted limits of territory, they may be considered as possessing better qualifications for a
comi*arative inquiry than the figures of the census reports;
Cinni>ari3on n/ the Dta(h~Tate from Hutnrial Disease among the Whitt and Colored population of certain cities of the United States, from data taken
from lite Cnnsotidated Mortality Report of the National Board of Health for the year 1881. Bulletin of the Board, Vol. Ill, pp. 334-327.
CiTilis AND Towns.
District of Columbia
Norfolk, Virginia
Richmond. Virginia
Lynchburg, Virginia
Pelereburg, Virginia
Wilmington, Nonh Carolina
Charleston, >South Carolina .
A ugusta, (ieorgia
.\tlanta, Georgia
.Savannah, Georgia
Mobile, .Alabama
iSelma, Alabama
CulumL.'S, Mississippi
Natchez, Mississippi -
Vicksbnrg, Mississippi
New Orleans, Louisiana
.Shreveport, Louisiana
Raton Rouge, Louisiana....
Galveston, Texas
San .-Vntonio, Texas
Nashville, Tennessee
Memphis, Tennessee
■St. Louis. Missouri
I
POPUIJkTIOX.
Deaths from
i:il:trial disease.
White.
120,000
11,933
35,756
7,484
10,000
8, 893
22, 712
12,3fi4
31, 086
15, 007
16,837
3, 345
3,760
3,421
5, 975
158, 379
3,739
2,917
16,900
17, 525
27,004
18,622
338,233
Colored.
White. Colored.
60,000
10,033
28, 047
8,475
12,000
10,468
27, 287
I
10. 659 ;
16, 335 !
15, 674 I
14, 368
4,184
2,470
3,637
5,839
57, 761
7,278
4,300
5,353
3,036
16, 457
14, 971
22,390
360,932
9
6
5
30
19
8
1
2
19
2:)7
16
13
11
20
345
84
21
10
4
7
13
9
5
3
24
11
1
20
119
27
7
15
27
42
460
Katio of deaths per
100,000 of living.
While. Colored.
05.0
142.5
30.8
36.7
30.0
87.0
.19.6
48. S
3a 7
199.9
112. 8
339.1
36.3
58.5
318.0
149.6
428.0
171.4
59.3
68.5
40.7
107.4
105.1
ioa4
140.0
209.3
35.7
47.2
.58. 3
134.3
33 0
46.9
18.3
153. 1
70.7
525. 8
81.0
27.5
343 5
206.0
371.0
162.8
93.4
65.9
91.1
180.3
ie&4
isao
88
MALARIAL FF.VERS
It is not possible, in view of these figures, to decide whether the negro is less sus-
ceptible to the malarial influence than the white race; but the assertion may be allowed,
In twenty-three United States cities which contain a notable coiored population, the death-rate from malarial fever among- the white people in 1881
was in nine cities larger than that of the colored people; but the excess in the other direction was so g-reat in the remaining' fourteen cities that in a total
population of eee.SlU white and 300,922 colored, the deaths were 100 in every 100.000 of the former and 133 in every 100.000 t.f the latter. It is probable
that local conditions were involved in the production of the various death-rates given in-this table : for although in some towns that are notably malarious,
as Shreveport, Louisiana, and in others that are not so, as Atlanta, Georgia, the death-rate among the colored people was less than among the whites; in
some that are notably malarious, as Selina, Alabama, and Vicksburg. Mississippi, and in others that are not so. as Richmond and Lynchburg. Virginia.
the death rate among the colored people was greater than among the whites. The only inference that may with propriety be drawn from these municipal
statistics is that which has been reached in the text frora a comparison of the figures relating to malarial fevers in the whitt- and colored commands during
the war: that the colored race suffers greatly from these fevers, but whether to greater or less extent than the white race, cannot be determined in
the absence of a thorough knowledge of the surroundings and exposure. Manifestly, since in any of these cities the colored people may or may not have
been aggregated in unhealthy lucalities, nothing can be said of their relative liability to malarial fevers until a comparison is made of the prevalence of
these fevers in the two races in certain wards or sections of the city having the same medical topography.
Our army experience since the war jiresents statistics which ought to be of more value in this connection than those heretofore adduced. Certain
posts have been occupied by a mixed garrison nf white and colored troops. The two commands have been similarly quartered, clothed and rationed ;
they have performed the same guard, fatigue, escitrt and scouting duties, and have necessarily been exposed to the same malarious influences. More-
over, the same medical autluirity has supervised the recnrd of the sickness of both races. The facts tabulated below may therefore be accepted as
obtained under conditions which permit the relative liability of the white and colored races to be as satisfactorily tested as if they had been specially
arranged for the experimeu*. I'nfurtunately, however, owing to the small number of posts garrisoned by mixed commands, the strength represented is small.
Table exhibiting the Prevaltrice of Ptriodic Fevers at difftrent Posts in the Department of Texas.
Fort Bliss. Texas.
Fort Bliss, Texas -
Tro<ips.
Fort Brown, Texas .
Fort Clark, Texas.
Fort Mcintosh, Texas .
Fort Mcintosh, Texas .
Fort McKavett. Texas
Fort McKavett, Texas.
Fort Ringgold, Texas .
Fort Ringgold, Te.xas ..
Fort Ringgold, Texas .
Fort Ringgold, Texas .
-.- 1
White...
Colored .
White...
Colored .
White...
Colored .
White...
Colored .
White ..
Colored .
White...
Colored .
White ..
( I Colored .
White...
Colored .
White...
Colored .
White...
Colored .
White...
Colored .
White...
Colored .
1878-9
1879-80
1879-80
187i;-7
1877-8
1876-7
Total White ..
Total Colored .
54
26
340
56
2.i()
1-20
98
9»
65
1S7
263
59
164
30
199
74
155
"8
126
119
107
166
1,887
1,016
3
1
30
3
21
12
10
19
'1
5
16
11
14
4
91'
5
14
3
31
3J
7
22
14
4
1
10
1
1
113
24
18
4
g
10
11
12
106
47
358
134
10
1
5
48
6
06.
16
11
14
4
113
G
35
8
35
37
12
26
29
3
29
1
151
27
41
17
22
30
15
18
512
188
.^t4
"So
is--
B c B.
266.6
21i.r.
2.'i9. :i
I0S.9
332. 4
107.1
136.7
66.6
357.1
373.7
184.6
189.8
110.3
50.8
176.8
33.3
758.8
364.9
264.5
217.9
174.6
252.1
■]40.2
108.4
271.3
185.0
At Forts Bliss, Brown, Clark aud McKavett, Texas, there was a greater prevalence among: the white troops : at Fort Mcintosh the white and
colored troops suffered at about the same rate ; while at Fort Ringgold, in the year 1878-9. there were more malarial cases among the colored than amt)ng
the white soldiers. But in dealing with such small numbers as are represented at each of these posts the records of a single garrison do nut have much
value, as they may be affected by unknowu local conditions. The totals tabulated show a less degree of prevalence among the colored troops, the annual
rate per thousand among them being 18.0, 0, while among the white troops it was 271. 3.
AMONG THE U. P. KORCKS.
89
that the colored troops did not sufllr in a marked degree as compared with the white men,
although it is not unlikely, from the then generally accepted belief in their partial immunity,
that they wore often stationed in localities that would have proved specially dangerous to
white men. It is probable, therefore, that if strictly comparaljle figures were obtained thcv
would show the black man to be less susceptible to malarial attacks than the white soldier.
Seasonal variations in Prevalence. — The following table shows the monthly rates of
malarial cases among the white troops, and permits a comparison to be made between ihi-
i-att>s among the troops operating in tlie several regions.
Looking tlrst at the totals in the army, the purely malarial fevei-s (the intermittents
antl remittents) are seen to have a distinct maximum and minimum of prevalence in
each year. These seasonal variations will be more readily followed liy a reference to
the diagram facing page 90. The maximum in the year ending June 30, 1862, was
attained in the months of September and October, 1861, when the monthly ratios were
61.3 and 60.7 respectively, and the minimum in January, February and j\Iarch, 1862,
when the ratios were respectively 18.8, 18.2 and 17.0. Tn October of 1862 the maxi-
mum, 62.6, was again reached, after which the fevers subsided rapidly, and comparatively
few cases occurred during the months of January, February, Marcli and April, 1863, the
ratios for these being 29.4. 26.8, 28.6 and 29.3. A steady increase in the number of
cases reached its maximum in .August and September, with ratios of 88.5 and 80.7 per
thousand of strength. The fall to the minimum in January and Februarj^ 1864, was as
Table XXVIII.
Showing the Seasonal Variations in the Prevalence of Malarial Fevers among the White Troops in tlie
several 7-egions during the years of the War and the year following tlie War, expressed in monthly
7'atios per 1,000 of mean strength.
YEAR ENT)ING JUNE 30, 1862.
Disease.
Eegiok.
1861.
1862.
<
:£
0
5
3
S
a
S
1
an
5
§
i
<
3
%
■<
i
a
a
1
■<
s4
<
S
Ed
Intennitt^nl (iiirliidin^ Conge.<;tive) Fever . .
Atlantic ...
Central....
Pacific
10.2
38.9
8.2
27.6
W.O
30.6
:i9.4
56.9
18.2
-
34.6
65.5
21.7
22.2
41.7
20.1
14.2
30.7
13.9
7.9
21.9
7.2
8.5
17.2
10.1
6.9
19.1
8.8
12.3
26.7
10.0
15.S
27.6
8.9
15.8
27.1
13.0
19.1. 9
379.9
161.8
22.2
35.9
43.2
44.2
28.4
19.6
11.7
111 -
ti. :
10.0
1.8
18.9
21.2
21.2
260.8
;. J
Atlantic . . .
Central....
Pacific ...
2.8
, I)
7.3
9.9
31.6
.4
15.9
26.3
1.3
16.0
18.4
7.4
13.7
18.6
ai
9.3
las
4.S
5.7
11.3
1.3
8.5
15.8
1:1.7
1 7
14.2
17.9
8.9
15.9
124.4
182.1
55.0
9.5
4.3
lae
Keinittent in all the reruns
14.3
18.1
16.5
14.9
las
7.1
7.4
6.5
10.4
■20.8
39.3
18.5
15.8
143,2
Intennitteiit ami Kemitteiit
Atlantic. ..
Central
Pacific
13.1
52.4
9.1
37.5
98.5
21.0
55.2
8a2
19.5
50.6
83.9
29.1
3.5.9
GO. 3
23.2
23.5
44.0
18.5
13.5
3a2
8.4
15.1
27.2
11.9
12.2
28.7
13.1
31.0
43.4
10.6
30.1
45.0
21.9
320.3
562.0
216.9
Total Malarial in all the regions
29.4
50.2
f.1.3
m.7
1
43.3
30.1
18.8
18.2
17.0
29.3
37.0
37.1
404.0
Med. Hlst., Pt. 111—12
90
MALARIAL FEVERS
YEAR ENDING JUNE 30, 1863.
Disease.
Region.
186S.
1863.
ti
H
><
d
•-a
i
O
s
S
a*
CO
a
a -
i
o
1
<
sa
<
S
S
^
<
s
Intermittent (including Congestive) Fever . .
Atlantic . . .
Central
Pacific
20.4
32.3
12.5
21.4
36.8
17.4
24.4
56.3
17.6
30.8
61.2
11.4
19.4
46.0
11.1
12.9
33.9
8.0
11.3
28.5
8.2
8.6
26.9
6.0
9.2
29.2
7.3
1».4
28.6
8.2
15.3
29.1
7.7
18.8
44.0
9.8
191.2
440.8
124.5
Intermittent in all the regions
25.4
2a 8
39.3
46.3
33.2
23.1
19.9
17.9
19.5
20.3
2ao
34.3
319.8
Atlantic - - .
Central....
Pacific
21.4
19.0
2.4
16.1
18.1
6.6
13.4
18.4
1.5.0
16.7
16.3
7.0
10.5
12.6
5.7
8.0
10.3
2.7
8.0
11.2
1.5
6.6
11. a
.7
6.7
11.6
1.8
6.8
10.9
4.0
8.5
12.2
a 6
9.0
14.9
a2
12a 3
138.3
sae
19.9
16.9
15.8
16.3
11.5
9.1
9.5
8.9
9.1
9.0
10.5
12.5
140.4
Intermittent and Remittent
Atlantic . - .
Central
Pacific
41.8
51.3
14.9
37.5
54.9
24.0
37.8
74.7
32.6
47.5
77.5
1&4
89.9
58.6
16.8
20.9
44.2
10.7
19.3
39.7
9.7
15.2
38.1
6.7
15.9
40.8
9.1
17.2
39.5
12.2
23.8
41.3
11.3
27.8
58.9
lao
314.5
599.1
178.1
460.2
Total in all the regions
45.3
4^7
55.1
62.6
3.4
3.2
2.2
44.7
32.2
29.4
26.8
28.6
29.3
3a 5
46.8
Atlantic . . .
Central....
Pacific
6.1
4.8
2.0
4.1
4.5
2.3
3.3
a2
1.6
3.8
2.3
.9
as
1.9
a4
4.2
2.8
.2
2.9
a 9
.8
2.7
a3
.7
2.5
2.6
1.3
2.7
2.1
.7
a 5
2.0
2.2
42.3
34.8
18.0
5.4
4.3.
3.2
as
ao
2.9
a4
a4
ao
•
2.6
2.3
2.6
38.0
Intermittent, Remittent and Typho-malarial
Atlantic . . .
Central
Pacific
47.9
56.1
16.9
41.6
59.4
26.3
41.1
77.9
34.2
50.9
80.7
20.6
3a 7
60.9
17.7
24.7
46.1
14.1
2a5
42.5
9.9
18.1
42.0
7.5
18.6
44.1
9.8
19.7
42.1
las
26.5
4a 4
IS.O
31 3
60.9
15.2
356.8
633.9
196.1
498.2
All the regions
50.7
.50.0
58.3
65.9
47.7
33.1
32.8
30.2
31.6
31.9
35.8
49.4
YEAK ENDINOf JUNE 30, 1864.
BiSBiSE.
Region.
1863.
1864.
><
K
P.
1-3
1
§
o
H
B
>
o
i
Ed
Q
as
<
"5
•*
a
S
1
S
<
<
s
f-a
Intermittent (including Congestive) Fever. .
Atlantic . . .
27.6
44.7
52.0
47.8
38.8
23.5
19.4
17.1
21.0
24.2
22.2
24.5
359.7
Central
66.3
84.6
74.7
58.2
42.6
30.4
28.6
27.4
32.1
33.8
34.8
37.6
541.0
Pacific
ia8
15.7
23.3
25.1
15.7
10.7
8.0
7.4
10.4
10.6
11.8
11.6
161.8
51.6
69.0
65.3
54.0
40.8
27.7
25.1
23.4
27.7
29.7
30.1
32.7
470.0
99.8
Remittent Fever
Atlantic . . .
11.2
17.6
15.3
12.3
7.7
4.8
as
a7
4.6
5.5
5.1
10.7
Central...
19.3
91.0
15.7
10.0
7.1
4.9
5.0
5.5
6.3
7.7
9.8
las
12a 6
Pacific ....
5.0
5.1
6.8
11.3
11.6
a 6
2.7
.9
2.2
ao
5.4
5.6
61.4
16.2
19.5
15.4
10.4
7.4
4.9
4.6
4.8
5.6
6.8
8.2
12.4
114.1
Atlantic . . .
Central....
38.8
8.J.6
62.3
105.6
67.3
90.4
60.1
68.2
46.5
49.7
28.3
35.3
2aa
33. B
20.8
32.9
23.6
38.4
29.7
41.5
37.3
44.6
35.2
51.1
459.5
664.6
Pacific
18:8
20.8
32.1
36.4
27.3
14.3
10.7
8.3
12.fi
ia6
17.2
17.2
223.2
584.1
67.8
88.5
80.7
64.4
48.2
32.6
29.7
28.2
33.3
36.5
38.3
45.1
T3-pl]0-nialanal Fever
Atlantic . . .
4.4
4.2
ao
2.8
1.8
1.2
1.3
.7
.7
.9
1.2
ai
24.6
Central
2.9
a2
1.9
1.4
1.2
.8
.6
.5
.7
.7
1.0
1.3
16.1
Pacific
.8
.2
.3
.1
.4
.2
.2
.4
.1
.1
.2
.1
ao
18.9
a 4
a 5
2.3
1.9
1.4
1.0
29.5
.8
.6
.7
.7
1.0
i.O
Intermittent, Remitteut and Typho-malarial
Atlantic . . .
4a 2
66.5
70.3
62.9
48.3
24.5
21.5
26.3
30.6
28.5
38.3
484.1
Central
88.5
108.8
92.3
69.6
50.9
36.1
34.2
3a4
39.1
42.2
45.6
52.6
680.7
Pacific ....
19.6
21.0
32.4
36.3
27.7
14.5
10.9
8.7
12.7
ia7
17.4
17.3
226.2
71.2
92.0
eao
66.3
49.6
3a6
30.5
28.8
34.0
37.2
39.3
47.1
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AMONG THK U. S. FORCES.
YEAK ENDING JUNE 30, 1865.
91
Disease.
Region.
1864.
1-.,.,
<
■ g
3
i
c
a
s
X
(0
1
51.0
53 3
16,4
3
a
cd
E>
g
39.1
36.8
11.4
37.2
9.4
8.4
1.8
8.7
a
a
a
24.6
32.5
8.5
28.8
6.7
7.9
1.2
7.3
31.3
40.4
9.7
36.1
1.6
1.1
.3
1.3
<
3
1
16.6
36.3
9.6
a
<
s
b
<!
20.0
33 6
114
26. S
6.7
ao
3.4
7.3
26.9
34.1
12.0
39.4
bi
28.0
38.1
17.3
33.9
Intermiltent (inoludiiiK' Congestive) l-Vver. .
AllBntio...
Central
PHOiDc ....
33.6
5a 8
8.0
41.3
62.4
14.9
5a8
52.9
62.8
12.9
1&6
29.7
9.2
19.6
31.3
9.2
V>. 6
6.8
8.2
2.6
7.5
26.4
39.5
11.8
3a 1
1.5
1.0
359,3
49.5, 8
142,8
429.5
4a 9
.57.9
16.0
15.5'
as
15.5
51.6
13 7
10.8
8.3
12.0
24.7
6.8
7.6
2.6
7.2
25.4
37.3
11.8
21.6
Reinitteat Fever
Atlantic ..
Central
Pacific ....
17.4
18.5
5.4
17.4
22.8
8.6
20.6
58.7
85.2
aas
74.4
6.6
2.3
.1
5.8
7.1
1.9
6.4
7.6
9.8
as
9.H
11.7
4.1
119.3
137.3
46,9
127.8
17.8
8.7
10.7
Atlantic...
Central
Pacific ....
50.0
71.3
ia4
61.7
68.9
78.3
16.7
"•"
4.8
1.7
.4
64.7
64.1
24. 7
63 6
48 5
44,2
la^
45,9
2.9
.7
.5
22.4
33 4
11.5
28.0
1.3
.4
26.7
41.6
15.8
34.1
34.5
43 9
15,8
38,1
1.7
.S
37.9
49.8
21.4
43 6
478 6
633 1
1B9.7
31.9
1.4
.8
.4
1.1
557,3
Atlantic...
Central
7.6
a. 1
4.0
1.2
1. 1
2.4
1.4
1.2
.1
1,6
1,4
34.4
14.9
2.6
4.2
as
65.3
87.5
aa6
78,2
2.9
1.6
.8
1.2
1.2
1.2
1.5
22.9
513 0
648.0
193 3
Intermittent, Remittent iiiul Typho-nialarial
Atlantic . . .
Central
Pacific
57.6
TO. 4
13.4
7a 7
80.0
17.1
76.3
68.7
65.3
25,8
_
66.0
51,4
44.9
13 7
47.5
32.9
41.5
9.9
37.4
36. 8
38.1
12.2
-23 7
33 8
11.5
27.9
40.5
11.8
28.1
42.8
15.9
36.2
44.7
15.8
39.5
51.3
31.4
45.1
65.9
33 0
28 8
34.3
580.3
YEAR ENDING JUNE 30, 18G6.
DISEASE.
Recion.
1865.
1866.
•<
><
§
g
■3
D
3
<
a
a
a
O
a
a
S
1
i
a
•-a
X
•<
3
el
a
ta
b
c
o
as
<
S
<
i
•-3
Inteimittent {including Congestive) Fever . .
Atlantic...
Centra! ....
Pacific ....
45.9
6a 4
18.8
66.5
91.3
2.3.9
88.0
96.1
42.7
92.7
90.3
41.4
6.3.3
73.0
37.5
39.0
40.9
22.8
18 5
31.7
12.9
16.8
25.4
7.4
20.4
29.5
12.0
28 4
35.2
18.7
33.3
29.2
18.1
34.7
42,2
31,7
658.7
808. 9
385.0
693 4
Intermittent in all tlie regions
54.7
78. 2
88.1
85.6
6a 9
37.0
33:6
18.9
22,3
24,9
27.9
34,7
Atlantic . .
Central....
Pacific ....
13 4
19.3
a 4
16.7
26.1
a 5
21.8
21.7
5. 0
16.0
19.3
1 7
1C.4
108.7
109.6
46.1
6.5
8.2
4.6
5.1
ai
2.4
a 5
2.2
2.1
4.1
2.5
ai
a 9
a 2
4,5
4.4
2.5
5.1
6.2
2.6
8,7
11.5
2.3
144.8
197.2
39.0
Kemitlent in all tbe regions ^
16.3
21.3
20.3
109.8
117.8
47.7
6.8
69.8
81.3
40.7
4.6
3.9
ai
as
4.0
!i.O
8.3
159.7
Atlantic...
Central ....
Pacific ....
59.3
82.7
22. 2
71.11
83 3
117.4
27.4
43 6
46.0
25.9
30.9
35.2
1.5.1
26.5
18 9
29.5
9.9
2a 5
3a 4
15.3
32,9
29,6
31,3
38.4
35 4
30.7
43 4
5a 7
34.0
803, 5
1,006.1
324.0
Total in all the regions
99.5
108.3
102.0
70.7
41.6
23.0
35.8
28.9
32.9
4a 0
853.1
Atlantic . . .
Central....
Pacific...
1.4
4.5
.6
1.7
1.7
.1
1.6
1.0
1.7
I.l
.5
.9
.2
.2
.3
.1
.1
.3
.05
, 1
.1
.1
.2
1.2
.5
lao
32.5
1,5
1
Typho-nial.irial io all tlie regions
ai
1.6
i.r
1.2
.6
.2
43 8
46.3
26.0
.1
.1
.02
.05
.1 1 -7
16.6
Intermittent, Remitleatanil Typlio.malariEl
Atlantic . . .
Central ....
Pacific
60.7
87.2
38.8
84.9
119.1
27.5
111.4
118.8
47.7
110.4
110.7
46.1
70.3
82.1
40.9
20.9
35.3
15.1
19.2
29.5
9,9
2a5
3a 4
15.2
32,9
29,6
21,3
38.5
35.5
30.8
4a 6
.54.9
24.5
816.5
1,028.6
325.5
74.1
101.1
109.4
103 2
71.3
41.8
26.6
22.1
25.82
28.95
sao
4a 7
869.7
92 MALARIAL FEVERS
rapid and equable as the antecedent increase, the ratios for these months, 29.7 and 28.2,
being very similar to those of the preceding year. The maximum was again reached, 74.4
and 73.4, in August and September, and the subsequent minimum, 28.0, in February, 1865.
During the year succeeding the war the highest figures, 99.5, 108.3 and 102.0 were reached
in August, September and October; the fall to the minimum, 22.0, in the following Feb-
ruarv being as sudden as was the rise which preceded it.
The intermittents had similar waves of prevalence; in fact, the contour of the general
malarial waves was mainly due to the preponderance of fevers of this type. But remit-
tents also followed the same general course, having their maximum in July, August or
September, — 18.1 per thousand strength in September, 1861 ; 19.9 in July, 1862, and 19.5,
20.6 and 21.3 in August of the three following years. The minima corresponded with
January, February and March, and often included December on the one hand and April on
the other; thus the average monthly ratio for these five months was 8.4 in the year 1861-2;
9.1 in 1862-3; 5.3 in 1863-4; 7.1 in 1864-5; and 3.6 in 1865-6.
It is noticeable that only in the year ending June 30, 1862, was there a distinctly
marked occurrence of vernal fevers, as notable among the remittents as among the inter-
mittents, but in both cases this vernal rise culminating in May, was separated from the
autumnal increase not by a diminution in the number of febrile cases in June, but only by
the failure of that month to show an increase corresponding with that of May on the one
hand or July on the other. A tendency to a stasis in the advance of the febrile wave
occurred also in April or May of the other years, and was most defined among the inter-
mittents in 1864.
The great prevalence in the autumn of 1863, and again in 1865, must be considered
due to the meteorological conditions of those years favoring the evolution of the disease-
])oison or to the operations of the troops carrying them into more dangerous localities.
But these high waves were composed largely of recurrences; for the corresponding winter
seasons were not characterized by that increased prevalence which would have resulted from
the relapses occurring in a larger body of men subject to attack under the influence of
chill, fatigue and other so-called predisposing causes. The ratios of the winter months
may be regarded as giving expression to the relative numbers of men under the influence
of the malarial poison in each year, for there are not wanting reports such as that of Surgeon
J. M. Bates, 13th Maine Volunteers, to establish the principle that winter attacks were
generally recurrences.
Every case of intermittent fever has occurred in those who were afiected with the disease during last summer
and fall. The attacks have shown a very general tendency to recur every seventh, fourteenth, or twenty-first day.
Two conipanies that came from Ship Island, Mississippi, about the middle of February, have as yet given no indica-
tion of the disease, showing that the malarial influence is not sutticiently strong at this season of the year to induce
the disease in those not previously affected. — Forts Jaclcson if- St. Fhilip, La., March, 1864.
In view of this principle, it may be recognized as a fact that in October, 1862, our
armies became as fully saturated with the malarial poison as in any of the after years;
for while the minimum in March of that year was as low as 17.0 per thousand of strength,
the succeeding minimum, which was considerably higher, did not differ much from those
which followed it.
Typho-malarial fevers, which are included in the table and on the diagram, were most
prevalent in the year ending June 30, 1863, diminishing gradually in the after vears. The
waves of prevalence were abrupt, culminating in July and falling gradually during the
autumn months.
AMONG THE U. S. FORCES.
93
But the study of these seasonal variations lor the several years may he niudi facilitated
hy their consolidation into the average figures of Table XXIX and the corresponding linos
of the diagram facing page 94.
T.\BLE XXIX.
Average monthhj number of Cases of the several varieties <f Malarial Fever amon</ the White Troojisfrom
July i, 186 1, to June SO, 1860, e.vpresseil <^^• rutins jier 1,000 of mean strength.
IJl.SEASILS.
1
a
a
u
£
s
'A
a
<
y,
<
a ,
•<
D
K
<
11.00
10. oo
1.07
<
12.00
11.00
1.14
13.00
12.00
1.01
16.00
13.00
i..-,n
30. :i\
.45
30. 98
12.61
^ —
^ —
204. 00
1 1
171.00 1
1H,8.'
393. 82
6. 24
400. Oil
130.89 [
530.95
26.15
, 5.57. 10
aaoo
laoo
1.93
29.00
24.00
2.22
30.00
23.00
2.72
27.00
ai.oo
2.39
19.00
16.00
1.79
13.00
11.00
1.18
10.00
9.00
1.31
10.00
8.00
1.10
Qiiurtiiii liitermilteiil
Tula] iiimpio Iiiterinittt-Mils
41.92
.82
.'-W.22
.94
55.72
.89
50.39
.70
36.79
.47
25.18
.42
20.31
.39
19.10
.32
23. 07
.32
24. 14
.37
26.01
.39
Total Intennittenls
Reinilteut Fever
42.74
17.18
56.16
19.23
56.61
16.11
51.09
13.55
37.26
9.96
25.60
7.56
20.70
7.10
19.42
6.79
22.39
7. 2ti
24. 51
8.07
32.58
1.50
26.40
10.17
Tutal pure Malariul Fevers. . .
Typho-nialarial Fever (a)
59.92
4.07
75.39
3.52
72.72
2.64
64.64
2.45
47.22
1.98
33.16
1.71
27.80
1.85
26.21
1.66
29.65
1.65
36.57
1 . .'.1
43.59
2. 04
45. «l
Tidal Malarial K»'vers
63.99
78.91
75.36
67.09
49.20
34.87
29.65
27.87
31.30
34.08
38.08
(a) From July 1, 1862, to June 3P, 1866.
From these the purely malarial fevers, and the intermittents which constituted so
large a proportion of them, are seen to have attained their maximum in August and Sej)-
teniher. They decreased rapidly during October and November, and slowly thereafter to
their minimum in February. Their increase was slow and equable from March to June,
ami without any vernal wave other than that involved in the gradual formation of the
autumnal increase. During July the cases occurred with greater frequency, leading to the
maximum in August.
The remittents prevailed as a single annual wave, rising in !\larcli. culniiiiatiiig in
August, and falling, more abruptly at first but more equably than the intcrmiitents, to a
minimum during the winter months.
It is noticeable also that the autumnal increase affected the intermittents and the
remittents alike, i. e., both of these types of fever contributed to the annual maximum of
malarial fevers the same percentage of increase on their respective minima. Thus in the
intermittents the difference between the minimum, 19.42, and the maximum, 56.61, is 37 19,
an increase of nearly two hundred per cent, on the minimum; while the difference between
the minimum, 6.79, and the maximum, 19.23, of the remittents is 12.44, also an increase of
nearly two hundred per cent, on the minimum.
The seasonal cui've of typho-malarial prevalence rose abruptly in June to its maxi-
mum in July, fell gradually during August, Septemlier and October, and thereafter remained
at about the same level until the next June rise.
A similar table constructed from the statistics of the colored troops shows the maxi-
mum of the purely malarial fevers as having been reached in August, September and
94
MALARIAL FEVEES
October, after wliich the fall was rapid to the minimuin in February. A notable increase
in May, with a less marked rise in June, gives a suggestion of a vernal wave as well among
the remittents as among the interraittents. The remittents, as in the case of the white
troops, decreased in the autumn before a corresponding decrease occurred in the number of
the accompanying agues.
The typho-malarial curve differed from that of the remittents in falling less rapidly
during September and October.
Table XXX.
Avei-age monthly number of Cases of the several varieties of Malarial Fever among the Colored Troops
from July 1, 1S63, to June SO, 1866, expressed in ratios per 1,000 of strength.
DlSEASEB.
o
1-5
i
<
a
s
CO
OCTOBEH.
-A
1
<
<
i
o
<
s -
1
'A
<
Kg
34.00
25.00
1.93
41.00
32.00
2.26
50.00
36.00
2.97
49.00
39.00
2.95
33.00
30.00
1.98
25.00
20.00
1.04
20.00
18.00
1.14
17.00
16.00
1.24
J 9. 00
14.00
.91
17.00
16.00
1.53
21.00
15.00
2.01
20.00
18.0ft
1.50
349.00
278.00
21.39
Total simple Intennittents
60.93
1.56
75.26
1.57
88.97
1.93
90.95
1.99
64.98
.94
46.04
1.17
39.14
.85
34.24
.72
33.91
.93
34.53
.45
38.01
.88
39.50
.83
648.39
13.83
Total
62. 49
23.20
76.83
23.08
90.90
21.61
92.94
17.51
65.92
12.10
47.21
8.57
39.99
7.77
34.96
7.46
34.84
8.51
34.98
9.05
38.89
13.61
40.33
15.08
662.22
167. 10
829.32
41.06
Total pure Malarial Fevers . . -
85.69
6.34
99.91
6.87
112.51
6.11
110.45
4.44
78.02
1.90
55.78
1.66
47.76
1.97
42.42
1.56
43.35
2.13
44.03
1.96
52.50
2.95
55.41
3.29
Total Malarial Fevers
92.03
106.78
118. 62
114.89
79.92
57.44
49.73
43.98
45.48
45.99
55.45
58.70
870.38
Seasonal Variations in Mortality. — This has been illustrated by the plate facing page
20, on which are delineated the monthly variations in the level of the malarial death-rate
in juxtaposition with the corresponding variations in the mortality from certain of the
more fatal classes of disease and from diseases in general. The autumnal prominences
are clearly defined, particularly in the last three years, the culminating points being in
August in 1863 and 1864, when 1.14 and .94 per thousand are reached, and in September,
1865, when a rate of 1.18 is shown. The autumn waves in 1861 and 1862 do not have
so, distinct a culmination. These death-rates will be found to correspond precisely with
the variations in the line of prevalence in the diagram facing page 90; whence it may be
inferred that in general these fevers caused death within the month of the attack.
Influence of Pi.egion on Prevalence. — Table XXVIII, already presented, shows the
seasonal variations in prevalence as affected by the climatic and other influences of the
region in which the white troops operated during the several years of the war. The mala-
rial fevers were more frequent in the Central than in the Atlantic region, while in the
Pacific region the ratio of cases was much smaller than in either of the others. During
the year succeeding the war the increased prevalence of these fevers affected the troops in
all the regions. In the Central and Atlantic regions this was due to the occupation of
southern and malarious territory ; in the Pacific region it was owing in part to the estab-
Di(t(/ranis shinsnmi flic .hyr<n/r ^In/iiiiiJ Curves n/' Pi-cviiJnicr
of the Mai ai'ial Ferns (inuuiii Ihr While (iml iJie. Colored Troojis diirijia
the liar, in Moii/hlv Rales jier Thousand of iHlrenqth .
'Ihliil jtoi'f niiiJiuhd /t\ y/:s
Iii/rrnidtna.s
indfr Troe>p.s.
1 1 i ^1-1 i-^.i'S^ I'll 1
11411^
114
1 12'
112
11(1;
1 Ul
i lOM '
_10Hj
1U« .
IOC. 1
KMf
104
10 2*-
102
loo
lOo
88
98
96 1
96
94
94
92
H 90 II
92
00
! 8« i
88
HO
80J
84
84
82
82
80
80
7B !
78
76 }
7B
74,
74
72^
^-
I
k
72
7(1
\
70
68
1 68
GGi I r
1
66
6-CT^
n.lJI
627 p
; iM' '
60 I t
hi-^
1 '"':
38 : I
: ." 8 .
36 ! f\
. .
,'(. 1
34 /I \
'' "L;l
52 1 / 1 /
52
50 /
1
50
48
;/
1
48
46
1
1
46
44 !
'
1
44
" 42T ■""
B
\
42
40 '
/
I
40
38 ;
/
\
38
30
,T4I
J
1
36
/
, I
34
32]
>
\ '
32
;)0 I
/
1(
V
30
. 28 iy
/
\
\
28
26'^^
/
1
N
26
2 4
y
\
24
22
y
s
22
20
/
20
18
/
/
s
IB
16
y
\
16
14
/
\
14
le
V
12
^''i
^
s
10
s'
^
/
\
8
6f
"^
6
4
4
2
/L
*"■
— -
^
1^-.
g_
- \ r- t
■
1 Ii4tli--|-t5^i-i5 j
Hrnuttcnl.'i .
lypho iniiliiricd
^
niofcd TrdOft
,v.
^k^^:\%M%kk\%
114
1
1 14
112
1 12
110
N
no
108
I
108
106
I
106
104
/ F
104
103
/ 1
loa
10 0
L(- "c
100
H8
/- I
98
36
1
1
96
84
1
1
94
92
1
, \
92
!10
V\ '
' \
9 0
HS
l\.
1 I
88
86
.- \ / i / Ll
86
84
/ 11
8 4
82
I . .11
82
80
1 1 1
8<)
78
1 W -
78
76
It U -
76
74
I \
74
72
1
72
70
1 : '
7()
68
/ ■
68
66
1 / '
66
6 4
/ /
64
62
1
62
60
60
38
S8
36
36
34
J
i
04
52
f
\
32
60
/
\
*
50
48
/
; I
'
48
46
/
>v 461
44
42
^
\ 44
" ■ N 42
40
40
;1K
^\
' ' ■ 38
36
Vl 36
a 4
■^
^^ 34
32
32
30
^■^ 30
28
28
26
■ ■ ' 2Gj
24
r-^
24
22
i
■^v. 22
20
■■ i \ / \
2(1
18
1 1 / '^ ■
18
16
\
,_10
14
^ J
\
14
12
jf 1
>
121
10
y^' . : 1
s.
10
8^
>«»
8
pi
•^
,^-.
0
4
/
'^
4j
2
^^
^
\
si
0
-
^-*» ^
—
0 1
||4tlt-f=^5^||^ J!
96
MALARIAL FEVERS
PACIFIC REGION.
Diseases.
■-5
1
<
s
g
o
o
33
'A
s
a
8.9
i-
•A
<
'-a
<
<
•A
Annual
AVKKAGE.
H. 8
11.9
17.2
1.15
13.8
5.6
4.9
6 7
9.4
Tertian Inteniiitlent
4.6
5.0
6.6
7.8
. S.5
3.8
S.8
3.6
4.0
4.6
4.6
4.3
55.5 1
Quartan Intermittent
.9
.9
.7
.6
.6
.4
.9
.4
1.0
.8
.3
1.2
8.6
C'on^'estive Intermittent
. 2
.:!
._o
.1
.a
.1
.1
.1
.1
.3
.2
2.6
^4.8
-M. 1
20.0
13.3
9.4
8.0
9.8
13.2
15.0
178.2
Bemittent
3.S
5.7
6.6
7.6
5.0
3.0
3.1
1.6
2.8
3.7
5.1
4.6
50.6 ,
Total pure Malarial
16.3
24.2
31.4
31.7
S5.0
16.3
11.5
9.6
13.6
15.9
17.0
19.6
228.8 ;
Tyjtho malarial -
--
.,;
f
.0
■'
.3
.2
.5
.■i.8
Total Malarial
17.0
24.7
31.8
33.4
25.4
17.0
U.5
9.9
12.7
16.2
17.1
20.1
233.7 j
DiAGKAM allowing the Seasonal Prevalence of the
Malarial Ferern in the Atlantic," Cenlrali and
PacificX Bet/ions.
100
100
i 8
9a
9 i
96
n
9*
52
+
Si
9 0
'
9 0
8 i
88
a
j
36
8*
/
[
at
8 2
/
\
82
80
/
\
80
78
/
\
7S
-'6
/
\
76
7t
/
\
74
72
72
70
70
68
6 S
66
\
6S
6'^
\
64
62.
\
62
60
/
*
\
(a
si
s
\
58
56
]
56
64
■ ^f
52
/
\
bJ
50
/
\
60
48
/
\
48
46
/
\
46
44
/
\
44
42
\
42
40
/
40
38
y
s
Js
36
/
\
J6
34
/
\
34
32
31
30
^,
1 — 1
30
28
/
^
28
26
/
*
26
24
f
^
34
22
/
y
\
2i
lU
/
/
*v
20
) 8
^
V
s.
/
^
\i
1 6
■s
'
16
14
/
^
14
1 2
V
t 2
1 0
/
'
s
10
i
'
a
6
6
4
4
i
1
0
0
The concurrence of an elevated temperature
and liigli ratios from malarial fevers, so well
marked in the seasonal variations in prevalence, is
noted also in the geographical distribution of the
cases. Table XXXII, which follows, exhibits an
increased prevalence in the departments of the
southern part of the Atlantic coast, as compared
with those on the northern part of that coast. The
increase from an annual rate of 144 cases per thou-
sand of strength in the Department of the East,
through the Middle and other coast departments, to
1,035 in Xorth Carolina and 930 in the Department
of the Gulf, shows in a general way the connection
of these fevers with temperature as affected by lati-
tude. In the interior their increased prevalence in
the river towns, as compared with the higher ground
constituting the water-shed, may be seen in the 538
cases in the Department of the Missouri, the 8(35
cases in the Department of Tennessee and the 1,287
cases in the Department of Arkansas, as against
227 in Western Virginia and 265 in the Depart-
ment of the Ohio; while the country bordering the
great lakes gave 526, as against 238 in the north-
west.
In compiling this table it was found that the
highest malarial sick-rate for any one year was
presented by the Department of North Carolina, in
which during the year 1863-4 there were recorded
23.848 cases in a strength of 10,226 men, or 2,353
cases per thousand.
AMONG THE U. S. FORCES.
97
Table XXXTI.
Shotcing the Prevalence of Malarial Fevers in the Departments on the Eastern and Southern Coasts of the
United States, end in thos-e of the high and low grounds of the Central Region, expressed in annual
raliosper 1,000 of stnngth, ra/cntated from the statistics of the four years ending June 30, 1865.
Department of tbe East
Jliddle Department
Department of Virginia
Department of the Sonth
Department of North Carolina.
Department of the (inlf
Ids
172
503
396
828
7:iK
32
81
110
131
179
148
Department of W'est Virginia ...
Department of the Northwest...
Department of the Ohio
Department of the Cumberland .
Northern Department
Department of Missouri
Department of Tennessee
lit)
I. ".(I
187
•Xi
390
1)61
Department of Arkansas 1, 103
71
82
66
135
126
V.W
181
166
Typho-
malarial.
Total
Malarial
Fevers.
I
11
37
31
28
44
10
6
12
15
14
12
23
18
114
2&I
650
5.'i8
1,035
930
227
238
265
456
526
538
865
1,287
But while the seasonal wave was made up of a proportionate increase of the inter-
mittent and romittent cases, the increase in the number of malarial cases, which coincided
with lower latitudes and lower grounds in the same latitudes, was largely composed of inter-
mittent cases. It is evident that the 32 remittents in the Department of the East do not
bear the same relation to the 108 intermittents of that command that the 166 remittents
of the Department of Arkansas bear to its 1,103 intermittents. Although remittents
increased in their absolute number with an increase in the total of malarial cases, their
number as a percentage of that total became diminished in the more malarious localities.
This is readily gathered from Table XXXIII, in which the various types of fever that
occurred in each department are tabulated as percentages of the total number of its mala-
rial cases.
At first sight it appears as if no relationship existed between the prevalence of the
remittents and intermittents; for of the two departments, the East and New Mexico, which
had less than 200 cases of malarial fevers annually per thousand of strength, the one had
7-T per cent, of intermittents and 22 of remittents, while the other had 61 per cent, of the
former and 35 of the latter. But if an examination is made of the figures from such
departments as the South, the Missouri, the Northern Department and Part I of the Mis-
sissippi Division, which had an annual rate of from 500 to 600 malarial cases per
thousand of strength, the intermittents will be found to have constituted from 71 to 73 per
cent, of the total and the remittents from 23 to 25 per cent. It is noteworthy also, that
Mjii>. Hist., Pt. UI— 13
98
MALAFJAL FKVERS
these figures agree with the averages iVoni the army as a whole, for with 539 malarial cases
annually per thousand of strength in all tlie departments the i)ercentage of intermittents
was 71.71 and that of the remittents 24.01.
Table XXXIII.
IShoiciiKj — 1, The relcdive prevalence of the Malarial Fevers among the White Troops in the several Depart-
ments and Rcgionx during (he four yeais ending June 30, 180.'), expressed as ratios per IpOO of
strength; ^, The relative frfijaenci/ of the forms of these Fevers, expressed in percentages of the total
number of cases; and 3, The relative frequeney of the varieties of Intermittent Fever, expressed as
pereentuges of the total number of Intermittent cases.
144
264
284
32'J
390
315
288
650
1,035
559
423
238
526
227
.538
265
4Sfi
865
.595
457
1,287
930
648
195
212
DtrAliTMENTS ASH REGIOX.S.
Department of the East
Mirt'Ilf* Dei'.Trtment
Depiirtineiit i>t the .Slienaudoab
Middle Military division
Departnifnt of ^\'ashil|f^t^^n
Army of tlie Potomac
Department of Ihe Kappahannuel; .
De}tartment of Viro;iniu - -
Department of North Carolina . .
Department of the South
.Atlantic; Kf-yion
Department of tin; Northwest
Northern Department
Department ot \Ve.st \'ir^inia
Dejiartnient <»f the Missouri
Department of the Ohio - -
Department of the Cumberland
Department of the Tennessee - - -
Military Division of the Mississippi, Part I -
Military Division uf the Mississippi, Part II
Department of Arkansas
Department of the Gnlf
Central Rofji.m
Department of New Mexico
De])artnient of the Pacific - . .
Pacific Region
Total in the Regions .
6,330
12, 275
4, .560
15, 297
40, 349
138, 494
4,075
67,249
64, 389
36, 175
75.07
65.04
69.99
64.64
62.51
52.73
53.50
77.43
80.00
70, 82
e
a;
K
22.29
30.56
30. 06
30. 13
26.15
38.43
46.50
16.90
17.21
23. .50
389, 193
4,
20,
14,
54,
22,
107,
211,
65,
40,
7,3,
115,
2,987
5,052
8,039
1, 126, 294
li;>.u4 ] 27.71
63.07
34.. 59
73.35
24.03
64.19
31.22
72.54
25.31
70.44
25. 07
67.03
21). 75
76.43
20.68
73.46
2;!. 44
70.43
27.20
8,5.74
12.85
79.38
1.5.87
60.73
77.16
35.15
20.70
2.64
4.47
- (n) .-
5.23
11.34
8.84
. <a) ..
5.68
2.79
5.68
6.65
2.34
2.62 \
4.59
2.15
4.49
3.22
2.69
3.10
2.37
1.41
4.74
3.03
4.12
2.14
4,752
7,984
3,189
9,889
25, 224
73, 031
2,180
52,068
51,512
25, 619
255, 448
2,967
14, 732
9,035
39, 239
15, 9.50
72, ISO
161, 445
47,756
28, 775
62, 999
91, 517
546, 544
1,814
3,898
5,712
807,704
45.27
58.20
64.36
52. 89
47.34
51.50
43.53
51.33
58.75
47.73
52.26
61.61
50.55
50.08
48.79
52.08
52.13
.51.74
52.53
50.37
49.21
44.23
50.03
60.73
49.77
.37.04
33.68
43.67
47.29
41.27
47.16
43.48
:i8.07
45.56
42.27
33.27
42.37
46. 00
42.72
42.23
41.02
41.36
41.15
44.92
43.26
49. 0(1
43.18
59.81 I 33.78
50.85 42.77
O
4.48
3.31
1.38
2. 52
4.34
4.83
6.05
3.85
2.44
4.77
3.94
4.04
5.38
2.78
6.34
4.16
5.19
5.13
4.93
3.84
6,14
5.10
5.19
7.72
5.44
.48
1.45
.60
.92
1.04
2.40
3.26
l.M
.74
1.94
1.54
1.08
1.70
1.14
2.15
1.54
1.65
1.77
1.39
.88
1.39
1.66
1.62
{(i) These departments became niei-ged in others before the introduction of the term tifphn-maUirial.
■*
If, however, the specially malarious localities are examined, it will be found, as indi-
cated in the presentation of Table XXXII, that the remittent fevers did not form so large
AMONG THK V. S. KORCES. 99
a percentage of the total as in tlic (Irpartmcuts wlicrc tlie malarial influence was manifestly
not so extensively prevalent. Tims, in the Department of Arkansas scarcely 13 per cent.
of remittents occurred in 1,287 malarial cases annually per thousand of strength, in the
Gulf deinirtment 16 per cent, in 930, in North Carolina 17 per cent, in 1,035 and in Ten-
nessee 21 per cent, in 8G5; in the whole of ihe Central region 22 per cent, in OlS, and in
the whole of the Atlantic region 28 per cent, in 422.
In other departments, as the East, New Mexico, etc., where, with similar totals giving
expression to the malarial influence, the remittents and intermittents were not similarly
distributed, it is pi'obable that the jiercentages of each may have been largely determined
by the existence of those conditions which are recognized as predisposing causes. The
highest proportion of remittents occurred in the .\i-mies of the Potomac and llappahannock.
Predisposing causes such as fatigue, exposure to weather changes, loss of sleep, improper
food, impure water, etc., were undoubtedly at their maximum among the actively engasxed
troops of those commands.
The typho-malarial cases, while more frequent in a malarious locality than in one
comparatively free from malarial disease, do not ajipear to have exhil)ited any fixed rela-
tionship to the malarial fevers. Thus, the Department of Arkansas had the lowest per-
centage of typlio-raalarial cases, although presenting thi' highest annual total of malarial
fevers, and the Department of Washington and Army of the Potomac gave by far the
highest ]:>ercentage of typho-malarial cases, although they were below the average as
regards the prevalence of malarial disease.
The statements of medical authors as to the relative frequency of the types uf inter-
mittents are somewhat at variance. Thus, Brow.n''' represents the tertian as most fre-
quently met with, the quartan standing next, and the quotidian as in some degree rarer
than the latter. CoPLANnf also gives the tertian the greatest, and the regular quotidian
the least, prevalence. Climate and season have no doubt an influence on the production
of these varieties. HertzJ says that in temperate climates the tertian occurs most fre-
quently, and that the short types approaching the continued form prevail in the tropics and
in the teiiq^erate climates during the hot season. Indian experience appears to sustain this
view. Si'LLlVAN§ gives the order of frequency as quotidian, tertian and quartan. Maillot
and E. Collin II have published statistics of prevalence among the French troops in Algeria
which show a similar order of frequencv. Onr own statistics give the following percentages:
Quotidians 50.85, tertians 42.77, quartans 4.79 and congestive attacks 1.59.
On the assumption that the short types are most common in hot weather and in hot
climates, quartan agues ought to be most frequent where the total of malarial disease is
smallest. But the table just presented shows similar p<'icentages of this type of fever in
the Department of the East and in that of the Boutli. in the Northern Department and in
that of the Gulf, while the Department of Arkansas had many quartans and the Depart-
ment of the Cumberland comparatively few. The tertians were more frequent than the
tpiotidians in the Department of the East; but the same statement holds good with regard
• JOSKni Browx in the Cyclopxdia of Practical ilrdicitte, Phila., Pa., 1845, Vol. II, p. 206.
f A IHcliotiary o/ Practical Medicine, by J.\MI-;s Cori,AM>. London, 1858. Vol. 1. p. 9:J5.
: Hertz in Zirmssen's Ci/clopxdia , Amor. Traiisl.. New York, 1f7.'i, Vol. II. p. VJi't.
5 Endemic Piseases nf Tropical Climate.t. by JOIIX .SLLI.lv.vx. M. D., London. 1877, p. rW.
II F. C. M.VILI.OT— 7Voi( </m Fifrres IntermitUntes, Paris. 18»' — ffives, on p. 414, u table showing the occurrence in Iho military hospitals at Bone of
'-'.3:t8 clearly dcGned inlennittents, of which 1 ..WS were <|Uutidians. 7:i0 tertians and l!fi <niarlans. E. Coi.l.lX— in his Rerlierchrs sur U.n affections de la rate,
published in Reeueil dc Mfmoiies de .M6>lecine, etc.. 2' Sferie, T. IV. Paris. 1S4S — states, p. 116, that of 6,63(i cases observed at Philippeville in Algeria,
3,523 were quotidians, 9l(i tertians, 58 quartans, 31K1 erratic of variable type and 1,836 remittents.
100 MALARIAL FEVEKS
to the Department of the Gulf. A closer inspection of the data from which this table was
made up gives greater prominence to the irregularity in this respect. While the nature of
the disease-poison is no doubt the main factor in determining the type of the disease, it is
probable that predisposing conditions exercise a strong influence on the resulting fever.
Congestive fever constituted .48 per cent, of the interraittents in the Department of the
East; .60 in the Shenandoah; .92 in the Middle Military Division, and .98 in the Depart-
ment of the Pacific, in each of which the malarial total was comparatively small: 1.66 in
the Department of the Gulf, and 1.39 in Arkansas, in which the totals were large; but it
constituted only .74 per cent, in the highly malarious Department of North Carolina, and
1.93 in the comparatively healthy territories of the Department of New Mexico. Since,
however, the highest proportionate number of congestive cases was found in the Army of
the Potomac, 2.40 per cent., and in the Department of the' Rappahannock, 3.26 per cent.,
it may be assumed, as in the case of the remittents, that these pernicious fcers were largely
due to the fatigues, exposures and deprivations incident to active operations.
Tlie distribution of the malarial fevers during the war, presented in numbers in the
last two tables, has also been illustrated by the tinted map which faces this page. It is
impossible to show on a single map of this, or perhaps of any size, the many changes
wliicli the exigencies of the moment necessitated in the boundaries of the various military
departments. For this reason no attempt has been made to secure such official accuracy
in their outlines as would be required were the map intended as an illustration of a mili-
tarv study. Nor is this needful, for the depth of tint indicating the prevalence oi ,cJ
fevers in a given department was determined not by the malarial character of the depart-
ment as a whole, but only by that of the part, oftentimes a small one, occupied by the
Union forces. The lines and circles of solid color show in what parts of the various depart-
ments our armies operated during the years of the war, — red, yellow, blue and green res-
pectively representing the portions held during the years ending June 30, 1862, '63, '64
and '65. In certain of the home departments, as the Northern Department and those of
the East and Northwest, no lines of position are given, as the troops serving in these
'military commands were scattered generally over the country at recruiting depots and
camps of instruction, etc.
The Departments of the Rappahannock and Shenandoah and the Middle Military
Division are not represented on the map. The first two temporarily formed independent
commands in the section of country which was for most of the time known as the Depart-
ment of the Potomac, and the last, during the latter part of the war, included West Vir-
ginia and the Valley of the Shenandoah. Nor does the Military Division of the Mississippi
appear on the map. Part I of this Division included, during the last year of the war, the
country composing the Departments of the Ohio, Cumberland, and Tennessee and such
parts of the neighboring States as were occupied by the army under General Thomas ; while
Part II comprised the territory passed over by General Sherman's army in its march through
Georgia to the Atlantic Coast, and thence northward to Washington, D. C.
The map shows in a general way the greater frequency of the malarial fevers in the
southern portions of the Atlantic and Central regions. Apparent exceptions were due to
easily explained circumstances. Thus, in the Atlantic region the troops in the Department
of the South suffered less than those of the North Carolina command, because the greater*
portion of the former occupied dui'ing most of the war comparatively healthy sites on coast
AMONG THE U. S. FORCES. 101
islatnls. Hacl the fortune of war carried them into the more malarious districts, they would
undoubtedly luive had an experience similar to that of the rebel troops that held those dis-
tricts.* Thus, also, in the Central region the deptli of color expressive of prevalence is
greater in the Department of Arkansas than in that of the Gulf, on account of the occupa-
tion by the troops of the unhealthy bottom lands in the former section of the country.
It would be interesting in this connection to discuss the geographical distribution of
the malarial fevers among the civil population of the United States and the garrisons of
our military posts in times of peace. Information on the latter head will be found in
Fokry"s bookf and in the publications of the Surgeon General's Office. | As to the former,
the works of Drake and Hirsch § may be consulted. Both these writers have relied to
a considerable extent on the military statistics compiled by FoRRY and Coolidqe.
Tliroughout the .Vtlantic region malarial fevers were, during the war, most prevalent in
the swampy districts and lowlands adjoining the sea and bordering the water courses: they
became milder in the dryer and more elevated districts of the interior, and disappeared in
the highlands of the Appalachian chain and the mountainous districts of New England and
New York; but south of Pennsylvania the}^ were found in the river valleys at a consider-
able elevation.
In the Central region the malarial influence was most intense in the lowlands border-
ing the Gulf of Mexico and along the rivers that discharge into its waters; thence it
extended northward with diminisliing intensity to the vicinity of the great lakes, where it
again became markedly prevalent. On the East it penetrated toward tlie headwatei's of
the streams arising in the Appalachian range, and on the AVest it because gradually milder
towards the Rocky Mountains, finally disappearing on the lofty slopes of that system,
though still existing to some extent in its elevated valleys.
In the Pacific region the relative prevalence of the malarial influence corresponded
closely with tha,t which obtained in the Atlantic region on the same isothermal lines.
* Cum(>are the statements <>f thi* freqiieiK-y of the malarial fevers among the Confederate troops iii these very Jistricits, given in a subsequent part
«f Ibis chapter, p. U»,1, on the authority of Br. JOSEI'II JONKS. .See also the testimony of KDl.l.Oi'K, cited by J, V. POSKY — Hejxtrt on the Utpxyraph}/ mul
tpidtmic diftasfs of Ote State of Georgia, .Southern Med. and Sur^. Jour., Vol. XIV, 185^, p. 191 — with roftjard to the freedom from niiasmatio fevers of
those sea ishinds on the coast «if Oeorg-ia, which have "few or no brackish ponds or lagunes as compared with the opjxtsite main." For further remarks
ou the ineiliciil toj>og:niphy of this part of the Southeni States, see a reference to the report of the Confeilerate Surfifeon SamI'KI, I.or.ANj infra, ijago 171.
t Samiki. FoitKV— ry**; CUmatr of the I'liited Stales, '^d Edit., New York, 1842. See also, t)y the same author, Slati.ttical Ri-sforches elucidating
thf CHmate of the Uniteil States and its relation with diseases of Malarial origin, etc. The Anier. Juiir. of the Med. .Sci., N. .S., Vol. II, 1841. p. i;j,
aivil the Endrinic tiitiuences of the Umted States, in the same volume, p. '^*y3.
; See the Statistical Rejttirts on the SicL-riess ami Mortality in the. Army of the United States: the first. /rom January, 1819, to January, ie:i9,
Wasbtnglon. I?40. Edit, by FOKiiv ; the second,/mm Janvory, 183M. to January, 1855. Washington, 18rj<J, edited by It. H. Cooliuge^ the third, from
January. 1855, to January. Ititjll, Washington, IH60, edited by the same; also the two reports edited by Assistant .Surgeon (now Surgeon) J. S. ISlL-
LIXOS. V. S. A., viz: Circular So. 4, Surgeon General's Office, Washington, Dec. 5, 1870,—^ Report on Barracks awl Hospitals, with dtscriptions of
Military Posts, and Circular A'o. 8. Surge^in General's Office, Washington, May 1, lfl7.T — A Report on the Hygiene of the United States Army, with
description nf military posUc.
^ Uasiri. Drake— Oh the Principal Diseases of the Interior Valley of Xorth America, Cincinnati, 1850; also, the same work, Second series,
Philadelphia, 1854. A. Hin»vn—Handb. der historisch-geoyraphischen Pathologie. Erlangeu, 1860, Bd. I, S. 1 1 et .t<r(/. .See alsf., besides the several
essays riteil by Hirsch. the following: Oliver Wenhell HoL>tE.'j— ^'acfs and traditions resi>ecting the existence of indigenous intermittenl fe.ver in
y'ew England : being the Boylston Prize dissertation for the 3-ear 183fi. Boston, 1838. — An interesting (wiper, jjiving a good dt-al of evidence to show
that at various times during the previous teiitnry. and even earlier, inlerniitlent fever prevailed more extensively in New t^ngland than it did at Ihe time
it was written, or indeed for a number of years jtreviously. J. W. Wv.V^Tls— Medical facts and intfuiries resiterting the cause, nature, precention and
cure offerer in the Southern States, etc., Cahawba, Alabama, 18.;5. R. S. H0I>MES, late of the Medical Stalf, V. S. Army— 0** Malaria in connection
with Medical Topography. The St. Louis Med. and Surg. Jour., Vol. V. 1848, p. 519 — comiiares the topography of certain military posts in Florida,
Pnrtland and IIolti>n, Maine, Prairie du Chien on the Upper Mississippi, and certain ptiints in Mexico. E. D Vksskr— Southern Medical Reports, New
Orleans and New York, Vol. I, 184l», Vol. II, 1850. .JOHN F. Po&E\—R^j>ort upon the Tojtography and Epidemic Diseases of the Stale of Georgia,
Southern Med. and Surg. Jour, Vol. XIV, 1858, pp. lOfi and 191. J. C. Harris «.f Alat>ama — An Essay on the climate and fevers of the Southicestern,
Simthfrn Atlanticand Gulf States. The New Orleans.Iour. of Med., Vol. XXIII. 1870. p. 401 et seq.; also Charleston, S. C. lS7i». H. BliONSON— //iVory
nf intermittent fever in the Xew Haven region, with an attempt to distinguish the known from the unknown causes. Pn^ceeding.** of the Connecticut
Medical Society. 2d .Series. Vol. IV, 1872-5, p. 29. A. W. BaRROWs — On Malarial fever in New England. (President's Address.) Same pr..ceed-
ings, 1877. p. 22. See also the Reports on the Epidemics and Climatology of various States, made to the Section of Meteorology, Medical Topography
and Epidemic diseases, scattered through the volumes of Transactions of the American Medical Association prior to and including the year 1873: subse-
quently, many of the rejiorts to the section of State Medicine and Public Hygiene (organized in 1873J in the same Transactions.
102
MALARIAL FKVERS
In eacli of these regions the niahirial influence became in a general way more intense
towards the south; but local conditions everywhere exercised a controlling or modifying
power. Malarial fevers were less prevalent in well-drained rolling districts, elevated
plateaux and mountain slopes, while they increased in frequency and severity on low plains,
in moist river valleys and in swampy lands. In fact, their distribution during the war
corresponded intimately with that already outlined by FoRRY and Coolidge, and with the
indications of the mortality tables of the Census Reports* and of the deaths returned by
municipal boards to the National Board of Health.f
II.— MALARIAL FEVERS AMONG THE CONFEDERATE TROOPS.
Prevalence. — The consolidated monthly returns of the Confederate Army of the Poto-
mac, preserved bv Dr. T. H. Williams, have served for the computation of ratios indica-
ting the monthly prevalence of malarial fevers in that army from July, 1861, to March,
1862, inclusive. In the table on the following page these ratios are given in juxtaposition
•with those for the Federal Army of the Potomac during the same months.
These figures shuw that malarial fevers were even more prevalent in the Confederate
tliaii ill the Federal Army of the Potomac. The average monthly strength represented
by the Confederate sick reports was 49,394 men, among whom occurred the monthly ratio
of 38 malarial cases per thousand, while the average strength represented by the Federal
sick reports was 111,169 men, and the monthly ratio of malarial cases 28.
It is not possible to contrast statistically the mortality of tlie two armies from these
fevers during the period in question, as the Confederate returns give the number of deaths
only under the heading "total from all causes."
'' ill tills <-niiiiecli(iii the folluwing tjibl
ieaths IVoin iiialanal t'evt^rs per 11IU,UU0 livii
e liHS b
-Hii ('(inii.ilfil In. Ill tlic Sfatistii-s of tl
us:
p ('ens
IS years 187(1 anil 1880. The figures
tabulated represent
Atlantic Rehion.
1870.
1880.
Ckntkal Reoion.
1870.
1880.
Pacific RRGiqir.
1870.
1880.
8
18
18
6
121
11
15
15
15
20
29
3
4
1
y
4
.
-1
5
9
29
20
47
24
28
39
69
73
69
112
5
,0
l-J
22
27
17
20
4,')
■17
1
36
59
83
«
104
91
140
93
92
Utah
13
15
25
38
47
WhnI \'irs-iuia
Daki.la
l*alifuriij;i
[ Nevada
4
Connectu^iit 5
Maine. . , . - - . t,
Nebraska . -
Ohio
I J
14
14
21
2.j
31
■M
3.->
45
61
6G
76
77
91
114
115 ■
! . ^
7
Mic^higan
Keiitiifky ....
Indiana
Miniie-sola
Arizona
('cUirailo --.
New Ycirk 10
18
20
21
42
52
60
114
Florida
t See note on p. 87, supra.
AMONG TIIR CONFEDERATE TROOPS.
103
Tlie cases embraced in the reports of Dr. W'iij.i.vms consisted of 9,954 intermittents
and 6,827 remittents. Of the former, 5,713 were (juotidians, 3,769 tertians, 389 qnartans
and 83 congestive cases.
Table XXXTV.
A Comparimn of the Prevalence of IntermiUent and Remittent Fevers in the. Confederate and Federal
Armies of the Potomac from July J, 1861, to March 31, 1863.
CONFEDBBATF. AltMT.
U. S. Akmv.
Number of Cases.
Jul}-. ISiil
Aiifrnsl. leiil
Scl.tinilMT. isi;i
o<-t..i»r. im:i
November, ll^tjl .
l)tHfml>er, Iflil
JuiiiiKry. I'-'tlw
Kebruury, \&\'i. .
.Miircli, 1862
M..nthlv
5U, .W5
K<,.T60
nt<,918
5.'),09n
56, 700
ra, 089
54,P10
ai, .iTO
49, 394
Sil9
1,1174
.1,739
1,864
1,405
1,148
687
65(1
488
1,106
330
1,716
1, 739
1,347
664
477
262
171
lai
759
629
3, 390
3,478
3,2n
2, 069
1,625
949
Ml
609
1,865
Ruliu per 1.000
strength.
Number «f Cases.
Katiu
sir
per 1,000
.■iiKlb.
29 17,709 165
67 ! Mjm ' 1,607
no ' 85.4(18 I 3,514
.54 j' 113.204
984
133,669 I 3.011
152,7.)9 I 2, 151
167,21.7 ;.17()
153, 3(a
126, 588
111,169 1,971
1,344
793
(»
584
1, 340
i,7.'.(;
1,922
1.474
982
1, 148
664
1,104
228
2, 191
4,854
5, 740
4, 9X1
3, (i25
2, 1.52
2, 492
1,457
3, 075
a*
a>
E
a
<£
9
4
32
11
41
16
35
16
23
14
14
10
7
(;
9
7
7
5
1-
ID
I
13
43 i
57
51
37
24
13
< 16
12
The consolidated monthly reports for certain general hospitals in Virginia during tlie
last fonr months of 1862 give, in a total of 34,890 admissions for disease, 3,095 admissions
for malarial fevers, distributed as- follows: Remittents 931, or 30 per cent, of the malarial
total. (jUotidians 623, tertians 1,309, quartans 215 and congestive cases 17. Unfortunately
the mortality from these cannot lie ascertained from the reports.
According fo Dr. Jones, the reports of sick and wounded for the years 1861 and 1862,
filed in the office of the Surgeon General of the Confederacy, exclusive of those from the
Trans-Mississippi department, gave a total of 819,286 cases of disease and injury, not
including gunshot wounds, while the cases of malarial fever numbered 1 15,115, or one case
of malarial fever in 7.1 of the cases constituting the total. The corresponding figures*
from the records of the United States troops give 1,709,416 cases of all diseases and injuries
exclusive of gunshot wounds, and 274,053 cases of malarial fever, or one case in every 6.2
of the total. These rates indicate that the proportion of malarial cases to the whole
number taken on sick report was greater among our men than among the Contederates.
But it would be unsafe to conclude from this that the ratio oi' the paroxysmal fevers to
strength was at all less with them than with us. Indeed, in the few instances in which it
has been possible to ascertain the ratios of cases to strength in certain portions ol the
Confederate armv. they have been fouud to be actually' greater than in the corresponding
parts of the United States forces. Among the statistics preserved by Dr. JoNES is a table
relating to the Confederate Army of Tennessee, the figures of which may be compared with
those of the Federal Army of the Tennessee for the Same year. The table covers fourteen
♦ See Table XIII, tupra. page 31.
104
MALAKIAL FEVERS
months, from April, 1862, to May, 1863, inclusive; but the mean strength for the first two
months is unfortunately not given. Dr. Jones remarks, also, that the returns for Julv,
September and October, 1862, are "incomplete." They represent, however, a sufficiently
large part of the force to give a fair notion of the prevalence of the disease under consid-
eration in the whole army. In the following table the malarial statistics of these armies
are contrasted :
Table XXXV.
A Comparison of the Prevalence of Intermittent and Remittent Fevers in the Confederate and the United
States Armies of the Tennessee from June 1, 1862, to 3Iay 31, 1863.
June, 1862
July,1863
August, 1862
September, 1862 .
October, 1862
November, 1862 .
December, 1862. .
January, 1863 ...
February, 1863 . .
March, 1863
April, 1863
May,1863
Monthly average .
COSFEOEBATE AKMY.
40, 675
10,658
30,025
9,311
15,082
33, 791
48,958
50,604
63,494
61,226
64,441
55, 121
40, 282
Number of Cases.
3,269
982
2,161
543
902
1,310
1,695
1,795
2,213
3,103
3,734
4,030
a, 144
2,487
927
1,593
97
2-30
268
398
491
613
908
1,418
1,498
911
5,756
1,909
3,7,54
640
1,132
1, .'>78
2,093
2,286
2,826
4,011
5,159
5,528
3,055
Ratio per 1,000
strength.
23
141
179
125
69
75
47
43
45
44
65
80
100
76
U. S. ARMV.
66,042
80,647
70, 997
82,972
111,891
136,503
13;), 119
143, 942
141,158
146,790
143, 367
140, 277
116, 475
Number of Cases.
2,541
3,045
3,245
5,898
7,338
6,783
4,643
4,771
4,566
5,076
4,695
3,911
4,709
1, 574
1,927
1,725
1, 702
1,669
1,643
1,405
1,891
1,715
1,919
1,736
1,565
1,706
4,115
4,972
4, 970
7,600
9, 007
8, 426
6,048
6,662
6, 2i!l
6, 995
6,431
5,476
6,415
Ratio per 1.000
strength.
40
15
In the case of these confronting armies, as in the case of the Confederate and Federal
Armies of the Potomac previously coutrasted,* the Confederates had actually a larger pro-
portion of cases than was reported bv the Federal Army. Other statistics published by
Dr. Jones point in the same direction. The rebel command serving in the river batteries
below the city of Savannah, Ga., reported from October, 1862, to December, 1863, inclusive,
a mean strength of 878 officers and men, with 3,313 malarial cases, of which 2,824 were
intermittents and 489 remittents. As this command occupied the low rice lands of the
Savannah river its experience may serve to indicate what our own troops in the Depart-
ment of the South would have suffered had they been advanced by the fortune of war
from the comparatively healthy coast islands to the lowlands of the main. Looking only
to the statistics of the year 1863, Dr. Jones's figures give 2,214 intermittents and 461
remittents, a total of 2,675 cases of malarial fever in a mean strength of 873 men. In
ratios per 1,000 of strength these are equivalent to 2,536 for the intermittents, 528 for the
remittents and 3,064 for all the malarial fevers. Among the United States troops in the
Department of the South the ratio of malarial cases for the year ending June 30, 1863,
* Page 103, supra.
AMONG THE CONFEDERATE TROOPS.
105
was luit 528, that of the intermittents being 359 and of the remittents 169; while for
the following year the malarial ratio was 594, the intermittent ratio being 492 and the
remittent 102.
Equally instructive is the contrast between our reports from the Department of the
South and those published by Jones as from the Confederate troops serving in the De])art-
ment of South Carolina, Georgia and Florida, from January, 1862, to July, 186)), inclusive.
The mean strength of the command during this period was 25,723 men, and the cases of
malarial fever 41,539, of which 35,925 were intermittents and 5,614 remittents. Con-
sidering only the figures for the fiscal year ending June 30, 1863, the following results are
obtained, which may be compared with the ratios just stated as from the Federal Depart-
ment of the South: Mean strength 26,185; number of intermittents 30,322, or 1,158 per
1,000 of strength; remittents 3,665, or 140 per 1,000; total of malarial fevers 33,987,
or 1,298 per 1,000.
Another table presented by Jones embodies the statistics of the Confederate troops in
and around Mobile, Ala., for the period from January, 1862, to Julv, 1863, inclusive:
Average strength 6,752; malarial cases 13,668, of which 10,500 were intermittents and
3,168 remittents. The figures for the year ending June 30, 1863, give a mean strength of
7,659, and a total of malarial fevers amounting to 10,878, of which 8,635 were agues
and 2,243 remittents. The ratios obtained from these numbers, respectively 1,420, 1,127
and 293 per 1,000 of mean strength, exceed those for the same year I'miu our Department
of the South, and even those for the same period from our more unhealthy Department
of the Gulf, which reported per i,0(M of strength 863 cases of malarial fever, 696 being
intermittents and 167 remittents. ^
The Army of the Valley of Virginia, during the ten months, January, 1862, to Octo-
ber, 1862, inclusive, had 3,885 malarial cases in an average strength of 15,582 men.
The figures for the first six months of this period may "lae contrasted with those of the
Federal troops in the Department of the Shenandoah. An equally trustworthy comparison
cannot be made for the remaining four months, because during that period the Federal
reports for the district in question have not been separately tabulated.*
• We may. however, contrast the figures furnished by Dr. JONES for the Confederate Army <if the Valley of Virginia during the months of .July.
August. September and October, I8fi2, with those of the Federal troops in the Middle Department for the same period : for on the breaking up of tlie
Department of the Sheuandikah the sicli reports of the troops which remained in it were consolidated with those from the Middle Department.
A Comparison of the J'revalence
of Intermittent and Remittent Fevers in the Confederate Army of the I
of the Atlantic Region for the period from July 1 to October 31
'alUyof
1862.
■irginia and the V. S. Middle Ihymrimmi
COXFEDEKATE ARMY.
V. S. Ahmv.
tii
S
Y,
15,589
15, 643
21,123
34, SIW
Number of Cases.
Ratio per 1,000
strength.
s
Y,
S
s
Number of Cases.
K»t
s
o per 1,000
trength.
a
9
1
0)
c
•E
o
1
®
1
'i
•c
1
1
•c
a
"a
s
o
1
"1
*
a
—
1
a
•c
s
1
July, lgC2
473
4:i4
348
239
305
127
■35\
712
739
475
983
31
28
16
19
15
19
6
10
46
47
22
29
12,357
9.135
19, 101
21,531
266
214
235
473
150
82
139
193
416
296
374
666
22
23
13
22
12
9
7
9
34
.12
20
31
August, 1862
Septt-inber, I8«2
October. 1862
21,639
472
255
727
29
12
34
15,531
297
141
4:i8
19
9
38
Med. Hist., Pt. Ill— 14
106
MALARIAL FEVERS
Table XXXVI.
A Comparison of the Prevalence of Intermittent and Remittent Fevers in the Confederate Army of Virginia
and the U. 8. Department of the Shenandoah from January 1, 1862, to June 30, 1862.
These statistical fragments indicate that malarial fevers were more prevalent among
the Confederate than among the Federal soldiers.
Murtahty. — For want of data on the rebel side it is not possible to determine the rela-
tive mortality from these fevers in the opposed armies; but, as bearing on the question, we
have Dr. Jones's statement that the records of the Surgeon General's Office for the years
1861 and 1862 gave 1,333 deaths in connection with 115,415 cases of paroxysmal fever
and 31,238 deaths from all causes excepting gunshot injuries. Table XIII, already pre-
sented, shows that these figures are equivalent to 43 deaths from malarial fever per
thousand deaths from all the included causes, and to a fatalitv rate of 1.15 per cent., or
one death in 86.2 cases, while the corresponding figures from the records (jf the U. S.
troops are equal to 160 deaths from -malarial fever per thousand deaths from all causes,
and to .95 per cent, of fatal cas'es, or one death in every 105.3 recorded attacks.
According to these figures the ratio of deatiis to the recorded cases was greater among
the rebel than among the northern troops; but there is no certainty that the recorded cases
m the two armies liore the same relation to the number of cases that actually ocmu'red. It
appears not unlikely that tins larger ratio of deaths to recorded cases may have originated
in a failure to report the lighter agues. The familiarity of the Southern people with
malarial disease suggests that many attacks which would have appeared on the sick reports,
had they occurred among Northern men, may have been suffered without excuse from duty
in the Confederate camps. It will be noticed, also, that the lai-ge ratio per thousand deaths
from all causes constituted by the deaths from malarial fevers among the U. S. troops, as
compared with the small corresponding ratio on the Confederate records, is opposed to the
view that the fatality of these diseases was greater among the rebel troops.
The summary whicli Dr. Jones has given of the field reports from the Department ot
South Carolina, Georgia and Florida, is available for estimating the gravity of the malarial
fevers, as he has fortunately published in connection with it a tabular consolidation of the
hospital reports from that department foi the same period. From these it is found that
AMONG THK CONFEDERATE TROOPS.
107
41,539 cases of malarial fever corresponded with 227 deaths, or one death in every 187
cases, constituting a smaller percentage of fatal cases, .55, in tiii.s malarious department
than the average percentage, .70,* among tlie Union troops in all the departments.
The opinion that the rate of fatality of the malarial fevers as a class was smalh-r
among the Confederates than among the Union troops gathers support from a study of the
totals in the following table, which show that the percentages of the different types of fever
were not the same in the two armies:
Table XXXVII.
Showing — /, The Behiive Frequency of the Forms of Malarial Fever among the Confederate Troops as
compared trifh their Frequency among the Troops of the United States, crpresscd in percentages of
the total number of 3f(ilarial Cases; and, 2, The Frequency of the Varieties of the Intermittent^,
expressed in percoitages of their totals.
C0MH.\KD.
Garrison of SnTnnnah, Ga. Coofed.
Department of the South U. S.
Deparltnent of South CaroliDa, Georgia and Florida f 'onfed.
Department of the South V- S.
Garrison of Mobile, .\Ia Cimfed.
Department of tlie Gulf U. S.
Army of Tennessee Confed.
Department of the Tennessee : U. S.
Army of Virginia Confed.
Department of the Shenandoah, Middle Department U. S.
Army of the Potomac Confed.
Army of the Potomac U.S.
Pf-rku*
INDEK OBSEUV.VTION.
Oct., '62, to Dec,
15 months.
' Jan.,'C'2, to .luly,
I 19 months.
1
'63,
Jan., "62, to July
19 months.
, '63. (
\April,'62,toMiiy,'63, 1
I 14 months. J
1 Jan. to Oct., 1.SC2, 10
r months.
{
}July, 'Cl,to Mar., '62, J
9 montlis. I
Toul Conf. derate ..
Total United States .
3, .313
17,8S1
41,539
/4,«M
13,940
?«, 7SS
40, 133
si,,ies
3,885
S,!5T
16,781
S7,67S
119,591
175,tl,S
;h
Pkrcentaoe op
Total
ISTEItMITTF.NTS.
2,824
IS, 91,0
35,925
10, t'JJ,
111,772
21, 576
28,099
el,80.t
2,573
i, 167
9,034
17, 730
90, 147
t!7,5S5
a
?.
S
a
CJ
1
.07
6
1.00
3
.50
6
!.00
3
.80
S
f.OO
6
2.00
C
s.oo
7
2.00
;.«.
3S
iO
1
5
5.00
.90
47
4
i$
5
S.OO
The remittents, for instance, constituted a larger prupiirtimi of tlie nialarial case.s
among the Union than among the Confederate troo{)s. It must be remembered, also, that
only the remittents and intermittents occurring in the Federal forces are here tabulated,
the typho-malarial cases having been omitted as the Confederate reports had no corre-
sponding heading.. No doubt some of our typho-malarial cases, had they been in the hands
of southern officers, would have been reported among the remittent fevers, as some of the
remittents of the Confederate sur^Teons miuht, on account of a Ary dark tongue or oth^r
symptoms, have been called typho-malarial had they occurred in the practice of northern
medical men. It may therefore be assumed that if the same medical views had determined
the diagnosis of all the cases tabulated above, the difference between the percentages of
remittents in the two armies would have been greater. Had the diagnosis been made by
our northern medical men the remittents of the Confederate armv would have been dimin-
• Table XXII. supra, p. 79.
108
MALARIAL FEVERS
ished by the abstraction of a certain number of typho-malarial cases, while, had the
southern officers made the record, the remittents of our army would have been increased in
the absence of the typho-malarial group. On either supposition the preponderance of grave
cases of malarial fever, shown by the table as having existed among the Union troops,
would have been augmented. The greater percentage of congestive cases among our-
troops is also suggestive of a larger mortality. Indeed, these percentages may be used to
determine approximately the average gravity of the malarial fevers among the Confederate
troops. If it be admitted that the various types of paroxysmal fever, as they occurred
among the Confederates, were attended by the mortality which characterized them in their
attacks upon our soldiers, as shown in the last column of Table XXII,* the influence exer-
cised on the mortality by the smaller proportion of remittent and congestive cases among
them may be estimated. The deaths thus calculated formed .57 per cent, of the cases,f
or one death in every 175 cases among the Confederate troops, and .97 per cent., or one
death in every 103 cases that occurred among the United States soldiers for the periods
stated in the table above presented. It seems probable, therefore, that although attacks of
malarial fever were of more frequent occurrence among the Confederates, the gravity of
these attacks, including the consequent mortality, was less than among the Union troops.
m.— MALARIAL FEVERS AMONG THE PRISONERS OF WAR HELD BY THE REBEL AUTHORITIES.
It might reasonably be supposed, from the situation of the principal places of con-
finement, that malarial fevers of local origin would not have prevailed so largely among our
captured men as among our troops on active service; but the statistics bearing on this
question are not of a satisfactory character.
Dr. Jones has endeavored to show that the Federal prisoners in the Andersonville
stockade suffered less from these fevers tlian the rebel troops serving in South Carolina,
(reorgia and Florida, or even in such an elevated and comparatively healthy region as the
Valley of Virginia.| A reference to Table XVI. § compiled from figures published by him,
will show that during the six months of 1864, March to August inclusive, there were
reported among the prisoners 2,966 cases of malarial fever, 119 of which were fatal. Of
the cases 1,170 were quotidians, 775 tertians, 195 quartans, 8 congestive fevers and 818
remittents. The intermittents caused 64 deaths and the remittents 55. The monthly
ratio of cases per thousand of strength was 23, a number considerably smaller than the
average monthly ratio among our white troops in the Atlantic region for the months stated,
as may be seen by a reference to Table XXVIII. || Dr. Jones, however, recognized the
* See page 79, supra.
t In every hundred cases of pure malarial fever there were —
Among the union Thoops.
■ ■
Among the Confederate Troops.
35 8 Quotidians with
.0358 deaths.
.03)4 deaths.
. .0073 deaths.
. .539S deaths.
. .3537 deaths.
36.0 cases with
35. 3 cases with
.036 deaths.
. 0359 deaths.
.0060 deaths.
;i6i;4 deaths.
. 3S75 deaths.
•Jl, 4 Tertians with
3. 6 Quartans with
2. li Cttu^estive with
27.0 Remittents with
0. 7 cases with
25.0 cases with
100. 0 Malarial with
. .9680 deaths.
100.0 cases with
. 5711 deaths, i
I See his Investigations upon the diseases oj the I^eral Prisoners, etc., cited in note, page 29, supra.
§ Page 35, supra. || Pages 89. tH» and 91, supra.
AMONC, THK PRISONEKS OF WAR. 109
fact that his figures did not embrace the whole number of cases that occurred williin the
stockade during the six months.* Tiieir deficiency may l)e appreciated by an examination
of the original hospital register of the prison, now on file in the office of the Adjutant (lend'al
of the Army. This document shows the number of deaths caused by these fevers between
February 24, 1864, and .\pril 17, 1865, to ha\e been l(i.>; of which I I*.) occurred during
tlie period covered by Jonks' compilation, being 30 in excess of those reported bv him.
But the register throws no direct light on the number of cases. Only a small minor-
ity of the malarial fevers occurring among the prisoners in the stockade were admitted to
hospital. While Dr. Jones' statement embraces 2,966 cases in a period of six months,
the hospital register acknowledges tlie admission of only 254 cases in a period of over
fourteen months, which included the six months aforesaid. The character of the admitted
cases may be inferred from the fact that 163 of their number terminated I'atally. There
were 160 intermittents with 101 deaths, 88 remittents with 59 deaths, and 6 congestive
cases with 3 deaths: in 1.) of the cases no disposition is recorded.f
Dr. Jones has pointed out that after a considerable increase in the prevalence of the
malarial fevers among the prisoners during the month of May, when the maxinuun ratio
of 77 per thousand was attained, the cases thereafter diminished to a ratio of 17 per thou-
sand in July and 15 in August. Although the figures which he has published liavo no
absolute value, it is probable that they give a fair expression to the relative prevalence at
different times, especially as confirmatory evidence is obtained from the mortality as
recorded in the hospital register, which shows 149 deaths from malarial fevers during the
six months ending August 3, 1864, and but 14 deaths during the subsequent eight months.
In explanation of this, he has suggested that the morbific influences generated by the over-
crowded and filthy condition of the stockade neutralized or destroyed the malarial poison ;|
and in view of the well-known infrequency of malarial fevers in densely peopled cities this
suggestion appears probable enough.
The only other statistics bearing on the prevalence of malarial levers among Federal
prisoners in the South are from the register of Division No. 2 of the hospital at Danville,
Va. This record extends from November 23, 1863, to March 27, 1865. There were
4,332 admissions and 1,084 deaths, of which but 233 cases and 17 deaths are attributed to
malarial fevers. Such figures suggest similar conditions, so far as concerns the occurrence
of these fevers, to those which existed at Andersonville.
IV. -MALARIAL FEVERS AMONG THE PRISONERS OF WAR HELD BY THE UNITED STATES.
The alphabetical registers of the Surgeon General's Office record the deaths of 1,134
Confederate prisoners from malarial fevers in a total of 23,591 deaths from all diseases;
of these 122 were attributed to simple intermittents, 169 to congestive, 489 to remittent
and 351 to typho-malarial fever. These figures afford no basis for calculating the relative
* He remarks, in speaking generally of tbe statistics of the Andereonville prisoners, — " No classified reoonl of the sick in the stockade was kept
afler the establishment of the hospital without the pri.s(>n. Tliis fact, in conjunction with facts already presented, rclatinfi: to tlic insullicicni'y of
medical ollicers, and the extreme illness, anil even death, of many of the prisoners in the tents in tlie stockade without any medical attention or ri-trord
beyond the bare number uf the dea<l, demonslrate that tlic fifrnres, larf^e as they appear to be, arc far below the truth." 1*. ."(TO, op, cit. When, hnwcver,
he c<iine9 to discuss the freqneriiy of malarial levers ani.ini.' these prisoners, ho takes a soTucwbat moditicd view : " While it is evident from llie
.results of the exuminalitins recorded in the fourth chapter that these stalislics are below nillier than above the absidute numlicrs, still it docs not ap|»'ar
thill the errors were preater in this class tif diseases than in Ilo- others, and in fact, from the nature of malarial fever, we should be disitosed to consider
them less.' P. 5<'>i;, np. cit. On the contrary, it would sooni that in an establishment where tbe medical attendance was insufTlcieiit, us at Andersonville,
such comparatively mild forms of disease as ordinary intermittent fever would have been most likely to escape rejiort.
t See Table SV, p, 34, supra. ; Op. cit., p. 568.
110
MALARIAL FEVERS
frequency or fatality of malarial disease among the prisoners; but the following table,
compiled from tlie monthly reports of sick and wounded from the priiicii>al prison depots,
is of value in this connection:
Table XXXVIII.
Ca.sen of Mahirial Fever with resulting mortality, reported from the jirincipal Prison Depots as Imvimj
occurred among the Confederate Prisoners of War; with the annual ratios per thoxhsand of strength
present.
«
.12
a s
n
_; =
— a
c 1
ST
a:
.00
1!
H
-1"
Johnson's Island. Ohin,
June, 1863— June, 1865.
4
H
!- r-t
c ,
It
"^2
p r
1 i
4
■«s
u
J
o
5,361
1,008
6,030
2,865
2,114
3, 570 '
6,591
6.406
9,610
40, 815
n, 864
5, 234
1,230
722
1,365
1,009
10
2,384
1,032
416
.'506
228
135
54
2, 527
1,728
3
321
305
2, 49S
653
1, .574
5,209
1,620
35
24, 278
U, 240
3, 069
38,387
213
424 1
4,124
163
10, 151
7,206
1,954
417
4,258
628
4,725
6,864
48
134
51
30
25
122
17
23
12
12
;i
98
3
3
4
14
11
9
5
59
1
27
57
91
57
103
1
Deaths I'nmi Typln'-inularial
233
177
52
119
10
31.8
30.7
12.2
34
499.7
341.7
.6
65
175
161
1, 02(1
Annual nitins per tliousand uf strength tor cases of—
320.5
225.4
fc.9
1,832.9
437.9
• 252.0
l.'i9.8
118.1
1.2
172.9
69.7
84.8
48.7
. 46.3
.3
203.5
53.2
128.2
29.'). 4
91.9
2.0
i
2'.l7. 4
137.7
37.6
472.7
2.6
,5.2
4.8
12.6
All Miilaiial Fevers '
534.8
2,523.7
279: 1
387.4
94.7
. 7
.7
.9
843.0
95.3
384.9
389.3
Annual ratios per thtnisami ut' strength fnr deaths from —
2.6
7.3
2.8
10.5
8.8
42.7
2.0
2.7
,.4
2.0
1.5
16.4
2.2
1.8
.g
8.9
2.2
4.6
7.4
3.3
5.9
.0
All Malarial Fevers
12.7
62.0
G. I
19.9
2.3
6.7
9.9
14.3
9.2
Till' ratio of cases to strength at Jolmsoii's Island and Rhnira was very small; at
Rock Island and (Aimp Morton it was less, and at (Janips Chase and Douglas more, than
tlie ratio for tlic United States troops in the Northern Department — 526 per thousand
annually. At Fort Delaware and Point Lookout the ratios were somewhat less than that
hiniished liy our own tmops in the Dejiartment of Washington — 390 per thousand. Only
at Alton, Illinois, was the ratio such as to suggest the existence of intense local malarial
influences. Here the proportion of cases was greater than in any part of otir army except
the Department of North Carolina during the third year of the war.* But when the facts
relating to the frequent changes in the individuals composing the average number present
at this post are understood.^j" the large rates may be accounted for without assuming the
* See supra, p. 96.
t See supra, p. 62.
AMONG TKE PRISON KRS OF WAR. Ill
existence of malarial influences of local origin; ami inJced the prison, according to ihe
reports of tlio inspectors, was on a dry, olevateJ ami gene-rally liealtliy sitf.
The deatlis from the purely malarial fevers in our army, as shown by Talilc XX\ 1,
were 3.36 per thousand of strength annually, or, including the deaths from ty|)ho-nialarial
fever, 5.(l-l per thousand. These figures are exceedfd liy the mortality rates of all tlu'
prisons excejtt Johnson's Island. On the other hand the annual mortality ratu among
our colored troops, 10.03 for the puruly malarial fevers, or 16.82 including the tvpho-
malarial group, was consitlerably greater than the average of the prison rates, 7.8 for the
pure malarial fevers or 12.6 inclusive of tln' I v]ilio-malarial cases.
The extent to which these fevers prevailed among i\ni Confederate armies renders it
probable that many of the cases that occurred among the prisoners were recurrences of a
disease contracted in the Held before their capture.
II.— CLINICAL RECORDS OF MALARIAL DISEASE.
The clinical records of the war contain but few casrs ol malarial disease, and these,
as a rule, are exceedingly meager in details, seldom giving more than an identilication
of the patient and a statement of the diagnosis, treatment and result. A description
of the symptoms as they varied from day to day in the progress of the fever, or as
influencetl by remedies, was rarely attemi)tt'd. But a word or two occasionally introduced,
indicating deterioration of the constitution, length of time during which the disease had
been in progress, or the existence o£ notable complications, give an interest to the reconls
by impressing an individuality on many of the cases.
The absence of details is not surprising, in view of the great prevalence of malarial
fevers. Disease which is of daily occurrence is not usually noted by the profession unless
prfsenting some difference in its symptoms from those generally accepted as characteristic.
Thus, from the very absence of records it may be concluded that the intermittents, remit-
tents and congestive fevers which were so prevalent in our armies, presented little to
distinguish them from the same diseases as observed by our medical men in their practice
before the war.
Moreover, intermittent cases were mainly treated in the lield where medical officers
had few facilities for note taking. Remittents seldom got farther away from active service
than the hospitals at the base of supplies except bj' furlough during convalescence, for
death occurred from the violence of the morbific agency, or a cure was effected by specific
medication, during the period occupied by treatment in the field or at these base hospitals.
The temporary character of the latter and their liability to be at any time crowded with
wounded from the field of battle constitute a sufficient explanation of the paucity of
clinical histories among their records. It was only at the general hospitals, the permanent
establishments situated at a distance from the conflicting armies, that clinical records of
disease were kept; and malarial cases seldom reached the wards of these except as instances
of chronic malarial poisoning, or debility, or as complicating other diseases having a length-
ened course, such as diarrhoea or typhoid fever.
The following cases may not, therefore, be considered as illustrating malarial dis-
eases under their ordinary aspects, but as presenting certain exceptional features which led
112 CLINICAL EECOKDS
to their being recorded, the exceptional feature in some instances consisting of nothing
more remarkable than the presence of the case in the wards of a general hospital in which
clinical records were kept with more or less regularity. Nevertheless, most of the cases
may be taken as typical of a class or series, for it seems unlikely that any one of them
would have been unique if tlie records of the whole vast number of cases had been preserved.
A quolidiaii infennittent. — Ca.se 1. — Private Patrick Shehan, Co. H, 146th lU. Vols., was admitted September
23, 1864, with quotidian intermittent fever. Quinine was given every four hours for three or four days, and after-
wards vegetable tonics. He was furloughed November 1, and on his return on the 18th was sent to his command
for duty. — General Hospital, Quincy, III.
A quotidian uith relajjses. — Case 2. — Private J. M. Hinchee, Co. K, IH3d IlL Vols.: age 19: was admitted October
12, 1863, having been affected with intermittent fever since September 19. On the 18th he had a chill, for which
eight grains of quinine were given in divided doses. The chill returned daily until the 21st. It recurred on Novem-
ber 3, and again on the 1.5th, but by continuing the (juiniue no further relapse took place up to December 8, when
he was returned to duty. — General Hosjntul, Quincy, III.
A tertian with relaj}scs attributed to orer-eating, <.1c. — Ca.se 3. — Private Anthony Monsieur, Co. C, 13th 111. Cav.; age
30; was admitted August 19, 1863, with tertian ague. His skin was sallow, conjunctiva; yellowish, tongue coated,
bowels loose, pulse full and strong. Quinine, blue-pill and opium were given, and when the paroxysms were
checked, strychnia was administered. He improved rapidly under this treatment, but as he was given to excesses
in eating and drinking, several relapses occurred. He was ultimately returned to duty with his regiment October
13, 1863. — General Hospital, Quincy, III.
A quartan with sloic recovery after several relapses. — Case 4. — Private James Wright, Co. F, 2l8t 111. Vols.; age
21; was admitted September 25, 1863, having a chill every third day. His skin was sallow, tongue coated and
bowels loose. Strychnia, blue-pill and capsicum were prescribed. He improved slowly, sutl'ering several relapses;
ultimately Fowler's solution proved eftectual and the patient was returned to duty February 14, 1864. — General Hos-
pital, Quincy, III.
Debility from recurrimj attacks of ague. — Case 5. — Private William Lambert, Co. G, 19th Mass. Vols., a feeble-
looking boy, was admitted October 10, 1861, much prostrated from repeated attacks of ague. He had one paroxysm
after admission. He took fifteen grains of quinine at once and three grains three times a day afterwards. He was
confined to bed by weakness for some time; but after this, when able to walk out a little, his improvement was
more rapid. He was returned to duty on November 29. — Regimental Hospital 19th Mass. Vols.
Case 6. — Private George Frazer, Co. D, 7th Va. Vols.; age 20; was admitted May 23, 1865, from Lincoln
Hospital, Washington, D. C. He had contracted intermittent fever in March in the pine swamps at Humphrey's
station before Petersburg, Va. On admission he was very weak and aniemic. Fowler's solution in live-drop doses
was given three times a day until the 31st. On June 7 he was placed on hospital-guard duty, and on July 12 was
returned to duty with his command. — Satterlee Hospital, Philadelphia, Pa.
Case 7. — Corporal Jno. AV. Moore, Co. K, 13th Iowa Vols.; age 24 ; was admitted Sept. 23, 1863, with debility
from intermittent fever. He was placed on duty in the ward as he had no chills, and his tongue was clean and
appetite good. Quinine and iron were prescribed. About October 20 he had a rigor with high fever every few days.
Quinine and strychnia were given. On November 20 the chills continued, and there was some diarrhoea, for which
nitrate of silver and opium were ordered. By December 25 he was gaining strength slowly. The diarrhoea was
checked by January 10. 18W, but the chills continued. Fowler's solution was given. He was returned to duty
March 22. — General Hospital, Quincy, III.
Cases complicated with diarrhoea and dysentery. — Case 8. — Private Dennis O'Brien, Co. C, 56th 111. Vols.; age 37;
was admitted October 11, 1862, with intermittent fever and diarrhcea, with which he had been att'ected since Septem-
ber 29. He was treated with quinine, blue-pill, opium and turpentine emulsion. He improved steadily and was
returned to duty on the 27th. — General Hospital, Quincy, III.
Case 9. — Private Frank Gad, Co, A, 84th 111. Vols.; age 17; was admitted Sept. 18, 1864, having been sick
for two weeks with quotidian intermittent and dysentery, the i)aroxysms occurring about 3 r. M. The bowels were
loose and the tongue coated white. Five grains of quinine with three of Dover's powder were given every three
hours. A relapse occurred on October 9. The patient was returned to duty October 27. — General Hosi>ital, Quincy, III.
. Case 10. — Private Thomas L. Dixie, recently discharged from Co. A, 38th Iowa Vols., was admitted August
29, 1863, much prostrated by chills and fever and a diarrhoea of ten or twelve stools daily, from which he had suf-
fered since July 3. The diarrhira and chills were checked on September 4, and his appetite iniproveol. He went
home on the 8th. — Union Hospital, Memphis, Tenn.
Ague uith diarrhua, ana'mia and enlarged spleen. — Case 11. — Private James J. Wolfe, Co. G, 10th 111. Cav., was
admitted August 30, 1863, with intermittent fever and diarrhiea. He had been subject to diarrhoea for more than a
year, but the ague dated only from .Inly 1. On admission he was emaciated and ana-mic; he had some diarrhiea, a
short hacking cough, a weak pulse, 95, an anxious countenance, a systolic cardiac murmur and a spleen which
extended three inches lielow the false ribs; he hatl, however, a good appetite. He gained strength and ultimately,
on October 23, was returned to duty.— niioH Hospital, Memphis, Tenn.
OF MALARIAL DISEASE. 113
Ague trilh diarrhtea «nrf dehiliti/ ; slow rccovenj. — Cask 12. — I'rivate Jiio. .1. Hand, Co. E, 12Ttli IIL Vols.; age 21 ;
was admitted SeiitemlxT 23, 18IJ3, with intiTiuittent fever. He liad a rlilll overy day followed liy lii;;U fever; he had
also dyspmea aud pain in the hypochoudrinni ; tonj^ue eovered with a white fur; api)etite moderate. Quinine and
tincture of iron were prescribed. Diarrluva supervened on October 10, and was treated liy nitrate of silver and
opium ; the af;uish paroxysms continued to recvir. At the liefjinnin;; of N'ovemlier he was furlouf;lied for two weeks.
At the end of the month he was much debilitated, havin;; from three to five discharges from the l)owels daily. In
December one-sixteenth of a grain of -strychnia was j;iven three times a day. Improvement was very slow. He was
not returned to duty until March !1. — Oinerul Hospital, Quinvy, III.
Ague folloiced by dgsentery. — Case 13. — Horace Hastings, drummer, Co. E, U»tli Mass. Vols., was admitted on
November 2, IWil, with quotidian intermittent. One lifteen-grain dose of uninine was given, followed by five grains
three times a day. The chills were suppressed, but the patient had some bloody and painful discharges from the
bowels. While taking Dover's powder and acetate of lead the passages became reduced to two daily, but were
accompanied with much pain, protrusion of the rectum and free liu'morrliage; he had also some tenderness in the
epigastric region, which was relieved by sinapisms. The tongue became cli'an and the diarrluea checked on Novem-
ber 14, and the patient was returned to quarters on the IGth. — Uigimiiilul IIospil<il l\Uli Mans.
Ague pralructed <tiid complkaUd tvith juuiidkr. — C.isK 14. — Private .James .1. Kay, Co. I, lOtL Wis. Vols.; age 26;
was admitted March 3, 1863, emaciated, feeble and jaundiced, with a thickly coated tongue, small appetite aud very
ra])id pulse. He had been taken with intermittent fever iu August, 1802, and had done no duty since that time.
After his admission he was attacked with excruciating pains in the bowels. He was treated with gelsemium, taraxa-
cum, iodide of potassium and extract of cinchona. He improved rapidly, gaining in flesh and strength, and was
returned to duty August 31, 18(53. — General UonpUul, Qiiincg, III.
Ague followed by Jnitiidice and diarrhan. — C.\SE 15. — Sergeant Charles Legrist, Co. E, 3.5th Mo. Vols., had an
attack of intermittent fever early in August, 1863: Janndiei' anil diarrluea supervened. He was admitted Oi'tober 1
with increasing debility and a diarrluea of twelve stools <laily. He failed rai)idly and died on the 10th. — Union
Hospital, Memphis, Tenn.
Protracted ague followed by carbuncle. — C\.SE U>.— Private A. Lydick, Co. D, 78th Pa. Vols.; age 44 ; was admitted
March 10, 1863, having been unfit for duty on account of intermittent fever since August, 1862. At the date of
admission he was feverish and had on his back a large and ]>ainfnl carbuncle. Tonics were given and creasote dress-
ing applied. In healing, the carbuncle left him stooped very much, and the cicatrix was very tender. He was
transferred November 2i> to the 27th Company, 2d liattaliou, Invaliil Corps. — General Hoxpitiil, Qiiincy. III.
Protracted ague followed by ulcers of leg. — Case 17.— Private John llogan, Co. E, lUlth 111. Vols.; age 23; was
admitted Augusf 10, 1803. This patient had intermittent fever from May, 1862, to March 9, 1863, when the chills
cea.sed with the appearance of a sore upon his left leg. On admission his leg was swollen, red and firm, presenting
between the ankle and the upper third many open suppurating sores. Under the use of iodide of potassium, rest
and bandages, he improved. In January, 1863, having o\er8tayed a pass he was reported as a deserter, and on his
return was transferred to the care of the provost marshal. — General Hospital, Quincy, III.
Ague with con-iuinption supcrrening. — Case 18. — Private M. E.Williams, Co. A, 87th III. Vols.; age 26; admitted
August 20, 1863. This man was taken with intermittent fever iu November, 1862, and did no duty from that time.
On admission he complained of pain in left subclavicular region, where there was dulness on percussion ; his respi-
ration was hurried and dithcnlt. pulse frec|uent; he had hectic fever, night-sweats and colli(iuative diarrluea. (,'od-
liver oil, porter, quinine aud aromatic sulphuric acid were employed in the treatment. Afterwards he improved
somewhat while taking syrup of wild cherry. On November 11 he was transferred to Cincinnati for discharge. —
General Hospital, Quincy, IU.
Tertian becoming quotidian and afterward.i remittent. -^Casb 19. — Lieutenant H. M. Kideout, 10th U. S. Art'y, was
admitted November 3, 1863. He had been attacked ten days before with a severe chill, followed by fever and head-
ache ; two days after this he had a second chill with fever and some delirium. The fe.ver was accompanied with
much pain in the back, anorexia, gastric irritation, prostration and constipation. The chill recurred daily during
the next three days. .Vfter the fifth chill there had been only imperfect remissions of the fever. The jiatient had
been on duty for eight months in the low swampy lands of Louisiana. On admission his ])ulse was 120 and skin hot,
dry and pallid. Ten grains of blue pill were given, and iiuinine and capsicum ordered every three hours. Under
this treatment the fever abated and there was no recurrence of the chills. On November 9 there was slight fever,
the pulse 96 and .somewhat corded, liut this condition lasted only a few- hours. He was returned to duty on the 30th.
— Iloxpital, Xatclu:, Miss.
Intermittents becoming remittent. — Case 20. — Sergeant John L. Hopper, Co. I, 119th 111. Vols.; age 28; was
admitted October 31, 1862, with remittent fever, having been sick for four days with intermittent fever. On admis-
sion the tongue was clean but red at the tip, pulse 96, skin hot bnt moist, bowels loose; the patient complained of
much thirst and pain iu the back and stomach. He was treated with quinine and aromatic powder, morphia and
carbonate of soda. Medication was stojiped on November 4, and he was returned to duty on December 1. — General
Hospital, Quincy, III.
Case 21.— .Sergeant Jas. M. Price, Co. (i, 26th Mich. Vols.; ago 31 ; while en route with his regiment for New
York City on account of the draft riots, was taken, while in Washington, D. C, July 13, 1863, with intermittent
fever, which recurred daily. On admission on the 18th he was much i)rostrated, having just i)a88ed the sweating
stage of that day's paroxysm. One grain of quinine was prescribed for administration every hour until symptoms
Med. Hist., Pt. I i I— 1,5
114 CLINICAL RECOKDS
of cinchonism were produced. He took eleven grains, and next day the skin was hot and dry, the tongue coated,
and the urine high colored and scanty; towards noon there was a remission. On the 21st the disease was distinctly
remittent. Quinine was given during the remissions and acetate of ammonia during the exacerbations. In a day or
two the fever ceased and did not recur, but the patient was quite feeble, aua-mic and without appetite. On the 28th
he stayed up dressed for a short time. Tincture of iron was given. He was returned to duty on September 7. — Act.
Ass't Surg. G. If. Smith, U. S. Army, Ladies' Borne Hospital, New York City.
Intermittent fever becoming continued and accompanied zvith diarrhcca. — Case 22. — Private Orlando Wood, General
Steel's escort, taken sick with intermittent fever, followed by a continued fever and diarrhcea after recurrences of
the intermittent, was adndtted October 11, 1862. He was very sallow. Quinine, blue pill and opium were given
for the fever and turpentine emulsion for the diarrhoea. The patient improved rapidly from his entry into hospital,
and was discharged on the 28th on account of an old fracture of the femur. — Hospital, Qnincy, III.
Intermittent followed by typhoid fever. — Case 23.— Private O. S. Raymond, Co. F, 28th Wis. Vols.; age 19; was
admitted June 21, 1863, with typhoid fever. He was attacked with intermittent fever June 1, while in camp at
Helena, and the fever assuming a typhoid type, he was removed to tliis hospital. On admission his tongue was dry
and brown, the edges and tip red; pul.se 85; skin dry and harsh; bowels irritable and tympanitic. He was fur-
loughed August 19 and returned to duty September 11. — Lawson Hospital, St. Louis, Mo.
Cases of remittent ferer. — C.\SE 24. — Private George Vaden, Co. B, 24th Tenn.; age 20; was admitted November
6, 1864, with remittent fever, having been sick for six days before admission. Quinine, capsicum and morphia were
given. He had no fever in the morning after the 7th, but every evening up to the 16th, some febrile action was
manifested, and the tongue remained more or less furred. Blue pill and Epsom salts were given on the 9th. Cough
was troublesome on the 10th, and muriate of ammonia, ipecacuanha and opium were prescribed. After this, quinine,
Dover's powder and capsicum were given, and a blister applied on the 15th. He was returned to duty on the 28th.
— Hospital, Rock Island, III.
Case 25. — Private E.W. Kirkland, Co. H, 4th Ala. Cav.; age 30; was aflmitted November 8, 1864, with remit-
tent fever. He had been sick for eight days prior to his admission. When admitted he was greatly debilitated, but
had no fever, which, however, returned at night for some time. Three grains each of quinine and Dover's powder,
with one grain of capsicum, were given every three hours. Blue pill and Epsom salts were prescribed on the 10th,
as the bowels were constipated and the tongue much furred. There was great irritability of stomach on the 13th.
The quinine was combined with carbonate of ammonia and camphor, and whiskey was given. A blister was applied
on the 16th, on account of pain in the left side. Treatment was continued until December 6. The patient was
returned to duty on the 10th. — Hosjntal, Bock Island, III.
Case 26. — Private Wm. R. Kimball, 2d Batt. V. R. C; age 41; was admitted May 12, 1864, with remittent
fever. He had headache, weakness, pain in the back and limbs, loss of appetite and much thirst. The fever was
aggravated in the morning, and did not remit until some time in the night. His tongue was yellow-coated and his
skin somewhat jaundiced; his bowels were quiet. Quinine and blue pills were administered, and on the 20th the
patient was improving slowly. On June 11 he was placed on light duty in the ward, and on the 18th was returned
to duty. — Act. Ass't Snry. D. C. Owens, Z7. S. Army, Hospital, Qiiincy, III.
liemiitent with relapse. — Case 27. — Private Louis Ebcrhard, Co. E, 111th Pa. Vols.; age 47; was admitted April
27, 1865, from David's Island, New York Harbor, as a convalescent from remittent fever. He was in good general
health, although somewhat debilitated. Full diet was ordered, but no medication. On May 18 he was placed on
fatigue duty. On June 14 he re-entered the ward, having been sick for six days before presenting himself for treat-
ment. His pulse was full, strong and bounding; skin hot and dry; tongue furred; breath fietid; stools light
colored; he suffered also from headache. Blue-mass was ordered on the 15th, to be followed by citrate of magnesia.
Two copious stools were procured, and on the 17th he was in better condition, although the fever continued with
anorexia and foul tongue. Blue pill, ipecacuanha and quinine were given in small doses every four hours, and on
the 20th the patient was able to sit up. The medicine was omitted on the 21st, and on the 28th the man was well
and walking about. — Salt erlec Hospital, Philndclphia, Pa.
liemiftenl with hepatic complication. — Case 28. — Private Charles Laihn, Co. E, 16th 111. Cav.; age 42; intemperate;
was admitted .luly 31, 1863, with remittent fever. A day or two before admission he was taken with a chill followed
by the usual symptoms of common remittent fever, but accompanied with pain, tenderness, slight fulness and
hardness in the region of the liver. He was treated with quinine, chalk with mercury and Dover's powder, sinapisms
to the ankles and a blister to the hepatic region. The fever began to subside on August 2, but the pain and fulness
in the side continued. On the 7th a half drachm of iodide of potassium with extract of hyosciannis was given after
each meal instead of the quinine and mercurial, and the blister was reapplied to the side. He improved but slowly,
his bowels meanwhile being very torpid and requiring the use of laxatives and enemata. The iodide was omitted
on September 10, and on October 10 the patient was returned to duty. — Act. Ass't Surg. F. K. Bailey, U. S. Army,
Hospital, Quincy, III.
Case 29. — Private George Hurst, Co. D, 25th Ind. Vols., was admitted October 12, 1863, having had diarrhcea
and fever for three days. He was greatly prostrated; his mind dull; countenance suffused; lips and tongue coated
black; pulse 110 and quick ; skin hot. Next day he was delirious. One ounce of brandy was given every hour. On
the 14th the fever was found to remit in the morning, becoming increased in the afternoon. Mercury with chalk and
rhubarb was given, and during the night the bowels were opened twice. Next day there was less fever; quinine
was prescribed in three-grain doses three times a day. On the 16th there was less fever, but the patient vomited
OF MALARIAL DISEASE. 115
fretinently. Ten grains of quinine wtni- given at once, iinil the iiieicmy, cliiilk and ilmliaili wcio repeated with
(■urbonatc of soda. On tlie following day the bowels were opened several times, and the mind lieeame clearer. The
skin and eon.jnnetiva' beeanie yellow-eolored on the l!Hh, and on the 2t)th he had i'pista.\is, but was otherwise
im])roving. Ho was transferred, Deeoniber 15, to .\dams Hospital, Memphis [and afterwards to .Jed'crsoii Harracks,
St. Louis, Mo., February 22, 18(i4]. He was ultimately returned to duty May 2"). — I'liiiin Hospilal, McmphiH, Teiiu.
liemittiiit with sviirrii. — O.VSK 30. — Private Samiud \V. Flemuiini;, Co. 1, 2(llst I'a. N'ols.; age 2'S: was admitted
November 4, IXtil, with remittent fever from which he had been suliering lor .some tinii'. He was quite |>r()strated,
being unable to speak above a whisper; his tongue was pale, gums spongy and liowels uuived with great frei|iu>nev;
he was aua'mic and had some cough. On the tith he was (bdirious; the tongue black; tlie teeth covered with
sordes ; the bowels were moved less fre(iuontly, but there was great tenderness in the right iliac region. Turpentine
was prescribed. On the lUth the patient was much improved. He was returned lo duty .January 11, 1865. — Uogpitul,
Jlixunitriii, J'li.
Bemitti-nt with dynentery sujterveniny. — C.\SK 31. — Private Albert Frane. Co. C, 21th Ind. Vols., was admitted
September 21, 1863, with dysentery. [On August 8 this man had an attack of remittent fever and continued sick
for four weeks, at the end of which period he was nnich debilitated. He was fnrloughed, but while bound home-
ward had an attack of dysentery and piles, much blood passing with the stools.] On admi.ssion he was very weak,
emaciated, aiul had abdominal pain and tenderness, with twelve to fifteen bloody stools daily; his appetite w;i8
poor; tongue thickly coated bvowu ; pulse 95 and weak ; skin hot : mind dull. On the 23d pain in the umbilical
region was somewhat relieved by sinapisms. The stools were frequent but not bloody on the 21th, when dilirinm
and dysjihagia siyiervened. He died on the morning of the 25tli, the stools bci'omiiig less fre(incnt for some hours
before death.— r«ion Hospital, Mcmj>his, Tiitii.
Remittent ferer uith cerebral symptoms. — Case 32. — Private Henry Taylor, (Jo. B, 85th Pa. Vols.; age 50; was
admitted November 3, 181)2. convalescing from remittent fever. As his general health and strength improved symp-
toms of cerebral congestion aiipeared. Of medium height, thick set, with a short and full neck and turgid connto-
nance, he was more or less con.stantIy attected with headache, disturbed vision and tinnitus aurium. Epistaxis,
with temporary relief, was of freciuent occurrence; the bowels were constipated. On the day after admission the
patient was bled from the arm to the extent of fifteen ounces, with prompt and decided r<dief of the iirominent
cerebral symptoms. Low diet w;us enjoined, and under the repeated ns(! of active hydragoguc cathartics the cerebral
symptoms gradually yielded; but the patient continued to have at times slight returns of epistaxis, which always
gave relief, his pul.se becoming reduced in force and volume. He was recommended for return to his regiment Feb-
ruary 14, and left the hospital to join it on March 4. On this case the attending physician remarks: "After the
summer's experience of hypainia, cachexia and adynamia, conditions so almost universally present in disease as
observed at the military hospitals, and requiring as they did a supporting and tonic treatment, it was with curious
interest that we recognized this exceptional case of hyperanuia demanding depletion from the general circulation,
conjoined with low diet and active catharsis." — Satterlee Hospital, Philadelphia, Pa.
C'.vsF. 33. — Ass't Surg. Samuel S. (jarrigeus, 29th Mich. Vols.; age 36; was admitted October 11, 18iU. He was
taken, while at Detroit on the 7th, with a severe chill which lasted an hour, and was followed by two hours of fever.
On the 8th and 9th he had fever but no chills. On the morning of the. 10th he took eight grains of blue pill and a
Seidlit/. powder, w liich procured an evacuation but caused nmch nausea ami vomiting. On admission he had fever,
anorexia, great thirst, otl'ensive breath, white furred tongue, constipated bowels and headache, and he had slept but
little from the time of the attack; pulse 120, respiration 30. Sweet spirits of nitre and extract of ijiecacuanha,
barley-water and cream of tartar were given, with a Dover's powder at bedtime; next day quinine was admin-
istered. The fever, headache and constipation continued, and on the 14th the patient was delirious during the
greater part of the day. Eight grains each of calomel and rhubarb were given, followed by a saline cathartic, which
moved the bow'els. Next day he was conscious, his pulse regular and slow. Tea, toast, soups and jianada were
given. After this he ini]uoved in condition; but on the 25th he had symptoms of cerebral congestion, which were
relieved liy cold to the head and mustard to the feet. These attacks recurred during the early part of Novenilier,
but by avoiding excitement and errors of diet they ceased to trouble him. On October 31 Fowler's solution was
given in fluid extract of cinchona and continued for three weeks. — Officers' Hosjniul, Louisville, Ky.
Case 34. — Private John McCammant, Co. B, 84th III. Vols., was admitted August 24, 1862, with remittent
fever. During the night following admission he was a little delirious, but next morning he was quiet. A blister
was ordered, as he comjilained of soreness in the bowels. About 2 i>. M. of this day, as he was resting quietly and
engaged in conversation with a friend from camp, he suddenly sprang from his bed and jumped through the scuttle-
way from the upper to the lower floor of the hospital, a distance of about thirty feet. He struck on his head and
right shoulder. He was taken up unconscious and <lied thirty-six hours after. A clot seemed to have formed behind
the right orbit as the eye-ball soon became consi<lcrably protruded. No post-mortem examination was made. —
Hospital, (Juincy, III.
Remittent with diarrhaa in a paroled ])ri8oner. — Case 35. — Sergeant Samuel S. Cook, Co. B, 27th Conn. Vols.;
age :J8; was admitted May 17, 1863, with remittent fever and diarrhoea. He was taken prisoner at Fredericksburg,
Va., May 3, and marched to Richmond. He had a chill two days before his capture, followed by diarrhoea and fever.
On admission his tongue was furred and dry; he had headache and pain in the back; his pulse was 80 and feeble,
but his general appearance was not bad ; one stool was passed in the twenty-four hours. Quinine was given in five-
grain doses every four hours. On the 19th his l>owels became loose, yielding four stools on that day and on the 20th,
116 ■ CLINICAL RECORDS
sis or seven on the 2l8t and only two on the 22d. On the 23d the diarrhoea ceased and there was no fever. The
patient quickly regained his strength and was returned to duty on June 13. — Act. Ass't Surg. E. J. Eadcliffe, U.S.A.,
Hospital, Anniqjolis, Aid.
Heviitteiit with a probable typhoid element. — Case 35. — Sergeant J. N. Richardson, Co. E, 2d West Tenn. Cav.;
age 22; was admitted September 24, 1863, with remittent fever. He had been a prisoner on Belle Isle since July 4,
during wliich period he suft'ered from diarrhoea and chills. " This, like many other cases of fever among paroled
prisoners from the South, has been very much ski generis and difficult to classify, having symptoms of malarial
remittent and of typhoid. It has been characterized by irregular remissions, the pulse sometimes as higli as 130,
sometimes as low as 80, irregular diarrhoea, delirium, swellings under the chin and of the parotid and frequent
micturition. He was treated with quinine, blue pill and opium, effervescing mixture, chlorate of potash and sina-
pisms. He began to improve in strength and flesh in November and made rajiid progress to health. He was trans-
ferred to Ohio January 6, 1864." — .ftc^ Ass't Surg, A.Claude, U. S. A., Hospital, Annapolis, Md.
Cask 37. — Sergeant William J. Goode, Co. F, 16th 111. Cav.; age 25; was admitted .July 21, 1863, with severe
fever, tongue coated, skin hot and dry, pulse frequent, liowels irritable. Quinine, Dover's powder and turpentine
emulsion were prescribed. By August 2 the fever had lessened, but the bowels were more relaxed, and there was
abrlominal tenderness; the tongue was coated except at the tip, which was red; the stomach was irritable; the skin
moist. Medicine was withlield. On the 14th the patient was improved but feeble; the bowels continued loose and
the abdomen tender. Elixir of calisaya was given. The fever returned on the 19th, and recurred nightly, although
the administration of tjuinine was resumed, until the end of the month, when profuse sweatings took place towards
morning. The fever at this time was recorded as haviug become "somewhat typhoid." On September 3 the tongue
was red at the tip but thickly coated at the base ; bowels loose ; pulse 60, feeble and compressible ; appetite poor.
Aromatic sulphuric acid was given until the 14th, when it was replaced by the elixir. The patient was pale and
feeble on the 16th, but able to walk about. On the 22d there was some fever at night, and the tongue was red and
coated but not dry; diarrhtea continneil. On October 1 the roof of the mouth was sore and spongy. Next day a
blister was applied on account of pain and soreness in the left hypochondrinm. After this he improved rapidly, and
deserted on the 16th. — Hospital, Quiney, III.
Eeeorded as typhoid but treated as remittent. — Case 38. — Private Matthew Baird, Co. C, 3d Mich. Vols.; age 23;
was admitted October 19, 1861, .as a case of typhoid fever. About October 5 he had been seized with pain in the
head and bones, fever and chills ; he had some nausea and vomiting at first, and a diarrhoea which continued for
two days ; the headache lasteil four days ; during the second week his urine had to be i^moved by catheter. On
admission his pulse was 62 and of fair strength, skin soft and warm, tongue pale, moist and slightly coated, brownish
in the center, teeth and gums clean, appetite good; he had tinnitus aurium and giddiness, but no pain, eruption
nor sndamina; one thin watery stool was pas.sed, but there was no tenderness, borborigmus nor tympanites, and
the abdomen was soft; there was no cough and the urine was normal. Quinine was prescribed in full doses
three times daily. Next day the face was calm and natural; the pulse 64, steady and of fair strength ; the skin soft
and warm ; the tongue slightly pale and flabby, but moist and clean; the appetite good ; one thin fietid stool was
passed. On the 22d the quinine was reduced to two grains three times daily, and during the night the patient had
a chill, but next day its effects disappeared. On the 28th he rested badly and had some diarrhcea, but there was no
tenderness nor tympanitis ; the tongue was pale and moist and the appetite fair. The skin and coujunctivic became
jaundiced on the 31st. Small doses of calomel and opium were given. On November 4 he slept well; his mind was
clear, countenance calm, bowels regular and appetite good. He was transferred to Annapolis, Md., on the 18th. —
Seminary Hospital, Georgetown, D. C.
Ilemitlcnt following typhoid. — Case .39. — Private Sidney Nafus, Co. F, 143d Pa. Vols.; age 22. [This man entered
Stanton Hospital, Wasliington, June 15, 1863; Diagnosis — debility; and was transferred to Satterlee Hosiiital,
Philadelphia, on the 17th: Diagnosis — chronic dysentery. He was returned to duty August 28, but contracted
typhoid fever October 2, and was confined to bed for four weeks. On November 23 he was admitted to Douglas
hospital, Washington, as a convalescent from typho-malarial fever, and on the 27th was transferred to Satterlee
Hospital; diagnosis — intermittent fever.] On December 13 he was reported as much improved, aud the quinine and
carbonate of iron, which he had been taking, was omitted. On the 18th he had a i)aroxysm of fever, which was
repeated next day ; pulse 120 ; tongue coated and somewhat dry; skin moist; headache; tenderness in the epigas-
tric and right hypochondriac regions. Quinine in three-grain doses was given every two hours. The fever con-
tinued, but with diminishing intensity for a week, the skin being sallow and dry, the tongue white coated, the
bowels regular or constipated. The medicine was omitted on the 28th; but on January 1, 1864, the heart's action
became much increased, pulse 138 and skin hot and dry. Digitalis was given and a blister applied to the chest.
Next day the skin was cool and the pulse reduced to 96. After this he was treated occasionally with digitalis, but
he remained weak for a long time. He was put on guard duty April 25. — Satterlee Hospital, I'hiludelphia, Pa.
Continued fever quickly changing to remittent and intermittent. — CvSE 40. — Private George 11. Gardner, Co. G, 19th
Me. Vols.; age 19; was admitted December 16, 1862, with varicocele. After some time he became affected with sore
throat aud pain in the ears, and presented symptoms which the attending physician was inclined to attribute to the
presence of the typhoid fever poison. On January 5, 1863, the first day on which these were noticed, the skin was
hot, face flushed, tongue furred, pulse tense and rapid and there was considerable gastric disturbance. On the 6th
these symptoms were much increased. On the 7th the fever was accompanied by diarrhoea with tenderness in the
abdomen, pulse about 95, tongue coated but moist, red on the edges. Neutral mixture and sweet spirits of nitre
were given. Next day there wei'e two rose spots; the abdominal tenderness was increased; the mouth not so moist,
OF MALARIAL DISEASE. 1 1 7
lint not ilry ; l>ofh oars wpio discliarsrin^ freely, and there was great drowsiness. On the 9th there was no diarrho'a,
Imt the abdomen eontinned painful, esi)ecially on pressure: the fever was much increased, the pulso having risen to
120; but towards noon there was a decided remission, lasting about three hours, during which the skin was cooler
and the patient in a pleasant sleep. At noon on the 10th a distinct chill was followed by a fever of about three or
four hours duration. Quinine in three-grain doses was given every three hours. Tenderness and pain in the abdo-
men continued. The chill recurred at noon of the 11th, but was not so violent as on the previous day; the patient
complained of great pain in the right shoulder, and wa.s unable to move the arm, which was very sensitive to press-
ure, but without redness or swelling; he also complained of pain on percnssion over the liver: the eyes were not at
all yellow but natural, and there was diarrh(ea. The i|uiuine was continued. No chills nor fever occurred on the
12tli; the pain in the shoulder continued, but there was no more pain over the liver than over any other part of the
abdomen, in which there were acute flying pains seemingly neuralgic in cliaracter. Next day tin- patient was much
better: tongue cleaner, appetite returning, shoulder less i)ainful and fever absent. Quinine was continued in two-
grain doses every four hours. On the l.'ith he s;it up for a short time, lint the pain in tlu- shoulder was troublesome
and was felt even as late as the ;iOtli. ''The above case is presented as a curious instance of what was apparently
tyi>hoid fever in its commencement, changing to remittent and then to intermittent fever in the short space of a
week."* — Sulterlee Hospital, Fltiliidelj>hia, Pa.
brmittcnt followed by inUrmitlcnt. — C.\SE 41. — Private Thomas Gaitly, Co. E, Iflth Mass. Vols., had a paroxysm
of intermittent fever on November 9, 1861. He had been recently discharged from hospital on recovery from remit-
tent fever. He was readmitted on the lOth and had a marked paroxysm on admission. Kifteen grains of (juinine
were given at a dose, with live grains in a half ounce of whiskey to be taken thereafti'r three times daily. On
November 12 there was no return of the chill: the patient's appetite was good and he felt well but weak. He was
returned to quarters. — HegimentuI Hospital Vith Mass. Vols.
liimiltint endiiii/ J'alall!/. — C.\.'iE 42. — Private Christopher Commars, ()9th Co. 1st Batt. V. R. C; age 22; was
admitted November 11, 1803, with remittent fever. He said he had been sick for six days, but had continued on
duty although he suffered from a chill on the 10th. On the 11th he had a severe chill aud was seen by the medical
orticer of the day, who ordered him into the ward. Two grains of quinine were given three times a day. On the
12th he had vomiting, and pain and tenderness in the left side of the chest. The quinine was omitted and three
grains of calomel ordered every four hours until four powders had been taken, with a .Seidlitz powder after the last
dose. The bowels were moved on the 13th, but the vomiting continued until death on the l.'ith. During his sick-
ness the patient expressed no anxietyas to its result; he was contident that he would be able to return to duty in a
few days. — Act. Ass't Siiry. Ilinry .)/. Dean, V. S. A., Lincoln Uospitul, Washington, D. C.
C.^.'iE 48. — Private David Kensiuger, Co. I, 8th Tenn. Vols.; age 19; was admitted May 10, 18(i4, suffering from
remittent fever aud debility. Quinine in five-grain doses three times a day was prescribed and an eneuui of castor
oil administered. On the i;Sth the patient had a hot skin and fre<iuent jjulse, with much prostration, wakefulness,
restlessness, loathing of food, nausea and vomiting, but no pain. Carbonate of ammonia and brandy were prescribed.
On the 14th there was a slight abatement of the fever in the morning and an exacerbation in the evening, which
liecame more marked on the evening of the 1.5th. On the 19th there was much nervous disturbance, restlessness and
jactitation. On the 2l8t the stools became frequent and the tongue dryer and darker. On the morning of the 22d
the tongue was not so diy as during the preceding paroxysm, but iu the evening the patient became delirious.
After this each successive exacerbation was more severe and protracted, and each remission less decided until death
took place on the 28th. Clammy Fweats, collapsed features, involuntary passages and imperceptible pulse preceded
death for several hours. — Act. .iss't Surg. ./. II. Coover. V. S. A., Hospital, Annapolis, Aid.
Malarial congestions. — Case 44. — Private H. Straight, Co. C, 1.54th N. V. Vols.; age' 25; was admitted December
12, 1862, with jaundice, chronic nephritis, enlargement of the spleen and duluess on percussion over tlie summit of
the left lung, with some rude respiration and a dry hacking cough. His sickness began during the Peninsular cam-
paign with a severe attack of remittent fever. He was much emaciated and had anorexia, hissitude aud mental dul-
ness; his stools were deficient in bile; his urine was albuminous; the pulse about 90; rigors and exacerbations
oi-cnrred every evening. lodiile of potassium and bicarbonate of pota.sh were prescribed, each in five-grain doses
three times daily, with fluid extract of taraxacum in teaspoonful doses aud tin; application of tincture of iodine
over the enlarged spleen. By December 20 the jaundice was somewhat lessened and the stools tinged with bile, but
the cough was aggravated, the sputa nununular and blood-stained, and the patient complained of flying pains
through the body and of constant nausea. On enquiry it was found that his father had died of tuberculosis. An
anodyne expectiiraut mixture was prescribed. Ten days later, while the jaundice was disappearing the nei>hritic
symptoms became prominent. Tincture of iron with (luinine in two-grain <loses three times a day was added to the
previous treatment. By January 8 the nausea had ceased and the appetite wiis better: the albumen iu the urine
was decreasing in ((uantity although the ])atient complained of great pain over the region of the kidneys and along
the ureters. I'he iodine mixture was omitted and the following substituted: Ten grains of bicarbonate of potash,
three drops of liquor potassie, five drops of tincture of cannabis iudica and one drachm of extract of uva ursi to be
* II is possible tliat an e.vplatialinn of Uie anonialmis course of the Odnstitiiliuiial disttirbanrc in this instance miglit have been discovered bj' a
el«*er examination and reptirt of tlie progress of the aiiral intfamniation. DilTtise infiummatioii of the ear is often accompanied with much febrile action.
hea4larlje and seeminjr mental dulness, which is in reality a disinclination to be disturbed by enquiries. The fever subsides on the establishment of a
diseharge from the e-jr. but sli(jht exposures not unfrequently cause a sudden suppression of (he dis<'barge with a recurreni;e of the febrile condition often,
times preceiled by rigors and jrastric disturbance. The local inflammation with its symptiunatic fever superimposed on a case of specific fever of so mild
a rliaracter as to be indieatetl only hy a fujfitive diarrhcea, some abdominal tenderness and t\vo rosc-sjiols, might be regarded aa accounttng for the
changes which constitute the anomaly in tlii-j case.
118 CLINICAL RECORDS
taken in a tablespoonful of mint-water three times a day. On January 14, 1863, the splenic enlargement and lung
symptoms continued unchanged, but otherwise the patient's condition was much improved. I3y January 25 the
albuminuria had ceased and tlie patient had gained flesh but was still very weak. Cod-liver oil was substituted for
the potash mixture; the ijuinine and iron were continued and iodine was applied over the spleen. On February 8
tlie pulmonary symptoms had almost disappeared and the patient's strength was returning. He was sent to his
regiment for duty on the 14th. — SatUrlce Hospitul, riiiladelphia, Pa.
Case 45. — Private Robert Wilson, Co. D, Ist Ky. Vols.; age 24; was admitted May 27, 1861. He had been sick
for two weeks with inflammatory rheumatism, for which he had taken colchicum, quinine and opiates. On admis-
sion he had fever and delirium, pain in the chest, with roughened respiratory murmur, vomiting and relaxation of
the bowels; his tongue was large, moist and white; skin moist, extremities cool; pulse 128 and feeble. One grain
of quinine with three of Dover's powder was given every three hours. He was very restless and did not sleep during
the following night ; his bowels were moved frequently and sometimes involuntarily, the stools being dark green and
watery, and there was much gurgling on pressure in the right iliac region. At midnight a \>mt and a half of dark-
colored urine was drawn off by catheter; sudamina appeared on the abdomen and lower part of the chest. Next
morning the jiupils were dilated, the right to a greater extent than the left, and there was dulness of hearing. A
pint of urine was withdrawn. There was a good deal of pain in the chest,' but the bowels were quiet until 2 p. M.,
after which the stools were frequent, dark and watery ; the delirium increased and the tongue became so swollen as
to cause much suffering. He died at 7 p. M. No autopsy. [After death a medical officer stated that this man had
been seized two weeks before with a paroxysm resembling a congestive chill ; that he had been bled from the arm, and
that reaction had been established with much difficulty.] — Marine Hospital, Cincinnati, Ohio.
Ilemittent followed by congestive ferer. — C'.\8E 46. — Private James S. West, Co. D, 16th 111. Vols., had a very severe
attack of remittent fever from which he recovered and was detailed on hospital duty. On July 3, 1862, while thus
employed, he was taken with a congestive form of intermittent fever. Mercurial cathartics and enemata were given,
with quinine, iron and pepsin, without avail, for the congestive paroxysm returned daily, and finally the patient
sank into a completely typhoid state and died August Ist. — Hospital, Quincy, III.
Congestive fever. — Case 47. — Private John Boman, Co. B, 5th 111. Cav.,'wa8 admitted September 1, 1863, having
had diarrhoea for three days. Early on the following morning he was found unconscious, with sluggish respiration,
quick feeble pulse and clammy yellow skin. He had vomited viscid dark-green matters and passed involuntary
stools which were offensive and bloody. A tablespoonful was given every hour of a mixture containing thirty
grains of qirinine in two ounces of cinnamon-water acidulated with aromatic sulphuric acid. At 4 p. M. the pulse
was better. Fifteen grains of chlorate of potash were ordered to be taken every four hours with stimulants and
beef-tea. He rallied much during the night, but in the morning relapsed into his previous condition. The adminis-
tration of quinine was resumed, but death occurred at 5 p. M. — Union Hospital, Memphis, Teun.
Case 48. — Private Edwin (jlraves, Co. D, 86th N. Y. Vols.; age 26; was admitted March 17, 1862; diagnosis —
typhoid fever. He was taken sick about March 12 with pain in the chest, headache, nausea, feeling of general swell-
ing and much debility, succeeded by a chill, fever and profuse perspiration, which symptoms recurred daily about 11
A. M.; he had also much annoyance from a numb feeling in his lingers. On admission the pulse was rapid and quick ;
the skin hot and moist; the tongue moist, red and slightly coated; the patient's appetite was poor and he had some
diarrhfjea and pyrosis. He stated that the chill and fever occurred at the same time in rapid alternations in different
parts of the body, the paroxysm lasting two or three hours. Twenty-four grains of quinine were directed to be
taken during the day. He was delirious during the 18th ; his pulse rapid and weak ; skin natural ; tongue nu)ist and
coated white. Punch and beef-essence were given every two hours. . He died delirious on the morning of the 19th. —
Seminary Hospital, Georgetown, D. C.
Malarial rheumatism. — Case 49. — Sergeant Michael Leffey, Co. F, 119th Pa. Vols.; age 24; was admitted Ma^!h
20, 1863, having been aftected with intermittent fever since early in January. On admission he had pain in the back
and left side and tenderness over the lumbar vertebra; : he had tremors, and was unable to stand erect. He was
treated with quinine, powdered iron, morphine and camphor, with tincture of aconite as a local application. He was
transferred to Christian street hospital April 21 [where his case was diagnosed chronic rheumatism, and whence he
was discharged June 2, because of general debility]. — Satterlee Hospital, I'hiladelphia, Pa.
Malarial neuralgia, deliility and adema. — Case 50. — Private Martin L. Robertson, Co. K, 4th Me. Vols.; age 23;
was admitted December 12, 1862, for torpidity of the liver, which was treated with mercurials and salines. During
his convalescence he had a severe attack of tonsillitis ending in suppuration of both glands. Soon after this he was
seized with violent jiains in the head and face, assuming the forms of sui)ra- and infra-orbital neuralgia, the parox-
ysms of which were distinctly periodic, sometimes quotidian and again on alternate days. During the exacerbations
he complained of numbness on the right side, with prickling of the skin of the face and a sense of fulness in the head.
Cups on the back of the neck and purgatives gave some relief to the symptoms, but dimness of vision followed, with
unpleasant illusions. Extract of belladonnai applied around the eyes relieved the pain slightly; but it was soon
thought advisable to have recourse to cinchona, the disease being conceived to be dependent upon the action of
malarial or miasmatic poisoning contracted on the Rappahannock, but remaining until now latent in the patient's
system. Quinine was perseveringly tried for some time, but it failed to arrest the paroxysms (as had been previ-
ously observed in some analogous cases in the hospital). Fowler's solution in five-drop doses was substituted, and
after a few days the neuralgic symptoms began to yield sensibly to its influence (as had also happened in similar
cases where the cinchona had failed). After exhibiting the medicine for a week, slight sickness of the stomach
seemed to suggest its discontinuance, and it was accordingly laid aside for a short time, when it was again resumed
OF MALAEIAL DISEASE. 119
with benefit at intervals. The original hepatic disonler reappeared, requiring a repetition of the mercurials. The
strength of the patient had failed cousideraldy, but his nutrition was pretty well iiiaintaiued. On March 28 lie had
a severe bilious attack, rei|uiriug mercurials and laxatives, to which it soon yielded, but lie was left with some wan-
dering neuralgic jiains in the head, arms and other parts of the body. The nervous system was impaired in power,
and it seemed impossible to rally his strength and spirits. Tincture of iron was given after the suspension of the
Fowler"s solution. On April 2 the neuralgic pains were very nearly gone, but his .system remained enfeebled and his
spirits despondent. At this time he was transferred by order to a hospital in Maine. — Sullerlie Hosjiital, I'hiUi., Pa.
Case 51. — Private Jno. V. Martin, Co. G, 13th Wis. Vols., was admitted December 8, 1864, as a marked case of
ana-mia following intermittent fever. He had occasional attacks of neuralgic supraorbital pain severe in character,
with serous effusion around the eyes, sometimes almost tilling the orbit ; the sclerotic was very white and the eyes
watery. He was improving rapidly 'and prouiising a speedy return to health, when a recurrence of the intermittent
fever was followed by a return of the supraorbital pain and the ana'iuic condition. After rallying frimi this another
recurrence was productive of similar results. He was treated with (luinine, iron and wine. A prescription which
api>eared of value in this case consisted of forty grains of chlorate if potash, twelve of <'itrate of qninine and iron
and two of powdered capsicum, taken in four doses daring the day. — UoHpitul, '.'/iihci/, ///.
C.\SE .^2.— Private Daniel W. Hufl", Co. H, 104th Pa. Vols.; ago 29; was admitted September 1, 18t>t, suffering
from enlarged spleen and general debility induced by malarial di-sease. He had severe neuralgic pain in the back
and limbs; his feet ami legs frequently became very much swollen, which condition, as it could be traced to no
marked lesion of the viscera, was referred to weakness of the circulation and aniemia. The treatment consisted of a
general alterative and supporting course. Iodide of potassium, iron in various forms, vegetable bitters, mineral
acids, stimnlauts, counter-irritation and anodynes were employed in accordance with the indications. No improve-
ment, however, was apparent; in fact he seemed to decline. After remaining in hospital three and a half luduths
he was discharged from the service December 16, 18t>l. — Hospital, Alexandria Va.
iii.-.sy:mptomatology of malarial disease.
I. — IxTERMiTTENTS AKD REMITTENTS. — The cases submitted above illustrate the recur-
rence of the intermittent paroxysm daily, every second day, or every third day, with the
frequent relapses which occurred in the progress of the disease and the congestions of the
abdominal organs as manifested by enlarged spleen, diarrhoea, dysentery and jaundice. The
debility and anaemia consequent on the prolonged action of the morbific cause are incident-
ally mentioned, and as a result of the altered condition of the blood, boils and ulcers are noted
among the sequelae of the disease. Consumption appears to have found favorable conditions
for its development in systems broken down by the continued influence of the ague-poison.
The identity of the cause of the intermittent and remittent fevers is indicated by the inter-
changeable character of these fevers, tertians developing into quotidians, and these into
remittents and congestive fevers, and the remittents becoming intermittent in their favorable
progress. The remittents also appear to have assumed a typhoid character; but whether
this was due to the presence of a specific poison or to some depressing agencies developed in
the system by the malarial influence is not manifest from these records. On the other hand
remittent is seen to have followed typhoid fever; and here also it is not evident that there
was any connection in this other than the accidental sequence of the disease causes.* The
relapses that occurred in remittent cases are illustrated as well as the frequent association of
dian-hcea, dysentery and hepatic congestion with the febrile phenomena. The concurrence
of scurvy is also observed. The tendency to an adynamic condition is noticeable in so many
that a hypersemic case in which bloodletting was used in the treatment on account of acute
cerebral congestion was considered worthy of special comment by the repoi ter. More or
♦ S. K. ToWLE, Surgeon 30th Mass. Vols., in his NoUt of Practice in the V. S. Army General Hospital at Baton Briuge, La., during the year
lem, published in the Bosttin Medical ami Surgical Journal, Vol. LXX (1864), pp. 49-5<i. alluding to the complicated character of the di^ases olBcrycd
in his hospital, says: "' Indeed, the syinpti>ins of many of the cases would indicate rather a combination of diseases than any one disease — fevers he'mg
inexplicably combined with diarrhoea or dysenterj', and vice versii, so that one would hardly know under which class to make the record. And again,
with the different variety of fevers, the record will often depend upon the period of observation; an intermittent, with well marked stages, will, if
neglected, often in a few days become an equa'ly well-marked remittent, or typho-malarial, or a little further on will prominently exhibit advanced
typhoid symptoms; or perhaps a few weeks or tiionths later die from chronic diarrhoea or dj-sentcry."
120 SYMPTOMATOLOGY OP
less of congestion of the brain, lungs, liver, spleen and kidneys was occasionally recognized,
and in some of these cases the internal congestion was so sudden and violent as to cause
speedy death. Rheumatism and neuralgia are also suggested as consequent upon the
malarial influence.*
But nothing is said of the aggregation of symptoms wbicli led to the diagnosis of
intermittent or remittent, as the case might be. The presumption is that in general there
occurred no special alteration from well recognized characteristics. In fact in some of
the sanitary reports it is definitely stated that nothing unusual was presented by the
malarial diseases under observation. In the intermittents the onset of the disease may be
assumed with or without preliminary feelings of languor, weariness, indisposition for physi-
cal exercise or mental work, depression of spirits, yawning, aching in the bones and soreness
in the muscles, with creeping or chilly sensations along the spine, loss of appetite and per-
haps nausea, which had been noted as having recurred for days prior to the advent of the
regular paroxysm. We may assume the cold stage as having presented its chills, developing
perhaps into rigors, and accompanied with goose-skin, shrunken features and lividity of the
lips and nails, and with internal congestions manifested by nausea and irritability of stomach,
epigastric pain, splenic or hepatic uneasiness, hurried respiration, rapid, irregular or slow
pulse, irritability of temper, headache, confusion of mind, drowsiness or even stupor and
coma; the gradual accession of reaction, the alternations of flushings and chills until in the
full development of the hot stage the cheeks became flushed, the skin hot, the mouth dry,
the tongued furred, the respiration accelerated and the pulse full and strong, or frequent
and feeble, if the patient was reduced by previous attacks of this or other enervating
disease; and lastly, concurrent with the outbreak of free perspiration, the gradual subsidence
of these symptoms and the re-establishment of a comparatively normal condition until the
commencement of a succeeding paroxysm. We may assume also the various irregularities
frequently presented, especially by the cold stage, it having been sometimes almost absent
or indicated only by depression of spirits, yawning or some other comparatively trifling
symptoms quickly followed by fever.
In the remittents we may- assume a preliminary stage of such malaise as seemed due
to hepatic disorder, followed by a chill and the development of a febrile condition, with
anorexia, thirst, nausea and bilious vomiting, epigastric or hepatic tenderness, pains in the
back and limbs, hot, dry and perhaps jaundiced skin, hurried breathing and frequent pulse
with throbbing headache, tinnitus aurium and occasional delirium. We mav infer also
constipation, a foetid or bilious diarrhoea or, even, dysenteric symptoms, as presented by the
bowels and a large, coated and furred tongue, cleaning as a favorable issue was promised, or
becoming dark colored as hiccough, low delirium, involuntary stools, clammy perspirations,
collapse, stupor and coma indicated impending death; while the exacerbations and remis-
sions are implied in the name.
On examining the cases that have been presented enough may be found to warrant
the acceptance of the above remarks.
The skin was sallow or pallid in the protracted cases ; and in the paroxysmal recurrences when its condition
is mentioned, it was hot aud dry or moist, according as the notes were taken dnring the exacerbations or remissions;
occasionally it is said to have been jaundiced. The pulse is represented as rapid in the majority of the cases, aud
* Although neuralgia was frequently regarded as a clinical associate of malarial fevers, or indeed as the legitimate offspring of the malarial poison,
the cases reported on the monthly reports had no autumnal tides of prevalence to indicate their connection with or dependence upon the cause of the
paroxysmal fcvei-s. (See diagram facing page 874 of this volume.) To account for this we must assume that all ncur.ilgic cases in any way counectetl
with malaiia nuist liave been reported under the heading of miasmatic diseases, or w*hich seems more probable, that neuralgia was less frequent in its
association with malarial disease thau was curreutly supposed.
MALARIAL DISEASE. 121
when its volume, iiiipuUe and resistance are not specifically stated, feebleness may be inferred as its characteristic,
for emaciation, debility, prostration or aniemia is noted in twenty-three of the oases. The pulse is re|)orted in
case 40 as tense; but in this the malarial character of the attack is not satisfactorily established. It is stated to
have been full and stron;; in three eases, one of which. 3, was a case of tertian a^ue, tho second, 27, a relapse in a
remittent case, and the third, 3'2, a remittent reported as hein-j of an unusually sthenic type.
The tongue in twenty-five cases in which its appearance is recorded was vU-im in one: white or furred in four-
teen: pale in one; large and white in one: soft, pale, nujist and coated in one: brownish in the centre and after-
wards becomiu'i pale and llabliy in one: dark-brown or black in three: red at the tip in two, and at the edges in one.
The clean tongue was recorded in a chronic case, 7. during the absence of paroxysmal manifestations ; the pale tongno
in the scorbutic case, 30, in which it afterwards became black and was accompanied with delirium. The brown or
black tougne appeared also in three cases, 20, 31 and 43, in which there was likewise delirium with much prostration,
and in the last two instances a fatal issue. The tongue was red at the edges in the anomalous case 40, and at the
tip in two cases, in one of which, 20, tliere was nothing to suggest that it was other than a remittent attack, while
iu the other, 23, the specific poison of typhoid fever was considered to be present.
The condition of the tongue in malarial fevers is usually stated by medical writers as white or yellow-coated,
becoming dry and of a brown or black color when the case assumes a serious aspect : as for instance Horton, Martin,
.Vitken, Copland. Watson, Hartlett and others,' many of whom speak of the edges and tip as being of a brighter red
than natural. The descriptive clause, red at the tip nud edges, is suggestive of the coiulition of the tongue in tyiihoid
fever, and, indeed, in llorton's statement of the pathological changes in his febrile cases the patches of I'eyer were
sometinu>s found inflamed and ulcerated. There is a probability, therefore, that spi'cific typhoid may have been
present in many of the tedious and low forms of fever that occurred in the practice of our medical men before l\u:
war: and that the condition of the tongue in such cases nmy have been embraced iu the account of the 8ymi)toms
of remittent as given by .Jones, Doni]>han, Holing and others. t
Hut in Sir ,1. R, Martins deserii)tion the red edges and tip are distinguished from a similarly stated condition in
enteric fever by the words loaded, clammt/ and moist, as applied to the tongue goni^rally. His account of the disease
corresponds with that given of the Kio Grande remittents by Dr I'eck in the report presented below,t in which tho
red tip and edges of the tongue are specially mentioned. In tho Bengal fever, as in that of the river bottoms of New
Mexico, there is seldom evidence of a co-existing enteric lesion. Hence a tongue with red edges and tip may be con-
sidered present in fevers of a purely nuilarial origin, although during our war this condition was seldom noticed. The
tongue was generally soft and flabby, somewhat enlarged, bro.adcned, thickened and indented at the margins, of a
pale, livid or bluish tint, and more or less coated or furred white, yellow or brownish, according to the severity of
the pyrexial attack.
* J. A. I!. HORTOX, 51. D., ill liis treatise on Distasts of Tropical Climates, I.nndon. 1879, p. 66, says of the tongue as it appears in the inareli remit-
tent fevois, tliut "it is more or less fiirieii. redder tlian natural at tlie tip anil edges." And again, on p. 68 : ■ Tlie Utngne at tlie commenceinent of tlie
diseasi- is (teiierally covered with a thicli whitish or yellowish -white fur. thicker towards the centre, having a feelini of beinff large anil llaliliy, anil
inarkwl on its iwriphery Ijy impressions of the teeth : the edges are usually red, but in a more advanced slnt'O the coating assumes a darkish brown
appearance. Sometimes the tongue is dry, presenting several furrows, accompanied with severe thirst." Sir J.tslEs K.vNAl.ti M.lirn.N, in his Injluencr,
of Tropical Climalts, London. 1861, p. 314. speaking of the remittent fevers of Bengal, states that " The tongue is red at the tip and edges, loaded,
clammy, and muist ; at other times, with a bitter or bad taste, the organ is but little changed from the healthy appearance." ArTKEX, in his Sciettce and
Practice nf Mtiticim. describes as follows : " The tongue, in the mild form of the disease (fever and ague), is clean in the cold stage, white in the hot stage.
and again cleans after the sweat has Howed. In severe cases the tongue is white during all the stages, and also during the apyrexia, while in the worst
cases the tongue is brown in all the stages." — .Vinerican edition, 1866. Vol. I, page 483. Coi'l.AXO's Diclinnury of Practical Meiliciiir. London. IS.'iH.
Vol. I, p. 948, says that the tongue in remittent fever is "clammy, moist or flabby anil coated, and afterwards dry, rough or brown," and on jiage 1135, that
tho tunpue of intermittent fever "is white and loaded." COXIIIK, in the .American edition if W.MSOX's I'raclice. Philadelphia. 1858, p. 50i, in his article
on Bilious Remittent Fever, says: " The tongue is usually moist, red at the sides and edges, and coated on its upper surface with a whitish, light brown
or yellowish fur, which often acquires considerable thickness." B.\KTI.E1T, in his Furer^i nf tlie United States, 3d edition. PhiLailelphia, Pa., 18,">2, p, 3ttl,
says : "The tongue is generally more or less thickly covered with a yellowish or dirty white fur— the color being probably occasioned in many cases by
the niiids ejecteil from the stomach. The edges of the tongue are often somewhat redder than natural. During the early periods of the disease the tongiio
usually retains its moisture : hut in grave cases, especially, and after the third or fourth paro.vysm. it frequently becomes parched and dry, dark brown or
nearly black on the dorsum, more intensely red on its edges, and sharpened at its point." (!K01t(;K B, WOOD thus gives the appearance of tho tongue in
a fully. formed case of remittent fever: "The tongue is now thickly and uniformly covered with a white, or yellowish-white coating, which, as the disease
advances, often becomes brown or blackish, especially in the ccnliv. In moderate cases the tongue is usually rather moist througlioni the iliseiise; but,
in those of a higher grade, it not unfreqilently becomes dry or dryish, and sometimes chapped or fissured upon the surface. It is occasionally disposed to
be dry in the paroxysm, and to become moist in the remission. At the sides, when not covered with fttr. it is usually red, and not unfrequently indented
by the teeth, in consequence of being somewhat swollen," — See Practice of Medicine. Philadelphia, Pa., 1847, Vol. I, p. 258.
I JosEcn JOXES, in Obsercntions on someof the Physical, Chemical, Phi/siological and Patholoyical Phenomena nf Malarial Fever, PhiUldclphla,
1859, says, p. 297 : " In almost every case the papilhe of the tongue were enlarged, and of a bright red color. In the mildest coses the tongue was only
slightly coated with white and light yellow fur, and the tip and edges were rodder than normal. In the severest cases the ti]> and edges of the tongue
a-Miund a bright red color, and the tongue was much drier than in the milder cases." • * " The fur on the tongue in many cases was thick, and of a
br,,wnish. yellow color." And ftirther: " In the active stages of remittent fever the tongue, iu many cases, especially if it be the first attack itf fever,
pri'sents nivin those ixirtions which are clean a brilliant scarlet color, and dry, glazed surface; the papilUe are enlarged; the fur which frequently coats
the tongue is of a yellowish or brownish-yellow, and sometimes black color, and almost always dry : the tongue, in many cases, feels, when the finger is
passed over it, as dry and haish as the surface of a rough hoard.' 1). A. DoxnMlAX, JL D., in Remarks on the Bilious Remittent Feeer of certain por-
turns of Louisiana, describes the toiigue in the early stages as red on the tip and edges, covered on the dorsum with a white or pale yellow coat, stating
that ill the advancol stage it "changes to a br,iwn or dark brown dorsum, while the tip and edges are red, an I present a glazed appearance." — .See West-
ern Lancet, Lexington, Xy., 1846, Vol. I\', p. 212. WM. ,M- BOI.IXG, M. D., of .Montg.imcry. AL-lbama. in Observations on Remittent Fever as it occurs
in the S'outhern part of Alabama, says : " The tongue in the first exacerbation may remain moist, sometimes almost natural ; but in most cases the edges
will Ije reilder than in perfect health, and the don>um covered with a thin yellowish or dirty white fur." • • "In the third or fourth exacerbation it is
apt to bei*,iine dry, at least on the dorsum, though the edges remain moist, and still later it becomes parched, rough and cracked." — Am. Jour, of Med, ,Sci.,
Philadelphia, K. S., Vol. XI. 1846, p. 2y7.
; Page \3f.
Med. Hist., Pt. Ill— 16
122 SYMPTOMATOLOGY OF
Thus, Surgeons. K. Towle, 30th Mass. A^ols.,* referring to the diagnosis of fever cases, says: "The white, thick,
pulpy, rounded tongue will dumbly speak of malaria." Surgeon E. C. Bidwell, Slst Mass. Vols.,t had already made
note of the thickening and rounding of the sides of the tongue, and considered this condition an unmistakable evi-
dence of the presence of the malarial poison in the system.
Dr. T. C. Osborn of Alabama, t has described and figured a condition of the tongue which he claims to be a
pathognomonic symptom of malarial disease existing in all cases, both acute and chronic. Its essential feature is
that the tongue presents a more or less wide, smooth margin, with slightly flattened and crumpled sides and edges.
The color amounts ordinarily to a very faint bluish tinge, which is often lost or merged in the various tints or furs
produced by other diseases. According to Osborn the crenated or crumpled condition of the edges is not due to the
impression of the teeth, for the transverse lines are closer together than would happen if this was their cause, and they
are observed in infancy and old age, when no teeth are present.
The appetite in the cases which have been presented is said to have been good in two instances, 7 and 11, but
in both the reports were made during the progress of recovery. Ordinarily, in acute attacks of malarial disease, there
was anorexia or impaired appetite with nausea and perhaps vomiting, these symptoms Ijeing noted in fifteen of the
cases. Thirst appears less frequently, having been recorded only in two cases. Disordered digestion was manifested
in two cases, 27 and 33, by fcetor of the breath. Constipation is mentioned in seven and diarrhtpa or dysentery in
twenty-two of the cases in which the condition of the bowels is recorded.
Abdominal pain or tenderness is usually reported as having been in the epigastric, hypochondriac or umbilical
regions. In one instance, 30, the scorbutic case, the right iliac region is stated to have been tender. The abdomen
was tympanitic in one case, 23, in which typhoid fever was considered to have been present.
Headache is reported in nine cases, in two of which delirium also is said to have existed; but as there are six cases
in which delirium occurred, although headache, if present, was not reported, the frequent presence of cerebral symp-
toms in these malarial fevers must be accepted. Epistaxis in one of the cases, 32, in which the delirium was accom-
panied with tinnitus aurium and disturbed vision, gave temporary relief to these special symptoms; but in case
29 the spontaneous bleeding from the nose did not take place until after the delirium had begun to subside. Ringing
in the ears was present also in cases 38 and 40; in the former a diagnosis of typhoid fever was entered, but the
patient was treated successfully by quinine; in the latter an aural inflammation gave a sufficient explanation of the
tinnitus.
The delii'ium in a few of the cases, as in 32 and 33, appeared due to cerebral hyi^ersmia, but in the jarger num-
ber it was manifestly of an asthenic character, and the concurrent symptoms were in some instances such as to suggest
the use of the word typhoid for their expression. In 29 the patient was greatly prostrated and his lips and tongue
coated black ; in 30 he was unable to speak, his tongue was black, his teeth covered with sordes, and there was ten-
derness in the right iliac region; in 36 there were "symptoms of typhoid" and swelling of the salivary glands; in
43, clammy sweats, involuntary passages, collapsed features and imperceptible pulse; and in 45, involuntary pass-
ages, gurgling on pressure on the right iliac fossa, dilated pupils and dulness of hearing. Whether these symptoms
were manifestations of the malarial agency or indicative of the typhoid fever-poison cannot l>e decided by the records,
although it seems likely that an adynamic condition may have existed independent of the specific poison of enteric
fever, for in 29 and 43 tliere appears nothing to warrant the supposition of a specific typhoid element.
The cliaracteristics of the intermittents consisted of the persisting tendency to recur-
rence induced by continued exposure to the influences determining the primary attacks, the
liability to. a fatal issue by a change to the remittent type or by the sudden onset of a per-
nicious attack, and the gradual production of that depraved condition of the system known
as chronic mala.rial poisoning.
The remittents were characterized chiefly by the accompanying asthenia, and as this
was present in cases free from diarrhoeal, pneumonic or marked cerebral symptoms, as well
as in those in which one or more of these symptoms gave increased gravity to the attack,
it must be referred to a deterioration in the constitution of the subjects caused by the
malarial or some antecedent influence. The frequency of diarrhoea as a concomitant must
*In his paper cited supra, p. 119.
♦ This officer, in an article entitled Diagnosis of tfie Malarial Diathesis: New Test Symptom'^ says: "It is a very peculiar and abnormal ,ap-
pearance of the tongue, in which its under surface appears to have trespassed upon the upper, the papill* of the latter being supplanted by the transverse
Tugie of the former. The sides are thickened and rounded, the normal well-defined edffe being obliterated, and. the line of demarcation moved nearer
to the jnesial line. This appearance of the sides may be associated with any and every poi^sible appearance of the remaining papillary surface, clean
or coated, thick or thin, light or dark, just as the malarious disease may be attended by any and every variety of morbid condition of the system.
Through all this variety it is peifectly distinct, and, when once learned by actual inspection, is unmistakable."' — Boston Med. and Surg. Jour., Vol.
LXVIU, 1863, p. 36.
JT. C. OsiiORX — Remarks on a peculiar appearance of the tongue in malarial disease. — The Western Jour, of Med. and .^urg.. Vol. VIII, 1851.
p. 109 — also by the same. A peculiar ajipearance of the tongue in Malarious disease. — Trans, of the Amer. iled. Assoc., Vol. XX. 1869. p. IT."! jwitli
colored plate] — and .-1 new variety of Malarial Fever. — Xew Orleans Jour, of Med., Vol. XXI, p. 664. The reference to a trespass of the under on the
upper surface in Dr. BHiWKLL"s article is a singular coincidence, if he was unaware of Dr. OSBORX'S paper published in 1851. in which occurs the fol
lowing: "The most fixed ci)ndition of this symptom is an appearance of iiulentation or crimpling, transversely, which is apparently confined to the sutv
jaceiit tissue, while the superficial tegument is moist, smooth, and tnaosparent. In a word, it seems to be a continuation or encroachment of tile inferior
surface upon the superior and lateral bonlers of the tongue, greater as we approach the root of the organ."
MALARIAL DISEASE. 123
be attributed to tbe simultaneous action of the causes of the alvine fluxes and the malarial
poison. Where so many men were affected with diarrhcea a certain percentage of Jiar-
rhoeal complications was to have been expected among the remittents, irrespective of the
action of the malarial poison on the integrity of the alimentary mucous membrane. But
as it is certain that the coincidence of diarrhoea and periodic fever was greater than could
be accounted for by these considerations, we are at liberty to consider it either as due
directly to the malarial agency or as a further illustration of tlie proposition that the mala-
rial influence, other conditions being equal, is more readily manifested in the debilitated
tlian in the strong and healthy. The diseased action as it aft'ected the lungs, excluding
from consideration the supervention of pernicious chills, was not manifested by any urgent
or prominent symptoms; it appeared rather to progress insidiously as in the course of
typhoid fever. If cases occurred such as were described b}- Manson in 1857 under the
name of malarial pneumonia, and by Gaines of Mobile in 1866,* who proposed for them
the title of remittent pneumonic fevers, they were not recorded by our officers as mani-
festations of malarial disease. The incidence of the disease-poison on the liver was very
generally manifested by bilious vomiting and not unfrequently by jaundice; in some
instances this latter symptom was so strongly marked as to suggest the idea of yellow
fever.f The kidneys did not come into prominence in the symptomatology. The urine
was aflfected during the febrile condition, and in the jaundiced cases it participated in the
general coloration, but it is not often mentioned as having been albuminous or sanguinolent.
The following extracts from special reports refer to the symptoms of the intermittents
and remittents:
Surgeon'H. R.Gage,25JA Wis. Vols.; Columbus, Ky., March SI, 1B6S: Bilious fever, as wp hare seen it in our present
location, presents the following symptoms: For many days liefore the patient gives np he eoniplains of languor, bitter
taste In the mouth, slight feelings of nausea, disinclination for food, sometimes constipation, and very generally a con-
siderahle degree of heavy, dull pain over the eyes. A chill, more or less severe, generally precedes the attack, followed
liy increased lieat of the entire surface, and slight or severe pain in the lumbar region; the skin becomes hot and
dry, the countenance flushed, the eyes red and watery, the pulse quick and breathing hurried; extreme irritability
of the stomach is a frequent and distressing symptom, and for many days sometimes, a persistent accompaniment,
nearly everything in the form of ingesta being rejected. There is commonly considerable thirst, a marked decrease
in the urinary secretion, which is highly colored and has a strong odor, and after the disease has continued for
a lime the skin shows a yellow hue, which tint also extends to the eyes. An exacerbation and remission of the
fever takes place during the twenty-four hours, each succeeding exacerbation, perhaps, acquiring greater" severity.
The symptoms above described, greatly intensified, with a more continuous exacerl)ation and less distinctly marked
remission, constitute the severer form of the disease. To allay the pain in the head and back, which is often dis-
tressing, mustard applied to the najie of the neck and the small of the back, together with cold applied to the head,
often aftbrds prompt relief. If the suffering is intense and the case more urgent, cupping the temples and back of the
neck is of the first importance, and should by no means be neglected : so also the cups may be applied to the epigas-
trium, if. as is siuuetimes the case, a feeling of death-like oppression is a constant and serious symptom. Cathartics
are at once resorted to, the prescription generally used being as follows: Four grains of podophyllin, ten grains of
bicarbonate of soda and ten grains of calomel, divided into six powders, one of which is taken once in two hours.
This combination ordinarily produces very free catharsis, and, together with the means already brought into use,
often affords prompt and permanent relief, and places the case in a condition to move through the course of the
disease in safety, if the latter is jiot effectually cut short. Bathing the entire surface in water to which a little soda
has been added, and of such a temperature as to feel comfortable to the patient during the exacerbation, is a matter
• Rep.irt of O. F. Maxsox on Unlarial Pnrumonia.—Nao Orleans Medical J\>w> and Hospital Gazette, Vol. 4, 1857-58, p. -100 et seq. Malarial
pneumnnia. .\n Essay read before the Mobile Medical .Soeiety, March ."i, ISfifi, by E. V. Galxks, M, D.—Xew (Orleans Mrd. and Surg. Jour., Vol. XX,
1<. 12 et seq. Maxsox descrilies this form of pneumonia, which he considers the prevailing type of the disease in the .South, as a severe remittent
fever nilh pneutnouic symptiiins superadded. The lungs become penneated with a l>lood-tinged serum rather than omwilidated by exuded plasma.
He considers the condition as one of congestion, for it often occurs with cold skin, flagging pulse and colliquative diarrhoea, manifestations which he
r.'gards as itiC4>nsistent with the existence of the inflammatory' process. GAINES says that cases ushered in with a severe chill are dangerous, as the
lungs may be ovenvhelmed by the sudtlen congestion ; but the fatality genemlly depends more upon the febrile disease than upon the pulmonary inflam*
mation whit-h accompanies it. In a few cases he bled for the sake of the immediate relief given to the congested lungs, and he had experienced no evil
after-efTe^ts from the bleeding; but cupping answered in the majority of cases. This was followed by calomel, and if the fever l>ecame high, by vera-
truni viride. When the remission recurred large doses of quinine were given.
t See Surgeon T0WI..E8 Xotes cited supra, p. lit".
124 SYMPTOMATOLOGY OF
of no small moment, and affords a pleasant relief from the intense heat of the skin and helps to keep that great
depurative organ in a condition the lietter to perform not only its ordinary functions hut the large increase of duty
now incumbent upon it. The etfervescing draught, spirit of niindererus, sweet spirits of nitre, Hoft'mann's anodyne,
Dover's powder and ipecacuanha are remedies of some imjiortance, and may be administered with advantage by an
election of cases, and if their exhibition be properly timed. Blisters are nseful after the force of the exacerbation
has been reduced in those eases where any considerable head, gastric or pulmonary difficulty remains.
Surgeon A. F. Peck, 1st ATeto Mexico Mounted Vols.; Los Limas, New Mexico, Sept. 30, 1862: Intermittents are
of the quotidian type; remittents approach very closely in character to continued fever. The cold stage, so well
marked in tlie intermittent fevers of the different sections of the United States, is but slightly developed on this
river (the Rio Grande) as far as I have observed; it amounts to no more than chilly sensations in different parts of
tile body, after which the stage of pyrexia supervenes and lasts for several hours, when the sweating stage begins
and the fever declines. The tongue is heavily coated with a white fur; there is great thirst with sometimes
nausea and vomiting; all disposition for food is lost; the bxeathing is hurried and often irregular, with feelings of
weight and oppression in the epigastrium ; the pulse is full, strong and frequent. The nervous system is much dis-
ordered; there are severe pains of a neuralgic character in the back, loins and extremities ; the secretions are dimin-
ished, the skin being dry and hot and the urine scanty. In the course of a few hours the sweating stage makes its
appearance, when all the febrile symptoms graduall}' abate. As it advances the skin becomes cool, the excitement of
the circulation subsides, the headache disappears and the patient falls into a calm sleep, from which he awakens
free from fever.
The symptoms of remittent fever differ in many particulars from those above enumerated: For several days
previous to an attack the patient describes himself as feeling languid and weak, with pains in the body generally,
epigastric uneasiness, deficiency of appetite, disordered taste and slight soreness in different parts of the body.
This state of system continues until a regular paroxysm of fever makes its appearance, which continues with little
or no abatement in the twenty-four hours. In many cases tlie only sign of a remission is a slight diminution in the
fulness of the pulse, the fre(iuency remaining the same, while the pains in the body may be less violent and the skin
not so hot as a few hours before. The tongue, at tirst covered with a yellowish-white fur, in the course of two or
three days assumes a dark and dry appearance in the centre with edges and tip very red; great thirst; intense
pains, especially in the head and back: sometimes diarrhfea and at others constipation; urine scanty and very dark;
respiration hurried and difficult ; skbi sometimes of a yellowish hue.
The treatment that I adopt for these two diseases, which are undoubtedly identical in character but different
in intensity, is as follows: If the bowels are confined I give three or four compound cathartic pills or half an
ounce of sulphate of magnesia; if there is diarrhoea, castor oil half an oiyice with half a drachm of oil of turpen-
tine to be taken at once. After the bowels are thoroughly cleansed 1 give fifteen to twenty grains of sulphate of
quinine morning and evening. If the patient has fever the next morning I repeat the quinine, giving twenty grains
of the sulphate rather than fifteen, as I find that this quantity answers mueli better, given at once, than a greater
i[uantity in divided doses. By this method of administration its full sedative and febrifuge effects are i)roduced.
I never have known two, or at most three, twenty-grain doses of the sulphate (and often much less is required) fail
in tills valley to reduce the fever and produce complete convalescence. In a few cases I have thought it necessary
to resort to alterative doses of mercurials combined with opium or Dover's powder at night to procure rest; and
if the urine should be very deficient in quantity I give sweet spirits of nitre, half a drachm to a drachm, three or
four times in the twenty-four hours. If there should be much prostration I give essence of beef with wine or brandy,
as circumstances may dictate. Method of administering suliihate of quinine, with some of its attendant results: I
never wait for an intermission or a remission ; if the bowels are open I give it at once, in the height of the fever,
in from fifteen to twenty-grain doses, and repeat if necessary in three or four hours. When the symptoms are of an
alarming character I very often combine the sulphate with a cathartic and give both at once, and if in three or
four hours no sedative impression is made I give an additional quantity. In ordinary cases I never have found it
necessary to give more than two twenty-grain doses in the twenty-four hours, although I haxe seen many cases in
which I have given double or triple this quantity with the very best results. The immediate results of the admin-
istration of the sulphate in large doses during the fever are so gratifying that I cannot refrain from noting some of
them. In from one to three hours the sedative effects of the medicine begin to appear. The pulse, before full,
bounding and rapid, now becomes soft, less frequent and more regular; the skin, that before was hot and dry, now
begins to be cool and moist ; the countenance, that was anxious and restless, now bears the marks of composure and
rest; the respirations, that were hurried and oppressed, are now easj' and free ; the tongue begins to show signs of
returning moisture; the urine becomes copious; and lastly, the whole nervous system is quieted and the patient
enjoys sweet repose.
Surgeon M. D. Benedict, loth Xew York; Suntti Bosa, Fla., April 3, 1802: We have had since March 1 a large
number of cases of remittent fever, mostly of mild type, although a few have shown a stronger tendency to congestion.
It seems like a fever of acclimation, and in its treatment quinine is our main dependence.
AssH Surg. J. H. Scheetz, ilth Pa. Vols.; Beaufort, S. C, August 31, 1862 : Remittent fever, which prevailed to a
considerable extent, was characterized by a daily exacerbation and remission. Most of the cases presented the following
symptoms: A general feeling of lassitude for two or three days, with partial loss of appetite, followed by alternating
chills and flushes of heat, cephalalgia, referred priuciiially to the supraorbital regions, sharp and lancinating in
character, but sometimes dull, aching and heavy; eyes generally sufi'used ; skin sallow, hot and dry during exacer-
bation, moist and flaccid during remission; tongue coated; thirst; anorexia; pain in the back and extremities;
bowels usually torpid, but in some disposed to looseness; tenderness over the right hypochondriac and epigastric
MALARIAL DISEASE. 125
regions; uausea frequently and sometimes vomiting; pulse from 85 to 115 per iniinite; urine generally liigh-colorcd
and occasioning frc<iuent complaints of scalding.
The treatment found most lieuclicial was to adiuinister a mercurial purgative in i:ase8 willi t(ir|iiil liowcls;
when nausea was present twenty grains Of ipecacuanha were added to the mercurial. After the evacuation of the
intestinal canal i|uinia in live-grain doses was given four to six tinu's daily. Diarrlio-a was treated with opium or
Dover's powder alternating with the qninine.
Suriiion ij. W.Pim.l.ll'S, 75(/i ///. Fvls.; /'<r)v/ri/?c, Md., Dncmbcr '31 , 18152: Many ca.se.i of miasmatic di.sease were
complicated with diarrhoea, bronchitis and hepatic derangement. Tlie i)aio.\y.sius in most of the cases were not dis-
tinct— occurring at a certain hour, and made up of distinct stages, as of chill, fev(^r and sweating — but light chills,
followed in a short time by Hushes of fever, but without subse(iuenl perspirations. The febrile action was n<it high:
skin hot but not burning: pulse frequent and often weak and small. A sense of great mu.scular prostration allended
all these cases: congestion of the kidneys was also common. They were treated with free doses of quinine.
Siirijion J. L. Hui.l'ORD, 48(/i X 1'. J'oh.: Fort I'uUtski, Ga., Septnnlnr 1, 18()2: The cases of malarial fever this
month have been of a mild form. The symptoms are nausea and vomiting, great lassitude and weakness, pain in the
back part of the head with a heaviness oyer the vertex, pain in the knees, high-colored urine, dark-color(Ml stools,
and slight pain in the liver. In all eases I think thediliiculty arises from an inactive liver. The treatment has lieen
mercurial purgatives and castor oil, followed by live-grain doses of quinine in aromatic sulphuric acid.
Suryion H. E.\RNKST GoODM.vx, 28//i Pa. FoU.; Point of Ilocln, Md., ScjHembir 30, ISCA : I have observed a pecu-
liar disease among the uu-n, beginning with a dull headache for several days, and then characterized by a harsh, dry
skin, dry tongue, feeble ))ulse, extreme debility, no appetite, probably a little fever once in several days, and with
more of a tendency to constipation than diarrluea. After one or two weeks spent in this condition the patients
brighten up, eat ravenously, and soon return to a healthy state. I have classed these cases under the head of remit-
tent fever: but the fever is seldom perceptible to the touch.
Jss't Surg. I). L. HfXTixinox, U.S.Armii; I'orl Monroe, Fa., Septemher 30, 18fi2: The prevalent diseasf* have
been those of miasmatic origin and those depending on a deranged state of the portal circulation. The bilious
fevers have been mild and easily managed. Intermittents have proved more obstinate, and in many eases have
continued a long time, quinine having seemed to exercise Irat little of its peculiar power. In these cases a resort to
Fowler's solution has been of great advantage. I have noticed a uuirked tardiness of recovery in these cases of mias-
matic disease, which I have attributed partly to the fact that the poison still renniins in the system, though held in
abeyance for the time, and partly to the enervating effects of the climate. It is i)roper to state that but little of the
disease has originated here; it was contracted during the campaign on the peninsula or previous to enlistnu'iit.
Siirijion .\. W. WijKiHT, 58//i I'u. Fol:i.: Suffolk, Fa.. Xorembcr 1, 1862: We had also a number of cases of a peculiar
type of remittent fever. A man would complain of a few ordinary bilious symptoms for a day or so, doing light duty,
when his messmates would report him as crazy. In a day the following symptoms would be developed: Dry tongue;
(juiek pulse, 110-120; slight heat of skin; good appetite: some tendency to diarrhrea; wildness of expression; nerv-
ousness ; constantly moving about, lying down only when ordered to ; embracing every opportunity to escape the
care of nurses, and talking rationally, although occasionally mildly delirious. These symptoms lasted about two
weeks, when the patient .suddenly awoke to a consciousness of his condition. Convalescence was rapid. I had six
cases of this kind, and all recovered except Private Putnam of Company (J, who became insane and was sent to tlu;
.\sylum at Washington. The disease sometimes assumed anotlii'r form: The nuin would have a slight chill, then
fever, quick pulse, dry tongue, either copious perspiration standing in drops all over the body or great coolness of
surface, delirium, great perspiration and death in twenty-four to tifty-six hours. 1 had two such cases in Oak Grove
Camp and lost one of them.
II. — The Pernicious Fevers.- — In the Ibrni of sick report used during tlie civil war
the term congestive intermittent fever was employed as the equivalent of the designations
pernicious intermittent fever, congestive fever and congestive chills, to indicate that dan-
gerous form of intermittent, characterized especially by the intensity and severity of the
cold stage, which had long been recognized as of frequent occurrence throughout the mala-
rious districts of our Southern States. Such attacks occurred not only in persons who
were for the first time exposed to a highly malarious atmosphere, but also among those
who had suffered more or less from the malarial influence before the supervention of the
congestive seizure; indeed it is probable that a majority of the deaths recorded by our
medical officers as from simple intermittents were really due to the occurrence of this per-
nicious type of the disease. It assumed various forms, one of which appears to have been
observed with much frequency. In it were presented grave symptoms of disturbance of
the brain and nervous system; excessive headache, drowsiness, even coma, occasionally
convulsive phenomena and sometimes delirium, accompanied its onset. In some cases the
126 SYMPTOMATOLOGY OF
nervous disorder manifested itself in the form of epileptiform convulsions, as observed by
Surgeon George Cooper, TJ. S. Army, while Medical Director of the Department of the
South.* In other instances unusual manifestations were recorded, as by Surgeon G. Rush,
101st Pa. Vols., who published two cases of pernicious fever in which unconsciousness and
insensibility were associated with so little disturbance of the organic functions that in the
first case which occurred the patient was suspected of malingering.^
Frequently the severity and prolonged duration of the chill or of the condition ul'
collapse that followed it, corresponded to what lias been described as the algid variety of
pernicious fever. Dr. Woodward^ mentions having seen at the siege of Yorktown a num-
ber of cases in which the collapse was profound and extremely prolonged. In other cases
congestion of the lungs appeared to determine the fatal issue. Although vomiting and
diarrhoea were frequent concomitants of the simple interraittents and remittents, it does
not appear that the concurrence of these symp^.oms, constituting a choleraic variety of the
disease, was often observed in our pernicious cases. When the incidence of the disease fell'
on the intestinal mucous membrane profuse haemorrhage was the more common result, as in
the cases described in Surgeon Merritt's report submitted below. § The hsematuric variety
of hsemorrhagic malarial fever, which has attracted so much attention in the Southern States
since the close of the war, does not seem to have been observed among our soldiers. But in
some of Merritt's cases intense jaundice, which, with blood in the urine, is regarded as the
characteristic symptom of the hsematuric variety, appeared in connection with the heemor-
rhagic extravasations from the intestinal mucous membrane. || In other instances the
hsemorrhagic tendency was shown by petechiie and vibices. Dr. Woodward's cases, which
* See the report of Surgeon Cooper, p. 231 of the Appendix to Part I of this work. Some of the cases referred to by Surgeon D. W. Hand, U. S.
Vols., as occurring during the summer of 1863 in the 27tli Mass. Vols., near New Berne, N. C , must also have presented marked cerebral symptoms, fur
he says ; " I have reason to believe that some of these cases were mistaken for cerebrospinal meningitis by the medical otficers in attendance.*'
1 1n tlie Philadelphia Med. and Surg. Rtporta\ Vol. X, IS63, page 'M^: Private C. uf Co. C, and private K., of Co. 1, lUlst Pa. Vols., who had pre-
sented nothing uiiusnal during the night and previous day, were found on the morning of Sept. 25, 18b"3, in a state of insensibility. Both lay motionless
and no movement could be excited in either of them; their temperature was natural "or perhaps a Httle higher;" their skin moist or perspiring; pulse 80,
regular and moderately full; countenance placid. The eyes were open and looked natural, the pupils acting under the influence of tight ; they would fol-
low an object moved before them, and away to a considerable distance, and close quickly when a sudden movement was made near and towards them.
To restore the patients blisters were applied to the cervical and dorsal portions of the spine, and carbonate of ammonia and quinine were administered.
For thirty-six hours they remained in this unmoved condition, the pulse meanwhile becoming weaker and the urine voided involuntarily. Beef-extract
was given as nnurishmeut. Two drops of crotoo oil were put on the tongue and copious dejections were followed by improvement in both cases. The
hearing was somewliat restored, and when the men's names were loudly called they made muttering efforts to speak. Forty-eight grains of quinine were
administered to private K. in twenty-four hours. He recovered. Private C. died fifty-two hours after the attack. J*06■^mo^^;m examination found the
brain and its membranes normal. Plymouth, North Carolina, where the regiment was stationed at this time, is surrounded by cj'press- swamps ; 90 per
cent, of the otlicers and men had been affected by miasmatic fevers.
* Camp Diseases of the United States Annies, Philadelphia, 1863, p. 174.
§ Page 142.
II The following sketch of haemorrhagic malarial fever, as it appears in our medical literature since the war. is of interest in connection with Surgeon
Merritt'.s oases: In the autumn of 1867 Dr. T. C. OSUORX, of Greensboro'. Ala. — JVew Orleans Jour. Med., 1868, XX, p. 044 — observed ten cases of a
variety of malarial fever characterized by chills, nausea and vomiting, followed by sudden bronzing of the skin and haematuria; tive of these proved
fatal, in some instances with suppression of urine and uraamic convulsions. In the recoveries convalescence was tedious. All the patients were thoroughly
imbued with the malarial poison, having been subject to intermittent attacks for a long time before the development f)f these tuuisual manifestations. A
few months later Dr. .1. D. OSBORN, in an essay on Malignant Congestive Fever, read before the Greensbm-o' Medical Society and published in the
New Orleans Jour. Med., Vol. XXII, p. 61, added but little to the description of the disease already given by his fatlier. But from his paper it is
understood that the new disease had become epidemic, and that the country people called it yellow fever. His cases occurred during the period from
September to April. About the same time Dr. H. C. GHENT, of Port Sullivan, Texas, in a letter published in the Richmotid and Lnuisrille Med. Jour., Vol.
V, p. 271, described the disease as it occurred in his part of the country in 18(i6-67. and from the recurring chills, blood in the urine and the name, black
jaundice, applied to the disease, as well as its fatality' and occurrence only in cachectic individuals, it is apparent that the new malarial fever of Greens-
boro', Ala., was endemic in certain parts of Texas. The next paper of importance which appeared was read by R. F. Micuel, of Montgomery, Ala.,
before the Medicil Association of the State of Alabama in March, 1861). In it he defines the disease as "a malignant malarial fever fidlowing repeated
attacks of intermittent, characterized by intense nausea and vomiting, very rapid and complete jaundiced condition of surface as well as most of the
internal oigans of the body, an impacted gall-bladder and ba-morrhage from the kidneys. These phenomena presented themselves in an almost uninter-
rupted link, attended by remissions and exacerbations. It is a fever peculiar to the United States." In the record of an aut<ipsy on a case of death from
this disease, contributed by Dr. Michel, the brain was natiu-al, its veins comparatively empty and its membranes jaundiced. The thoracic organs were
yellow-colored but otherwise normal. The omentum and its fat were saffron-colored; the stomach filled with dark grumous bile and its mucous mem-
brane thickcTied and injected, especially near tlie i>ylnrus: the intestines normal. The spleen was firm and solid, weighed nineteen and a half ounces and
was about three times its normal size. The hver was sliglitly enlarged, firm, solid and of n dark chncohite color; the gall-bladder was filled with an
alin<jst solid pasty pear-shaped nmss, the smallest particle of which tinged a basin of water the color of saffron. The kidneys were enlarged and of a
pale-reddish color, but dark-green on sectioq. X>v. Michel embodied the impacted gall-bladder iu bis definition of the disease, but in subsequent cases it
MALARIAL DISEASE. 127
were very fatal, presented these cliaracteristics. Perhaps the depravation of the blood which
gave origin to the petechial blotches was due, as suggested by him, to the concurrent action
of a scorbutic taint; but this must be considered doubtful, for, as will be seen hereafter, these
was fuuDd to contain a think greenish-black bile, the impnetioo in this case beiDg^ only an aggravation of the usual condition ; the spleen also has been
found to be more frequently softened and filled with disorganized blood than firm and solid.
The new disease was ailribiited by J. D. Oskokx to the uncared-for condition of the country. Dr. Wm. A. GREENE, of Amcricus, Ga., in the
Richmond and Lom'scine Med. Jour., J87;», Vol. XIU. p. 149, in an article entitled Mia.stnntie Htemaltiria, si>eaks of tho almost entire iicglecl ot
•Irainage consequent on the changed condition of agricultund pursuits since the war. Dr. NtiRCOM. of Edcnton. N. L'., in his address on lliPiuorrliagie
Malarial Fever, read befuro the State Medical Society in 1j^74, gave cvpression to similar opinions : " Before the war, tho Southern States wenj in a
high state of cultivation and the lands thnroughly drained, hence the malignant forms of malarial disease, as a general rule, were not known excopt in
very low badly-drained swamp lands. Within the i»asi eight years, owing to so much land lying waste, defective drainage and the geiieml unsanitary
ronditiuu of the country, the malarial poisnn hiis acted with intense virulence, and caused tho disease we an; now considering." In fact the morbid state
was generally regardetl as malarial in its origin, but no satisfactory explanation of its evolution was presented. Dr. E. 1>. McDaxiei-, of Camden,
AlalKima. consideivti this questii>n in his article on Ilxuuirrhagic Malarial Fever in the Tnmsactions «>f (he State Medical Association, 187-1, p. 2J>7.
He says: "Why should those localities which, years ago, showe«l the most une(|uivix-al and extreme influences of nnitaria by nnnital aiiinmnal
visitations of e»ingestive or peniicinus inlermiilcnt, remittent and pseudf> eontinueil malarial fevers, almost putrid in gcnnral intensity, have not, in those
times, preseiitt?d with considerable frequency and in considerable numbers cases of this now justly dreaded si'tiurge { And why did thosti Nime localities,
soon a^er the earliest November frosts, become in old times as healthful, so far as fevers were concerned, as momitain tojts, while the insatiate malaria of
to-day relentlessly pursues its bleeding victims in mid- winter, when the air is filled with snow-flakes and the forests are hung with icicles? And why are some
places ttnce s*» salubrious that they knew no malarial fevers at all, or if any, only the mildest intcrmittents. then popularly regarded as trivia! and almost
harmless, now not exempt from even this the direst of all malarial ills — the very summation of all extreme malarial manifestations? • • • » j have
seritvisly iwndered this whole subject, and I am folly convinced that the grave, new order of symptoms now occurring in nuilarial fever in Alabama and
ihe adjacent Stales, even in localities not lieretofore known as specially insalubrious, is not due to any marked increase in the quantity, intensity ur exten-
sion of malaria; for with exception, perhaps, of 1B67 and I8*i8. the average numerical manifestations of nmlaria have been fewer since the advent of tho
irtemde hemorrhagic i>eriiHl than they were bt^fore that |ierio<l set in. Xor to any allotropic or otherwise modified condition of malaria, be this chemical
or dynamical, orsporoid in its nature; nor to any marked deterioration of the blow! and constitution due to depression of sj>irit or exhaustion of body, but
to a tride-fpread epidemic influence." It is to be regretted that none of the obser\'ers gave any consideration to the chanicter of the water-supply in these
virulent manifestations of malarial disease. The violence of the morbid action occurring at a time when exhalations from a malarious sod were not avail-
able in explanation, and the occasional appt^raneeuf two or more eases in the same household indicating a local cause, in the absence of contagious quali-
ties, are facts suggestive of water-infection.
The publication of the articles which have been mentioned attracttMl the attention of the profession to the hsematuric fever, and h number of papers
on the subject have since appeared in the journals recording cases and discussing the pathology and treatment of the disease. But first it was denied that
OSBORX's new disease was a hitherto unobserved expression of malarial poisoning. Dr. J. C. Facet, in tho .Veiu Orleans Med. Jour., 1869, p. 768, in
reviewing MICHEL'S paper, called attention to the facts that this disease, although new to the majoritj- of our Southern practitioners, had been described by
DiTROUL.\l" and other French authorities as occurring in the colonies in Madagascar, Cayenne and the West Indies, and that he himself in 185!t and
18*>4 had treated of Hiemorrhagic Paludal Fever, and specially of its hiematuric form. The ha*inatemesic variety, he contended, had been frequently
seen in Xew Orleans, but had been generally confounded by medical men with j'ollow fever. Indeed. J. C CUMXUNGS, of Monroe. Ala., in the Xtic Orleans
Mfd. Xeics and UospH Gaz.. ]S59-t>(), Vol. \T, p. 811, rceorcb six coses which diflfer in no respect frotg those afterwards described by OsuoKX and others,
and refers to the prevalence of the disease during previous seasons. XORCOM instanced McLE-vx's article on malarial fevers in Hetfnold's Practice to show
the fitmiliarity uf that writer with a hiemorrhagic variety of the disease. The cases which are described at length by our Southern brethren dwell ujHm
Ihe bl»KHl in the urine and in the serum which collects after the application of blisters; but other haemorrbaEres aj^pear to have been rare, although mentitm
is »K*casionally made of bleeding from the nose, mouth and stomach. Dr. Faget, as already intimated, considers that haBin<»rrhage fn)ni the stomach is a
fr»»quent expression of the morbid action. "And when I speak of large clots of bU»od, still red, let no one imagine that 1 then saw WwhI coming from the
nasal fossa or from the gums, swallowed, and. afterwards, ejected before undergoing the influence of the acid of the gastric juice. By no means. I beg
that I may have the credit of examining things closely, and that I may not be charged with having committed an error of so grave a cbaracler." Hence
N«>K<OM s** enlai^es the lines used by MiOHEL in defining the disease that its name of necessity be<-omes Haimorrhagic Malarial Fever instead of Malarial
Ho'maturia as given by those whose field of observation bad been restricted to the one hatnorrhagic manifestation. He says: ".\ malignant malarial
fever, the result of frequent attacks of intermittent, or of a prolonged and exhausting remittent, characterized by btematuria, bsematemesis, epistaxis,
enlerorrhagia, metrorrhagia or haemorrhage from the gums and fauces, or from two or three of these at the same t^.me; most distressing and incessant nausea
and Vomiting, and complete jaundiced condition (greenish -j-ellow hue! of body. The cold stage, though not always, is generally well marked, and the
)ian>xysms oftenest re*;ur about everj- ten or twelve hours, but far more frequently Ihe fever is uninterrupted by intermission or remission." A few years
later, in 1S^4, the work of B6iiKN«EK-FtKALI>. De la Fih're Bilieuse Melanurique des Pays Chaud,< romftaree actc la Fievre Jaune. and in IS?.!, his
chapter on Mflanuric fever in his Traite Clinique des Maladies des Eitropeens au Sinigal. sbow the existence i»f a disease which corresponds in its general
fcatuies with the American ha>maturie fever with the exception that the dark color of the urine is attributed to the presence of a large fiuanlity of biliary
matters. Relying upon the accuracy of M. BEKEXGEK-F^KAt'^^'sobser^'atiuns and exjieriments. Ihe writer of a review of his work in the AvtericanJour.
Med. Sciences, New Series, Vol. l.XIX, p. IS'A, throws doubt upon the hx-maturia so frequently reported by our .\merican practitioners, and suggests that
thej- may have been deceived by Ihe biliary coloring matters with which the system is so thornuglily i>ervaded. Or. Faget begged that he might have
the credit of examining things closely. If our other tibservers did not emphasize in like manner it is probably due to the fact that they cjuld not realize
that their testimony as to blood in the urine would be questioned, cijnstituting as this condition did, with the concurrent jaundice, the pathognomonic symp-
tom of the disease under obser\'ation. M. BfeREXGER-FfeBAUi* regards melanuric fever as differing only from other expressions of acute malarial poisoning
in having an excessive secretion of bile replacing the more usual perspirations or choleraic discharges. Our American writers allow the presence of bile in
the urine, as the whole system seems deluged witii it, but they are positive as to the presence of blood not only as manifested by a coloration due to the
dissi)lved hsematine of disorganized blood corpuscles, in which case the symptom is regarded as an eifort to restore the blood to its normal coDstitutii»n
by the elimination of the debris of its destroyed corpus<^ular elements, but as shown by the presence of the red corpuscles themselves, and even in
many cjises by unmistakable blood-clots which must be regarded as the result of a true hemorrhage from ruptured capillaries during a stage of active con-
gestion. McDaniel regards the haemorrhage as due to interrupted cutanetms actitni such as explains the bsematuria in rheumatic, catarrhal and scarlatinal
cases. The sudden appearance of jaimdice when there is m* apparent obstacle to the free passage of bile from the system by the alimentary canal has
been referred fur explanation, by Profess«»r Jov\ES in the Richmond and Louisville Med. Jour.. Vol. XXill, p. 2iH. to the following from XirmeyEK's
eliapter on HEematogenous leterns in his Ttj-t-Book of Practical Medicine. Vol. I. p. 684 : " The views regarding the occurrence of jaundice without reten-
tion and reabs«.ri»tion of bile have totally changed since the observations of VlRCHOW. KChxe and Hoppe-SeVlek have shown that bile-coloring matter
may be fiTraed from the free coloring matter of the blood without the action of the liver; and we may induce artificial jatmdice in animals by injecting
substances that dissolve the blood corpuscles. There is now no doubt that some of the formerly enigmatiail forms of icterus are due to the disintegra-
tion of blood cor^niscles, and the transfonnation of the freed coloring matter circulating in Ihe blo<»d into bile-coloring matter. This is particularly
tnif .if those cases of icterus occasionally caused by poisoning from chlon)form or ether; for. as exi>erimeut proves, these substances possess the power of
dissolving blood coipuscles This mode of origin is very probable, (hough not absolutely proved, for other varieties of jaundice, as iu that
128 SYMPTOMATOLOGY OF
blotches in fulminant malarial cases were found oftentimes in men wlio had been robust and
healthy until struck down by the pernicious influence. Surgeon Jackson, 11th Pa., Vols.,
in a report, hereafter presented, describes a number of cases which occurred in a command
camped in and around Annapolis, Md., in the winter of 1861. Some of the regimental
surgeons reported these cases under the head of tyj^hus fever , others called them spotted fever. ■
Surgeon Jackson designated them at first as malignant congestive fever, and afterward.s
simply as congestive fever, and his reports indicate that he looked upon them as congestive
intermittents modified by the overcrowded condition of the buildings occupied by his regi-
ment as barracks. The petechial spots, the uncoagulated condition in which the blood was
found in the fatal cases, and the early period at which ■post-mortera putrefaction set in,
strongly favor the view that the disease was cerebro-spinal meningitis; but the absence
during life of the usual brain symptoms of cerebro-spinal fever is opposed to this view. In
many of the fatal_ cases the mind was clear to the last. Moreover the necropsies made by
Surgeon Jackson show that although the cerebral membranes were congested they were
free from deposits of lymph or pus. It might be urged that winter is not the season at
which cases of congestive intermittent fever would be likely to occur ; but the statistics of
the war show that as a matter of fact congestive intermittents did occur at all seasons of
the year, and in Jackson's own regiment as well as in other regiments in the vicinit}^ cases
of ordinary intermittent fever were occurring side by side with the pernicious cases under
discussion ; as indeed ordinary intermittents were occurring during the same months in all
parts of our armies. The dangerous hiemorrhagic fever smce prevalent in the South is of
frequent occurrence during the winter months. The cases observed by Dr. J. D. Osborn,
which formed the basis of his paper calling attention to the hsemorrhagic form, occurred
between' the months of September and April. Again, the mortality of the Annapolis cases
does not correspond with the usual mortality of cerebro-spinal meningitis. The monthly
sick reports of the lltli Pa. Vols, show that during January, 1862, there were 7 cases and
3 deaths in the regiment; during February 17 cases and 1 death; during March 2 cases and
no deaths : in all 26 cases and 4 deaths. During the same period there were 13 cases of
quotidian intermittent fever and 11 of remittent fever, one of the latter fatal. Surgeon
Jackson attributed the small number of deaths among his petechial cases after January
not merely to the improved hygienic condition of the regiment, but to the fact that he had
recognized the malarial character of the disease and resorted to the appropriate treatment.
occurring after snake-bites, in that observed constantly in yellow fever, quite often in recurrent (relapsing') fever, septiciemia and puerjieral fever, and
more rarely in otlier infectious diseases, and acute diseases accompanied by severe fever." Commenting on this extract Professor JOYNES i-emarks : ** The
destructive action of the malarial poison upon the blood-discs is so well proved that none will question it ; and if we admit that under such intense and
concentrated action of the morbific agent as that which induces an attack of hjemorrhagic malarial fever, this destructive effect is unusually rapid and
extensive, the applicability of the above view to the icterus occurring in this disease becomes at once ob^-ious. and the relationship between that symptom
and tlie liajioaturia receives important elucidation.' Recent researches have cleared away much of the difficulties that surrounded this subject. Thus,
POXKir — Hiemoglohinttria — Berlin Klin. Wochf:n.. 18^3, No. 26 — sustains by further experimental evidence the view that the destruction of the red cor-
puscles within the vessels is the essential element of the process. Having introduced blood dissolved by freezing into the veins of an aniuial, he found
that the remains of the destroyed corpuscles were taken up by the spleen while the coloring matter was renmved by the liver: but when there was an
excess of haemoglobine the kidneys participated in the excretion. When the blood has been so deteriorated that the action of these organs is insufficient
to remove the detritus the patient becomes jaundiced by the metamorphosis of hasmogiobine into bilirubin within the current of the circulation.
The treatment adopted for the disease is based upon the recognition of its malarial causation. Quinine is given in free and repeated doses, by the
stomach, if the gastric irritation can be allayed sufficiently for its introduction in this way, or failing this, by the rectum or hypodermic injection. Many
practitioners consider an evacuant dose of calomel of advantage preparatory to the administration of quinine. NOKCOM allays the vomiting by the hyjK)-
dermic injection of morphine, and refers to the fears entertained by many lest the opium lead to suppression and unemic convulsions, mentioning some
cases where unemic symptoms, which had already appeared, yielded after the exhibition of the morphine. Beresgek-FkraVD also appn>ves of the use
of opiates. Medication is seldom addressed specially to the haemorrhage. But some writers have objected to the generally accepted methods. 'J'hus
MclJANiEL urges as the first care of the practitioner in these cases the control of the hsemorrhage from the kidneys by the restoration of cutaneous action,
whieh he endeavors to effect by the application of hut air and vapor-baths. Sac. or by alternating these with cold affusions as stimulants to the genei-a!
surface. He is doubtful as to the benefit to be derived fnun quinine, and instances the aggnivation or recurrence of the haeniaturia under its influence.
Other pinctitioncrs have also claimed that quinine was injurious. MalOSE, in the Missisippi Valley Med. Monthly, Vol. I (IS^l), p. (52, while he does
not l>elieve that quinine will produce the disease, thinks that he has otten seen it precipitate an attack in those predisp<)sed. He regards the fever as due
to the presence of a micro-organism, and claims great success for the hyposulphite of soda in thirty-grain doses with one fluid drachm of extract of buchu
given every three hours.
MALARIAL DLSEASE. 129
III. — Chkonio j\lAi.AiaAL roisONiNG. — Those soldiers who had been long exposed to
malarial influences frequently became the subjects of a peculiar form of cachexia known as
chronic malarial poisoning or malarial cachexia. It was generally observed in men who
had already suffered from acute attacks of malarial disease, but it appeared also as a primary
affection in those who had never been attacked by fever.* This chronic disorder was essen-
tially an ana?mia accompanied by more or less of hepatic disorder and enlargement of the
spleen. The complexion was early modified, acquii-ing a peculiar yellowish pallor, which
was usually unaccompanied by any icteroid tinge of the conjunctiva. The skin became
diy and harsh, the lips livid and the tongue large, flabby, pale or of a faintly bluish tint,
indented on the sides, and generally fissured on the dorsum, which was thinly covered with
a whitish or yellowish coat. The patient lost his appetite and suffered from pains and aches
in the bones and muscles, and frequently from neuralgia. In some, muscular debility was
a.ssociated with tremors, which prevented the individual from assuming the erect position.
Choreic movements and paralysis agitans are also referred to as having occurred. The
patient became dull in mind, depressed in spirit, homesiek, indisposed to undertake any
work involving even slight exertion and unable to carry it out from physical disability.
The heart appeared to be early influenced by the debility affecting the muscular system;
pi'obably many cases of sudden death were due to heart-failure.f At first the bowels were
constipated, but generally, on account of the conditions of camp life, diarrhoea supervened
and became very intractable.
That a notable alteration in the quulitv of the blood was one of the first results of
malarial poisoning, was manifested by the anajraic appearance of the patients. This blood-
change was intimately connected witli the generally accompanying enlargement of the
spleen; but the enlargement was not in all cases proportioned to the cachectic condition.
In most instances the increase in liulk of the spleen could be detected by careful physical
exploration, and in some it was very marked. Disorder of the liver and kidneys could
also generally be discovereil in these cases. In many, oedema of the feet and legs, and even
ascites, appeared, due to. organic changes in the viscera in some instances, but in others, in
which no organic lesions could be discovered, the serous transudation must be attributed to
the altered condition of the blood and the weakness of the circulation.
IV._POST-MORTEM RECORDS AND PATHOLOGY OF MALARIAL DISEASE.
I. — Post-mortem Records. — A full history of the attack is seldom given in these cases,
but ante-mortem notes, when taken, were of the same general character as those already
submitted in the clinical records. The tongue was coated or furred, dry during the fever,
moist at other times, occasionally brown in color. Diarrhoea was a prominent symptom,
but sometimes constipation was present, with anorexia, thirst, vomiting, jaundice and
* Sir JO.«F.ril Fayuer in his Tropical Diseases, London, 18,91. p. 2ih!, says : *" Malarious enlargement of the spleen, and the attendant or consofiurnt
corhexin, nre frequently, but by no means constantly, the result of repeated reeiirrences of malarious jieritidic or remittent fever in those UmK exiciseil to
nurh influences : and when the patient has previously suffered from ague it is to be exjtected that whilst the spleiil remuiTls affecird, sn tang will the person
be liable to rerurrenre of paroxysms of fever. These. lu>\vever, are not by any means the most serious or obstinate cases of splenic cachexia : on the
contrary, they are often more tractable and amenable to remedial measures than others apparently of a less formidable though more chronic nature,
which not infrefiuenlly i«resent themselves in a marked form where no fever has previously occurred."
t Surgeon To\vi,E. of the UOth Massachusetts, in his paper cited sujjra, p. 119, says: "In August, 1862, a patient convalescing in my regimental
hospital fr.im malarial fever, who had recovered sufficiently to walk out of doors, by a mistaken order of his commanding officer, was stripped and
waslKHl with water brought from the river. In the midst of the washing he fell hack. gns|>ed feebly a few times, and before I readied him, though near
by. he was dead." l»r. TOWLE regarded the fatal consequences as due to the inability of the enfeebled and enervated heart to overcome the che<-k
received by the circulation,
Med. Hist., Pt. Ill— 17
130 POST-MORTEM RECORDS AND
abdominal pain. The pulse was frequent, ultimately becoming imperceptible. There were
pains in the head, back and limbs. Delirium, cough, dyspnoea, hiccough, profuse sweats,
involuntary discharges and coma led to the fatal result in remittent cases. Convulsions
were occasionally regarded as the manifestation of a cerebro-spinal engorgement due to th>'
malarial poison. The symptoms in some cases are of interest as suggesting the ante-morte-m
formation of heart-clot.
The autopsies in tlie nine cases, recorded below, of death from intermittent fever, show
that the fatal result depended on 'congestion of certain of the internal organs, the hypei'semia
in some instances leading to the formation of inflammatory products. No one organ ap}:)ears to
have been specially liable to injury by the malarial influence ; for in one or more of these cases
the brain, lungs, heart, stomach, intestines, liver, spleen and kidneys are reported healthy,
while in others they were found in an abnormal condition, to which the symptoms observed
during life may with propriety be referred. In case 53 the force of the disease-poison was
expended on the lungs, causing fatal congestion, and although fever of a paroxysmal typi'
had persisted for some time, and the symptoms had at one time assumed a typhoid charac-
ter, no diseased condition was observed in the intestines; the stomach was normal and
the liver healthy; the brain and spleen were not examined. As there is no clinical record
in 54, the post-mortem appearances must be taken in connection with the diagnosis of int(-r-
mittent fever. The stomach and intestines were healthy, as were the lungs, but the
heart, liver and especially the spleen were markedly altered. The recurrence of aggravated
paroxysms in 55 caused the patient to fall into an adynamic condition marked by sordes,
imperceptible pulse, profuse perspirations, hiccough, stertor, insensible pupils and involun-
tary passages; and these symptoms were associated with congestion of the brain and left
lung, pericardial adhesions, notable alteration in the liver and spleen and patches of con-
gestion in the ileum. In 56, which presented diarrhoea, vomiting and jaundice, the small
intestine was of a purple color, the stomach ecchymosed, the liver altered in color and
the lungs congested in their posterior portions; but the brain, heart and spleen were normal.
In 57, after the suppression of the paroxysms, the patient instead of recovering his usual
liealth became morose, apathetic and ultimately comatose, while affected with cough and
diarrlioea, symptoms which might be considered obscurely suggestive of typhoid fever or of
that fever as masked by the presence of the malarial cachexia. ' But the autopsy revealed
such indications of repeated congestion of the brain as might be conceived to account for
the cerebral symptoms, while the intestines presented no other lesion than patches of con-
gestion in the ileum and of black pigment in the sigmoid flexure; broncho-pneumonia and
nutmeg liver were present, yet the spleen was normal. A special interest attaches to this
case, as the manuscript bears, in Dr. Woodward's hand-writing, the words "Typho-malarial
fever. JVote.'' — as indicating that it was intended to occupy a prominent place in the
expression of his views regarding this fever. It seems evident, however, by a reference to
the time which elapsed between the suppression of the paroxysms and the date of death, that
there was no specific typhoid element in the case, else the agminated glands would liave
been found extensively ulcerated. Case 58 is from the clinical stand-point an undoubted
typho-malarial fever, if such a fever is susceptible of diagnosis. A continued adynamic
fever persisted after the suppression of the chills, but the intestines were not altered from
the healthy condition. In 59 the necropsical record indicates that the force of the disease
was exj)ended on the lining membrane of the intestinal canal. In 6U tliere was latent
tATHOLOCY OF MALARIAL DISEASK. 131
pneumonia, witli licart-clot and affection of the liver, spleen and kidney8; and in 61 a
coincidence of tubercular disease and malarial manifestations.
Cask "iS. — Private Thdiiias W. Paikcr, Co. K, 'Sd M<L Cav., was admittfil fruiu Prince street pritsou October 1(1,
18(>4. The patient stateil that he hail snlVoreil for some time from reguhir j)aro.\ysm8 of a<i;iie. Mia comlition on
ailniission indicated great nervous depression. Quinine and whiskey were prescril>ed, and the bowels moved liv
comiionnd cathartic |)ills. Six days later the fever assumed a typhoid tyi>e, but this was speedily followed by an
imi)rovenieut, the tongue becoming moist and clean, the pulse 85 and the skin natural. On the 21st, after harin;;
been unusually comfortable and even lively during the morning, he conii)lained in the afternoon of dyspnica, for
which counter-irritants were applied, and as there was some cough, an expectorant mixture was given. At 5 P. M.,
after eating a good meal of bread and milk, he was suddenly seized with intense dyspnoea ; in the course of half an
liour convulsions set in, and he died shortly after. Stimulants, friction of the extremities, etc., were tried without
etl'eet. roit-mortim examination eighteen hours after death: I5otli lungs were much congested tliroughout, with the
exce]itioii of a small portion of the anterior border of each; they contained no tubercles, nor was any other lesion
oliserved in them. Nothing abnormal could be detected in the stomach or intestines. The liver was healthy. The
;)ther organs were not examined. — Tliinl Dirhion Ilospitul, Jltxundria, I'd.
Case 54. — Private Patrick Hradley, 17th Ind. liat"y; age 25; was admitted Octolier 11, 18(i2, with intermittent
fever, and dieil November 9. Post-mortem examination : There were pleuritic adhesiiuis <hi the left side; the pericar-
dium contained four ounces of serum; the heart was enlarged and fatty. The stomach was normal ; the liver greatly
enlarged and congested; the gall-bladder distended and ulcerated near its duct : the si)leen much enlarged, softened
anil inhltrated with pus in its ujiper i>art. The circular libies of the colon were strongly contracted in its entire
length. — //. Pient, Ass't Siiiy., lHOth X. Y., Strwurt's .Mansion, Baltimore, Md.
Ca.se .55. — Private .John McVea, Co. 1!, 10th U. S. Inf ; age 32; was admitted October 20, 18ti5, having been sick
live weeks, first with diarrha-a for two weeks and afterwards with cliills and fever. He had a diill daily at S.'.U) i'. M.,
for which live grains of c|uinine were ordered at H, 10, 12 and 2 o'clock. IJuring the paroxysms the patient's intellect
was clouded and his replies delayed; he fainted on sitting up; passed his urine involuntarily; had pain in the head,
back and limbs ; the heart's action was tumultuous : the pulse too rapid to count, and most frequent at the connnence-
ment of the sweating. Some roughness of the heart-sounds were observed. The tongue was coated, dry during
fever, moist at other times; the bowels were open. On the 22d the quinine was repeated, but the chill and fever
recurred in a nuire aggravated form. The patient was very weak ; had sordes on his teeth ; pulse scarcely ])erceptible
at the wrist: urination involuntary. Whiskey was given and mustard a|)plied to the epigastrium. Next day he had
hiccough, stertor, profuse sweats, vomiting of snuiil blood-clots, dysijhagia, insensible pupils and involuntary passages;
crepitation was heard over the lower part of the left side of the chest. Me died at 2.30 i>. .M. Poxl-mortem exami-
nation twenty hours after death: Right arm Hexed and rigid; left arm llaccid. There was a quantity of serum in the
ve;itricles of the brain ; the brain-substance was of a darker ash color than usual, and sections jiresented many points
of black engorged vessels. The right lung was healthy; the lower lobe of the left lung much congested, nearly
hepatized. The pericardium contained three ounces and ii third of light-pink serum; the ape.x of the heart adhered
to the pericardium by a lymph-patch the size of a shelled ahnoud; the right ventricle of the heart was unusually
llaccid, the mitral valve thickened and of a dull yellow color. The omentum was thin and dark lead color. 'The
liver weighed eighty-five ounces; it was of a dull slate color. 'The spleen was pulpy, weighed twenty ounces and
a half. Some patches of congestion were observed in the ileum. The kidneys were large but healthy. — Dougtas
HoKpilul, Jf'ashiixjton. D. C.
Case 56. — Private Leonard liennett, Co. I), 199th Pa. Vols., was admitted .June 30, 18()5, suff'ering from inter-
mittent fever. There was great emaciation with a yellow tinge of the conjuctiva and skin, anorexia, occasional
vomiting, live or six loose passages daily and restlessness; the tongue was moist and slightly furred ; pul.se 70 and
feeble. He died August 15. Post-mnrleni examination twenty-four hours after death: Body emaciated and rigid.
Hrain normal. Lungs intensely congested in their posterior portions. Heart normal. Liver of light color superlicially,
blackened anteriorly and below : bile yellow and granular. Spleen firm and of normal size ; ))ancreas normal. Stom-
ach presenting blood-spots in its mucous membrane. Small intestines generally discolored and very offensive; jeju-
num black or dark purple; ileum cherry-colored in its upper part, darker below. Kidneys large. — Aag't Surg. George
.M. MeGill, U. S. A., Hiek'x Hospital, liallimore. Md.
Case .57. — Private James Hight,Co. D, 23d Ohio Vols.; age 23; was admit ted .January 18, 18)i5, with tertian inter-
mittent fever. He had chills at irregular intervals succeeded by ])rofuse sweating; his intellect was unnaturally dull :
he would not eat nor try to help himself though he ap|)eareil strong; he had no pain : pulse regular and compressible.
The chills yielded readily to iininine, but he remained without appetite or energy. After the first week he de-
clined gradually, becoming morose in disposition and absent-minded, and art'ected with cough and diarrhipa. On
Kebrnary 20 he was reported as emaciated and imbecile; he had no diarduea but passed his stools in bed. On March 1
he rallied so as to answer simple questions correctly; but he had dyspntea, much expectoration and extensive crc))-
itus in both lungs. Ou the .5th he became half comatose with quick short breathing, and died on the evening of
that day. Post-mortem examination thirteen hours after death: Much emaciation: blister mark on back of neck.
There was eft'usion under the cerebral membranes, which were not injected but pale; the arachnoid at the foramen
of Bicliat was thick, opacpie and white; the ventricles were distended with serum: there was a cream-colored spot
of softening, apparently covered by serous membrane, on the ventricular wall fornu'd by the right cori>us striatum;
the middle commissure was re.mark;iblv firm, as it stretched out to nearlvan inch in length and so renuiineil without
132 POST-MORTEM RKCORDS AKD
breaking across; the substance of the cerebrum was hard, that of the cerebellum and cord soft. The anterior medi-
astinum was emphysematous. The bronchi in the right lung and in the lower lobe of the left lung, especially beliiud
and below, were dilated, of a dark purple color and filled with a pus-like fluid, while the luug-tissue around theni
was here and there dark and solid, the affected lobes as seen from the surface being sunken and of a dark lead color.
The heart contained a fibrinous clot. The liver was large and finely marked with nutmeg foliations: the spleen nor-
mal. There were patches of reddening along the ileum, and pigment patches in the sigmoid flexure. — Third Divli<i<}ii
Hospital, Alviandria, Va.
Case 58. — Horace Hill, a robust muscular man, age 25 years; colored; was admitted November 7, 1865, witli
quotidian intermittent fever; tongue yellow-coated ; appetite poor; pulse during the intervals of the paroxysm 84, full
and of good strength ; bowels quite regular ; urine scanty and of high color ; no ditficuUy of breathing ; no cedema of the
feet and legs. After treatment for two days the chills left the patient, but a febrile pulse remained; two days later
sordes appeared on the teeth and lips, and the tongue became exceedingly dry ; mental torpor and slight delirium
were manifested. There was fulness and slight tenderness on pressure in the right hypochondrium and greater pre-
cordial duluess than natural. Moderate vomiting took place about noon of the 13th, and in a few minutes the
patient suddenly and unexpectedly died. Post-mortem examination sixteen hours after death: The riglit ventricle
of the heart much dilated; spleen greatly enlarged and softened; liver much enlarged; kidneys fatty; other organs
normal. — Surgeon Edwin Bentley, U. S. Vols., V Ourerture Hospital. Alexandria, Va.
Ca.se 59. — Private W. P. Jones, Co. M, 3d IT. S. Art'y, was admitted September 5, 1863, and died on the lOtli,
of intermittent fever. Post-mortem examination twenty-four hours after death: Both lungs were congested and
adherent. The heart was hypertrophied and coated on its exterior with a thick layer of adipose tissue. The liver
was slightly enlarged, its concave surface congested and of a dark bluish color, which extended about one-eighth
of an inch into the substance of the organ. The spleen was congested and dark colored. The intestinal canal con-
tained a black mixture of coagulated blood and mucus; its mucous membrane was deeply congested and almost
black. — Act. Ass't Siiry. J. A. Murphy, West End Hospital, Cincinnati, Ohio.
Case 60. — Quartermaster-Sergeant William L. Billman, Co. H, 3d Pa. Art'y ; age 38; was admitted January 22,
1864, with intermittent fever and died March 7. He was able to walk about up to the evening of his death; he was
present at inspection, undressed himself and went to bed apparently feeling well. Post-mortem examination
twenty-fonr hours after death: Both lungs were in the third stage of pnuemonia; there were adhesions on both
sides and three ounces of liquid in the left pleural sac. The pericardium contained four ounces of liquid. Tlie
aortic valves were thickened; on one of them was a considerable quantity of adherent fibrin; the left side of the heart
contained coagula of fibrin. The liver was hypertrophied; the spleen large and soft; the left kidney much larger
than the right, and the pelves of both kidneys contained pus. [No. 336. Medical Section, Army Medical Museum, is
the heart from this case.] — Act. Ass't Sury.B. B. Miles, TJ. S. A., Jarvis Hospital, Baltimore, Md.
Case 61. — Private William T. (irift'ey, Co. G, 1st Conn. Cav.; age 23: was admitted January 12, 1864, with
intermittent fever. He died April 7. Post-mortem examination: The right lung was tuberwilous. The left pleural
sac and the pericardium contained efi'used sernra. The liver was enlarged and tubercles were diffused througli its
substance ; it weighed four pounds ten ounces. The spleen was soft and friable ; it weighed sixteen ounces. — Act.
Ass't Surg. B. B. Miles, U. S. A., Jarvis Hospital, Baltimore, Md.
In the next case the intermissions disappeared and the patient became affected with
remittent fever ; yet the post-mo7- fern appearances did not differ from those ah'eady described.
The stomach, lungs and kidneys had suffered, but the otlier thoracic and abdominal organs
were not perceptibly altered.
Ca.se 62. — Private Henry Morton, Co. E, 56th Mass. Vols, (colored); age 30; was admitted December 16, 1864.
from field hospital, with intermittent fever. Tlie paroxysms were checked by quinine, and the patient was soon able
to walk about. About Decemlier 31 he had an attack of diarrhcca, which wa.s readily controlled by astringents. A
few days later his ague recurred, and persisted in spite of the administration of quinia. The disease assumed the
pernicious form, the remissions being but slight; the respiration became hurried, and delirium setting in, he died
January 9, 1865. Post-mortem examination: The left lung was congested. The mucous membrane of the stomach
was of a dark yellow color and much softened. The kidneys were congested. No other abnormal appearances were
observed. The brain was not examined. — Act. Ass't Sury. F. Stoddard, L'Ouvertnre Hospital, Alexandria, Va.
The twelve cases Avhich follow are illustrations of remittent fever. In 63, the diag-
nosis, originally quotidian intermittent, was changed in the progress of the case to typhoid
fever; but there was no diarrhoea during life, and no intestinal lesion was discovered at the
necropsy; delirium was present, and there was an effusion of jaundiced serum in the ven-
tricles and under the membranes of the brain. Delirium is mentioned as having been
present in one other case, but in it the brain was not examined. The lungs were congested
in two cases, 63 and 72, tubercular and splenified in one case, 69, and hepatized and infil-
trated with pus in a fourth case, 73; in four cases they were unaffected; in one they were
PATllOI.OGY OF MALARIAL DISEASK. loo
not examined, and in tliree their condition is not stated. Tlie heart does not appear to
have been subject to notable alteration ; it is reported as normal in six cases and in the
others its condition is not stated. The stomach contained a n\iiddy-green liquid in two
instances, 69 and 70. In all the cases except 63 the intestines were more or less affected.
In two. 68 and 74, both tiie large and small intestines are said to have participated in the
morbid action; in five, 64, 65, 67, 70 and 72, in which the intestines are stated to have
been congested, inflamed or ulcerated, it is probable that the large and the small intestine
were both intended to be included in the statement, for in 71 the inference that the large
intestine was affected is fully warrantdl by the phraseology — "the intestines wore ulcerated,
the ulcers in the small intestine being of large size." In 70 the mucous membrane of the
intestine was in part almost gangrenous, the duodenum ulcerated and the peritoneum
intlaiiu'd ; in 73 the intestines were congested and the ileum extensively inHamcd; in 66
the small intestine presented signs of inflammation, but the condition of the large intestine
is not recorded ; in but one, 69, of the twelve cases is it definitely stated that although the
small intestine was congested the large intestine was in its normal condition; in none was
there any affection of Peyer's glands, but the solitary follicles near the ileo-csecal valve
were prominent in one instance, the case last mentioned.
The liver is reported as normal in two cases; in a third case nothing is stated regard-
ing its condition; in nine cases it is variously described as large, fatty, pale, fawn-colored,
bronzed, soft, congested, etc.
The condition of the spleen was normal or not stated in six cases; it was enlarged,
soft or dark coloi-ed in live cases, and contained u purulent collection in one case, 74.
CvSE 6.S. — Sei>;e:iiit Owi-n C'los.siiuiu, t'o. H, 2Stli Mich. \'oIs.; age 4."); was ailiiiitteil Kilnuary ">, 186.5. Diag-
nosis— iiuotiiliaii intt'iiiutti'iit fever, eliauged (in the Sth to typhoid fever, lie hail suffered from chills every night
for two we-eks, hut had none after his admission. He was much emaciated and depressed in mind; had a slight dry
cough lint with easy and natural hreathing; tiucasy fellings in the up))er part of the abdonutn; darting pains in the
alidonien and thorax: anorexia: thirst ; his skin was dry lint covered at times with a clammy sweat; bowels regular.
On the 14th he had profu.se jierspiration, delirium and involuntary pass;iges. He died next day. Pont-morti-m examina-
tion twenty-two hours after death: Skin jaundiced. Much ert'usion under arachnoid at vertex; lirain-suhstance quite
liard, most of the vessels having yellow spaces hetween tracks of black lluiil Idood: lateral ventricles full of liquid;
elioroid plexus sliowing bulbs of yellow liquid about the size of peas along its posterior lower edge; locus niger very
dark and broad. A little high-colored liut clear serum in the pericardium; small yellow fibrinous clots in the
heart. Kight lung so congested posteriorly by hypostasis as to sink in water, soft, gray-colored and adherent to
walls of chest by many white bands; left lung dark but crepitant posteriorly, iirnily adherent. Liver pale and
fatty: gall-bladder the size of a butternut: s])leen very large and soft, ana-mic: kidneys pale. — Third Division Hospi-
liii, AUxanilrid . I'li.
Cask 04.— I'rivate .lohn (jav:illfnce icommand not stated): age 27; was admitted .July 8, 186.S, from Alexandria
jail, having been sick six weeks with bilious remittent fever. From his delirious mutterings he was suppo.sed to be
a rebel deserter. He did not rally sufficiently to converse rationally, but died on the 12th. J'ust-mortcm examination
ten hours after death: Liver and spleen sonuwhat enlarged; lirunner's glands enlarged; mucous coat of intestines
extensively inflamed, but with no ulceration. — .Id. .I.wl Siiri/. .1. I'. ('ritfl.H. Third Dirixion lloHintal, Alexandria, la.
Case 65. — Marcellas F. Dixon, citizen of Missouri ; age about 20; was .admitted December 6, 1864, with remit-
tent fever. He' afterwards had erysipelas, and on recovery from this was attacked with diarrha'a and laryngitis.
He died .January 28, 186.5. Past-morUm examination four hours after death: There was a tough frothy mucus in the
tradiea and bronchi; the larynx did not exhibit definite signs of inflannnation. The pericardium contained effused
serum. The right lung was adherent. The bowels were congested but not ulcerated: I lie mesenteric glands were
enlarged.— Jt^ Anx't Siirij. J. B. Vuuikj, l'. S. ./., Hock- Island Honpital, III.
C.v.sK 6ti. — .Sergeant Charles M. Gould, Co. M, 3d Va. Cav.; age 20; was admitted June o, 186:j, with remittent
fever. (Quinine was administered with apparent success, but during convalescence the patient being imprudent in
his diet, was attacked with diarrhoea, and died .June 22. roHt-mortem examination six hours after death: The liver
was fawn-colored. The spleen was soft and measured eight inches by five. The small intestine contained some
undigested food and its mucous memlirane was slightly inflamed. — Tliird Dirinion Ftmpilal, Alexandria, Va.
C.\SK 67. — Private William Cornog, Co. .\, .">lst I'a. Vols.; age 34 ; was admitted August 7, 186J, with remittent
fever. He was very ill when admitted, and for three days liefore death, on the 18th, suffered constantly from sin-
134 POPT-MORTKM RECOUPS AND
gultus. Post-mortem examination : The lungs and heart were normal. The thoracic cavity contained four ounces of
serum and the abdominal cavity fonr ounces and a halt'. The liver, spleen and pancreas were normal. The kid-
neys were large and white, weighing six ounces and a half each. The intestinal mucous membrane was slightly
ulcerated. — McDougall Hospital, Fort Schuyler, JS'. T. Hurhor.
Case 68. — Private L. D. Johnson, 2d Ohio Battery, was admitted Jlay 10, lS(i3, with remittent fever, havin;;
been sick since March. HediedMayl4. PosZ-nioWcm examination: Thoracic viscera normal. Liver large. Kidneys
large, soft and fatty, weighing seventeen ounces. Mucous membrane of small intestine thickened and softened:
large intestine congested. — Citij HrmjtitnJ, St. Louis, Mo.
Case 69. — Private John Ingraham, Co. C, 17tli.U. S. Inf'y : age 23; was admitted November 23, 1863, witli
remittent fever. He died November 26. Post-mortem examination: Body not much emaciated: rigor mortis well
marked. There was some venous congestion in the membranes of the brain. The right lung weighed thirty-three
ounces; its upper lobe contained tubercles, some of which were cretefied. and 1>eneath these a cavity the size of
a horse-chestnut ; the middle lobe was healthy ; the lower lobe splenified. The left lung weighed twenty-four
ounces; it was firmly bound to the thoracic parietes by old adhesions, which also obliterated the division of the
lobes; the posterior portion of its lower lobe was splenified and contained some tubercular deposits. The bronchial
glands were large and black. The right auricle of the heart was greatly distended by fluid blood; there were no
clots in any of the cavities. The liver was bronzed and weighed fifty-two ounces; the gall-bladder contained
twenty-five drachms of bile. The spleen was firm and of a dark mahogany color. The pancreas was <[Uite white
but not very firm; it weighed three ounces. The kidneys were very much congested. The stomach was enormously
distended with a muddy-green liquid. The mucous memlirane of the small intestine was congested throughout and
intensely purple; the valvuhe conniventes were prominent; Peyer's patches were not elevated; the solitary follicles
near the ileo-ciecal valve were conspicuous, their summits being of a deeper purple than the adjacent mucous mem-
brane. The large intestine was normal. — Jss't Surg. Harrison Allen, U.S. J., Lincoln Hosjntal, Washington, L). C.
Case 70. — Private Elias Henderson, Co. A, 10th East Tenn. Cav.; age 46; was admitted September 11, 1863,
having been sick in camp five days. His skin was yellow, uriue high-colored, bowels moved slightly three to five
times per day, abdomen somewhat tender, especially in the right hypochondriac region ; pulse 80 and weak. He
was much prostrated, vomited very frequently, and ejected food alnmst as soon as taken. Hiccough came on next
day and continued with jaundice, vomiting, abdominal pain and increasing prostration until death occurred on the
20th. Post-mortem examination ten hours after death: The heart and lungs were not examined. The stomach con-
tained about six ounces of dark grumous liquid, and was highly injected near the pylorus; four inches below the
l)ylorus an ulcer three lines in diameter penetrated the coats of the intestine, which contained in this locality about
an ounce of sanious pus. The mucous membrane of the intestinal canal was inflamed and in some parts almost
gangrenous. There was some peritonitis, evidently recent. The pancreas was enlarged an<l scirrhous; the spleen
softened; the liver somewhat enlarged and its peritoneal coat inflamed : the gall-bladder filled with dark inspissated
bile; the kidneys normal. — Hospital No. 2, Nashville, Tenn.
Case 71. — Prii-ate Dallas Sechler, Co. H, 92d 111. ^'ols.; age 20; was admitted September 8, 1864, with remit-
tent fever, and died on the 14th. Post-mortem examination on day of death : Lungs and heart normal ; liver congested
and softened; spleen eighteen ounces; kidneys normal ; intestines ulcerated, the iilcers in the small intestine being
of large size. — Field Hospital, Chattanooga, Tenn.
Case 72. — Private Francis Felton, Co. M, Stth Ohio Vols.; age 27; was admitted .August 27, 1864, with remit-
tent fever, and died September 23. Post-mortem examination on day of death: Lungs somewhat congested; heart,
spleen and kidneys normal ; liver pale and soft ; mucous membrane of intestines congested, softened and showing
many ulcers, large and small. — Field Hospital, Chattanooga, Tenn.
Case 73. — Private Orrin P. Tracy, Co. H. 3d Pa. Art'y : age 29; was admitted March 25, 1864, with remittent
fever, and died April 8. Post-mortem examination : Extensive pleural adhesions on both sides ; right lung infiltrated
with pus; upper lobe of left lung hepatized; three ounces of eft'usion in pericardium; liver four pounds ten ounces
and a half; left kidney ten ounces and a half, right seven ounces and a half, all normal in appearance. Intestines
much congested and presenting extensive marks of inflammation in the ileum. No ulceration of Peyer's patches. —
Act. Ass't Surg. B. B. ililes, U.S.A., Jarris Hospital, Baltimore, ild.
Case 74. — Private H. H. Wade, Co. A, 18th Mass. Vols., was admitted August 7, 1862, in a dying condition,
probably from malarial fever. Death occurred next day. i*osi-nior(cni examination : Body much emaciated. The
heart and lungs were healthy. The liver was sound. The spleen was moderately enlarged and its substance
natural in appearance except that a part of the organ was reduced to a thin sanious puruloid li<|uid forming an
abscess about as large as a goose's egg. This abscess was in contact with the diaphragm, the left extremity of the
stomach and the edge of the left lobe of the liver, and was separated from the peritoneal cavity by adhesion of the
spleen to the parts mentioned. The stomach was exceedingly contracted Imt healthy. The mucous membrane of the
ileum and colon was inflamed, but the agminated glands were natural. — Act. Ass't Surg. J. Leidy, Satterlce Hospital,
Philadelphia , Pa.
In tlie six cases, 75-8C), the fever became complicated with dysentery, pneumonia,
pericarditis or peritonitis. The brain was liealthy in the only case in which it wa.s
examined. The heart was natural in two cases and unnoted in the others. In three the
mucous membrane of the intestines was congested or ulcerated; in one the duodenum and
PATHOLOGY OF MALARIAL PISEASK. lo")
pancreas were ulcerated. The stomach contahied a mud-like liquid in two cases, 75 and
79, and its mucous membrane was thickened and slate-colored in one case, 80. The spleen
was normal in one, unnoted in three, and enlarged in two cases. The liver was affected in
three cases and unnoted in the others.
Ca.se 75.— Private Asa L. I'atteii, Co. I, MIth Ohio Vols.; as<> 21 ; was admitted F.-liruaiy fi, 18G.'>. Itilious mala-
rial fever, with dysentery. Died February 8. rust-mortem examination six hours after death: liody very mueli
emaeiated. Heart eontaiuing a large fibrinous clot ; liver enlarged ; stomaeh distended with almost lialf a gallon of
a dark grumous liquid; intestines congested and ulcerated; blood watery and degenerated — Jvt. Aaa't Sitry. IV.
Bryan, Stuiiton Hospittil, WaKhington, V. C.
Cask 7(). — Private Michael MeCuskey. Co. F, Oth Ohio Cav.; age 18; was admitted Febniary 22. ISfil, witli
remittent fever, from which he recovered liut remained weak and did not leave his ^>v^\. On Mar<h 2."> pleuro-iineu-
inonia set in. and death occurred on the 30th. I'unt-mortciii examination .seventeen hours after death: The lowi'r lobe
of the left lung was hepatized, exuding a red frothy liquid on section; the lower lobe of the right lung was lie|ia-
tizeil: the riglit lung was covered with unorganized lymph; each pleural ca\ ity contained twenty ounce's of reddish
si'rum. The heart was healthy; the liver presented the nutnu'g ajii)earance; the spleen and kidneys w(U'e large and
congesteil; the mesenteric glands enlarged. — Hospital jVo. 8, NashiiUv, Teitn.
Case 77. — Kecruit Casper Christeuson, G6th N. Y. Vols.; age 40 ; was admitted March 7, 18lil, with remittent
fever, for which quinine and brandy were given, but he did not improve. Two days before his death his left leg and
aukle became enormously swollen aiul painful, and next day the right leg became similarly affected. He died March
18. PosZ-mor/cHi examination forty-eight hovirs after death : There were old i)leuritic adhesions on both sides. The
pericardium contained about two ounces of bloody senim, and there were other evidences of recent pericarditis. .Some
old ulcers were observed in the intestines. — Third lUrisiaii Hospital, .tlixunilrin, Va.
Ca.se 78.— Private Uriah K. McFarlaud. Co. K, 4th Ind. Cav.; age 36; was admitted ,Tuly 24, 1803, with chronic
diarrhoea. He recovered and was doing light duty, when on December 2.')th he was attacked with remittent fever.
He improved after the ti.se of quinine for three days; his a))i)etite returned and he was able to walk about, when, on
.lanuary 5, 18G4, the chill recurred and was followed by fever; bowels somewhat constipated. Three compound
cathartic pills were given at once, and the (luinine was again resorted to in six-grain doses. Next day he had a
burning jmin in the epigastrium, increased by pressure and deep inspiration, incessant nausea and vomiting, a white
furred tongue, feeble pulse, 130, and short and hurried respiration. Morphia and warm fomentations were employed.
On the 7th small and repeated doses of calonKjJ and opium were given, and a blister was apjilied to the epigastrium,
but the vomiting continued, and on the 8th hiccough, restlessness and great anxiety were added to the symptoms.
On the 9th delirium supervened and the extremities became cold. He died next day, the vcuuifing and hiccough
having ceased for some hours before death. 7'().v(-mor(<»i examination eighteen hours after death: The ]ieritoneum
was much thickened: the ouu'Utnm adhered to the intestines and anterior wall of the stomach: the serous coat of
the large and small intestines was disorganized; the coats of the stomach were thickened; the spleen waH twice the
normal size, softened and friable. — Hospital, Madison, Ind.
Case 79. — Private Samuel Clancy, Co. li, 1st K. Y. A'ols. Admitted .July 2li, 18()2. Diagnosis — pernicious
fever. Died August 1st of peritonitis. Shortly before death this man vomited a considerable quantity of a dark
olive-brown, muddy li(iui(l. rost-mortrm examination: The peritoneum was inflamed throughout its whole extent.
Pseudo-membrane was found on the intestines, but they were not agglutinated. The stomach eontaiued about a
pint and a half of the mud-like liquid above mentioned. The mucous membrane presented a small patch of inflam-
mation, but elsewhere appeared neither softened nor otherwise unhealty. The mud-like liquid, examined micro-
scopically, exhibited an abundance of epithelial cells but no distinct appearance of Idood. — Act.Jss't Siiry.J. Leuly,
U. S.A., Sutlcrhe Hospital, I'hiladvlpliia, Pa.
Case 80. — Private Lewis T. Fisher, Co. K, 149th Pa. Vols.; age 20; was admitted March 2(5, IWl. Diagnosis —
remittent fever. Died April 2."). Post-mortem examination nine hours after death : Brain, lungs and heart healthy.
The mucous memlpraue of the stomach was thickened and slate-colored. The intestines were unich congested, and
their serous coat, which was of a slate-blue color, was adherent to the abdominal walls. The upper half of the
duodenum was extensively ulcerated and almost perforated in some places. The liver was much softened in the
neighborhood of the gall-bladder; the spleen firm and healthy; the pancreas somewhat ulcerated along its attached
surface. The left kidney was enlarged and nnjch (congested. — Lincoln Hospital, Washington, D. C.
Typhoid symptoms are spoken of in the two cases which follow, accompanying in the
first case a relapse which was complicated with inflammation of the parotids, and in the
other a pneumonic abscess; but in neither does the post-mortem record indicate the presence
of an affection of the patches of Peyer.
Case 81. — Private Adam Hauser, Co. G, 38th N. Y. Vols.; age 25; was admitted October 14, 1862, with remit-
tent fever, which assumed a typhoid form, with dry tongue, diarrhira and low delirium. During convalescence a
relapse occurred, accompanieil by inflammation and suppuration of the parotid glands. He died Xoveraber21. Post-
mortem e\;tinmatiini eighteeu hours after death: Extreme emaciation. The lungs were healthy. The pericardium
contained about four ounces of serum. Nothing abnormal was noted in the liver; the gall-bladder was tnoderately
136 POST-MORTEM RECORDS AND
filled with bile. The spleen was enlarged and softened. The intestines were distended with flatus ; their peritoneal
coat washighly injected and their raucous coat softened. The kidneys and bladder were healthy. — Third Division
Hospital, Alexandria, Va.
Case 82. — Private Louis Buckmyer, Co. 1, 37th Ohio A^ols., ■was admitted October 24, 1862, with chronic diarrhcea
terminating with symptoms resembling those of typhoid remittent fever. He died November 13. rost-mortcm ex-
amination: Body extremely emaciated. There were pleuritic adhesions on the left side posteriorly, and an abscess of
considerable size in the lower lobe of the right lung. The liver was enlarged. The mucous membrane of the small
intestine was injected, softened and ulcerated. — Third Division Hospital, Alexandria, Fa.
In the next case the patient, during convalescence from an attack of intermittent,
appears to have been taken with true tj'phoicl fever, developing diarrhoea and rose-colored
■ spots at the end of the second week and ending fatally on the sixteenth day. The mucous
membrane of the small intestine was ecchymosed and the agminated glands enlarged but
not ulcerated.
Case 83. — Corporal William T. Reeves, Co. L, 10th Ky. Cav., was admitted April 23, 1863, with intermittent
fever. He had an attack of hiccough which continued for three days with but short intermissions; but he speedily
convalesced under anodynes and quinine, and on May 10 was up and walking about the ward. On the 12th he was
seized with colicky pains, which, on the two following days, became very severe, but were relieved bj- cathartics and
opiates. From the 16th to the 20th he complained of headache and had considerable irregular fever. 13y the 24th
diarrhcea had developed, with tenderness of the bowels and some mental confusion. Next day the tongue became
dry, and on the following day glazed; stupor had set in, and there was tympanites of tho abdomen with gurgling
under pressure and an eruption of rose-colored spots, well marked, over the whole of the body. He died on the 27th
after copious jiersijirations, great prostration and increased stupor. Post-mortem examination twelve hours after death :
The rose-colored spots, which were very numerous on the trunk and also on the limbs, presented a purpuric appear-
ance. The small intestine was mottled with purple, and there were two or three spots which seemed ready to slough ;
Payer's glands were enlarged and inflamed but not ulcerated. The spleen was very large; the liver and the thoracic
viscera healthy. — Act. Ass't Siiry. J. B. Smith, Washington Park Hospital, Cincinnati, Ohio.
In the next case the patient, during the debility consequent on intermittent attacks,
became sick with fever which proved fatal about the seventeenth day, the tongue in the
meantime becoming dry, brown and fissured and the teeth covered with sordes. Peyer's
glands usually become ulcerated at an earlier period of the disease than this ; but, as in the
last case, death on the sixteenth day did not give ulceration of the patches as & post-viortem
lesion although the disease was apparently enteric fever, it is probable that the poison was
present in this case also; and in this connection it may be inquired if the occasional deposits
of tubercle recorded as discovered in the ileum were not typhoid enlargements of the agmi-
nated and solitary glands. In 85 the relapse, which was accompanied with typhoid symp-
toms, may perhaps be regarded as an attack of enteric fever.
C.\SE 84.— Private James Coady, Co. B, 24th Vet. Res. Corps; age 21; was admitted February 2, 1865, with
debility from malarial disease. The patient had a haggard look, but complained of nothing but weakness and
inability to sleep; his tongue was slightly coated with white fur, bowels somewhat loose, pulse !tO, skin natural.
He said he had recently suffered from intermittent fever. Wine-bitters and quinine were given, with Dover's powder
at night. He slept well duriugthe following night, but in the morning he was feverish, his tongue dry and brown
in the centre, his bowels loose, and he complained of jiain in the right iliac region; there was also some cough, with
pain in the right breast and dulness on percussion over the upper third of the right lung. Acetate of ammonia and
brown mixture were given and the quinine continued. During the next few days the typhoid symptoms became
more marked; deafness, fissured tongue and sordes. Milk-punch was ordered. He died on the 19th. Post-mortem
examination: There wiere old pleuritic adhesions on both sides, but particularly on the right. The right lung was
infiltrated with tubercle, some of which was softened, and there was some intercurrent pneumonia; the mucous
membrane of the bronchial tubes was thickened and of a dark-purple color. The liver was large and somewhat
cirrhosed; the spleen dark-brown and soft. There were patches of inflammation and occasioual deposits of tubercle
in the ileum. The mesenteric glands were enlarged. — Third Division Hospital, Alexandria, Va.
Case 85. — Private .John Herman, Co. F, 59tli N. Y., was admitted September 9, 1864, jaundiced; convalescing
from remittent fever. He was up for several days, but a relapse occurred and the disease assumed a typhoid char-
acter. Diarrhcea set in with much fever and tenderness over the abdomen. Death, on October 16, was preceded by
low delirium, involuntary stools and retention of urine. Post-tnortem examination : Lungs healthy ; heart loaded with
fat; liver of proper consistence but abnormally yellowish-brown; intestines injected with blood; Peyer's patches
somewhat diseased but only slightly ulcerated; kidneys congested. — Act. Ass't Surg. Henry (Hbbons, jr., U. S. A.,
Douglas Hospital, Washington, D. C.
PATHOLOGY OK MAI.AKIAI. I'l.-^KAsK. 137
In 86 a reference is made to typhoid symptoms, and tlie necropsy appears to liave been
held witli the intent to discover whether these clinical features were dependent on enteric
fever. The cases 87 to 91 are apparently of a similar character; no mention is made of
typhoid symptoms, but the anatomical lesions in the small intestine differ from those aljove
described as present in malarial fever and agree with those found in S3, in which enteric
fever seems to have seized upon a convalescent from malarial disease. Althougli these
cases appear to indicate that many others giving a record of typhoid svmptoms were prob-
ably of an enteric nature, it may be noted, on the other hand, that, in causes 53, 55, 57, 58,
63, 64, 81 and 82, these symptoms were apparently unconnected with a specific lesion.
Case SG. — Cliarles Lasscll, Co. L, 14th N. Y. Heavy Art'y; age 28; wa.s admitted June 1,">, 18GI, with remittent
fever. On the 20th typhoid symptoms, including diarrhoja, were developed, and he died on the 22d. J'ont-morttm
examination twenty hours after death : Some of IVyer's patches were enlarged and some intlamcd, but none ulcerated.
— Third Dirinion Honjiital. Ak\ruiidrUi, Vii.
C.\SE 87. — Private George Williams, 4th Miili. \'ols.; age 19; was admitted August 111, \XiV2. Ueniittent fever.
Died August 11. rnst-morldii examination next day: The hody was mucli euuuiatod. Tlie thoracic organs were
healthy. The spleen exhibited .a remarkable number of the so-called Slalpighian bodies, which were of uniform size,
white and about the size of yellow mustard-seed. The liver, stomach, kidneys and pancreas were healthy. The
mucous membrane of the intestines was more or less inflamed throughout, the redness being moderate ; the glands
of Peyer and the solitary glands were more than usually prominent. — Act. AsuH Surg. J. Leidy, Satterlec HoHpilal, Philn-
delphia, Pa.
Case 88.— Private Ananias Spangler, Co. K, 204tli Pa. Vols.; age 19; was admitted October 28, 1864, with
remittent fever and died November 9. PoHt-inorlrm examination nineteen hours after death : Rody emaciated; rigor
mortis nuirkcd; suggillation posteriorly; muco-puruleut matter escaping from nostrils; large but superficial abscess
in perinieum. The pharynx anil (esophagus were normal. The larynx and trachea were filled with muco-purulent
matter, but the mucous membrane was healthy. The right luug was adlierent to the thoracic parietes by recent
lymph; its ])Ostenor portions were infiltrated with pus. The left lung, heart and jiericardinm were Iiealthy. The
liver was darker in color than usual, but was otherwise healtliy; the gall-bladilir contained six drachms of bile. The
spleen, pancreas and kidneys were normal, as were also tlie stomach and the greater portion of the small intestine.
The lower part of the ileum presented three or four ulcers wliicli apjieared to be in Peyers patches ; but the patches
were not thickened and the ulcers seemed to be healing. The colon and rectum were normal. — Act. Am't Surg.
Thomas Boucn, Second Dhision IJospUal, Alexandria, Va.
Case 89. — Private Charles Reed, Co. C, 185th N. Y. Vols., was admitted January 17, 1865. Diagnosis — remit-
tent fever. Died on the 21st. Pogt-mortem examination: The right lung weighed thirty-two ounces; its ujiper lobe
was adherent and hepatized; the left lung weighed twenty-five ounces and had a slight tubercular deposit near its
apex. The heart weighed ten ounces and was healthy; the liver seventy-six ounces, pale; the spleen twenty-four
ounces, soft; the stomach was injected in spots and had one ulcer on its posterior wall; the duodenum and jejuiiuin
were healthy; the ileum thickened; Peyer's patches and the solitary follicles enlarged and thickened; the solitary
follicles of the colon enlarged and infiltrated; the mesenteric glands much enlarged; the kidneys normal, each
weighing six ounces.— ;.lct. Asu't Surg. If. I.oeurnihal, U. S. Voh., Fifth Armtj Corpn Field Hnspitul, Army of Potomac.
Case 90.— Private Perley J. Blodget, Co. H, 5th Wis. Vols.; ago 21 ; was admitted October 17, 18G4. Diagnosis-
remittent fever. Died Xoveniber 1. Post-mortem examination forty-eight hours after death: Eight ounces of serum
in right and two ounces in left pleural sac, one ounce in pericardium and a pint in the abdominal cavity. Spleen
soft, dark, weighing about two pounds; liver and kidneys normal; Peyer's patches in the lower ileum, and the
solitary follicles in the ca-cum and u])per colon much thickened :ind ulcerated; mucous nicmbraue of colon intlamcd.
— .Second Dirixion Hnspital, Alexandria, 1'u.
Case 91.— Private Peter Blair, Co. I. 125th Ohio Vols.: age 21 : was admitted November 17, 18t;3. Intermittent
fever. Died December 9. Poxt-morlem examination eighteen hours after de;itli: Slight emaciation. Lungs healthy;
heart nine ounces, valves slightly thickened; liver fifty-iiine ounces, healthy; gall-bladder large and distended
with bile: spleen fourteen ounces; kidneys seven ounces each, normal; stomach healthy; Peyer's patches much
thickened, some ulcerated : large intestine presenting a few superficial ulcers. — Hospital Xo. 1, Xashville, Tcnn.
The tive cases wliich follow come under tlie heading of congestive chills. In 92 the
patient died comatose from cerebral congestion; but the liver, spleen and lungs were also
affected and the blood was difSuent. In 93 the oedema and congestion of the abdominal
viscera must be regarded as tlie result of the malarial influence, for, had the condition of
the heart been responsible for them, the right lung would not have been reported as healthy.
Violent convulsions took the place of the chill in 94. In 95 the fatal cliill was accom-
panied with difficultv of breathing ; but the jjod-mortem, record declares the brain, lungs,
Med. Hist., Pt. 111—18
138 POST-JIOETEM RECORDS AND
liver, stomach, intestines and kidneys of normal size and perfectly healthy; the spleen was
enlarged and there was a thrombus in the ridit auricle. Whether the heart-clot was con-
cerned in the production of the fatal seizure is uncertain. But in 96 death apparently
resulted from the formation of fibrinous clots in the cavities of the heart. They probably
originated during the chill, when a tendency to stasis in the heart, increased by the incom-
petency of the valves, gave opportunity for their deposit. The muffling of the heart-sounds
must be referred to an internal obstruction, since there was no excess of liquid in the peri-
cardium nor other external condition to account for it. The other symptoms described arc
consistent with the theory of the ante-mortem formation of the clots in this instance.
Case 92. — Private Henry Wolfus, Co. I, 187th N. Y. Vols.; age 25; was admitted May 10, 1865. Diagnosis-
intermittent fever and cerebral congestion. Tlie patient was quite cold and comatose; pulse irregular; respiration
noisy. There was no dulness on percussion except over the posterior and lower part of the left lung. Warmth was
applied to the feet, cold to the head and a large stimulating enema was administered. He died next day. Fost-
mortem examination eleven hours after death: Lower lohe of right lung hepatized; liver congested; spleen congested
and softened ; venous blood diffluent ; cerebral sinuses and veins tnrgid ; three ounces of serum in arachnoid. — Sloitgh
Hospital, Alexandria, Vii.
Case 93. — Stephen McLaughlin, who was discharged from 2d U. S. Art'y August 17, 1865, on account of prema-
ture old age, asthma and general debility from twenty years' service, was admitted September 11, confused in mind
and with tremors of the limbs and voice; pulse 136; he appeared to have been drinking to excess. His legs were
cedematous ; abdomen full, tense and fluctuating ; auscultation disclo.sed roughness of the heart-sounds with increased
impulse, the sounds being heard all over the left side; there was absolute dulness from a little below the nipple to
midway between that point and the crest of the ileum; the respiratory murmur was absent at the base of the left
lung, puerile at its summit and on the right side; the left side of the chest was contracted, the right side enlarged.
At 2 p. M. on the day of admission he experienced a severe chill, for which brandy and quinine were given and
mustard applied. He recovered, but the chill recurred at 2.30 P. M. on the following day and he died at 7 P. M.
Post-mortem examination seventeen hours after death: Body bloated; skin of the head dark and livid; a thick greenish
liquid flowing from the mouth. The lirain was normal. The right lung was healthy. The left pleural cavity was
partly obliterated by adhesions, but contained in its sacculi serum and lymph; the lung was diminished to half its
size, the lower lobe being very friable and having its air-cells filled with a pruue-juiee liquid. The pericardium
contained four ounces of serum. The heart weighed fourteen ounces and a half; the ventricle was hypertrophied,
the middle valve somewhat thickened and the curved margins of the pulmonary and aortic valves hardened. The
liver was enlarged and softened; the spleen, weighing twenty -two ounces and a half, was pulpy. The peritoneum
was darkly injected and contained ten ounces of serum. The stomach and intestines, which were much distended
with gas, had their mucous lining congested. The kidneys were nodulated on the surface and contained several
cysts somewhat larger than a pea. — Douglas Hospital, Wusliington, D. C.
Case 94. — Private Otto Ziegera, Co. G, 1st U. S. Vet. Vols.; age 25; was admitted September 13, 1865, and died
September 19. He stated that he had been sutfering from remittent fever. On admission his skin was of natural
temperature and perspiring freely, but he had headache and his appetite was poor, tongue furred, pulse intermittent'
and countenance anxious. In four days he had improved so much as to be able to walk about. On the 17th he was
said to have had a violent convulsion, which was considered as a congestive chill by the attending medical officer,
who found the patient next morning collapsed, almost speechless, and covered with a profuse cold perspiration.
During the day he rallied, but on the morning of the 19th he had another violent convulsion and expired in an hour.*
Previous to death he had been eating watermelon and boiled eggs. Post-mortem exifaiination eight hours after death:
Rigidity marked. The arachnoid was opaque and presented numerous white spots of small size, chieiiy over the
* A case in which the fatal chill assumed convulsive features is given by Act. Ass't Suro;eon HENRY M. LYMAN. U. S. A., as having occuired in Hos-
pital No. 2, Nashville. Tenn. The patient was admitted June 26, 1862, having the appearance of being well nourished; but at the same time th^ewasan
unusual paleness of the tongue and palpebral conjunctiva. Prior To admission he had complained continually of rheumatism and debility. Quinine and iron
were prescribed. During the two weeks following his entrance into hospital he was twice attacked by malarial fever, which was readily suppressed
by quinine. On July 17 he began to suffer much from pains which he called rheumatic, and at the same time his surface was covered with a fcetid per-
spiration ; the latter continued through the day and following night. A scruple of Dover's powder was given during the day, and next morning
a scruple of quinine w-as administered, .\fter this he continued well until the night of the 23d, when the fcetid perspiration again appeared and lasted
through the following day. Ten grains of Dover's powder every four hours were '"ordered till the cessation of the ftetor." Quinine w.'is again pre-
scribed ; but whether it was taken or not was uncertain, because of the prejudice of the patient against the remedy. Subsequently he expressed himself
well until the 27th, when he complained of pains in his limbs, of a burning sensation in his stomach such as he never felt before, and of insatiable
thirst. A scruple of quinine was prescribed for him. which, however, be did not take. He walked about the ward conversing with his comrades and
presented nothing unusual in his appearance. He lay down on his bed and was soon seized with convulsive movements of the feet, arms and head, and
stertorous breathing with frothing at the mouth ; his surface grew purple and he died in a few minutes. The post-mortem e.\aminati<m, five hours after
death, found considerable serous effusion under the arachnoid and about four ounces of fluid at the base of the brain, with much softening on the lower
surface of its middle lobes. The lungs were healthy : the pleura presented nothing of any importance ; the heart was normal ; in the riglit ventricle was
found a small white clot ; the left ventricle was empty and contracted and the riglit auricle enormously distended with black fluid blood. Five ounces of
clear serum were contained in the pericardium. The duodenum externally exhibited a pinkish hue< the ileum and colon were of a darker appearance.
The spleen was n<»rmal in size and of a slate color, and the liver of a dark chocolate hue. Everywhere throughout the body the blood was found uiicoag-
ulated. This case of congestive fever was presented in the .Second Part of this work, p. 239, as Case 776 of the diarrhceal and dysenteric series.
PATHOLOGY OF MAIARIAT, PI^^EASE. 139
sulci on the lifjlit .siilr of tlir ciMiliruiii: tlir pia iiiatiM- was congested. The substance nf the hniin was of nnrmal
consistence: it presenlcd many piincta: the linin;; nuMnhrane of the lateral ventricles was opaipie, Imt the cavities
contained no serum; the lloor of the fourth ventricle was eonjjested and sliowcil some small icehymoses. Hotli lunss
were marked in spots with nielanie matter, the foreign siihstance of which i-ould he felt hy passing the tinker over
the pleura coveriuj; it: the right lung was congested hy hypostasis posteriorly and interiorly, and the suhslance at
the summit of the left lung was puckered, tough, inelastic and of the same s])eeitic gravity as wati'r. The heart
contained loosely-firrmed l)lack clots. The liver was normal in specific gravity and consistence: the s))leeii enhirged,
soft, flaccid, weighed tifteen ounces; the pancreas was large; thekidneys and suiuarenal ca])sules normal. The ileum
and lower portion of the.jejunum were colored yellow with bile; the large intestine presented internally a hlaekish
color which was not associated with softening, uh-eiation or any apprecialde h'siou. — (!tu. M. Midill. ./.•..■<'/ Sni-y.,
r. S. A., Hkkn Jloiij)itiil, Ilallimon', Md.
Case 95, — Private David Calvin Legrone, Co. D, lOth .\la.; rejected frontier man; age abtuit. '2'A\ was reported
on the morning of the 6th of December, 1864, as having inlermittent fever. l''ive grains of iiuiniiu' were directed
to he taken night and morning. Next day he had no fever and made no complaint, remaining up till S) i'. M, He
then went to sleep, but in about two hours awoke with a chill and dithculty of breathing and died in .ihout half an
hour. I'osl-mortim examin.itiou sixtei'n hours after de;ith: The brain, lungs, liver, stomach, bowels and kidneys
were of nornuil size and perfectly healthy. There was a thrombus in the right auricle of the heart and about three
or four ounces of serum in the pericardium. The spleen was about twice the usual size and very soft, dark eidored
and engorged with blood. — Act. Anx'l Siiri). IV. li. Mutlhvwx, V. S. A., Iluck Iiluiid IIo«pil<il, 111.
Ca.sk ilfi. — Private George Evans, 6th Kansas Cav. (a Delaware Indian), weight 1W> ])ounds, was admitted
Feliruary 23, 1863, with a large ulcer, of several years' standing, on the right leg. This healed kindly under treat-
nu'nt with ointment of carbouate of zinc and adhesive strips. The patient, however, was taken on March ii with
a severe chill which lasted several hours, and was followed by fever, with a full and laboring pulse, 120, dysjjna'a
and great anxiety of expression. The fever gradually abated and with it the force and frecineney of the pulse: but
fre(|Uent palpitations supervened with cou.seiiuent lo.ss of sleep. Next morning the pul.se was so small and fre(iuent
that it could not be counted: there was a suffocating feelitig at the pnecordia, with a pain which exteniled to the
left shoulder: the countenaiu'e continued distressed; the dyspnrea increaseil; freiiuent vomiting of greenish matter'
occurred throughout the day; the sounds of the heart were niufiied and indistinct; the bowels open and stools
healthy: the urine normal: the skin moist and warm: the intellect clear. The pulse became ini])erceptihle at the
wrist and death took place at 3 A. .M. of the 16th, forty-two hours after the accession of the chill. The treatnu-nt
consisted of five grains of fiuinine every three hours, with opiates, Hoffmann's anodyne, nitrate of bismuth and
mustard cataplasms. I'oHt-morlan examination thirty-five hours after death: Kigor mortis well marked. The lungs
were healthy throughout. The pericardium contained one ounce of serum. The right cavities of the heart contained
dark clotted blood and a large white clot which projected into the veins and puhuonary artery; the left cavities
also contained a fibrinous clot, which extended several inches into the aorta; these clots had nunu-rous attachments
to the walls of the heart; the valves of the left side were thickened and incomplete. The spleen was luilarged, soft
and pulpy; the other abdominal viscera were healthy. — Hospital, Fort Scoil, Kunsas*
Tlie following case, discovered among the records after the other.s had been ])laced and
numbered, is inserted here as of interest in connection with those just recorded:
Private Philip Kiser, Co. JI, 3d Ky. Cav.; age 20: was admitted November 29, l!S64, with a gunsliot wound of
the left leg near the head of the tibi.i, received at Marietta, (ia., October 5, 1864. He was put u|ion light duty at
the barracks until January 1, 1865, when he was admitted to hospital, having had a chill which was followed hy
fever, nausea and vomiting. When first seen, .January 2, the vomiting continued. A sinapism was applied over the
Btoniach, and mercury -with chalk, morphia and camphor were administered in small doses every two hours. Next
day the pulse was small and rapid, 50 per minute, the respiration thoracic and hurried, 35 per minute, and the abdo-
men exceedingly tender, particularly over the ciecuni. On the 4th the vomiting persisted and the bowels were
tynijianitic, the pain and tenderness being much increased. Brandy-toddy or milk-i)uiuh was given hourly, and
friction and artificial heat were apjjlieil to the feet. On the 5th the symptoms were ;iggravated; the respiration
increased to 60 per minute: the pulse imperceptible at the wrist; the extremities cold and the general surface
cyanotic. Death occurred on this day, I'oxt-morteni examination eighteen hours after death: Thi' calvaria was not
opened. The pericardium contained five ounces of serum ; the pleural surface of the h^ft lung was thickened and
its a))ex intensely congested liut not hepatized: the right lung was healthy; the heart of normal size: firm clots
were found in both ventricles, attached in sonu; jilaces to the auriculo-ventri<-ular valves. The liver weighed sixty-
two ounces : its left lobe was softened and crumbled easily on pressure; the gall-ldailder was distended. The peri-
toneal cavity contained eight ounces of sanguineo-puruleut serum; the omentum was inflamed and the surface of
• .\ .limilnr case hm been detniled l)y Dr. JOSEl'll JOXES: The patient «ii« sallow, anaemic and subject to attacks of chills and fever. He liail a
chill allrnded with much cmbarrassnu-nt ,»f respiration on the night of Jatuiary 25. IPtifl. and was admitted into the Charity Hospital of New Orleans on
thffitllon-inf; day. There was great dyspnoea and much restlessness, but the respiratory uuiruiiir was audible enough. The heart's a<:Ii<tn was irregular,
rapid and tunmllnous and its seanuls nuiffled ; the ailerial oinailation was weakened, the puLse being small and intermittent and the surface cold ; the
venous system wiis engorged. Oeath took place suddenly at 1 I'. M. of the liSth. The elol, consisting of distiiu't fibrinous lamime free from blood
crpnscles. was tirmly attaclierl to the nniscular (columns and cords of the right side of the heart ; it sent a branching prolougalioTi into the pulmonary
artery, llr. JoXKs is of opinion tliut tlie foriimlion of heartitlot during life is very common in malarial fever. — .See Clinical Lrclarr—llmHcM. Xtio
IMe.n.xJmir. of Htd.. Vol. XXII, IgliS, p. iW.
140 ■ POST-MORTEM R?:COR.DS AND
the iutestiiie leddeued and coatoa with lymph. The cardiac eud of the stomach was highly cougestcd. The si)lcen
weighed fourteen ounces and was softened. The kidneys were small and healthy. — Act. Ass't Sm-g. D. W. Flora, C.
S. Arniy, Hospital, Madison, Ind.
Cases 97-99, from their rapidly fatal course and the purpuric blotches which charac-
terized thera, were regarded as cases of spotted fever.
Case 97.— Private Alonzo A. Lumbert, Co. H, 7tli Wis. Vols.; age W; was admitted from Haddington Ho.s-
pital, Philadeliihia, Pa., July 20, 18tJ4, suffering from partial paralysis of the left arm, resulting from a gunshot
wound received at the battle of the Wilderness May G. The ball had entered on the anterior surface of the arm
a little below the shoulder-joint and emerged near the spine of the ninth dorsal vertebra. The patient improved
under treatment, gradually gaining the use of the arm, until August 11, when he was seized with nausea, head-
ache, weakness and pain in the lower limbs. Next morning he had a chill followed by fever, pain in the bowels and
slight diarrhiea; the nausea, headache and debility were increased; the tongue was coated with a white fur. He
was treated with two-grain doses of (juinine every three hours. There was no improvement on the 13th ; in the
evening he vomited frequently and complained of great weakness. Next day the vomiting continued; he was rest-
less; his extremities were cold, face and lips bluish, pupils slightly dilated, pulse imperceptible at the wrist, but his
mind remained clear. Circular purplish spots, which were not elevated, made their appearance on the face and right
arm ; they disappeared under strong pressure and returned slowly when the pressure was removed. Brandy was
given freely and bottles of hot water applied to the lower extremities. About 11 P. M. convulsive movements
of the limbs occurred, with retraction of the head and mnscnlar twitchings of the face. Death took place within
half an hour of the convulsive seizure. Pnst-mortcm examination four hours after death: Body well developed;
rigor mortis marked ; slight discolored spots were observed on the face, right arm and lower extremities; there was
also some suggillation posteriorly. The vessels of the pia mater were greatly congested and some exudation of
lymph marked their course, especially in the vicinity of the longitudinal sinus; the brain Avas of natural consistency,
the punota vasculosa numerous; there was no exudation at the base of the brain nor eft'usion into the ventricles;
the cerebellum was less congested than the cerebrum; the pons and medulla appeared to be normal. The surface of
the spinal cord in the cervical region had a pinkish hue, due to congestion of the pia mater; its substance was
natural in consistence and color. The lungs were engorged with blackish fluid blood, which exuded on section. The
heart was rather small and was filled with black fluid l)lood, which was frothy in the right but not in the left cavi-
ties. The liver was of natural size, but darker than usual in color and engorged with fluid blood. The spleen was
rather large and congested and its parenchyma ilrm. The mucous membrane of the" stomach presented a number
of ecchymosed spots; portions of the small intestine were much congested and the solitary follicles and glands of
Peyer were enlarged; the mesenteric glands were engorged with dark blood. The kidneys were likew"ise engorged
with blood. — Act. Anii't Sitri/. Charles Carta; U. S. A., Turner's Lane Hosjiital, Philadelphia, Pa.
Case 98. — Private Charles Octniier, Co. G, 79th Pa. Vols.; age 45; was admitted May 17, 1865, with diarrhoea
of six weeks' duration, two to six stools daily, but with no pain nor fever; his feet were (edematous, which condi-
tion was ascribeil to hard marching. Delirium of an acute character was developed on the 20th, the patieut talking
loudly, making frightful grimaces and constantly seeking to leave his bed. Next day at 8 a. m. his pupils were
dilated and lie was unable to recognize'any one: pulse rapid and feeble; tcmgue dry and parched; stools and urine
passed involuntarily; a purple petechial rash appeared over the body, especially on the abdomen. At 9.30 A. M. he
slept quietly. Two hours later he was in collapse and gasping for breath; pupils much contracted. He died at 1
p. M. Post-mortem examination twenty-three hours after death: There was much emaciation. The lungs were
adherent on both sides, congested posteriorly and contained crude tubercle and several chalky concretions; the
apex of the right lung contained also a small vomica about the size of the thumb-nail. There were two ounces of
yellow transparent serum and two yellow coagula in the pericardium; on the surface of the heart was a serous effusion
which appeared around the auricular appendices as a jelly. There were three ounces of a turbid, reddish liquid ui
the abdominal cavity; the mesenteric glands were softened; the liver was small and soft; the spleen semi-fluid; the
kidneys normal; the stomach eroded and ecchymosed; Peyer's patches exhibited the shaven-beard appearance; the
rectum was much ulcerated; the bladder distended with urine. — Doui/las Hospital, Washington, D. C.
Case 99. — Private Louis Gross, Co. H, 9th Invalid Corps; age 42; admitted November 19, 1863. On admission
this man had much fever and a hacking cough, with an expectoration of frothy mucus. A cough mixture and solu-
tion of acetate of anmionia were ordered. Next day at 7 a. m. he had a hemorrhage from the bowels ; at the same
time the superficial capillaries of the thighs and abdomen became congested, and the capillaries of the whole surface
of the body were soon aft'ected in like manner, assuming in patches the appearance of hemorrhagic extravasation.
Whiskey was administered every half hour, but he sank rapidly and died at 10 a. m. Post-mortem examination five
lionrs after death: Extravasations of blood over the entire surface of the body. Bright-red spots on the surface of
both lungs; extensive pleuritic adhesions over the left side. Eight auricle and ventricle of the heart considerably
dilated, the auriculo-ventricular opening being large enough to permit the passage of three fingers ; the mitral valve
thickened and feeling like cartilage. Liver weighing seventy-two ounces; gall-bladder distended; spleen normal.
Mucous membrane of stomach, ileum and colon presenting bright-red spots similar to those on the surface of the
lungs ; the descending colon containing a large quantity of fluid blood ; the last twelve inches of the ileum presenting
old ulcers, and the lower part of the ileum and the large intestine generally much congested; kidneys healtliy. —
Act. Ass't Snrg. Lhn/d Dorsci/, Hun wood Hospital, Washington, IK C.
PATHOLOGY OF MAI.ARTAI, DISEASE. 14]
In connection with these cases the following reports are of interest:
Siiryeon R. M. S. Jackson, llth Pa. VoU.; Annapolis, Md., January 31, 1862. — The cases of unusual interest in
tliis report are those of a disease now popularly called KpotUd fciir, and catalojjued as maliijuuut congestive f ever.
The following aro some of the leading features of the cases, all of which presented great uuiforniity of nosographic
points, there being but few premonitory symptoms. First a severe chill with extreme oppression; violent pains in
the head and limbs, the latter com))lained of as an "awful soreness," or as "stinging" and " burning;" expression
of terror and alarm in the countenance, particularly noticeable in the eyes; cold skin; most of the cases pulseless at
the wrist when first examined. .Si>ontaneous vomiting occurred in some, and in one case constant inclination to go
to stool, with but little or nothing passed from the bowels. Spots appeared in from four to ten hours after the
attack, the patients dying generally from ten to twenty hours after the appearance of the spots; one case lingered
three days. The shortest time from attack to death, including appearance of spots, was sixteen hours. The spots
were of various sizes and shapes, first appearing on the feet and legs; some were of a stellated or radiating form,
bright red; others roundish and irregular, of a bluish color, and from a mere point in size to a quarter of an inch in
diameter. They gradually extended over the whole trunk, superior extremities and face, at last appearing on the
eyelids as small blood blisters. These spots, as death approached and after death, became larger, more difl'iise and
of a bluish or purple color. In some of the cases there were large blotches of the size of the hand or larger, con-
nected together irregularly over the body and limbs: in some, after death, the face became of a livid color, pufly
and swollen, the eyes protruding, lips turgid and flabby, ,a frothy mucus boiling from the mouth and a sanious
substance issuing from the nose and ears. Before death some of the cases had the mottled appearance of persons who
had been bitten by venomous reptiles.
The poat-mortvm appearances very soon after death exhibited a dissolved condition of the blood and a putre-
factive tendency of the llnids and solids. Cadaveric odors were emitted by some of the bodies almost immediately
after death, while the abdomen became enlarged by distending gases and the face presented a bloated appearance,
with frothy boilings from the mouth, already described. The brain revealed the marked post-mortem appearance of
(lissolrid or dead blood; its inferior portions showed a gradually increased saturation of the membranes and cerebral
substance, the bloodves.sels blackening almost the entire surface. The sinuses and large veins being punctured
discharged their contents of inky blood in a state of perfect dissolvedness. The hyperuiuiia from hypostasis was
particularly marked, the blood ai)pearing to sink from gravity by percolation like water through the tissues. The
membranes of the brain showed no evidence of inllanmiation, only passing engorgement. The substance of the
brain, exposed by jslicing it down from the vertex to the base, seemed unaltered in mechanical consistence, but darker
of line in both medullary and ciueritious substjiuces. The cut vessels penetrating the cerebral mass exhibited the
same conditiiui as those of tlie periphery. The ventricles were full of a light straw-colored serum, no doul)t the
efl'ect of a mere mechanical transudation of the watery portion of the blood from relaxed ve.ssels and tissues. It was
evident that no intlammation could have existed in the brain or its investing membranes, for the mental manifesta-
tions were clear in many cases to the last. The cavity of the abdomen showed some efl'usion ; its contents presented
the same general tendency to ecchymosis of tissue as existed on the skin and other organs. The stomach exhibited
no evidence of inflammation, but the same dark anil mottled ,ap])earance predominated. The inner surface was of a
dark-yellowish niudily color, as if slightly stained by bile, but contained only iiuk'US and undigested material recently
swallowed in the shape of beef-tea, brandy, etc. The whole bowel was of a dark mottled color, the large intestine
being distended with gas. The liver was normal but of a darker brown color than usual.
The troops of this regiment came from llarrisburg on the Sus(|uehanna river. This is a well-known malarious
region, the Juniata and Susquehanna rivers having been long noted for their autumnal fevers. Most of the men
enlisted had come from districts of the State where these diseases are unknown and were thus, as is a well ascer-
tained fact, more liable to attacks of miasmatic affections. Before leaving Harrisburg, where the regiment remained
from the latter part of August until the L'Tth November, 1861, the principal diseases were clearly of malarial origin —
intermittent and remittent fevers assuming a typhoid form. A number of typhoid cases were left at Harrisburg;
many of these died. On our arrival at Annapolis over one hundred men were on the sick-list, nearly all of whom
were taken sick at Harrisburg. For one mouth after our airival at Annapolis the troops had no vegetables, as they
could not be procured. They were crowded into the buildings of St. .John's College, where many other regiments
had been quartered at different times. These buildings had never been cleansed, renovated or disinfected in any
way. The deleterious influence of over-crowding was thus added to the transported poison, Efi'orts were made to
get lime and disinfectants in vain, and as the troops were constantly expected to move from this station no radically
reformatory measures with regard to the vicious condition of thi; post were persevered in. * " * W'hen the troops
were supplied with vegetables the scorbutic condition of the blood of many of the men was soon changed and the
health of the regiment was speedily improved. [On the monthly report of sick and wounded from this regiment for
.lanuary, 1862, signed by Surgeon Jackson, are 7 cases and 3 deaths reported under the head of other fevers, and on the
list of deaths the three deaths are ascribed to febris maliyna coni/estUa.']
Surgeon R. M.S. jAfKSox, Uth Pa. Vols.; Annapolis, Md., March 1, 1862. — The cases of interest in the accompa-
nying report for February, 1862, are of the class of fevers: Congestive 17, intermittent 9, remittent 8. The occurrence
of such a number of intermittent and remittent eases with clearly defined features is significant as showing a
rational genesis for the whole class. The cases of congestive fever were clearly the old form of "spotted fever." The
symptoms were the same, with a slight modification in some of the characteristic points. Many of the cases exhib-
ited the same style of maculation, the same intensity of quickly locked and gorged congestions of the splanchic
cavities, the same disposition to fatal first chill, etc. One striking modification was observed : Some of the cases
142 ' POST-MORTPJM EF.CORDf! AND
without spots on the extremities, but with the same symptoms otherwise, sliowed a remarkable swelling; of the intci/K-
ments of the head and fact: This bloated pufiy look was the most striking appearance, together with a dingy blueness
of the integument in other parts of the body, while the injected condition of the vessels of the conjunctiva pro-
duced a regular chemosis or elevated ring around the cornea. Only one of these cases proved fatal.
The improved condition of the general health of the troops, from' a proper supply of food or mixture of vege-
tnble matter in their rations, accounts for the increased power of resistance to disease; bloodless and scorbutic
constitutions having become more highly vitalized, the surgeon's efforts to arrest the destroying powers have
been of more avail, A clear apprehension of the true pathology of the disease having been established, tlie remedies
employed have had marked success,
iSiirgeoii S.vmuei, A. Sabine, 9Wi X.Y.Jrt'ii.: Fart Midisjield, Md., Frhriiai-)/ 8, 1864. — You will observe in my report
for January that there have been taken on the sick report seven cases of congestive intermittent fever, of which
four have died, I find that the disease occurs most frequently among the new recruits, and from observation I have
ascertained that the locality from which they were taken appears to have a controlling influence. A large number
came recently from Onondaga County,. N, Y., which abounds in malarial poison exhaled from the nnmerons swamps
in that portion of the State, Four out of the seven cases of congestive fever have occurred among these recruits
The .symptoms of this disease are extremely varied, indeed no two cases are the same; yet a similarity exists which
enables the careful observer to detect the same matrries murhi exerting its influence with deadly effect upon the brain
and nervous system. In some cases the symptoms are identical with those occurring in the congestive fevers of the
West, while in others there is no perceptible chill from first to last. But a better idea of the symptoms may he
obtained by reporting a few of the cases : —
1. John Boyer, Ordnance Serg't, 47 years of age; married: in the service seventeen years; always healthy.
Was called to .see him about 8 r. M. and found him in a profuse sweat, his clothes being completely saturated;
pulse 115, small and soft; tongue clean; extremities inclined to be cold; resiiiration normal; countenance jiale and
anxious. About 5 o'clock he had eaten a hearty supper, soon after which he went for a liail of water; on returning
was attacked with faintness, indescribable sensations and pain in the epigastrium and right side of the chest,
Sinajiisms were applied to the extremities and stimulants directed to be given at frequent intervals until the pulse
grew stronger. I placed him in charge of a competent person and left him. He soon became conrfortable; took
something to eat and drink during the night; told his wife he felt so well she must go to bed. She did so, and he
was perfectly quiet and comfortable until (i a. m. when, while standing upon the floor, he was again seized with
the same feeling as at first and died immediately. No autopsy.
2, Albertus Cowan; 20 years of age; healthy. He was taken with a chill on the morning of January 14
and continued to get worse until night, when he became insensiljle and was brought to hospital. He moaned con-
stantly, and when disturbed was violent. The pulse was 64 and intermitted occasionally; it was slow and had but
little force; respirations 3.5 and some catching of breath; no stertor; skin natural in color and but slight coolness
of surface; pupils dilated and insensible to light. He could not be aroused nor induced to swallow anything.
Directions were given to have his head shaved and blistered. At 6 r. M. some slight improvement was manifest; the
I)ul,se was stronger and the respiiation improved. The blister had drawn well, and some beef-tea and stimulant had
been given during the evening, but the patient remained perfectly unconscious. On January 16 there was a decided
improvement. He was semi-conscious, and took beef-tea in suflicient quantities; pulse 70 and regular. Ordered
thirty grains of quinine in two powders, four hours apart. On January 17 the improvement continued. It was
noticed that there was a slight strabismus of the left eye. The blister was re-applied to the scalp. On the 20th the
pupils had resumed their natural size and the strabismus was entirely removed. After this he gradually improved
until the present time, but has had symptoms of remitting fever. He convalesces slowly.
8. (iarrett S. Prosse, 20 years of age; healthy. He had been in the service but two or three days when he
was attacked in the same manner as Cowan. I did not see him until twenty-four hours after the attack, as the
men comi)osing the comjiany were all new recruits and their officers were not notified of bis illness He did not
become in.sensil)!e until al)OUt eight hours after the chill. His ])ulse was 60, slow, soft and with but little force;
resiiiration ;-i4 and sighing. A bri.sk cathartic was given which moved the bowels thorouglily : but his condition did
not improve. He died on the third day. No autopsy.
In all the cases that recovered there has been a tendency to remitting or intermitting fever during convales-
cence, which has invariably been slow.
Surffcon David Mekritt, 55»i 7'<(. Vols.; JSaiufurt, S. C, May 10, 1863.— We have also had in the regiment a few
cases of congestive, or as it is termed by some writers, pernicious fever. In most of them there has been very little
time in which to do anything by way of medication, so rapidly has the disea.se resulted in death. In these eases the
congestion has manifested itself in various ways: In one case spinal congestion was evinced by the prolonged
spasms which occurred w ith hardly any intermi.ssion ; in other cases spinal irritation or spinal meningitis ; in others,
congestion of the brain at a very early period, with obliciuity of vision, sardonic grin and evidences of a dispositio i
to convulsions; in others, intense congestion of the lungs, which, upon examination after death, were found
engorged with dark venous Idood; in others, congestion of the liowels, accompanied by extravasation of venous
blood from the mucous membrane of the intestine and by softening of the mucous nu-mbrane to a remarkable degree.
One case, sent to General Hospital No. 3, Beaufort, S. C, Ass't Surg. F.T. Daiik, U. S. Vols., in charge, I particularly
remember: Private John Moyer, Co. H, 55th Pa. Vols., came to me after surgeon's call and asked for "a dose of
physic," as his bowels had not been moved for three days. He did not appear to be sick. I gave him at one dose
twenty grains of mercury with chalk and fifteen grains of powdered rhubarb. This was taken at about 8 a. m. At
2 IMI. I was summoned to his tent and found him in a state of syncope, from which be rallied under the admiuis-
PATHOLOOy OF MALARIAK OISEASE. 14o
tratiou of stiiiuilants. About ;{ r. M. lic' was iviiiovcd lo liospital, anil died the .saiiu? night at about !) o'clock of
intestinal h;i'nioriliage, a pool of dark venous blood beneath him in the bed. PeiNulphate of iron had vainly been
given by enema, and sulphate of (|uinia, ca]isicuni, ether, brandy, etc., administered internally, liy invitation of
Dr. l)Ai>K I was present at the iiunt-mortcm examination twelve hours after death. The brain was slightly eon-jested.
The lungs were nearly normal and not noticeably changed. The heart was normal. The liver presented the nutmeg
ap|)earan<-e; on section it was found to be considerably congested. The si)leen was verij much cnlunjid, rvry friahle
and much congeiitcd. One of the kidneys preseuted an extravasation of blood on its surface. The stomach was xliyhiUj
congested. The intestines contained a iiuantity of extravasated Idood ; I'eyer's glands and the solitary follicles
were somewhat congested and the mucous coat of the whole intestiiuil canal was so nnicii softem-d that it was pos-
sible, with the handle of the scalpel, to scrape off the iidicoiid coat and leave the mnnciilur coat denuded.
Another patient died during the chill, living only about ten minutes after being brought to the regimental
hospital on a stretcher from his quarters, where, less than throe hours previously, ho had been joking with one of
the drummer boys. This was Private Kdward Riley, of Co. D. Auothor case, Private Philip Miller, of Co. H, died
coniatosi- a few days after adniLssiou to regimental hospital, the whole external surface of his body presenting an
icteroid hue before death. Another, Private Irwin Little, of Co. I, died soon after admission to regimental hospital,
and in this ease the surface of the body became .jaundiced immediately after death. This man, like the others, was
treated with iiuinine. capsicum, brandy, etc.: calomel was given with a view to stimulating tho secretion of the
liver, and mustard applied to the surface of the iiody and limbs.
Siirncon W. M. Smith, 85//I A". 1". Voln.; yew Heme, X. C, Fehruar!/22, 18ti3. — Two men died in hospital at .Suffolk
of remittent fever with meningeal complications. Post-morlem examination showed that the arachnoid surface of
the falx cerebri was much congested, having ^jfrts/ic exudation at several places on its surface. In one case the right
lateral ventricle contained one ounce of turbid serum tinged with blood; the left ventricle contained six drachms of
serum less turlvid than bloody. The arachnoid surface of the tentorium cerebelli and the visceral layer of the arach-
noid covering the cerebellum were greatly congested.
Surgeon W. 11. GniMK.s, 13//i Kavxaa Voh.; near Springfield, Mo., Fehruar;/ 2, 18()3. — Many of the men wore taken
with high grades of bilious fever and several died of congestion of the brain. In these cases the most active treat-
ment was pursued : the ])atientM were bled, cupped, blistered; had calomel and the bitartrate of jiotash and antimony,
and other remedies as the indications demanded; yet we were unsuccessful. We began to doubt our i)owers of diag-
nosis, but the citizens told us that congestion of the brain is a conmion disease in this region, and that their doctors
bleed and give large doses of calomel.
Ass't Surg. J. W. Masox, 12/* CorpK d'Jfrique; Port Hudmn, La., February 23, 1804. — Nearly all the cases that
rame under my observation in the months of October and November, 1863, were the result of zynujtic influences;
tlie.se, cooperating with the scorbutic taint that had been largely developed in the regiment, produced, in even the
ordinary incidental diseases, an adynamic condition of the system. Many laboring under this pathological condition
were attacked with typho-malarial or congestive fever. The typho-malarial cases were in most instances amenable
to treatment, but a large pro])ortion of the congestive cases proved fatal. The nujst prominent point of interest
developed in this unmaiuigeable di,sea,se was a loss of vital force. As an unusual thing the disease was ushered in
with a slight chill, but generally this was not apparent. In some cases the patients would soon become cold and
pulseless; and no treatment, however vigorous, succeeded in establishing reaction. Death closed the scene in a few
hours, or the jiatients lived for .several days conscious and without pain, and then died quietly, as though they had
fallen iuto a gentle slumber.
Lastly, two cuses of chronic malarial poisoning are given, with some references from
New Berne, N. C, to this condition among the troops operating there in 1863. In both
cases the blood was evidently greatly altered. In one, the spleen weighed sixty-eight
ounces and the veins contained soft greenish-white clots, while in the other there was dit-
fluent blood in the pleural cavity and the liver and spleen were disorganized.
Case 100.— Private Levi Beech, Co. D, 1st Mich. Cav.; age 36; was admitted October 27, 1864, with a contusion
of the left side caused by the kick of a horse. He was feeble; the spleen was much enlarged, occui)ying nearly the
whole of the left lumbar region and parts of the umbilical and left inguinal region, lie had suffered from ague eight
years before for fourteen months, the disi-ase intermitting <)<-casionally for about a week at a time. After admission
his appetite was variable, and he lost llesli although his bowels wen^ regular. He was treated with citrate of iron
and quinia, stimulants and nourishing diet. He was able to be about the ward and out of doors: occasionally he
had some cough. About noon on December 31 he became s|>ecchless and unal>le to swallow. He died at 6 v. M.
I'ost-mortem examination : No rigor mortis. The brain was normal ; its membranes somewhat adherent to the meduiha
and pons. The right cavities of the heart were di.stended and a greenish-white, soft, almost pus-like clot floated
in the ventricle. The right lung was somewhat congested and adhered by old firm fibrinous bands; the left lung
was congested by hypostasis; one or two glands at the root of the left lung contained cheesy and chalky matters.
The liver was large and bloodless; its jiortal veins filled with soft yellow clots. The spleen weighed sixty-eight
ounces and adhered to the diaphragm and stomach ; its veins contained soft greenish clots; a secondary spleen the
si/e of an nnhusked walnut was found at the head of the pancreas. The mesenteric glands were indurated and
about the size of a pea. The ileum and colon were normal. The psoas muscles were softened and their surfaces
blackened. The external iliac arteries contained blood. The kidneys were white and fatty. Microscopically the
144 • POST-MORTEM RECORDS AND
greenish-white cliits of the heart and liloodvessels consisted of granules and polynucleated cells, many of the hitter
a little larger than a blood corpuscle, hut the majority much larger.— T/iii-rf Difisioit Ho«pHnl, Alcxainlnu, Fa.
CvsE 101.— Corporal S. Cininion, Co. K, 44th N. C; died June 13, 1863. The patient had been sick for some
time and died suddenly and unexpectedly. Post-mortem examination: The right lung was adherent to the costal
pleura. The heart was very soft but contained no clot. The thoracic cavities on either side contained three ounces
of uncoagulahle blood, the red corpuscles of which, under the microscope, were seen to be broken down, stellated
and withered, the serum of a yellowish-red color and the white corpuscles very numerous, seemingly from the absence
of the red. The liver and spleen were pultaceous and disorganized. The kidneys were flabby.— Jss'« Sim/. H.
Allni, r. S. .-)., Lincoln Hospilid, Washington, D. C.
Suri/ion F. J. D'AviGNON, 9tith X. T. Vols.; Xeir Berne, N. C, Fehruury 28, 1863. — The low diet, constant exposure,
want of rest and severe labor from which the regiment suffered during the summer of 1862, while before Richmond
and at Harrison's Landing, so reduced the vitality of the men that the influence of the miasmatic atmosphere of the
swamjis, the intense heat and the impure water used, met but feeble resistance. It was a common thing for healthy
robiist men to lose thirty, forty and even fifty pounds of flesh in a few days; and the sunken eyes, emaciated form
and languid step demonstrated the existence of agencies beyond the influence of medicine. The ordinary remedies
for disease seemed of no avail.
SnrgeoH Isaac F. Gali.oupe, Yith Mass. Vols.; Xnr Berne, N. €., Fehrtinri/ 20, 1863. — In the latter part of June,
1862, intermittent fever and other malarial diseases began to appear in this connnand, increasing in severity and
prevailing more extensively as the season advanced, until November, when the regiment was quartered in town.
Notwithstanding the extreme prevalence and severity of miasmatic diseases but few deaths occurred. During the
months of August and September several hundred cases were reported, but of these only five proved fatal. In many
cases, however, paralysis agitans, chorea and ascites resulted. In other cases the constitution was completely broken
down and the men were discharged the service. No treatment was of any avail except by quinine, and this was most
effectual. When cinchouism was rapidly produced the disease was promptly and almost invariably broken up. It
was rare that a patient would have a second paroxysm after coming under treatment.
Besides the relatively small number of cases presented above, it is recorded in thirty-
eight of the cases embraced in the chapter on the alvine tlu.xes that the patients were
suffering or had recently suffered from intermittent fever;* and references to remittent
fever occur with equal frequency. In view, however, of the enlarged spleens and other
more or less characteristic conditions found at the post-mortem examination of the diar-
rhoea] cases, it is probable that a much larger number of them than is shown by the clinical
notes were concurrently affected b)' the malarial influence.
11. — Pathological Anatomy and Pathology of Malakl\l Disease. — In summar-
izing the pathological appearances presented by the recorded cases of malarial disease, it
seems proper to exclude the nine cases, 83-91, in which typhoid fever is suggested by the
clinical history or morbid anatomy. There remain forty cases of death from malarial
affections in which pod-morteni, investigations were Iield.
The Stomach. — In twenty-one of the cases the condition of the stomach is not stated; it was normal in five
and constricted in one. In thirteen cases a morbid condition is specified thus: In four the organ contained a green
grumous or mud-like liquid; in (wo its mucous membrane was congested; in aiie softened; in one slate-colored; in
one thickened, and in/o«c ecchymosed.
The Intestinal Canal. — In »i,r of the forty cases the intestines were reported healthy; in nine their condi-
tion was not stated. In thirteen of the remaining twenty-five eases the large and small intestines, so far as can be
ascertained from the phraseology of the reports, were both affected. t Five of these cases, 59, 64, 65, 73 and 93, were
much congested or inllanied, but not ulcerated ; in the first-mentioned, for instance, the canal was almost black from
the engorged condition of the capillaries, and coagulated blood was found in its interior. In one of the thirteen cases,
81, the mucous membrane was softened and in seven ulcerated; in two of the latter, 70 and 80, the duodenum alone
was ulcerated, although the canal generally was highly congested; in 67 the ulcerations were reported as slight;
in 77 as old; in 71 and 72 as large and small, and in 75 as associated with a congested condition of the mucous mem-
brane. In »j.f of the twenty-five cases the condition of the small and the large intestine is specifically stated : In 74
both were inflamed, but the patches of Peyer were not diseased; in 99 both were much congested and ecchymosed :
in 57 and 94 deposits of black pigment were found in the large intestine, while the ileum in the former was but
slightly congested and in the latter merely stained with bile ; on the other hand the patches of Peyer in 98 presented
» See, ill tlic Secor.d Part of this wnrk, cases 9.5, 10:), 1(M, 171, 189. 191. 194, liW, 243, 2B0. t.>72. 305, 31«. 373. 389, 3911. 401, 410, 433, 517, 552, «ll,
614, (l:i9. (igC, 704, 735, 738, 742, 747, 7.')8, 7711, 809, 853, 854, 857, 858, 859.
t In Alfferia, where the French tnmps were e-vpused to influences similar tci thnse affecting our soldiers in the malarious districts of the South, the
lesions of chronic dysentery were, according to LavekaN, constantly found in cases of fever when death occurred a long time after tlie comiiieueeiuent of
the malaiial ailection. — Recueil de Meiiunrfs ile Midecine di Chirurgie ct dt Pharmacir Militaires, 1 s^rie, t. LII, 1642, p, 83.
PATHOLOGY OF MALARIAL DISEASE. 145
till' iiif;iiii'iitcil appearance, while the reetmii was uleerated : in (>X the niueons meinhiiuie of the ih'iini was softeneil
anil tliickeneil. that of the eolon eonjiested. In the renniining «/ap of the twenty-live eases the small intestine or
ileum only w as aft'ected : In 55, (!8 and !'" it was congested, and in the last-mentioned case the jiatches of Peyer and
the solitary j;lands were enlarjted : in 8J it was nlcerated ; in (i9 congested to a purple color, which presented a deeper
tint in the apices of the solitary glands, although the patches of Peyer wore uuaftectcd ; in 5(> also there wag a deeply
colored congestion, which was specially marked throughout the jejunum.
In two of the cases, 78 and 7!', in which the condition of the mucous lining is not stated, there was iieritonilis,
and in two, 70 and 80, in which the mucous lining was congested, there was, in addition to i)eriloneal inllamniation,
in one ulceration of the duodenum and in the other ulceration of the duodenum and pancreas. Some serous I'tVusion
was found in the peritoneum in two other cases, and in several there was more or less injection and darkening of
the serous coat and omentum.
It would appear from these records that althougli inflammatory tendencies in tiie intes-
tinal canal were not an invariable consequence of malarial disease, they occurred wilii
more frequency than might reasonably be referred to the concomitant action of diarrhoeal
causes as distinct from the malarial poison; and furthei-, that the incidence of the disease
was not localized on any particular part of the tract, but affected alike the large and the
small divisions of the gut. The slight preponderance of cases in wliich the small intestine
was affected may be referred to diarrhoeal causes, as in Maillot's cases; given below,* the
preponderance seems to have been due to the inclusion of typhoid fever.
In tliis absence of partiality for a particular region of the intestine as the site of its
manifestations, the malarial poison differs essentially from the tvplinid. The lower part of
the ileum, as will be seen hereafter, was the site of typhoid developments when no other
part of the canal was affected; and when a greater extent of the canal was involved this
|>art of the ileum was more intensely affected than others. But in the cases at present under
con.sideration the duodenum, jejunum and colon were found, one or all, to be at times impli-
cated without a corresponding intensity of the inflammatory action in the ileum.
Another and striking difference will be observed between the action of the malarial
poison and that of the typhoid disease on the intestines. In the latter the inHanimatory
action was circumscribed and its force expended on the closed glands of the mucous tract,
which were destroyed by ulceration or sloughing, while the general surface was not neces-
sarily involved. In the former, on the contrary, the action was general over the parts
of the intestine implicated and not confined to a particular anatomical component ; and if
the closed glands were affected they were not specially so, but only as forming a part
of the congested tract. Moreover, while in the typhoid cases the mucous lining of the
intervals between the glands was sometimes darkened or i-eddcned with congestion, the
engorgement was never so diffuse or intense as in the malarial cases in which the intensity
of the congestion was often manifested, as in 97-99, by ecchyraoses, or as in 59, by the
escape of blood into the canal from its engorged and blackened membrane.
■ The Iiiiltnviiifj [^uiuinary of MAILLOT'S observ,itii»ns are given for comparison with the test. — See Traiti des Flivres InUrmittenUs. Paris, 1836, p.
Ift-'S rt ffn. \uniug the obsen'ations that I have enUet-ted and reported there are tweoty-eight cases of pniit-mortcm inquiry. In all these the digestive
orjniDS were examined : in a single case the head was not opened, and in another case the chest ; in twenty-one cises the condition of the spinal cord is
recorded. The different organs presented the following abnormities: Pirjfjitive Organs. — Twenty-seven times the muctnts membrane of the stomach
ofTereil something Wfirthy of note ; only once was it in a normal state. The alterations were : Gray sl.ite-colored softening, without vermilion-colored injec-
tion, five times: gniy slate-eolored softening, with punctated vermilion injection, in a case of quotidian fever which became typhoid: dirl}*-gray softening,
with vermilion injection, eleven times : dirty-gray sot^eniug, without vermilion injection, in a case in which death did not «tceur until after tweiity-thrtfe
days of npyrexia; ru.sset-colored s*»ftening four times: red-brown softening twice: blackish softening, without injection, once; in a case of rupture of the
spleen, the mucous membrane of the stomach presented only a very slight recent injection with a gray tint ; finally, in a case of typhoid fever, there
was found that red color, with softening, pecidiar to acute gastro-enteritis. The siiiatl iitUxtine presented the following ehimges : Fifteen times soften-
ing with a gray, brown or slate-eolored tint with or without recent injecticm ; once the red sot^ening of acute enteritis; twelve times vestiges of honey-
etind»e<i i«itches, of which three presented the shaven-beard appeamnce; eleven times an abnormal development of llie solitiiry follicles: twice the circular
whitish pjitclies depressed ; once oidy nlcenitions: twice intussusceptions without redness : tViur times there were ni> lesions, and once the condition of the
small intestine wa« not re<:orded. The Iftrgt itiUxtinr presented anatomical lesions le.ss friMpicntly than the stotnacb and the small intestine. Inel.^vcn
cases it offered nothing of note : in three its c«»ndilit>n was not inentiimed ; its changes of texture and color were similar to those in the small inlesline
with the exception of the honey -comlwMl patches, which cannot be fonnetl there.
Mei.. Hist., Pt.'iII-19
14G POST-MORTEM RECORDS AND
The oondition of the liver was not stated iu /V»ni- of the cases; in eight it was reported normal. Enlarge-
ment is mentioned in sijcteeit cases, of which one was reported in addition to be pale and with soft yellow clots in
its vessels, one congested, one soft, one tubercular, one bluish, one slate-colored and one as presenting nutmeg folia-
tions. In one the liver was congested, in one congested and softened and in ttro softened; in one it presented the
nutmeg appearance; in one it was fatty, in one' pale and soft, in one fawn-colored, in one partly blackened, in
one bronzed, in one dark-colored and engorged with fluid blood and in one pultaceous. In one case the gall-blad-
der was found to be ulcerated.
Dr. Stewardson,* after a series of necropsies in cases of remittent fever, came to the
conclusion that a change in the color of the liver from a reddish-brown to a mixture of
gray and olive was the anatomical characteristic of the disease in the series which he
had studied, and probably also in all cases, as this series was made up of cases extending
over thi'ee successive seasons, and originating not in a single locality but in different and
widely separated places. The organ was described in individual cases as of the color of
bronze, of a mixture of bronze and olive or of a dull lead-color externally and bronzed with a
reddish shade internally. Post-mortem records antedating Stewardson's observations, made
occasional mention of an engorged and dark-colored liver in cases of malarial fevc; and
in 1847 MECKELf referred the coloration to pigment in the blood, where it was found later
by other investigators.
FrerichSjJ in 1854, during an epidemic of fever in Silesia, resulting from an overflow
of the Oder, observed deposits of pigment in the liver and spleen, and frequently in the
brain and kidneys. The liver was steel-gray, blackish or chocolate-colored, sometimes pre-
senting brown insulated figures on a dark ground. The pigment to which this coloration
was due consisted of granules, larger masses and true pigment-cells in the capillary net-
works of the portal and hepatic veins, and in many cases in the arteries. It was noticed
also that while there was enlargement from congestion in acute cases, the organ was fre-
quently diminished in size.§ Some years later Dr. J. Forsyth Meigs || made a series of
observations in the wards of the Pennsylvania Hospital which he presented as attesting
the accuracy of Frerichs' views.
The post-mo-rtem notes given above show such variety in the color of the organ that it is
impossible to consider the bronzed or gray and olive liver as a constant pathognomonic lesion.
Maillot ^ and E. Collin ** show similar autopsical results ; and Dutroulau, while
regarding congestion, with augmentation of volume and consistence, as the prominent
condition, refers also to fatty degeneration and changes in color from altered secretions, and
especially from the presence of pigment formed in the liver itself or derived from the spleen.ff
The SPLEENtt was normal in seven cases, while in einht its condition was not reported. There was
* See Observations on Jiemittent Fever/ounded upon cases observed in the Pennsylvania Hospital. Am. Jour. Ued. Sciences, Vol. I, N. S., 1841, p. 289.
t H. Meckel — ITeher schwarzes Pigment in dtr Ililz uvd dem Bluie finer Ccisteskranken. Allg. Zeitschr. fiir Psychiatric, Bd. IV, 1847, S. 198 —
first observed black pigment-cells in the blood of an insane patient who died of phthisis: it is not known whether he had intermittent fever. The spleen,
liver and brain were rich iu pigment. Vlltciiow— 2ur path. Phi/siologie des Bluts. Archiv, Bd. II, 1849, .S. 587— observed pigment-cells in the blood of
the heart of a man dead of malarial cachexia.
XA CJi:.i':al 'Idealise on Diseases of the Liver. New Sydenham .Soc, London, 1360, Vol. I, p. 317.
§"In all the cases which terminated fatally (38) tlie liver contained a quantity of pigment; in ten it appeared enlarged and congested and in eight
atrophied; in nine c?.ses the cells contained much oil ; lardaceous matter eoiild be detected in three cases, but ouly in small quantity. Except in one case,
pigment was always found in the ipleen ; throe limes this organ was lardaceous, and in thirty cases its volume exceeded the usual limit." Op. cit., p. 334.
II On thi Pathological Appearances presented in Marsh Fever. Am. Jour. Ucd. Set., Vol. L, N. S., 1865, p. 305.
TIThus Maillot; In Ivc instances the condition of the liver was not indicated; in five it presented nothing abnormal; nine times it was congested;
three times friable ; once brittle ; three times yellowish, pale and soft ; once jreenish-ycUow, and once it li.id the aspect of a cake of chocolate.
■** In Collin's S^ cases of pernicious fever the liver was normal in size in six cases and hypertrophied in forty-six ; in ten of the latter it was softened
and in two indurated. The color was altered in nineteen cases to such tints as dark -brown, chocolate, bistre, fawn-color and earth-color ; but he notes his
failure to observe the morbid coloration mentioned by .STEWARDSOX ia his Pe.insylvania Hospital cases. — Recueil de Memoires dc Medccine de Chirurgie
et de Pharmacie Militaires, *J« s6rie, t. IV, 1848, p. 128.
tt DUTBOULAU.— JVaifc des Maladies des Europeens dans lej pays chauds. Paris, 1864, p. 196.
JJ Maillot speaks of the spleen thus : In five cases its condition was not indicated ; in one only it appeared normal ; twenty-one times it was larger
than usual, in one instance without change of color or texture ; thirteen times it was of the color of the dregs of wine ; seven times chocolate-colored ; in
one case i t was broken and reduced to a wine-colored pulp, and iu one in which it resembled a cake of chocolate, its fibrous membrane was easily detached
and crackled like a sheet of parchment.
PATHOLOGY OF MALARIAL DISEASE. I4-
enlargenient in nineteen cast's, accouipanieil in ludrc with solteiiinji or luilpiiifss, ' in two with conjicslion
in OKC with ahscesst ami in one with inliltiation of pus. One spleen was conKt'steil and softened, ohp conftestcd
and <Uirk-coIored, owe soft and small, one seniilluid, one i)ultaceon8 and one iiiiii and of a dark mahogany-color.
The connection between enlargement of the spleen and periodic fevers has been rcco"--
nized from the earliest times, but as late as 1828 M. Gendrin noted the fact that medical
authorities maybe searched in vain for a thorough description of the changes in the spleen
in subjects dead of intermittent fever. He endeavored to determine the anatomical charac-
ters of these changes by massing and comparing the isolated facts recorded in special papers
and works on pathological anatomy. His results showed that the spleen was eitiier tumeiied,
with or without induration, or softened, with or without tumefaction. | M. Nepple,§ in 1841,
arrived at similar conclusions from a study of cases, but he added also that the stagnation
(if the blood in the spleen tended to hypertrophy, acute and chronic inflammations, soften-
ing and degeneration of tissue, which were often fatal. More recently Dutroulau|| sum-
marized the alterations in the spleen as simple congestion causing augmentation of volume,
hypertrophy of tissue from repeated congestions, and changes in the contained blood involv-
ing ditfluence and accumulation of pigment, with disorganization of the splenic tissue when
the blood has attained an extreme degree of dyscrasia. The cases presented by our
medical officers during the war illustrate the various splenic conditions from the normal to
disorganization without, and occasionally with, the intermediation of inflammatory action;
but no mention is made of pigmentary deposits in the organ ,T[ as the microscope was
seldom used in their post-mortem investigations.
Medical writers generally consider the changes in the spleen as the most frequent and
characteristic of those occurring in malarial fevers. In all of Laveran's cases the spleen
was enlarged and more or less softened.** In l)ut one of Maillot's cases was it normal.
Nevertheless in the cases presented by our medical records there are seven instances of
normal spleen in thirty-two cases in which its condition was reported. PiORRvff found it
healthy iu six of twenty-seven cases of intermittent fever. HaspelJ| also observed it
• RoKITA.seKI in his Pathological Atiaiomy. B. HI. S. 381. says tliat in obstruction of the circulation the blood, accumulated and retained in the
ni'lwn. creates a condition of hypenpniic turgescence with a dark-red color of the organ, and by its continuance produces hypertrnpliy of the tihrous
lissuefi as well as <»f the pulpy substance. This turgescence is alwaj-s characterized by some increase in consistence, firmness and density. The changes
■ ■f tissue following such turgescence may be very ditTcrent, inasmuch as they depend on the constitution of the blood, and therefor© may sometimes occur
as an induration and sometimes as a softening.
t COLUX — RenwH dts Mimoirts de Mid. Militaires. 2' s6rie, 1855, t. XV — Ruptures de la RaU — considers that external violence often acts as the
determining cause in the production of suppurative inflammation. Kl.ANC alsi». in his Absces dt la rate dans la cachexie palud/enne, Paris. 1879. agrees
with CoLLIS. as enlarged spleens are so common and abscess so rare in inalarions subjects, and especially since the piiiiits where abscess is deter-
mined are those most exposed to violence from without or from the traction caused by the weight of the enlarged organ. These iMiints are the suiierior
■ Ttremity. the external faee and the anterior margin ; hut the org.tn may be converted into a capsule filled with pus. in which case it is im(H>ssible to
i.-termine the point of initiation.
; The following is a rendition of M. tlF.XDRIX's conclusions; 1. The spleen is frequently affected in intermittent fever, and this affection has
■ T its prinei{tal characteristic an augmentation of volume. 2. The augmentation of v«tlume is always somewhat large and frequently considerable.
: The tumefaction is sometimes carried so far as to incommode mechanically the functions of the digestive organs. 4. The augmentation of volume extends
■' all directions, but particularly in length, ."i. The tissne of the tumefied spleen is augmcntcil in density, but there is no alteration in its texture ; its
v.-swls remain jiermeabte. 6. The tumefied spleen ma.v experience a certain degree of displacement by its own v,-oiglit. 7. The softening is the imme.
diale effect of certain intense periodical fevers or the result and termination of some old splenic engorgement. 8. The softening is of two kinds : 1st. Idio"
l<athic. or not seemingly dependent on any morbid affecti if a different nature; iid. Intlammatorj', and dependent niMin the infl;'.cimation the organ.
•It. There seems ut exist a direct relation between certain lesions of the spleen and cert.iin alterations of the blood. I '. The engorged and softened spleen
ID fevers may Ije nipturetl by causes direct*;d against it anil oper.iting against its tissue mechanically or through aug;nentation of the congestion of which
it is the seat. II. The rupture may be spontaneous fnuu the simple progres-s of the malady. 12. The chmnic engorgement >f the spleen following inter-
mittent fever is a frequent cause of fatal gastrij-intestinal haemorrhage. 13. >Vhen this accident occurs the spleen is softened and engorged with
blin,d. m'-re or less black, as if it were ruptured; the gastro-splenic veins are dilated, varicose and s<Mnetimes ruptured. 14. The spleen is directly
and immeiliately einpiie<l by li;piuorrhage into the digestive passages from the gastro-splenic vessels. 15. This disgorgement may be salutary, because
it may ilestroy the morbid comlition of the spleen. — Imirnal Giniral de Hid., Paris, lf27. t. C, p. 36.
^ Journal deMdfcixedr Li/on.t. I. 1841. p. M". - \\Op.cit,, p. 195.
•■ FliF.Klrils ileserilws the spleen as bluish hl.iek or dark-brown in color, either uniform or speckled, from deposited pigment. Op. cil., p. 318.
"' I.AVRU,\x. Ih^umnitf pftur ttrrir a 1' fluttnirr des Maladies du Xord de VAfriqtu. Mhnoires dt Mid. Militaires, !« ser.. t. Lll, 1842, p. 85.
tl na^rlu .Viilicnl, dt Paris. 1833, p. 398.
.;n.\iri£.\..— Maladies de I'Algerie. Paris. Is5l>, t. II, p. 318.
148 POST-MORTEM RECORDS AND
occasionally in its normal condition, especially when the fatal fever had not been of long
duration. Indeed, he considers the absence of splenic lesions in pernicious fevers as
frequent and remarkable, referring to Bailly and Jacquot for illustrations. Dutroulau
believes the spleen to be normal in 20 per cent, of the endemic fevers of hot climates.
The KIDNEYS were normal ill nine cases recorded by our medical officers, and not mentioned in sij-teeii. They
were large in tiro cases; large and white in one; congested hi five; fatty in three; flabby in one: jnile in one;
in one case they contained cysts and in another inis."
The condition of the heart was not stated in tnenty one of the cases ; it was recorded as normal in
ten cases, leaving only nine for special mention — thus: Hypertrophy in one case, dilatation in o/if. enlarge-
ment and fatty degeneration in one, flaccidity in one, softness in one and valvular lesions in fonr cases. Whitish
fibrinous clots were noted in the cardiac cavities in six instances, chiefly on the right side; in one case greenish
clots were found on the right side, in another loosely formed black clots on both sides, and in another black fluid
blood, which was frothy in the right but not in the left cavities. The pericardium was partially adherent to the
heart in one case, and in twelve cases there was an eft'usion of from one to four ounces of serum, which ^vas tinged
with blood in two cases and in one instance contained yellow coagula.
According to the French observersf changes in the muscular tissue of the cardiac walls
are frequently noted. Dutroulau, indeed, regards the alterations in the heart as second
in importance only to those in the spleen. M. Vallin| conceives the alteration to consist
of a primary transformation of the interfibrillar protoplasm into albuminous granules which
cloud the strine, cause swelling and end in fatty degeneration.
The Luxcs^ in the recorded cases were normal in nine, tubercular in three, more or less congested in ten,
inflamed in seven and ecchymosed in one; in ten their condition was not mentioned. There were adhesions in
fonr of the cases in which the state of the lung-tissue was not recorded, and a small pleuritic eft'usion in one in which
the lungs were normal. The pleura was adherent also in three cases in which the lungs were congested and in four
in which they were inflamed, and there was eifusion in two of the pneumonitic and one of the tubercular cases.
The BRAIN In ticenty-eigUt of the forty cases was probably not examined by our medical officers, as no men-
tion is made of its condition. An examination in twelve instances showed a normal condition in five. In one case
therf was venous congestion ; in three cases the brain was engorged with blood and presented efl"usion under the
membranes or in the ventricles; in one of these the serum was jaundiced, the blood black and the cerebral tissue
firm, and in another the brain-substance was of a darker ash-color than usual. In (/tree cases there were indications of
inflammatory action, in one injection of the meningeal vessels with some exudation near the longitudinal sinus, in
another a similar injection with opacity of the arachnoid, and in the third case thickening of the membranes, eft'usion
and circumscribed softening of the cerebral tissue.
Maillot found the brain affected so frequently || that he regarded malarial fevers as
* Dt'TROL'LAU says of these or^ns, that when blond and albutnen have been observed in the urine with some persistence the post-marttm examina-
tion shows either pigfmentation of the cortical substance or a lardaceous desrcnemtion with an accumuiation of pi^nent. Op. cit.. p. 197.
tTlms MaILLOI: The heart in si.ic cases was flabby and pule: one*' Habby witli ycllowisli coloration ; once flabby with dilatation of the let^ ventricle,
and fitur times the walls of this ventricle were hypertrophied. Laveuax — The heart was of diminished consistence in nine of fourteen cases. Op. cit., p.
H4. Col.Llx's experience also shows the heart as frequently alfected. In his fifty-two cases of peniicious fever it was nt)rmal in twt>-fiftlis: its volnnie
was augmented in three-tenths, and in one-half it was flaccid aud of a dull livid color. These characters were even luore prominent in the clminic cases;
In sixty-one cases the physiological condition was noted only in one-fourth, flaccidity with a dull or onion-peel color in two-thirds and augmented volume
in four-ninths. Op. cit., p. 139.
* M. E. Vallix, De^ aUtratimts Bistologiques du cceur et des Muscles rolontaires dans ks Jtieres pernicieuses et remittentes. Recueil de Memoirts
deMid. ilHitaires, 3»' ser., t. X.\X. Paris, 1874. p. 19 et stq.
^ M.\IL!.OT continues ; In one case the chest was not opened : in one. also, it offered nothing abnormal. Thirteen times the pleura presented old
adhesions, but the lungs were sound: in one case there was hepatization of the apes of the right lung, aud in another some siHiotifuls of russet-colored
serum in the left cavity. Lavek.\x says that in his cases the lungs were always engorged and the bronchial tubes oftentimes filled with blood-tinged
mucus. Op. cit., p. 65. In COLLlx's fifty-two pernicious cases the lungs were normal in only two instances ; they were deeply congested in the majority
and splenified in one-fifth of the subjects. Op. cit., p. 135.
II Maillot's summary is as follows ; MtmhraJies of the brain. — Five times the arachnoid was generally opaque (once this general opacity coincided
with the development of Pacchioni's glands ; once, with the s.tme alteration, there were adhesions to the dura mater and a gelatinous subarachnoid infil-
tration): three times the opacity was confined to the sulci between certain convolutions; in one case of algid icteric fever the arachnoid had a yellowish
tint; in one case of quotidian fever which had become typhoid there w.as a collection of purulent serum in the cavity of the arachnoid. In eleven cases
the pia aiater was more or less vividly injected, the arachnoid not being so: in six other cases these membranes were simitltaneously the seat of a vemtil-
ion-colored injection ; in the majority of the cases the superficial vessels of the encephalon were markedly congested: several times the injection of the
dilTerent membnines was sufficiently fine to form more or less e.vtensivc patches of an intense and brilliant red. Brain. — Twenty-two times the brain was more -
or less injected ; generally of a density and firmness which seemed much more pronounced than natural. Ordinarily it showed a closelj- imnctated red
*'oloration ; in some cases of comatose and delirious fevers the cerebnil mass was so intensely cimgested that on compressing it the blood issued from its
cut surface as if from a saturated cloth. Eight times we noted a dark coloration of the gray matter, which in five cases was even blackish ; six times the
choroid plexus was of a dark reil color; ten times the ventricles contained a sanguinolent serum. In a comatose fever the brain was soft, although much
injected: in a case of algid icteric fever it was slightly injected, of ordinary consistence and yellowish in color; in three other cases it was also slightly
injected, but without change of color or consistence. The nervous substance of the cerebellum presented less frequently than its membranes alterations
analogous to those in the brain and its membranes. Membranes of the spinal cord. — Fourteen times the spinal pia mater was the seat of a vermilion
injection; five times the arachnoid and the pia mater were simultaneously injected; in a case of algid icteric fever both had a yellowish color; in another
PATHOLOGY OF MALARIAL DISEASE. 149
due to ill! irritation having for its anatomical character a hyperjemia of the nervous
matter and its membranes. The dark coloration of the brain-substance was observed by
liim and others, especially by Bright/^' who illustrated the condition, long before Frkricus
drew attention to it and connected it with other pigmentations in malarial cases. More
recently Hammond has suggested the possibility of recognizing this condition during life.j-
In one of tlu- forty recorded cases the rAUOTii) t;L.vXD8 were iutlaiiu-d. and in one the pso.e :\irsci,Ks were
lilaekeiied and disorganized,}
The OKN'ERAL MASS OF THE HLOOD \s spcciaUy mentioned in two cases as having undergone change; in one it
was diffluent and in the other watery and degenerated. In a third case hlood, wliieh had t^seaped into tlie pleural
cavities, was xincoagulahle, its red corpuscles broken down, stellated and withered, its white corpuscles relatively
numerous and its serum ot*a reddish-yelhiw color. But an altered condition of the blood is suggested by the records
of many other cases: as by the occasional blood-tinge shown by the eft'usiou into the pericardium; the loose
lilack clots in the heart; the black blood with which the cerebral veins and occasionally those of other organs were
loaded, the vessels in one instance having presented yellow specks between tracts of black fluid blood; the soft,
greenish, pus-like coagulation which had taken place in the heart and portal veins of one subject, the filuinonsheart-
elots of several cast's, and the fr*Minent softening and occasional tlegcncration of tb<; livi . and s]>li'en, api)arently
unconnected with intlaniniatory i>rocesses. Unfortunately the microscope was seldom used, and the records therefore
liive hut little inf(»rmalion as to tlie details of this altered condition. 'iS
ii-ir otmdilion was not stated. MfdtUlary substance. — In four coses the cord was generally injected and more than ordinarily firm : in una case it was 1<>m»
hnii tliitn iiatuml; in one the injection was very slight ; three times it presented a normal consistency without injection; in two cases the injection wuh
Keneml. but much mi>re marked in the cerx'ical and lumbar regions ; in one it was of a yellowish tint without other change ; in four (here was general
Injeclior with red dursai softening: in three the softening. di»i"sal also, was white; in another the white softening had its scat in the cervical region;
finally, in oni' case the injection of the pray matter, generally more pronounced than that of the white matter, was very intense in the cervical arch, ami
extended to the red softening in the doraal portion.
* HUK^lir — Reptirls nf Mfdical Casts, London. 1831, Case CI. Vol. 11. p. 217, Plates XVII and XIX. 'I'he cortical substance of the bmin was almost
of the color of Idack lead, and the niinulc circulation ui the ciaeriiious substance was so loaded with venous blood as to give one genenil ]>urplegniy
color. The medullary nuitter was of a uniform dead gray-white color, which appeared to he given by innumerable line gray specks and short huir-like
vessels resembling ihc appcanince produced by scraping the nap of fine cloth upon a sheet of paper.
tin an article im I*igmtntary Deposits in the Brain resuUiug from Malarial I*tnsoning, in the Trans. Anier. JVctirolugical Association, 1H7.'»,
I tr. W. A. HAMMONn pointed out that in atTeclions of the nervous system having a malarial origin, and in which presumably there are cerebral pigment-
Hry ile|H.sits. similar fonnntiuns may often be detected in the retina by ophthalmoscopic examination. See also a contribution to the study of ilie nature
and consequences of malarial poisoning. — St. Louis Clinical Jttcord, \'ol. IV. 1H77. p. 129.
J SI. V.VLI.IX discovered cloudy swelling, obscuration of stria; and fatty degeneration in the fibres of the recti muscles, especially towards their
lower part. See article already referred to in connection with changes in the muscular tis.<ucs of the heart.
§The altered condition of the blood was studied by BEcciUEHKi. and Uomiiii—Jitcherches relatives d la composilion dii Sang, dajis Vitat
de santiet dans Vitat dt matadie. Compt. rend., Paris, 18-14, XIX, p. 1083; and by LtoXAUD and FOLEY in 3845 — Recueil de Mini, tie J/*'rf., rf-c.
MiUlaires, I. LX. The latter i-eporters made analyses of the blood in sixty six cases of Algerine fever. Their results show. p. 191, a watery condition
due to diminution of globules, albumen and inorganic constituents of the serum, without augmentation of fibrin, unless, as in rare cases, the congestion of
the organs had deveU>ped into inflammation. Dr. .Ioskch JOXKS gives the following as the results of his investigation into the character of the changes
in the blood: "1. In malarial fever the specific- gravity of the blood and serum is diminished. The specific gravity of the blond ranges in this disease
from 103(1..'» to 1042.4, and the specific gravity <>f the serum from 1018 to 10-,>:(.n. In health, on the «»ther hand, the specific gravity of the blood varies from
lOTwi to KKCJ. and the specifir gniviiy of the serum from 1027 to 1032. 2. In malarial fever the colored blood corpuscles are greatly diminished. In health
the dried corpuscles may vary from 120 to l.')0 parts in the 1.000 of blood, and the moist blood corpuscles from 480 to fiOO. In malarial fever, on the other
hanti. tlie dried colored corpuscles range from TiLiiP garts to 107.81, and the moist blood-corpu-scles from 207.92 to 323.63. The careful comparison of iliese
analyses of malarial bIo<id with each other reveals the fact that the extent and rapidit}- of the diminution of the colored corpuscles corrcsi>oiids to the
severity and duration of the disease; a short but violent attack of congestive or of remittent fever, in its severer forms, will accomplish as great a dimi-
nution of the C4ilored blood-corpuscles as ft long attack of intermittent fever, or the prolonged action of the malarial poison. 3. In malarial fever the
relation lietween the colored corpuscles and liquor sanguinis is deranged. Thus in healthy blood the relative proportions of moist blood corpuscles in the
l.UOU parts and liquor sanguinis may vary from 480.00 to (100.00 of the former, and from 520.00 to 400.00 of the latter; whilst in malarial fever the globules
Tary fhiin 207.M to 323.f>3, and the li(iuor sanguinis from 7^2.08 to 676.37. 4. The fibrin of the blood is diminished to a marked extent in some cases of
malarial ffver. and is altered in its pro|>crties and in its relations to the other elements of the blood and to the bloodvessels. S. The organic matters of
the liquor stmguinis. and especially the ulbumen. \s diminished in malarial (e\er. Thus the solid matters of the serum may vary in health from W to 105;
whilst in malarial fever they vary from 62.78 to 80.22 parts in the 1,000 jmrts of blood." — Medical and Surgical Memoirs, New Orleans, 1876, Vol. I, p.
5H6. Dr. JoSKS makes no mention of pigment in the blood although aware of Frekichs" views, which he discusses in connection with the autopsies of his
cases of rhnmic malarial poisoning, in both of which the liver and spleen, and in one the brain, were densely loaded with black pigment. American
ixithologisis do not appear to have pn>secuted the study of the blood-changes. HUTCHiNSOX. in an article on a case of enlarged spleen, with remarks on the
malarial cachexia, in the Med. Sncs and Abstract, Vol. XX.WIII, 1880, p. 449, reports a microscopical examination of the blood its follows : " 'I'he red corpus-
cles are irregular in shape and size, and form themselves poorly into rouleaux. Most of them show a tendency to alter in shape— to become double eon-
Tex. The white corpuscles also vary in size and are slightly increased in number, a few more of them being seen in a field than in hejilth, hut the blood
-is not leuciK-ylha'mie. There is no evidence «»f pigmentation." Dr. RiriiAIti) liKi^CHl>—t'cberI*igmentbildung nack Ffbris intermittais. Zeitschr. der
knis. kon. Geselhchaft der Aerzte zu Wein, Ud. I, 1850. S. 338 — describes the pigment as consisting partly of dark-brown and partly of dark-violet bodies
ab«mt as large as blood coriniseles. some enclosed in cells and the others isolated or adherent in masses of twenty or thirty granules, generaHy lying close
li» the ci»ais »»f the vessel. A subsequent article— Fetcr das Wechseljitber und die capillarcn Blutungen in der Melandmie. Oestcrreichische Xeitschri/t
fUr Praktische Beilk-unde. Wein, Bd. VIII. 1862, S. 810 ff .«7.— gives among others the fullowing conclusions: Thepeculiarpigmentof intermittent fever
cranes neither from an arrest of blood in the vessels, which VlltCHOW holds as one of the conditions of its occurrence, nor from haemorrhage, but from the
cohmng nmtter of the hinml leaving the blood -corpuscles. The coloring matter is communicated to the ctiats of the vessels, and may there ho foimd at
first as a reddish, and later, oftentimes as a dark-bn>wn substance; while the corpuscles not entirely deprived of their coloring matter continue to circulate
with the rest of the bliHwl as snmll reddish lo()king bodies. The principal sent of this pigment formation in severe cases is the brain, and in mild cases
t!ie liver or spleen. This peculiar hue of the coloring matter of the blood is due to the action of ftialaria, as it is ob«er\'ed only in cases of disease
ariMiiEr fr«,in this cause. Dr. Jti.. !*T.ANKK — ^eher das Vorkommen von Pigment im Hlute. Zeitschr. der k. k. Ges. der Aerzt*. zu Wien, 1854, Bd. I, S.
126(t**-y.— fuund pigment in the spleen, liver and brain of the subjtKJis of intermittent fever. Ilhxjd taken from (he living subject contained a nndtitude of
150 POST-MORTEM BECORDS AND
The varying and sometimes liealtliy conilition of eacli of the organs presented iu these
records gives assurance that no one of them is entitled to have its changes from the
normal state regarded as pathognomonic of malarial disease. The opinion of Maillot con-
necting the disease with a hypereemic condition of the nervous matter and its membranes,
that of Stewardson, holding the bronze coloration of the liver as essential, and that of
many French writers, associating the febrile manifestations with enlargement of the spleen,
are rendered equally untenable by this one consideration. Maillot considered the hyper-
£emia to be tlie cause of the fever and not simply an accompanying anatomical fact.
Stewardson was content to regard the liver-change as pathognomonic, without insisting on
its being the cause of the morbid phenomena, since there was no evidence that it existed
at the commencement of the fever and the early symptoms could not be traced to it as their
source. The enlargement of the spleen, so long known to be associated with malarial
disease, and the softening and occasional inflammatory appearances presented by it are
undoubtedly suggestive of an intimate relationship between the fevers and the changed con-
dition of the organ. Audouard* held the tumefaction to be the effect of a congestion
which preceded and determined the fever. At that time medical opinion generally considered
malarial fever as an affection of the nervous system, the particular seat of which remained
involved in obscurity, while the affection of the spleen was regarded as connected with an
obstacle to the circulation in the portal system not pertaining exclusively to intermittent
fever.f Following Audouard, Piorry concluded that the tumefaction was essentially a
brown and black masses similar to those often seen in post-morUni blood. But cell-like pigment bodies were constantly found. Dr. Plaser admits that
the subject of j^ignient-forraation is as yet far from being understood to its full extent, and that there is nothing in his observations to enable us to decide
upon the manner or place of its formation. Fkeuichs describes the pigment found in the blood as usually in the form of small rounded or angular gran-
ules, sometiaies sharply defined and at others surrounded by a brownish or pale margin. They are occasionally isolated, but more frequently lield
togetiier in small aggregatiuns by a pale hyaline connecting substance. The groups are rounded, elongated or irregularly branched. True pigment-
cells are also observed, although in smaller numbers than the granules and granular masses. The color is usually deep black, more rarely brown or
ochre-colored, and least frequently jeddish-yellow. The pigment exists in greatest abundance in the blood of the portal veins. He regards it as formed
chiefly in the spleen, as the spindle and club-shaped cells with rounded nuclei in the blood resemble those which are found along with free granules in
the spleen. But he conceives that the liver also may be concerned in the production of the pigment, as in one case of death after a protracted quartan the
spleen was enlarj;ed. lardaceous and completely free from pigmtnt, while the liver contained considerable quantities. A. Kelsch — Contribution a
VAnat. Path, dfs Maladies Palustres cudiniiques. Archiras tie I'hi/x. iiormale etpatJi., 2^ s6rie, t. n, 1875, p. ti'Jl. This investigator counted the number
of blood-corpuscles in seventy cases of acute and clironic malarial poisoning at the hospital at Phillii>evi!le in 1874-5 and found an invariable diminution
in the number of the red corpuscles (oligocythiemia). Twenly to tliirty days of simple remittent, quotidian or tertian fever reduced the number from five
millions to one million, or even as low as half a million per cubic millimeter. He observed that a quotidian or remittent fever, on its first
invasion, would reduce the number of globules as much as two millions per cubic millimetre iu four days or even one million in a single day. But
usually, as soon as the oligocythaemia was established, at one to two million globules per cubic millimetre, it remaioed stationary or nearly so. The white
globules were also generally diminished i.i number, and i»niportionally even more than the red, notwithstanding the enlargement of the spleen ; their
number was one to one, two or three thousand red: but there were exceptions to this: in a few cases the white corpuscles were relatively more numerous
than in health. He counted in particular instances 1 to 11)2, 118 or even 112 red. These blood-changes are more rapid during the first few daj's of the
fever; ttiey continue, but more slowly, for a longer period, and then remain stationary or nearly so. AVhile the red corpuscles were found t(» be diminished
in number their transverse diameter was increased, in some instances to U. 12 and even 13 raicromillimetres ; the smallest mean in fourteen cases, in each
uf which one hundred globules were measured, was 7.B89 and the largest mean 9.429 micromillimetres. In pernicious fever there is a rapid diminution iu
the number of the red corpuscles, amounting to from half a million to a million a day at the beginning of new cases ; but in those that super\'ene on previous
malarial anemia the decrease is less rapid, from lUO.OOO to 200,001) a day. In these cases the white corpuscles are relatively and absolutely increased in
number; there may be as many as 1 to 200 or even 70 red, in this respect differing from the blood in ordinary agues. He observed pigment in the white
corpuscles of the blood twenty-four times in twenty -four cases of pernicious fever. In forty-seven chronic cases he had twenty-one negative and twenty-
six positive results ; of the latter twelve were observed during life, the others after death. He never found pigment in the peripheral vessels unless the
portal and splenic veins, the liver, spleen and bone-marrow were saturated ; on the contrary, in fourteen autopsies he found it in these internal parts,
although there was none iu the peripheral vessels. In eight cases of ordinary ague, on jtricking the finger immediately after a paroxysm, he found the
pigment five times. In a later paper — JS'nuvelle Contribution d. VAnat. Path, des Maladies Palustres endnniqiifs. Archives de Phys. normale et path., 2*
s§rie, t. Ill, 187ii. p. 191 — Kelsch states that during the intermittent attack the leucocytes diminish in greater proportion than the red corpuscles. The
diminution is rapid and continuous, reaching as low as one-lialf or one third of their number before the attack. One or two days are required for their
re establishment. The swelling of the spleen is coincident with their disappeai-ance ; but these phenomena are not proportionate. In the cachectic cases
the leucocytes are diminished, but not in projwrtion to the splenic enlargement.
*Jour. Gen. de Mid., t. LXXXIII, Paris, 1823, p. 245.
f At a later date Dr. Eisexm.vnx, in an article on the proximate cause of enlargement of the spleen in intermittent fever and fevers generally, in the
Archivfiir die gesammte Medicin, B. V, Jena, 184'J, S. 401, refers the tumefaction of the spleen to the chill. He was led to this opinion by reading the
histories of two cases, one of hepatic phlebitis brought on by a fish-bone, which, in its progress from the stomach, had transfixed the superior mesenteric
vein, and the other a case of rupture of a metastatic abscess into one of the hepatic veins. In both there were repeated chills with splenic enlargement.
He considers, therefore, that since we have tumefaction of the spleen in varieties <»f fevers which in their origin, nature and indications are wholly differ-
ent, we may enquire whether this enlargement does not belong to the fevers as such, originating in the febrile movement, no matter on what cause the
latter is dependent. During the chill the capillaritjs are greatly contracted and tlie blmxl partly or wholly excluded IVoiu them, in consequence of which
PATHOLOGY OF MALARIAL DISEASE. 151
congestion, although intlamnuitory cluuiges might in progress of time appear, and was
inclined to view the fever as connected with the condition of the spleen.* NELETf strength-
.'ued this view by reporting a case in which an inflammation of the spleen caused by
ixternal violence was immediately followe^l by intermittent fever which was cured by
ijuinine. CohadonJ in his thesis argued in behalf of Piorry's theory, that interraittents
are due to a pathological condition of the spleen and of the portions of the nervous system
which correspond with that organ. Pezerat,§ however, was tlie most outspokeu advocate of
the view that intermitteats are due to an inflammation of the spleen. His principal arguuK-nt
was the existence of tumefaction and pain in the organ, but it was shown by Nepple,||
XiVET^[ and others, that while this pain is absent in many intermittent cases it is present
with tumefaction in other diseases, as typhoid fever, in wliic-h there are no intermittent
symptoms. The very character of the fever was an obstacle to the acceptance of Fezerat's
views, as the tendency of inflammation, once established, is to progress not to intermit.
Moreover, Gendrin had already shown that the tumefaction occurs witliout inflammation
or other material change in the intimate structure of the organ. The enlargement was
therefore held to be the effect, not the cause, of the febrile manifestations. Finally,
Dutroulau ** argued that while the state of the spleen is the most frequent and marked
characteristic of malarial fevers, and sometimes one of the causes of grave symptoms, it is
neither the point of departure nor the seat of the febrile phenomena.
But before, and during the continuance of, this contest as to the connection of splenic
engorgement with the intermittent phenomena, there was an underlying idea that th(; ron-
dition of the blood stood in a peculiar relation to the organ and occasioned its congestion.
One of Gendrin's conclusions points to vitiation of the blood. Nivet held that in inter-
mittents, as in scurvy and typhoid fever, in which also there is engorgement, the disease is
general and the blood probably altered. Even Fiorry regarded a change in the blood as
antecedent to the pathological condition of the spleen. Some light was thrown upon this
point by the discovery of the 23igmented condition of certain of the viscera in malarial
fevers. Frerichs considered that the disorganization of the blood was effected in the
spleen, suggesting in explanation that during the stasis which takes place in the blood-
current as it passes from the arterial system into the splenic sinuses, a stasis which is aug-
mented in the congested state of the organ consequent on malarial fever, conglomerate
masses of blood corpuscles are transformed into pigment, which is afterwards arrested in
the capillaries of the liver, brain, kidneys, &c. The spleen, however, could not be consid-
i^red the only organ actively concerned in the disorganization, as much pigment had been
found, in one case, in the liver, while there was but little in the lardaceous spleen. But
I !jt' Uirger vessels and lieart become overloaded. In this turgescence the spleen has a great share, as it seems designed for the reception of blood in a dis-
■ rilered state of the circulatitin, to obviate thereby the dangers arising from such disturbance. He alludes to the fact thatsplenic enlargement may arise from
ii>.'rdere<i circulation resulting from heart disease, as sh(»wii by Bltl^UA — (Jiitpjtorto della vliiiira di Padova, 1S12, p. 12} ; NA88E — {Horn's Archiv, IHly,
\iigust, .S. I'JO), and .SOUCHOITE. (.Wem. de la Soc. de Mil. Prat. di. Monlpellie.r, t. XX, p. 243-2.54)— and inquires why there should nut be au
vfrcharging of the spleen with blood, and a consequent enlargement, in a disturbance of the circulation due to spasm of the capillaries in the chill
"f fevere. He concludes that since all the facts and direct observations indicate that the chill causes the splenic engorgement, this condition will be found
.11 every fever which begins with a chill, and will be most marked in intermittents, because in theiu the chill is not only more severe than in other febrile
diseases but more frequent in its recurrences. Si> also in the fever arising from purulent infection, where the chills return frequently tlie enlargement of
the spleen will be marked ; but in those having only a single chill the augmentation naturally cannot be so great. Besides the character of the fever the
lone nf the tissues seem to have an influence on the enlargement ; for in adynamic fevers in whicrb the tissues have lost their tone the spleen will make less
resistance to the blood forced upon it in the cold stage, and in time will have less power to remove the accumulated blood, than in sthenic cases in which the
tiwiues remain vigonms. In irritative and inflammatory fevers the splenic enlargement need be sought for only while the chill lasts, and no great increase
neetl tie expectetl, while in asthenic forms it is not only great but (»f longer duration.
* ilimoirt cur r-lat dr la rait dans lesfiirres intermittcntes. Gazette ilidicale, 1833, p. 303,
t Archivet Giniralcs de .)/. i/fcint, S" serie, t. V, 18.34, p. J37, J COUAVOH—Colkction des Thhet. Paris, 1847, t. Ill, No. 31.
5 Archiret GineraUs dr .Vnlecinr, 2' s6rie. t. V, 1834, p. 199. II Sf.PVI.E— Gazelle Midicale, t. IV, -;:;:!, p. 613.
\ NIVET— Jnnu/ei de .V,:U. Belye, t. II, 1838, p. S5. ** 02>. cit., p. 19S.
152 POST-MOETEM EECORDS AND
the valuable researches of Kelsch appear to warrant liis conclusion that the pigment is
formed in the mass of the circulating blood and is deposited therefrom in the substance of
those organs when a stasis in the circulation affords conditions favorable for sedimentation.
He reo-ards the splenic melanosis as secondary to the appearance of the pigment in the
blood because in two of his cases there was little deposit in the spleen while the blood was
charged with masses of pigment, and because the deposition of this melansemic pigment is
conducted in the same manner as that of other matters, such as cinnabar, which have been
artificially introduced into the circulation.* In a later paper KELSCHf concludes from his
many observations that the presence of this pigment in the blood is a pathognomonic sign
of acute malarial poisoning; that it is not found in chronic cases in the absence of febrile
accessions, and that it is an intermittent phenomenon allied to the other intermittent mani-
festations of acute impaludisni, with which it appears and disappears.
In summarizing the post-mortem records left by our medical officers it is evident, not
only that tlie condition of no one organ is the cause of malarial manifestations, but that
these are due primarily to a morbid condition of the blood. In this way onlv mav death be
accounted for in cases characterized by alteration of the blood with but little enlargement
of the liver or spleen. In this way also may be explained the pigmentary deposits
associated with stasis of the blood, from engorgement as in the sj)leen. or from congestion or
inflammatory conditions in other organs as the liver, brain or intestinal canal.
The change in the blood is presented as of two different characters: one in which it
was thin and watery with a tendency to effusion and separation of fibrin; and the other in
which it became black and disorganized. The former was its condition in intermittent and
chronic cases, as indicated by such symptoms as anseraia, debility and eftusion, and by the
post-7norte?n appearances in those cases in which death occurred less from the intensity of
the poisonous influence than from some accidental circumstance, as heart-clot in cases 95
and 96, or from the effects of some complication, as in case 75. Tlie latter was its condi-
tion during pernicious attacks. These changes were produced in the blood by the operation
of the malarial influence. 'If they are regarded instead as due to the action of the enlarged
or softened spleen, which was s« frequently present, the disorganization of the blood would
be proportioned to the splenic alteration. But the presence of blood capable of continuing
life in a patient whose spleen weighed sixty-eight ounces, case 100, is inconsistent with the
idea of the participation of this organ in the disorganizing process. In other cases death
occurred from altered blood although the spleen weighed only a few ounces more than usual.
The notably enlarged spleen is a characteristic of chronicity; it corresponds to a mildness
of the poison, as where the disease occurs in temperate climates, or to an accommodation
of the system to pernicious doses, where it occurs in highly malarious localities. On the
other hand, in some of the fatal remittents the spleen was found to be unaffected. Instead,
therefore, of regarding this organ as an active agent in the disoi'ganization of the blood, its
action may plausibly be considered as conservative, preventing dangerous congestions in
other organs by its enlargement, and preserving the blood from that diffluent and black
condition which is the concomitant and probable cause of the more dangerous pyresial
manifestations. It may be that the action of the spleen is mechanical : as suggested by
*Lanzi and Tebrigi — II miasma palustrf. Kom.a, 1875 — connert niiilanal diseases with certain dark-colored granules found in the cells of micro-
scopic alg:«, which in the winter cover the Kutnan Cainpagna, but die under tlie heat and dryness of tlie sutnraer and are converted into a dark-uolore<l
humus. The dust particles from this are affirmed to be identical with the black pigment of malarial disease, and to act as a fermest when introduced into
the human system.
f .\. KELSOIl — Contrihution a Vhisttiirr ilfS muludii'ii pahistffS — lie lu Mt-hiiiei/n'i- — Archives Gen. fit Meil.. 7""' serie, t. VI, 1880, p. 385.
PATHOLOr.Y OF MALARIAL HI^iKASK. 15S
Kelsch, the pigment-masses may be removed from the cireiilating blood by a process of
sedimenj;ation; but the hypertrophy which is so frequently found in chronic cases appears to
indicate that there is a vital action involved in the removal of the malarial poison from the
bhiod and in the regeneration of the latter after its disorganization by the morbific a'l-ent.
v.— CAUSATION OF MALARIAL DISEASE.
The following extracts from sanitary reports have been selected from many of a similar
tenor as indicating the views of our medical officers on the causation of malarial disease:
Surgeon F. L. Diniu.E. Glh Coini. Vols., Ilawfiiskie Island, S. C, March 31, 1862. — Tlic regiment remained at Hilton
Head, S. C"., during tlie tirst twenty days of January, 1862, Avhen it was ordered to eniliark — aboiil 800 strong— on
the steamer I'oaiiiopolitan. Tlie l)oat at best was not eupalile of aoooniinodating over four liundred men for any length
of time. From some unexplained cause the command was kept on tlie crowded transi)ort for five days in the harbor
of Port Royal and for fifteen more in Warsaw Sound, when it was ordered to encamp on Warsaw Island, (Ja. Tlie side
of the islanil where the troops were lauded did not atVord sutlicient dry land to lay out a regular encampment, and
the tents of the men were huddled together without regard to order. What we saw of the island was one vast
swam|i. The climate is nearly the same as at Hilton Head, generally mild and eiiuable. The disease that particu-
larly aft'ected the regiment at this place was the congestive or pernicious fever of the coast, which raged for the first
five days after we landed with almost incredilile violence. Of the fatal cases not more than two lived twenty-four
hours after the coninieucement of the attack. While at Warsaw Island the only duty exacted of the troojis, besides
the usual guard and picket duty, was about three hours daily drill. The conuuand remained on shore about nine
days, when it was ordered to re-embark on the little transport, and there we lay lazily at anchor for the eleven suc-
ceeding days in Warsaw ."^ouud. At the expiration of this time (jeneral Sherman, by advice of the Medical Director,
ordered the return of the regiment to Hilton Head. It should be stated, however, that when the order came to
return lu) fatal ease had occurred for the previous twelve days. For the next twenty days the regiment remained
at Hilton Head, when it was ordered to the support of General Viele at Dawfuskie Island, S. C. [The report of
sick and wounded from this regiment for the ([uarter ending March 31, 1862, gives a mean strength of 0:12 oHicers and
men, among whom were 22 cases of congestive fever with 11 deaths.]
Surgeon J\s.\l.TuoMl'SOS. V2th Me. f'olx.. Xew Orleans, La., October 1, 1862. — The vicinity in which the above-
nu'Utioned companies were stationed is, if possible, more marshy and unhealthy than the rest. Tlie marshes are
irregularly intersected w ith deej) sluggish bayous and lagoons: this fact, in connection with the effluvia from the
canals or sewers before mentioned, explains the large number of intermittent and continued fevers reported.
Surgeon James Buy ax, V. S. Vols.,oppoiiite Vickahirg, June 27, 1863. — The vicinity of the great swamjjs near the
Mississippi ]iermitted the malaria to be borne by the prevailing winds to the locality of our hospital, and convalesc-
ents and patients from this cause were liable to new attacks and rela]>ses. The only erticient preventive, .judiciously
administered, was quinine. This was found a sure prophylactic; liut becoming .scarce we had to resort to cinchona,
which, in hirger doses, we found to be equally ettectual lioth as a prophylactic and a remedy.
Surgeon S. K. Towi.K. 30(/i Mass. Vols., Deaniher 31. 1862. — July 1, 1862, the regiment was in bivouac on the
swampy ]ioint opposite Vicksburg, where it had been about ten days. This whole locality had just emerged from
an overflow of many weeks' duration, and was still barely passable through mud and water from ankle to armpit
deep, the slope of the level being the only place upon which the men could sleep. About the 10th the bivouac was
changed to alongside the canal or cut-oft" being dug across the bend of the river through a heavily wooded swamp —
thus a<lding the deleterious influence of large quantities of fresh soil of vegetable origin, daily thrown up, to that
already experienced from the thick deposit of the long flood. This position was occupied to the end of the month,
when the place was evacuated. During this time the men had no tents, but were required to build booths of branches
as a partial protection from rains and heavy dews, and to construct platforms of ]ioIes two or three feet high upcni
which to sleep. Moreover, the duties were very severe. At first, on account of the mud and water in laying out the
canal and cutting the trees from its course, many of the men were wet day and night : after this, digging the cut-off
entaileil similar hardships and cxjiosures. There were also frequent alarms at night and much guard, picket an<'
>iconting duty, exposing them greatly to both dew and sun. Drills were also ordered, after the first few days, from 5
to ij A. M. (practically before breakfast) and again for two and a half hours in the afternoon. The diet was ex<:lu-
sively, as it had been with but slight exceptions since leaving .Ma.ssachusetts in January, salt meat and hard bread,
ami nuiny of the men exhibited in conseciuence the preliminary symptoms of scurvy. All the circumstances tended
to depress the spirits, and there was no prospect of any change for the better unless the entire object of the ex7>edi-
tion was abandoned.
As the immediate result of this long exposure to intense malaria unde'' circnmstances tending to still further
increa.se disease, a malignant form of remittent fever became very prevalent, with a strong tendency to take on the
congestive type. Out of the eight hundred picked men (one hundred and fifty feeble and second-rate men had been left
behind) eighteen died in the swamp, while at the time the regiment left that position more than half of the entire
Mkh, Hist., Vt. Ill— 20
154 CAUSATION OF
force was on the sick list, two hundred being in hospital and more than that number sick in quarters. The hospital
accommodations were negro huts and steamboat decks, with no beds, bedding, stores or provisions other than rations,
obtainable excepting by seizure.
During August the regiment was at Baton Rouge, La., where on the 5th it took part in the battle, losing four
killed and eighteen wounded. The sick list during this month was never below four hundred, almost entirely from
malarial diseases, chiefly remittent fevers. In September and October the regiment was encamped near CarroUton,
La., on the so-called Metairie ridge, near the swamp extremity of the fortifications defending New Orleans from
attack from up-river. This ridge at the point of encampment is but a few feet above the heavily wooded swamp
within gunshot on either side, and with the exception of the fresh deposit of decaying vegetable matter, was but
little if any improvement over the swamp opposite Vicksburg, producing the same class of diseases, although some-
what less pernicions in type. At Baton Rouge and Carrollton the men got vegetables enough to eradicate the scor-
butic symptoms, and the labor and exposure were less; but the sick list did not fall at any time much below four
hundred, and generally three hundred were in the hospital. Nearly all those who had remittent fever from the
exposure at Vicksburg had repeated attacks at Carrollton, and of the few who had escaped up-river not one, ofiScer
or private, escaped illness from the efl'ect of malaria at the latter locality. Although the general type of malarial
disease was somewhat less severe at Carrollton than at Vicksburg, the men had become so debilitated by repeated
attacks that the mortality was no less. There also resulted a class of chronic cases, with diarrhoea, anasarca and
anajmia, tending apparently irresistibly to death by exhaustion of the vital powers. Hospital accommodations were
much better than while up the river, and gradually became quite good, while the facilities for a proper diet were
also much improved.
In November and December the regiment was quartered at the U. .S. barracks four miles below New Orleans,
where, with but nominal duty, little exi)osure, good diei, dry airy quarters and a generally cheerful and contented
feeling, the men have steadily improved in health and strength. But while this has been true in genei'al terms of
the regiment, there have been many relapses, and in many cases the system has seemed so thoroughly poisoned by
long exposure, under the most unfavorable circumstances, to malarious influences as intense as could be found in the
.South, that no response would follow the exhibition of stimulants or the most nutritious food, but death would
inevitably occur from exhaustion or debility alone.
The treatment followed has been simple from necessity, if not from choice; for the majority of the cases have
been treated in the regimental hospital with only the limited variety of supplies furnished for field service. Sulphate
of quinine has, of course, been the great reliance, and in no case of intermittent fever, in which anything approaching
a fair trial could be had, has it failed in effecting a prompt cure. Cases of malarial fever treated in houses (contrary
to the results of my experience with typhoid fever on the Potomac) have progressed much more favorably and rapidly
than those in tents, and cases in Sibley tents have proved less tractable and more liable to a relapse than those in
wall tents with a fly. Indeed, in this climate, in summer a fly is indispensable for comfort cither in the hot sun by
day or the heavy dews at night. Capsicum has jiroved of great value in conjunction with quinine, especially in
cases reqviiring stimulants, as after the first most of them did. Mustard in the form of large por.ltices was more
Tiseful than when applied with baths, and, especially in the congestive cases, was of the first importance. Of stimu-
lants, ale was tiie most universally beneficial, and but few instances were noted in which it failed to act kindly.
The toral mortality in the regiment during the six months, in general as well as regimental hospitals, was
two hundred and two, or one-Jifth the aggregate strength July 1, which was one thousand and eleven. Of these 114
died during the quarter ending September 30 and 88 during the last quarter. The aggregate, December 31, 1862, is
seven hundred and thirty.
Surgeon J. M. Ali.ex, 5Uh Fa. Vols., May 31, 1862.— The regiment is on duty in the valley of the Potomac. This
region of Virginia is proverbial for almost every variety of miasmatic fever, and when the peculiar nature of the
climate, hot days and cold nights, is taken into consideration in connection with frequent overflows and rank under-
growth, the cause may be easily explained. The diseases incident to the vicinity are remittent, intermittent, typhoid
and congestive fevers, pneumonias, diarrhffial and bronchial affections.
Surgeon Robert Morris, mh N. T. Vols., Key West, Fla., April 1, 1862.— The ponds in this vicinity are a
fruitful source of disease; for the rains wash into them a large quantity of vegetable matter, which, during the
process of decomposition, evolves so much malaria or bad air that the odor is very offensive, particularly when
the wind blows over them towards the camp. One of these ponds, that nearest the encampment, has recently been
filled up, and no doubt the salubrity has been thereby much increased.
Surgeon A. W. Woodhull, 9Wi A". J. roll., Carolina City, X. C, June 1, 1863.— Some of the posts at which
portions of this regiment have done picket duty have been extremely unhealthy. Particularly is this true of Have-
lock, a post on the railroad, eight miles from Newport barracks and sixteen miles from New Berne, N. C. It is
situated in a low wet swamp on the border of Slocum's creek, which is here dammed for water-power. In the spring
of 1862 the dam washed away, leaving a large extent of surface which had been covered with water. This place
became extremely unhealthy, developing intermittent and remittent fevers in great abundance. The record shows
that 98 per cent, of the men of this regiment, who had been stationed there more than ten days, were attacked by one
or the other of these fevers. For a time they were kept subdued by administering daily portions of quinine, but the
supply being suddenly cut oft', they reappeared with greater frequency and increased severity. It is believed that
a sufficient supply of quinine will prevent at such places the prevalence of these fevers to any serious extent.
Surgeon A. W. McCluue, ith Iowa Car., near Helena, Arl:, September 30, 1862.— On July 1 we were encamped
on the Wliite river at Jaeksonport, Ark., perhaps the most malarious locality in the State. Our fevers were then.
MALARIAL DI^!EAPE. 155
as they liad lioeu for soino iiumths inrvioiis. of a iiiiili^iiaiit cliar:ii-lfi. (hi llii' liili wc moved down t ho river on short
rations. Miasmatic fevers prevailed to a eonsideralde extent, Imt of a mild eharaeter. About the last of July we
reached this i)laee. Our brigade has since been encamped six miles west of the town in a position as salubrious as
any in this vicinity, although the low cotton-lands extending to the south alVord fertile soil for the production of
malaria, and our men have not lieen proof against its withering intluence. Intermittent and remittent fevers have
readily yielded under the use of nuiuine; but the atmosphere is so impregnated with poison that there exists a strong
tendency to a return or relapse. After a repetition of the attacks, or even after a severe and protracted first attack,
diarrluea has supervened, attended with cachexia, and wc have found it- necessary to remove the patients to northoru
hospitals; nearly all such cases, however, have recovered by being thus removed and put upon a liberal diet.
Surgeon H. F. Conrad. 174//i Ph. Fols., Ikauforl, S. C, Aj>ril 30, 1863. — The cam]) wo now occupy is situated
on Port Koyal, one of the sea islands, a sandy jilain. Immediately in the rear of our location passes an inlet from
t'oosaw river. This inlet is about one-fourth of a mile wide. When the tide is in it is tilled with water, but is left
bare when the tide recedes. Long swamp grasses cover its bed, giving rise to an increased miasmatic influence
from the decomposed vegetation. As the warm weather advances a still greater quantity of the raiasnuitic poison
will be generated. The prevailing disease is intermittent fever, which has increased considerably within the last
two weeks, and is generally of the quotidian tyi)e. It has so far readily submitted to active treatment. I generallj'
commence with a purgative dose of calomi'l, followed, if necessary, by a dose of oil, rhubarb or salts. I then put the
patient on suli>hate of quinine, from twelve to twenty grains daily, divided into three or four doses. This seldom
fails to check the paroxysms; yet I generally continue the quinine for some time to prevent the recurrence of the
disease. I observe that it requires larger <|uantities of ([uinine to act efficiently in this climate than in our northern
States, no doubt from the miasmatic influences being more powerful in this region than in the north. I have not
as yet had any case of bilious remittent fever, but anticipate its prevalence as the summer months advance.
Suriji'oii S. X. SiiKHMAX, 34(A .V. T. Vols., Seneca Mills, Md., October 1, 1861. — Chills and fever have resulted, but
only in those doing guard duty on the river; and of those attacked few fail of a rapid recovery when quinine is
lilierally used and strict confinement to camp enjoined. With the ajiproach of the frosts of autumn the number of
attacks decrease and the recoveries are more speedy. Hut for diseases of malarious origin the health of the regiment
would be good.
Assl. Sitry. J.\MES B. Hunter, GOth Ind. Vols., on the condition of certain regiments near Thihodcaux, La., August 31,
1864. — It is worthy of renuirk that the sick reports of the 18th N. Y. Cav. and 1th Iowa Bat. show a much larger per-
centage of cases of intermittent fever than those of the 16th and 60th Ind. Vols, for the same time and under nearly
similar circumstances as far as camps and duties are concerned. The (luestion suggests itself whether the'difterence
in favor of the last two regiments is not due, at least in j)art, to the fa(-t that they are using the wedge-tent while the
other commands have only the intperfect protection of the shelter-tent, in which, in bad weather, the men cannot
keep their clothing or blankets even tolerably dry, and under which they are constantly exposed during the night
to currents of air probably charged with malarious poison, [In another regiment, the 33d 111., in which intermittent
and remittent fevers have been the prevalent diseases, prophylaxis has been attempted with fair success by the
administration to the portion of the command most exposed of a spirituous infusion of willow bark.]
Asst. Surg. Alex.vnder Ixgraji, V. S. Arniji, 2d C S. Cat:, Sharpsburg, Md., SejHember 1, 1862. — ^The first two
months of the quarter were passed on the Peninsula, where the men were exposed to excessive heat and miasm. Add
to these agencies the inHuences of water tainted with alluvial and animal matters, and the exhalations from the
various unwholesome accumulations incident to a crowded camp, and the essential causes of sickness in the command
will be comprised. These various causes resulted in irregular malarial diseases, nearly every case being benefited by
the administration of quinine. — intermittent fevers, remittent levers and diarrhceas characterized by torpidity of
the liver. That the malarial fevers did not assunui a typhoid type, as was the case in many commands, I attribute
to the superior cleanliness of the men in person and camp, and temperance in diet and drink, they being old and
disciplined soldiers.
Surgeon Charles J. Nordqcist, 83rf X. ¥. Vols., near Sharpsburg, Md., October 10, 1862. — On October 21, 1861, the
command was ordered to the scene of the Ball's Bluff disaster, and while at Conrad's ferry it was exposed to a
drenching rain-storm for eighteen hours. The men were without shelter of any description, and remained in their
wet clothing for forty-eight hours: this, in connection with the insanitary conditionsof their camp at Muddy Branch,
decaying vegetable matter, a clayey, moist soil and muddy, brackish water, caused a marked change in their health.
Remittent, intermittent, bilious and typhoid fevers prevailed to an alarming extent, and fully one-third of the regi-
ment succumbed to the evil infiueuce exerted on their systems by the above-mentioned causes.
These reports, as also occasional references in those published in the first part of this
work,* indicate the belief of our medical officers in the identity of origin of all the so-called
malarial diseases from simple languor and loss of strength, with slight splenic enlargement
or hepatic derangement, to the congestive fevers which were so speedily fatal. The essence
of these various and clinically dissimilar morbid phenomena was conceived to be an emana-
tion from certain soils, especially those which were rich in vegetable matter undergoing the
•See, fur iDsUnce, in tlie Appeudix tlie reports of Tkipub, p. 46; Coopeb, pp. 232-3; Hand, p. 239; Fbink, p. 318, and WlllTEillll, p. 334.
156 ■ CAUSATION OF
natural process of decomposition under the combined influence of heat and moisture. Hence
swamps, marshes, river-bottoms liable to flood, bayous, lagoons, ponds, dams and canals
were deemed sufficient to account for the presence of disease, especially towai'ds the close
of the summer season, when the heat was believed to operate indirectly, by lowering the
water-level and exposing larger surfaces of moist soil, as well as directly in promoting the
generation and evolution of the malarial miasm.
The disease-cause was recognized as moving, cloud-like upon, and for some distance
along, the slopes which faced its marshy source; and as capable of being carried in danger-
ous concentration for considerable distances by winds passing over such extensive swamps
as are found in tlie Mississippi bottom. Its greater concentration or more malignant char-
acter at night was illustrated by the frequency with which men were seized while on night
duty. Dr. Hunter, indeed, refers to the greater ])revalence of the disease among men who
slept in shelter-tents, the open ends of which gave free exposure to the air, than among
those who, other things being equal, were better protected by the wedge or 'A' tents.
It is manifest, however, that the presence of absolute swamps or marshes was not con-
sidered essential to the development of the miasm, as it was attributed to cotton-lands and
other soils where vegetation was rank. Frink noted the prevalence of intermittents in
some regiments camped in a strip of timber on rather low ground. The cutting' down of
trees for firewood or for the building of huts, corduroy roads, breastworks, bomb-proofs,
abatis and other military works was frequently followed by the development of malarial
fevers. As in civil life similar consequences have often been ascribed to the clearing of
timbered lands, the exposure of the soil to an increased solar heat was regarded as the cause
of the newly developed insalubrity. And, as in the inception of agriculture in a new country,
the removal of undergrowth and the upturning of the soil are so frequently followed by mala-
rial manifestations or the aggravation of pre-existing diseases, it seems likely that no incon-
siderable proportion of such diseases in our armies may have been owing to the clearing
of the surface and disturbance of the soil incident to the process of going into camp. It is
certain that many of our medical officers recognized this possibility, and were as earnest in
their eftbrts to preserve the natural integrity of a camp-site which appeared free from
malarial factors, as to drain and improve one which was manifestly insalubrious.
But a soil capable of evolving malaria under the theory of organic decomposition was
reputed, in one exceptional instance, as exercising no injurious effect on the health of the
troops camjaed near it: —
Ass't Surg. George H. Horn, 2rf Ctd. Cnv., Camp Independence, Owen's Valley, Cal., April 1, 1863. — The great
extent of swainji-laiKT might l>e sujiposed to cause miasmatic disease. No case lias, however, been known to arise.
All tlie causes favorable to the development of such diseases exist. Their absence can only be accounted for by the
extreme dryness of the atniosjihere an<l the ciiiantity of saline materials in the soil and water.
It is probable, however, that the swamps of Owen's Valley are as malarious as tho.se
of the river-bottoms in Arizona, where the climate, soil and vegetation are of a similar
character, and that the absence of malarial manifestations reported by Dr. Horn was due
to the absence of exposure. After the establishment of Fort McDowell, Arizona Territory,
on the dry mesa sloping towards the Verde river-bottom, the garrison remained free from
malarial disease for over a year. At the end of this period Indian hostihties called detach-
ments of the garrison into the field, and coincident with their exposure in temporary camps
in the river-bottoms malarial fevers appeared among them. Camp Independence was
established three miles from Owen's river, on high ground bearing only scattered patches of
MALARIAL DISEASE. 157
bimcli-grass and sage-bush. At tlie time Dr. IIorn madf his report tlie post had iiut
been ffirrisoned for more than a year. Its later records show the presence of mahirial fevers.
On the other liand, mahirial diseases of a pernicious character are reported in one
instance where the surroundings are said to have been inconsistent with the theory of
organic decomposition : —
Siirijeoii W. W. Bkown, 7th X. H. Vols., Fort Jrircrsoii, Torliii/as, Fin., June 30, 18(i'J. — Tlicre soeiiis to bo no caiiNU
for malarial disease, as tlio waters of the Atlantic Ocean constantly liallie llio walls of the I'ort ; y«t three or I'onr
cases of very severe ami iiiali^'nant coni;estive fever occurred in rapid succession, though nothing of that characlcr
)ia8 since appeared.
The records of Fort Jefferson show the prevalence of mahirial affections ;'•= but, although
there is little surface-growth, the absence of organic matter in the soil may not be
admitted. On the contrary, the soil appears rich in the elements of vegetable growth;
for at Key West, where a similar coral-sand is raised a few feet above the salt-water level,
it is covered with a thick chaparral, and produces uikUi- cultivation nearly all the tropical
fruits and vegetables."}'
A review of the observations bearing on the relation between vegetation and malarial
disease appears to indicate that the poison of the disease is elaborated during the reduction
of nitrogenous organic matter into the inorganic form in which it is available for absorption
bv growing plants, and evolved from the surface as malaria when the living vegetation fails
to absorb all the rii'liness of the prepared nutritive material. Thus, in the diurnal chauu'es,
malarial exhalation ceases when the vitality of the plant is at its maximum under the
inriuence of the sun"s light and heat, and becomes active during the night, the period of
vegetable repose. Our spring fevers occur when, with the northward advance of the sun,
the earth becomes heated before its surface is covered with the new vegetation. During
the summer, when vegetable life is in full activitv, malarial diseases do not increase in
proportion to the increasing heat of the season. In the autumn the hot sun and occasional
rains continue the processes going on in the soil, but the natural decay which succeeds to
the fructification of the annuals interferes with absorption and malarial diseases assume an
increased prevalence and malignancy.
The association of autumnal fevers with vegetable decay led to the belief that the
putrefaction or decomposition of vegetable tissues was directly connected with the febrile
occurrences. But it is well known that free exposure to the effluvium from decomposing
vegetable masses does not develop malarial affections. It is only wliun this vegetable
matter has been mixed with soil and is undergoing the fermentative processes which result
in the nitrification of organic ammonia that the presence of malaria is manifested. Sea-
sonal observations made in tlie tropics give testimony agreeing with that of the temperate
zones. The dry season is the analogue of our winter; but while with us soil-ferinentation is
held in check by cold, in the tropics moisture is the lacking factor. With the first showers
of the rainy season some cases of fever occur. AlibertJ explained these sudden develop-
ments by enunciating his sixth proposition: "Rains which fall in very hot weather may
contribute to the production of malignant intermittents by setting at liberty putrid vapors
which iiad beei> confined beneath the hardened surface of the earth.' But they corre-
spond to our vernal intermittents, and may be referred to the same cause, tiie presence of
the conditions needful to soil-ferraentatiou and the absence of growing vegetation. As the
* "Thf pnvailiiig iliseasce arc malarial ftveni, usually mild, and catarrhal anictloiis."-^Hj3i«»ie o/ the V. S. Army. Cimilar Xo. 8, S. G. 0., Wash-
ington, l>. <■., IsTj, |.. HO.
I Work last quoted, ji.J-H. ; Alibekt— .1 Treatue on MalujuaiU iiUmuiUenU. Caldwell's translation, Pbiladclpbia, 180", p. 182.
158 CAUSATION OF
rains cuiitinue tlie country becomes covered with an exuberant verdure, and the malarial
manifestations are lessened, but only to break out with increased virulence when this
annual growth wilts and decays at the end of the rainy season.*
Malaria may therefore be considered due to a want of relation between the nutritive
elements of the soil and its living vegetation. When thus viewed, malarial developments
following a removal of the natural growth in the preparation of the ground for agricultural
purposes are readily explained. Their subsequent disappearance when, by drainage and
cultivation, a proper relationship has been established between the soil and its crop, is an
obvious consequence. Exhalations from a parched soil bearing a withered vegetation, as
noted by Ferguson in rocky ravines, river-bottoms and bare open hollow lands in the Iber-
ian Peninsula, are also understood, as well as his remark that a healthv condition of soil in
these pestiferous regions was infallibly regained by the restoration of the marshy surface
to its utmost vigor of \-egetable growth.f There was underlying moisture in these rocky
ravines and temporarily dried up water-courses. So at Fort Jefferson, Fla., a rich organic
soil with underlying moisture, a high temperature and absence of living vegetation may
be accepted as the conditions which permit of malarial exhalation.
Oftentimes men in the full vigor of health were struck down by the miasmatic influence,
but in general the operation of predisposing conditions was recognized. These are variously
enumerated, but all undoubtedly acted by lowering the vital powers and rendering the sys-
tem less able to withstand the influence of a superadded miasm. Most of the conditions
affecting the soldier on active service were of a depressing or exhausting tendency. He
was often hungry; his food was not unfrequently poorly cooked; the issues of hard bread
and fresh meat at times occasioned diarrhoea; the sameness of diet developed a scorbutic
taint. One reporter, indeed, regarded the ration as the most powerful of the predisposing
factors, the excess of its carbonaceous elements inducing a congestion of the portal system
which opened the way to malarial attacks.| While generally warmly clothed, the soldier
was often chilled at night, or after profuse perspiration or exhaustion from fatigue. He
was exposed to rains, and had to remain in his wet clothes for days at a time, sleeping on
the wet ground without shelter. At other times the exliaustion was consequent on forced
marches or excessive labor under an oppressive sun. The water-supply was generally
surface collections, often foul naturallv, and usually tainted by the inflow of the surface
washings and drainage of neighboring camps. Lastly, a state of mental depression arising
from absence from home, domestic concerns, impending personal or public danger, etc., was
considered as adding to the predisposition.
Hot days and cold nights are mentioned by Surgeon Allen as predisposing the system
to malarial attacks; l)ut Oldham's theory, that malaria is chill, § is sufiiciently disproved
by Dibble's report from Dawfuskie Island, N. C, where, in a mild and equable climate,
the command became subject to some of the most malignant of the malarial affections.
The influence of predisposing conditions in determining the type of the fever is suggested
by a study of Table XXXIII, where the indicated prevalence of congestive and remittent
cases in the Potomac Department seems explicable only on the assumption ihat the fatigues,
exposures and privations of the troops operating between Washington and Richmond
* For an excellent description of the seasonal occurrence of these fevers at Sierra Leone and neighboring points on the African coast, see Boyle
on the Diseases of Westeni Africa, London, 1831.
t On Ihe -Vttftirf and Hislonj of Die Mmsli Poison. Trans. Koyal SocieUj, Edinburg, 1823. Vol. IX, p. 273.
J Frisk— .ffjRpenJfa to Pari First of this (Fort, p. 318. j What is Malariaf by C. F. Oldham, Loudon, 1871.
MALARIAL DISEASE. 159
iviulereil them more liable, when exposed to the malarial influence, to become affected with
an aggravated type of the disease than men who, though exposed to more concentrated
miasms, were in better condition to resist their prostrating influence.
Several of the reporters refer to impurity in the drinking-water as occasioning a pre-
disposition to malarial affections. In the early history of medical science paroxysmal fevers
and enlarged spleens were referred to the action of impure water. But as the doctrine of an
aerial miasm, enunciated by Lancisi, explained many things which had been obscure, it met
with general acceptation, and the possibility of water-infection was forgotten by the profes-
sion although it continued as a strong belief in the minds of the uneducated in all malarious
countries. This theory, however, of an air-borne swamp poison failed to account for all the
cases that occurred, unless on the supposition that the evolving surface was sometimes so
minute as to be readily overlooked.* Meanwhile an occasional instance was reported in
which the disease was apparently due to the drinking of an infected water, as for example
the well known case of the Argo.f But as malarious waters, supposing them to exist, are
usually and for obvious reasons found in localities presenting'all the conditions needful to the
evolution of an aerial poison, the disease, when it did occur, was referred-to the latter as a
matter of course, while the existence of the former remained unsuspected. The recognition of
water as an agent in the transmission of malarial disease has been gradually effected. Pro-
fessor Pakkes, giving weight to a number of cases which he mentions, accepted the theory
and speculated on the connection between the disappearance of malarial fevei's in England
and the coincident use of purer supplies of drinking water.J Professor Leon Colin, from
his experience in Algiers, denies that marshy waters produce intermittent fevers; but as
the troops under his observation were operating in a notoriously malarious country the diffi-
culties in the way of arriving at a positive conclusion must have been very great. His
testimony cannot be considered as authorizing a stronger statement than the denial of the
occurrence of cases which might not be plausibly referred to malarial exhalations.
A country where malaria is not exhaled from the soil, at least in quantity or concen-
tration sufficient to produce intermittents, would seem necessary to relieve observations on
malarious waters from the objection caused by the alleged jsresence of the aerial poison, and
•Thus Macctlioch, in his £>»iy on Malaria, Philadelphia, 1829, p. 28 : "If it is acknowledged or proved that manh or swamp, whether fresh or
salt, is ireuerative of malaria, it is also a very common opinion that a certain extent of this soil, and generally a considerable one, is necessjiry to the
prixiuction of disease. This is an error; and it must he classed among the dangerous ones, as being productive of false security.'' He then adverts to
ihe aii.ilo^'v between malaria and contagion, arguing that the quantity of malaria necessiary to produce its jieculiar disease or diseases nmst l)e
indi'finably small, for it is well known that often from a very limited spot the poison will proceed through the air or ou the winds to distances
of three or four miles, exhibiting, notwithstanding the dilution which must take place in transit, aluiost as much virulence as in its native mar^h ;
and he cites the hills of Kent as infected by emanations from the marshes of Krith, Northfleet and Gravesend. "The conclusion," ho says, "is
obvious; and there is nothing in it which seems to admit of dispute, since it is almost a question of arithmetic. If the produce of a hundred square feet
or acres or of any scale and number of l>arts can, under a dilution of one thousand or ten tliousiind times, excite disease, then nuist, in the inverse ratio,
Ihe produce of the one-thousandth or the ten-thousandth portion of that space bo capable, before dilution, of producing the same effects ; or a single
blaile of grass acting on water {if this be the cause) may be as efficacious as an .icn- ; supposing, of course, that it is actually applied to that part of the
body which can suffer from its action."' ToMMASl-CKf deli holds that malaria may be generated in quantities sufficient to produce intonnitlcnt fever
l'> the ganlen mould of flower-pots kept in bedrooms, and on the authority of Professor vox Kicuwalu, instances the case of a Russian Iiidy whoso aguish
lelapses, having been referred to this cause, were permanently cured by the removal of the flower-pots. — Practiiiotifr, Vol. XXVII, pp. 387-8.
f Parkes iu his Practical Hygiene summarizes and remarks ou this case as follows : "The case of the .\rgo, recorded by Boi-nix, — TraiUde titographie
d lie Slalitli,iue MtdicaieM, 1857, t. I, p. 142,— is an extremely strong one. In 1834, 8(10 soldiers in good health embarked on three vessels to pass from
Bona in .\lgiers to Marseilles. They all arrived at Marstilles the same day. In two vessels there were GSO men without a single sick man. In the
tliini vcss.'l, the Arg.i, ther' bail been 120 men ; thirteen died during the short piu«sage (lime not given), and of the 107 survivors no less than 98 were
disembarke<^ with all forms of jialudal fever, and as ItoiDiN himself saw the men there was no doubt of the diagnosis. The crew of the Argo bad noi. a
single sick man. All the soldiers had be<-n eX|>osed to the same influences of atmosphere before embarkation. The crew and the soliliers of the -Vrgo
won* exposed to the .same atmospheric conditions during the voyage; the influence of air seems therefore excluded. There is no notice of the food, but
the production of malarious fever from food has never been suggested. The water wass however, different — in the two healthy ships the water was
good. The soldiers on board the Argo had been supplied with water from a marsh, which had a tlisigreeable ta.ste and txlor; the crt-w i»f the .\rgo had
pure water. The evidence seems here as nearly complete as could Iw wished."
t " Is it n..t possible," lie says. " that the great decline of agues in England is partly due to a purer drinking water being now used ? Formerly,
there can l)e little doubt, when there was no organized supply and much fewer wells existed, the people must have taken their supply from surface
collections and ditches, as they do now, or did till lately, at Slieernese."
160 CAUSATION OF
the tendency to refer all morbid plienoinena to its intlLience. The writer was at one time
stationed in such a country, at Fort Bridger, on the northern slope of the Uintah Mountains
in Wyoming T'y, where intermittents were undoubtedly imported diseases which tended
to longer intervals and ultimate recovery.''' Nevertheless, in this country, a remittent fever
was well recognized as indigenous. It was known to the settlers as mountain fever , and
although in most cases recovery was rapid under mercurial purges and quinine, the patient,
if not subjected to specific treatment, would fall into an adynamic condition to which the
name of typhoid or ti/pho-inalarlal was occasionally applied. That this fever was malarial
in its origin was the general opinion of the medical men familiar with it, although the
source of the exhalation was not evident and although, moreover, the disease did not corre-
spond in its period of prevalence with the remittents of notoriously malarious regions. It
occurred with greatest frequency during the months of May, June and July, but appeared
occasionally in all the other months except September and October, f the months of special
prevalence of the ordinary autumnal fever.
This remittent was traced by the writer to the- use of the river-water constituting the
su]iply of the post. J He found that this water contained a larger quantity of organic mat-
ter than was usual in good river-waters, and tliat the maximum and minimum of the
prevalence of the fever corresponded in time with the maximum and minimum of the
organic impurity in the water-supjilv. Dui'ing the period of increased impurity the bed of
the stream was more or less flooded and the water turbid from the spring rains, and
especially from the melting of the snows oh the mountains. As the post was seven thousand
feet above the sea-level, and on the northern exposure of the mountain range, its springs
were late, the thaw beginning only toward the end of April and lasting well into July.
During the period of diminished impurity, as scarcely any rain fell on the mountains which
at this time were free from snow, the small volume of clear water which ran in the bed of
the stream must be regarded as percolated waters contributed by the mountain springs.
This led to a more extended survey of the history of mountain fever, which developed
in every instance a similar relationship to organic impurity in the water. Thus hunters,
miners, cattle-herders, surveying parties and soldiers on scouting duty, who made use of a
surface-water supply charged with vegetable impurities, were more frequently affected with
remittent fever than permanent settlers who liad provided themselves with a pure supply
from wells and springs. That the remittents which affected these nomads were not directly
due to malarial exhalations was manifest from their occurrence when the ground was
covered with snow and the tempei'ature far below the freezing point. At Camp Douglas,
Utah, such remittents were observed only among soldiers who had been absent frum the
station on scouting duty. On account of the small size of the stream on which this post
depended for its water-supply, and the possibility of its drying up at times during sum-
mer, a storage reservoir had been built. This was large enough to permit of an etficient
sedimentation ; but to prevent the unnecessary filling up of the basin by the intrusion oi
solids the instructions to the man in charge looked to the admission of water only when
it ran without turbidity in tlie stream.' The exclusion of the snow-waters and heavy rainfalls,
thus effected, gave a comparatively pure spring-water at all times for the use of the post.
Moreover, the gradual disappearance of these mountain remittents with the progress of
* Hi/ijiem of ihe U. S. Amii/.—Cirmlar No. 8, S. G. 0., 1875, p. 319.
tSee work last cited, p. :i20, where a tabic of monthly rfck i-nte.s is preseuteil. cmliracing tlie eiglit years 1866-t73.
JSmart. — On Mountain Fccer uml Malarious Wtden. Am. Jour. Med. Set., Vol. LXXXV, ISTS, pj). 1-27.
MALARIA]. DISKASK. 151
settlement was of some weiglit in tljo argument. In the early days of trans-continental
travel, when the overland journey implied months of weary marching and a water-suii|)ly
irom rivers, ponds, dams, etc., the disease was common and dangerous; hut when the
journey was accomplished hy steam in a few days, and the settlements furnished with a
lietter water-sui)ply, the remittent occurred only in those whose mode of life imposed on
tiiera the conditions common to all in the earlier days.
Soldiers on scouting duty are particularly liable to this remittent. Thev are i.-xposed
to climatic influences, over-fatigue, loss of sleep, anxieties, insufficient and hadly cooked
food and impure water. These are precisely the harmful agencies to which our troops were
subjected during the civil war, except that in the latter instance there was in addition an
exposure to malarial exhalations which was considered the efficient cause of all malarial
manifestations. But since the troops on Indian service in Wyoming and other Territories
are liable to a remittent which may not be attributed to emanations from the soil, it is pos-
sible that some of the remittents which affected our soldiers during the wai' may have l)een
due to other causes than an air-borne malarial f)oison. An<l if so, this cau.-;e must iiave
been an impure water; for the troops at Fort Bridger were also affected by tlio remittent,
and they had nothing' in common with the soldiers on scouting duty except the water-sup-
ply from the running stream, at times charged with vegetable impurities. They were well
fed, well clothed and sheltered, and had no exposures nor fatigues other than those borne by
their comrades at posts where there were no remittents, but where there was at the same
time a better water-supply.
In view of these facts and considerations, to which may l)e added a few instances of
probably malarious waters more recently I'ecorded,'^' it seems not unlikely that a certain
percentage of the malarial diseases which affected our armies was due to tlio introduction of
the malarial poison into the system by means of the drinking-water.
The writer was, and is, inclined to believe that the cases due to water-impregnation
were included among those characterized by adynamic tendencies, because remittents instead
of intermittents occurred at Fort Bridger, and these, when neglected, assumed a ty})hoid
character. It may readily be allowed, however, tiiat where the water is strongly charged
with the poison the morbid developments may be rapid and pernicious, as in the cases on
■ s.-.- Smabt on Water Analttm, in the AnmttiJ Report of the Nntioital Board of Heallh, WaehiDgton, D. C, 1880, p. .'")02, whore sample No. 45, sent by
Dr. tfAixrj; or Mohilc, on account of malarial remittents havioi; occurred among the persons using it, was found to contain .35 part organic ammonia
per milliun. No. 4ti of the same report, from a ci.stem in a well-paved and non-malarious section of New Orleans, was furnished by Dr. C. B. White,
Medical Director of the Citizen's Auxiliary Sanitary Association, that lead, if present, might be detected, as the [wrsons using the water had been affected
with many anomalous symptoms. No lead u.-is ftnind, hut the impurity of the water, .70 of organic ammonia, was such that the analyst believetl him-
s*>ir dealing with swamp-water furnistied for the purpose of testing his results. Pending the analysis a severe ca.so of remittent fever was devel«»ped in
thi* lii.u-^ in the jierson of a woman who had not been in a malarious neighborhood for many months. Suspicion was aroused in the minds of the ijeojde
and the cistern was clo.sed. When the analyst reported the water as a veritable swamp-water, the occurrence of this fever was made known to him.
Arconliog to the R^wrl r,f Ih- Snliini'il Hoard of HeiiUli, Usi, p. IK. Dr. E. D. focisiKV, of Mariner's Harbor, Station Island, N. Y., was called on a Wed-
nesday li> H-e the case of a girl si.\ years of age who dieil after a convulsive w-izure Avhich had be*'n preceded by twenty-four hours of chill, headache
and vomiting. No autopsy was held. On thi' following Sunday another child of the same family had a chill followed hy febrile excitement. The chill
rpcon>*d ii.-xt day. and death took jdaee after delirium and convulsions. .\s the remaining children, three in numlK-r, were now showing symptoms of
congestive fever, I»r. Coonlky orden-d the family to move into another hous(- about thirty rf>ds distant and situated upon higher ground. The ground on
which the vacatetl house stood was so hiw that occasionally it was surroundetl by the tide. The well was only about six feet deep, and about a month
tjeforv the death of the firet child it was completely tilled by a very high tide. This was baled out, and afterwanis, when the water came into the well,
a grv»'n s<-um wa- iioti.-ed on the surface of it. The rbior-yanl was kept in a filthy condition. This was the only water nsi-d froni the time tie- well
wa* lialiHl nut until the seconri chihi died; and the mother stated that these two children firank a good deal of the water. The n'maining children
promptly l»>gari to recover under sis-cific trcatiocnt ami were fully restored to health. Dr. Coosi.ry njfern'd the ejow-s to the use of the well-water. The
anahTt'-i n-|).irt nn this sample, the hi.story nf which was unknown to him, may Ite snninied uji in the remarks apis.-niled to the analytical details— "bad,
pnitnbly ililch-water." ."y-e also the Brili^i Mnlicot Joitnwl, Novenilier s, lSJi-1, to w hicli Mr. Wn.\LLEY, a member of the Indian Civil J^rvice, contributed,
p. 9i-l, an inten-sting nielnonindum concerning the prol>agation of malarial fevers by impure drinking-water, .\long the base of the Himala.vas, in
the northM-estern provinces of India, lies a belt of mar>»h and forest called the Tcrrai, which for many years has been uninhabitable owing to the malarial
fevers which pn.-vail then.-. Continuous efforts have been made by the government of the provinces to reclaim and populate this tract, but with only
fmrtiat Huci-ess, The strife iN-tween euter|>ris<* and malaria is continually carried on, but at the cost of a fearful sacrifice of human life. The [teople
b»ve for ages lielieved in the transmission of the fever by means of the drioking-walcr, and this belief, it is stated, has at last been accepted in its
Med. Hist., Pt. Ill— 21
162 CAUSATION OF
the Argo and in those recorded by Dr. Coonley.* The occurrence of hsematuric fever in
the winter months is suggestive of a water origin, f as are also the congestive chills which
occur in some instances without, an apparently adequate exposure to concentrated miasms.
These cases may not be all referred to differences in the physiological condition of the
individual, due to variations in nutrition or hygienic surroundings, since differences in the
type of the disease are manifestly less' dependent on such idiosyncratic conditions than on
season and locality, and, as in the case of the mountain fever, on the nature of the poison
or on its mode of introduction into the system.
The agency of .the water-supply in the transmission of the malarial poison has an
important practical bearing. A water free from vegetable organic matter is indicated as a
means of prevention. But, in addition, a study of the data collected concerning the effects
of impure water shows that while surface waters have malarial possibilities, filtered or
percolated waters have not been suspected of causing paroxysmal fevers. J. Filtration
appears to remove the malarial poison. The conditions of active field service do not always
admit of well-digging or systematic artificial filtration, and hence the occasions are of fre-
quent occurrence when an extemporized filtration by the regiment, company or individual
would probably prevent much sickness, disability and death.
Although the connection between vegetable matter in a water and a possible malarial
character of the latter has been established, there is no ground for assuming that the vege-
table impurity is the cause of these remittents. Infusions of putrescent vegetable substances
have been taken into the stomach without the production of malarial symptoms, § But as
malaria is generated in soils rich in vegetable matter, a water contaminated by the one will
be likely to be charged with the other, whether that water is stagnant on the surface of
the malarious soil or an air-cleansing precipitation on a non-malarious region. It is not
diflficult to understand the absorption of malaria by moisture in swamps, marshes and
other localities where exist the conditions recognized as needful to the generation of the
poison. It seems probable, however, that the processes of nature result in a general
entirety, though hesitatingly, by most of the medical profession in India. The illustrations given by Mr. Whallet are convincing: "A party of work-
men were sent two or three years ago, in the month of October, to repair a bridge over a stream called the Chuka, and they were dejiendent on the
stream for their drinking-water. Out of the thirty men only three escaped fever, and several died. Since then a deep masonry well has been constructed
iit a few hundred yards distance from th'- bridge ; and the forest guards, who are located there and drink only the water of the well, find the station as
healthy as any other. Again, a village named Bahrwa, two or three miles from the forest liorder, where tlie supply of drinking-water was obtained
from shallow wells fed by the infiltration of the surface drainage, had been repeatedly settled and deserted, owing to the fatal character of the fever
which pix^vailed there. Six yeai-s ago the landlord went to the expense of constructing a masonry well forty feet di-ep, reaching down to the spring
level, and closed all the shallow wells previously used. Since then the village has become known as one of the healthiest villages in the neighborhood.
The Forest Dejiartment now constructs deep masonry-wells at all the forest stations, and by this precaution is enabled to maintain a pennanent staff
iif guards at stations where formerly the men were invalided and had to he relieved every fortnight. Moreover, the villagers in the vicinity show
their appreciation of the measure by resorting to these weiis for their supply of drinking-water during the malarious season. There seems therefore to
be little doubt that in this tract the chief cause of malarious fever is the drinking-water, which has been exposed to some poisonous action above ground.
The streams which enjoy the most deadly reputation all take their rise i[i the dense forest, and are overhung for a portion of their course by a thick
screen of uviiran-hing trees and bushes. Streams which are bordered by sand or Itouldere are generally innocuous. Unhealthy villages are found mostly
along tlie sballnw drpreseions wliich convey the surface-water of the forests to tlie rivers. Botli fiicts seem to point to the cnnclusion that the malaria
ciintaini'il in the water is generated by the decaying vegetatit)n ; and the fact that the malarious season begins in April and becomes most deadly in
October, which has been used to establish another theory, does not militate against this, for these periods are coincident with the periods when the forest
trees shed their leaves. But, hov/ever this may be, there is no question that many places noted for malaria have now become healthy, and t!ie change
has been sharply marked, and contemporaneous with the construction of masoijry-wells." Surgeon E. G. Russell, Bengal Medical Service, — Malaria
ami Injiiries of the Spleen, Calcutta, 1880, — also gives from bis experience in India many instances of the association of malarial diseases with the use of
water diaining from jungles, terniis or marshes at the base of mountain ranges, and their disapi)earance on the substitution of a better water-supply.
*See last note.
f See note svpra, p. 126.
J The purer supply which in all countries has succeeded the use of impure surface collections, and which has coincided with the diminished
prevalence of malarial disease, has been in the first instance derived from wells or springs. The water of these has often been convicted on more or less
positive evidence of the propagation of typhoid fever; but in no case has a well-water been arraigned for the causjition of malarial disease unless there
has been an evident inflow of surface washings. In Professor Mallet's investigation into the value of the processes of water analysis— ^iHnHfi? Ilppnrt
of fhe National Board of HcalOi, Washington, 1882 — nineteen natuial waters were reported, in each of whi<!b there seemed fair ground for believing that
disease bad actually been caused in the pei"sons of those drinking them ; but of tlie.sc Dr. Coonley's case, noted above, is the only instance of a well-water
suspected of malarial infection, and in it a surface inflow was clearly esbiMishcd.
gSee expeinments of rARENT-Ducii.\TELET and Andral, noted in the Second Part of this work, p. 610.
MALARIAL DISEASE. 163
diffusion of malaria in the surface waters of the earth. If malarial exhalations be not
destroyed by atmospheric agencies they must accumulate as a part of the heterogeneous
materials which would collect to a suffocating turbidity in the aerial ocean but for their
precipitation from time to time with the rain and snow. The fogs or mists which gather
over marshes are known to be specially pernicious from the condensation or concentration
of evolved malaria accompanying the fine precipitation of the atmospheric moisture. It is
but a step further to assume its condensation and itrecipitation with the rainfall and snow.*''
"■in. \\ii.>i>\v.M!t<, III ii ii.tti' ou p. filO of the Second Part of this work, sivs liuit he will have "i-r-a.sion hiTfaftiT, wh'-n disiushiiit; \ho rti.ilof^y uf
mahirial fevers, to n-fer U> the art^iinieiits brought fitrwiml by Dr. Smart in favor uf the probahl"- pit-wnce of miliaria iu the snow. There is thus jire-
eeiite<| to the writer the delicate task nf eritirisiiig his own work ami n|Hiiioiis from I>r. Wouhward's point of view. Fortunately his article on Mounlnin
Ferer nnii Miilarioiut Witinv, Am. Jmir. .Mnt. .Si>(io«", .Jan., 1S78, was submitted while iu umnuscript to Dr. Wooowakd, who, iu a letter to .\ssistaut Surgeon
Oenenil r. H. Crask, l". S. .\..iLited May 1, 1877, entert?d his objections to the theory : 1st. " l^-t me point out," he says, ''that if Dr. S>iART's;tUiiIysesar»
cornM-t, the snow that falls at Camp Doughus contaiuH as much organic ammonia as Wanklvn, whose process he (-mploys, found iu the Thames at London
Bridge, ami nion» than lie found in some of the worst Loudon drinkiug-water. I confess it easier for »ie to believe that Dr. Smart liiu fallen into some
error in his ma'U|>ulations than to believe this. The process is acknowledged to be one of extn-me delicaey, iu which it is easy for an inc.K[)erienced
manipulator to fall into error, so that I cannot help susjwcting the extraordinary results obtained." Dr. Woodwaku's wuut of faith iu the accumcy of
the analytical R-sults prevenU-d him from giving the subject that consideration which it would otherwise liave received from him ; thus only may we
account for thp hasty and sui)crlicial views ou which his further objections were based. 2d. " Nor am I better satisfied with the hypothesis by which
Dr. Smaht accounts for the presence of so much organic matter in the air of the Rocky Mountain region. The prevailing winds of the continent aro
from the west to the east, the great m^ority of the stonns move in that direction, and they ought to carry the orgauic matter blown with the tjir from
the surface of the continent atcaij from the llocky Mountains instead of towards th«m. 3d. Moreover, if Dr. Sm.irt's hypothesis is correct, the vernal
intemiiltents in the Rocky .Mountain region ought to predominate in number and severity over the autumnal ones. So far as I know, however, the
reverse is the cas.-. The statistics of the Pacific region, including the stations iu New Slexico, Colorado and the slope between the Rocky Mountains
and the Pacitic Ocean, show malarial diseases to be as distinctly autumnal as iu the other regions. Ith. Even Dr. Smart's post nf Camp Douglas is no
exception to this rule. The annual number of cases of intermittent and remittent fever occurring at it is usually very small, but in 18t3t)-'69, '71, '72-'7;i
and "74 there were a good many cases. Those of 1800 were all imported from Florida ; the others originated on the spot, and give a distinctly autumnal
curve in every year except 1S74, in which the vernal fevers predomiTiated. oth. As to mountain fovor, I have never seen a case, and know it only from
the testimony of others. From what I have thus learned I am obliged to conclude that I>r. Smart's observations refer to certain mild ferimi epidemics,
and are heuce partial and incomplete. The more severe epidemic observed by Dr. Vollvm in 1871 at Camp Douglas was an autumnal one, and as his
account of it is interesting and differs in nuiuy resp<;cts from that of Dr. Smart, I submit a copy <)f the remarks on his sick report for September, 1871.
• • • 'During this mouth an epidemic of intermittent and n^miltent fever accompanied by diarrhoea, dysentery and tonsillitis has prevailed at this
place and iu the neighboring settlements. The officers' and soldiers' families were chiefly affected, but the severest cjises occurred among the troops.
The number of cases among the families was, intermittents "23, typhoid fever 4. Among the women and children sjinptoms resembling hysteria often
api>f^>ared and tended much to disguise the cases. In many of these cases there wtis a strong tendency to sink into a typhoid condition ; and the typhoid
cases reported among the troojw commenced as intermittent. Among the officers' and soldiers' families there were four cases of typhoid fever that com-
menced in the same way. This epidemic is styled by the resident physicians as the mountain fever, the tendency of which seems to be to pass on from
the symptoms of a simple iutennittent to tho.^ of true typhoid fever. Its habits in the intermittent or remittent stage are similar to malarial fever
elsewhere in the L'nited States, and it is controlled by quinine if pushed in ten-gmiu doses three times a day for a week or ten days, I have a belief
that if this treatment, accomi»anied by good nourishment and moderate; stimulation, were adopted early enough, the typhoid symptoms would be pre-
vented and the case kept within the bounds of intermittent or remittent fever,' "
In reply to these argumentsS the writer submits: — 1st, That an experience of many years in the processes uf water analysis, iiu-luding numerous
examinations of rain-water and snow-falls in various [xirts of the country, warrants a belief in the substantive existence of the vegetable matter rejtorted
l»y him in the river, rain and snow-waters of Fort Bridger, Wyoming Territory, and Camp Douglas, Utah Territory. 2d, That the prevailing winds
are from the west to the east is acknowledged ; but this cannot be considered as proof that the r:iin and suow-falls in the R(.>cky Mountains are especially
fn.'e fn.ini organic matter, when they are known by direct experiment to contain an unusually ^ar;re quantity. There an' currents and counter-cnrrents
in the air, as in the ocean, and we cannot predicate what may be going on in the higher strata of tb.' aerial oc-ean from the direction of the currents at
\U bottom. 3d. There are many malarious valleys in the Rocky Mountain region and in the vast section uf country known as the Military Division of
the Pacific, when; intermittents are produced by exhalation as in other swampy districts; and as these predominate so greatly over the mountain fever
cases, malarial diseases in the Pacific region may be exi^ected to be as distinctly autumnal as they are in the 3Iississippi Valley, There is, indeed, no
general season for mountain fever. Its apix?arance in a given locality is due to local conditions. At Fort Bridger it is vernal in its visitations, since
that is the season during which the stream is siwcially contaminated. On account of the high elevation and northern exposure the immense masses of
snow which ehoke up the mountain gorges during the winter take a long time to melt and drain ofT, during which period the river is swollen to two or
three times its average size and its waters are discolored and turbid. At Camp Douglas, however, the conditions are wholly different. The stream is
small, it lM.-ing one of a dozen which run a short course- down the mountain side to a main stream, the Jordan river ; the exposure is southern, the
altitude lower, and the winter climate much less severe than on the mountiiins above F<)rl Bridger, so that snow does not accumulate, but falls, melts
and is carried off »*venil times diiring the course of the season, from November to May, rendering the stream swollen and turbid for a week or two at a
tinif : and so, during the summer and autumn, a thunder-cloud creeping along the mountain range will flood the creek for a day or two, or if the mountain
shuwfTs are repeated at short intervals, for a week or two, thus disseminating the probable cause of mountain fever all oyer the spring, summer and
autumn, if the turbid and impure waters are used as a drinking-supply. Hence the time of visitation at Fort Bridger may not he the time of visitation
at another station. The time corresponds with the floiMling of the stream with snow and rain-water, and nut with any special month or season of the year.
Nor can this time be ascertained from the Record of the niinfall at a post, as it is the fall on the radicles of the stream which is iu question : the stream at
Camp Douglas^ for instance, is not unfrequently turbid from mountain showers while the post and its vicinity are dusty and parched for lack of rain. 4th,
Tlu' annual uumlH-r of cases of .malarial disease orcnrring at Camji Douglas is usually very small, but in certain years there were agoiwl many. In ISGO
the intennittents were imported from Florida, and in the other years characterized by their prest-nco then* w«?re very nutjiblc changes in the cunsti-
lulion of the garrison. The statement that the cases which occiirn-d in these years originatf^d on the spot is not sustained by a close inspection of tlio
history »tf ihe jiost. Some of them originated, to the knowledge of the writer, while the men were absent on Indian service. From the impossibility of
distinguishing in many instances the imported from the indigenous malarious ctises among those which appear on the records of former years, it cannot
W detennint-d that the latter are vernal or autumnal, nor which is of more importance, that they do or do not correspond with the impure condition of
the water-supply, .^th. Dr. Yollim attributed his casr-s in 1871 to rotting wood in the old barrack quarters, and to dampness and want of ventilation
and sunshine, factors which certainly do not enter into the causation of many undoubted cases of mountain fever. An improvement in the health of
the gitrri^on was coineident with the construction of the water-n-servoir ; but as at the sjime tituv tu:w and conmi(»diou8 qiuirters were built, the writer
did nut admit this increased beaUhfulncss of the post into his original argument iu favurof the trausmission of nialaria hy the water-supply. Inasmuch,
164 CAUSATION OF
Malaria is not an unstable organic gas, for were it so its dissipation in the air would be fol-
lowed by its destruction, and its subsequent condensation in the marsh mists would be
impossible. It has therefore a certain stability, and its presence in the rain may be as
readily accepted as its presence in the mists, if the same morbid phenomena follow the
ingestion of the rain-water as follow an exposure to the mists. This stability, in view of
the oxidizing influences of the air, is suggestive of a vital resistance on the part of the
miasm, and lends countenance to the views of those who regard as the essenti?J of malarial
disease a specific germ, which will be eventually, if it has not been already, identified.*
Relapses. — In some instances in which the individual had already suff'ered from the
disease the so-called predisposing causes operated so strongly as to be apparently the deter-
mining cause of a relapse or recurrence. It was observed, in commands aflfected by the
malarial poison, tliat a suddenly developed increase in the number of the intermittent cases
frequently resulted from exposure to chill, as from wet clothes, weather changes or incau-
however, as Dr. Woodward has brought the epidemic forward in this connection, it may be pointed out that while the local conditions mentioned by
Dr. VoLLUM may, and undoubtedly had their influence on the character and progress of the disease, they were not the essential, for he expressly states
that the epidemic was not contined to the post, but implicated the neighboring settlement,'', all of which, it may be remarked, made use of water from
the Camp Douglas stream or from others running a parallel course and subject to the same contaminating influences.
*The latest attempts at identification have been by Klebs and Tommasi-Cri"PELi — Sttuli mUa Xatura delta Malar'm. Ronm, 18T9, These estinvigatoR
announced the discovery of a bacillus which they found constantly present in the swamp-mud of the Roman marshes. This bacillus was susceptible of
cultivation in fish-gelatine, and wheu injected into rabbits profluced a fever similar to that which occurs in the human subject when exposed to paludal
exhalations. It consisted of short rods 5 to 10 microniillimetres in length which evolved into tortuous filameuts. jointed by the formation of dear
spaces at regular intervals in their protoplasm ; spores were developed in the centre or at the extremities of the joints. They considered this microphyte
as the cause of malarial fever, and named it B. malariie. But other observers have failed to identify it. Sternberg, who was sent by the National
Board of Health to investigate this subject in the malarious environs of New Orleans, found in the marsh-mud, among many other bacterial forms, some
which seemed to answer the description given of thf B. malaria?, but similar forms were found in dust from the city squares of New Orleans, and also in
culture experiment* at Baltimore, where malaria was not in question. Moreover, the int>culation exjieriments on rabbits were lield by him to be incon-
clusive, as the temperature curve in the rabbits operated on had in no case a distinctly jwroxysmal character, while healthy rabliit* sometimes showed
as marked variations in temperature as those delineated in the charts of Elebs and Tomm-^si-Crvpem. The changes in the spleen which these experi-
menters found at the autopsy of the inoculated rabbits, and attributed to the malarial influence, were shown by Sterxberg to occur in death from
septicfemia produced by the inoculation of human saliva — see Supplement So. 14, XatlontiJ Bonrrl of Ilenith JinUethi, Washington, 1881. We must therefore
conclude with him that the evidence on which Klebs and Tommasi-Crupeli baseil their claim tu a discovery- is not satisfactory. Nevertheless Dr. Ji'Lirs
Dreschfield, Pres. Microscopical Section. Manchester Medical Society, exhiluted at one of the meetings of the section .specimens of blood taken from a
sailor suffering from intermitting attacks of fever. The blo(Kl contained bacilli t>f exactly the (*ame character as those described by Tommasi-Crupeli.
During the intermissions the bacilli disappeared, but their spores could be readily distinguished. — BrUish Me<l. Jour., Vol. 1, 1884, p. 402. While Lanzi
and Terrigi (see note $iiprn, p. 152) reganl the pigment granules in the blood of malarial cases as resulting from a fermentative action produced by similar
granules derived from the decomposition of an Ahja miasmatiea, La\"Eran — Nature Pnnmtaire tlen Accidents de V Iinpnlrtdixnie, Paris, 1881 — insists that these
pigment granules are connected with the life-historj- of a microparasite which flourishes in the blood and which has heretofore been regarded by Kelsch
and others as a pigmeut-beariug leucocyte. In examinations of the blood in sixty malarial cases during his service in .\lgiera Laveran found the pig-
ment granules in forty-two cases. The large proportion of negative results was due to prnlongrd treatment in these instances by the sulphate of
quinine. But the interest in his observations attaches to the cellular envelope enclosing the pignu-nt granules. It was distinguished under three
forms, which he has figured. In the first the cells are elongated, somewhat pointed at their ends and ofttni incurved (banana-shaped); sometimes,
however, they are oval; the pigment grains are loosely aggregated or disposed in an annular fonn toward the Cfutn* of the cell. In the second
the cells are spherical, and in size sometimes even larger than a rod blooil-corj'nscle ; the itigment grains are usually arranged in a ring concentric
with the circumference of the cells. These spherical bodies are furnished with three or four slender hlam*'nts each about tbrei' tinifs as long as the
diameter of a red blood-corpuscle. When iu rapid motion the filaments undulate like the anguillula and their action impresses a movement on the
neighboring corpuscles. In the third form there are various deviations from the spherical outline : the cells are larger than those of the filamentt-d
series, and while the contained pigmet)t grains are irregularly disposed the annular arrangement is sometimes noticed. Laveran regard.^ these three
kinds of cells as representing different phases of the evolution of the same iwrasite, the second form furnished with mobile filaments being considered
the perfect state of the organism, while the third form is regarded as the cadavers of the parasitic ek-ments and as identical with the pigmented elements
found in the organs of jwrsons who have died of jx-ruicious fevi-rs. Recently Tommasi-Cri'peli, 5Iarcuiavava and Celli — Indian Medical Guzelte, Vol.
XXI. p. 7, (.'alcutta, January, I8S6 — •have shown that the apiK-arances regarded by Laveran as due to an exotic organism in the bloml arf in reality the
result fif degenerative changes in the red blood-corpuscles. The globular protoplasm appears to become absorbed or converted into a hyaline material
showing amoeboid changes of form, and the hfemoglobin is transformed into melanotic particles which exhibit oscillatory movements iu the interior of
the corpns<-le now rejtresented by a diaphanous spherule. The mobile filaments of Laveran have been observed by these investigators, but are believed
to consist of globular protoplasm nunlified in a way as yet unknown. The corpuscles ultimately become disintegrated and the black particles in various
degrees of aggregation are set free in the current of the circulation. Camillo Golgi — Fortschritte der ^fedi^:in, B. IV, 188G — has also seen changes in the
blood similar to those described, consisting of the develojuueut of colorless plasmic bodies in the red bbxHl-corpuscles, As these bodies enlarge melanotic
particles are found scattered within their substance. All trace of the normal constitution of the blood -corpuscle becomes lost in its transformation into
a colorless globule containing particles of pignient. The latter ultimately tend to the centre of the globule, appearing as a dark nucleus around which
the colorless substance undergoes fission in radiating lines, the resulting cellules presenting a semblance to the rays of a composite flower. When this
stage of development has been reached a febrile attack is imminent. Afterward the cellules and the central mass of pigmented matter are liberated into
the current of the blood. At Pavia, Golgi examined forty cases with negative results in two only. Most of his fevers were quartans ; and he claims that
the long inten'als between the paroxysms afforded time for the complete development and fission of the altered corpuscles, results which are not observed
in fevers which have shorter intervals. Whether the destruction of the red blood-corpuscles and the associated pigmentary changes result from the
action of the bacillus malaria- or of the alga of Lanzi and Terrigi, or are independent of both, does not appear to have been determined ; but Tommasi-
Crudeli regards them as of great practical importance in the diagnosis of obscure cases of nuilarial infection in continued and subcoutinued fevers.
As the germ theory of malarial disease explains so manj' of the morbid phenomena and is at the same time consistent with what is known of the
natural history of the disease-essence, there is a strong tendency to accept it in advance of the isolation and identification of the specific micro-organism.
MALARIAL DISEASE. 165
tious cooling after the perspirations of fatigue duty. That tliese attacks were not due to
fresh accessions of tlie poison was evidenced .by tlieir occurrence after the temporary chill. of
a batli und»n"taken as a luxury or in the interest of personal cleanliness. Pu^lapscs wore also
ofteuLiuies referred to errors of diet. They occurred at any time after the primary attack;
but in cases in which the operation of a predisposing cause was not manifest a tendency to
recurrence .at weekly intervals was generally conceded: thus Mkkkitt speaks of warding
off the hebdomadal chill by arsenite of potash."^' No observations were recorded on this
point; nor were they possible on an extended scale, as treatment interfered with the natural
progress of the morbid phenomena.*]*
VT. -PREVENTION OE MALARIAL DISEASE.
General Considerations. — From what has been said under the head of causation, it
is clear that the protection of the troops from the malarial influence is the all-important
preventive measiu'e. It is true that on active service the imperative military necessity
often requires the sacrifice of life by disease in the occupation of an important but unhealthy
locality, as it calls tnr exposure to death on the line of battle; but in both instances a
thonaigh knowledge of the grouuil mav permit it to be lieM witli a minimum of loss. Dr.
WooDHULL sliows that the disease in the 9th N. .1 . Vols, was due to the occuj>ation of a camp
near a broken dam presenting a large extent of bottom land as a malarial exhalent. Thie
6th Conn. Vols., in Dibble's report, became seriously damaged by its camp in the swamps
of Warsaw Island. Tln'scand various other reported instances may have been unavoidable
results of the military necessity ; but it is certain that tlu^ heaUli of many commands
suffered from the occupation of unhealthy camp-sites which were afterwards abandoned
although the military conditions remained unchanged. Thus we find Dr. Triplkr effecting
*See Mehritt's report^ i«fr«, p. 180.
t FoRRv iu his CUtitatv vf thr Vnitfd ,S/<(/c.e, New Yitrlv. 1S42, p. 283, says: "Tluit intemiittpnt fti'vor has a ten(h^ncy to a septenary revolution is a
fart that was fn'f|iieutly verifiml in Kloi'iihi uinh-r tin- unlhurV oltservatioii ; ami this too iu a manner so unequivocal that it nttiiu-ted the attention of
lh»' roiuiiiun soldier. At thvsv septenary [Kjriods, after the seventh, fourteenth or tweiity-lirst paroxysm, the disease has a disposition to terminate; spon-
taneously. It is at tliesp peritKls that f«'hrifiige remedies a«'t with the great^'st suecess; and iis reganN relapses, it is then tiio that u vast majority oarnr, —
a ein-innstance of surh freiiuent (H-cnni-not" in Florida that wohliei-s would vuluntarily 4-onie to the Iiospitjil to obtain medicine ti» prevent its return."
These statements are somewhat panid<ixical : The inllueuees oiwiutin;; at the septenary ^H-ritHis not only cause the suhsidenee of an attack in one who is
t^ufleriii^, hut have power to determine the occurrence- of an attack or rehipse iu one who is nut sutferini;. The doctrine of a periiMlicity dependent oh
luniiriiitlueiice has \h'vu lon^ entertained I.y aide observers, es|K*cially in India. l>r. Kkancis Bai.koik in his 'IWuiisi- on PnUid lirmUthnj /n/^-ViHu/ i-Vrenc,
Edinhurgh, \1'Mt, devehtped the the*iry t.f sol-lunar inHueiice. [n accin-dauce with his views daily remissions ajid aggravations, septenary returnaand
(^■iisoual pn-vah-nce were due Iu the ciHuhined inlluence of the sun and moon, the fehrile state heiug greater at the diur;iai meridional perio<ls than during
llie intermeritljunal intervals; at the uovi-lunar and pleni-lunar periods than during the intervening iK-riuls, and esj^cially at the hinar iw?rii)dB of
the iMpiJuoxes as compan-d with those of the inter-4*<piinoctial intervals. He states that the sol-lunar inHueilce iu fever is felt at Bouaris and
otiier places not Ies8 than thn-e hundred miles distant from the reach of the tides, and that eouse<jueiitly Lind's idea that tliese, and not the aK^ucies
t»y tthjeh they are caused, are connected with tlie pr*)trn'ss of fever is sufficiently refut^-d. Sir J. R, Mautin in his hijUte»ce of 'JVupiral Cliiiititt-jt, London,
lst;l, quotes the ohser\ations hy «]iich M i-. Kkam'IS Daly, of the Madras army, arriveil at the conclusion that then* is a soMunar intlueuc<' as argued by
I>r. U^LpoiR ; auil W. SlooKK in his Iii»fo.*tx ,.f Iml'ui, !-ondon, I«tll, pp. HT-S, says; " Indeed a very short practice in tlie tuopiis will »onvince the most
N-t'plical that individuals who havi? suffered from malarious feveix an- more or h*ss affected at either the full or cliant;e of the moon. Many experience
r»'tnrii of fever at these times; others, feelings of uneasiness or malaise, but not amounting to actual ague ; and tliis ])redispiisiiion to become perimlically
affiv|>-d may remain for months and even years, aud may recur at uncertain immiikIs^ the inti-rvals being |MWs**d in perfect health. That the moon per se
lias any effect in inducing this state may well be questioned ; but that the amount of mud surface exposed by the low ebb-tides and the consequent
gnater exiiiitittiun taking place nuiy act as an excitant, is at least prol»ablo in the neighhorhoo*! of the wa-<-oast. In far inland districts some other Solu-
tion of the mystery is, howitver, requisite ; and Mokkukau inclines ti) the opinion that when the coincidence of febrile disease and lunar i)ha.He8 is noted,
then- will gcnemlly W found present an appreciable atmospheric change of tempi'mtnre, of moisture or of direction of winds, which he aj)prehends is the
del -rmining caii.^' of the febrile disturbance." Neverthelciss, in the Anmih of MilUanj and Xaval Surtjn^t, itr., London, isrci, Ilr. II. (IntAUD, on page 184,
stales that Ihe wmit of reliable evidence on the subject of the moon's influence on i)erli»dlc fever having been bi"ought to the knowledge of the commander-
lu-ohief, onlers were Issutnl n*quiring that the ivconis of paroxysms should be kejit in evi^rj' nu^dical charge in the Bombay Presitlenoy during the year
ISOl, with a \iew t«> determine the question. The result showeil ."iti.lT'i paroxysms as tH-curring in 14li medirai charges at 44 stations, and it i^ concluded
from these that |mro\ysuis of f.-v.rdo not ^nvur more frequently at the springs than at oth.-r peri^Hls of the nionlli.
166 PREVENTION OP
the removal of the troops from the flats near Arlitigtou, Va., to the higher grounds beyond
the first ridge overlooking the Potomac river, that they might have the protection of its
crest from the malarious currents uprising from the bottom lands.*
The predisposing conditions or so-called causes were also unavoidable in many
instances, but not in all. Exposures to excessiv^e heat, cold, rain, fatigue, etc., might not
be avoided in the face of the enemy, but their influence was at times unnecessarily felt in
camp. At one period the men of the Army of the Potomac were turned out for duty
long before sunrise and breakfast, but Dr. Tripler, recognizing that this had much to do
with the prevalence of malarial fevers, obtained an order that reveille should not be sounded
until after sunrise, and that hot coffee should be issued immediately after roll-call.
A dry camp-site, good water and food, suitable clothing, the avoidance of unnecessary
drills and fatigues during hot weather, and of exposure to nocturnal chills, particularly when
the troops are fasting, will not only lessen the prevalence of malarial diseases in commands
wliich have unfortunately been exposed to the miasmatic influence, but when combined
with temperance, cleanliness and that regularity of life which old and well disciplined
soldiers find to be not inconsistent with active service in the field, will probably, as sug-
gested by Ass't Surg. Ingram, prevent the development of typhoid symptoms in the mani-
festations which do occur.
The experience of our medical officers is opposed to the idea of an accommodation of
the system to the malarial poison with the concurrent retention of a normal degree of health.
The febrile accessions might fail to recur, but the patients continued antemic, weak and
languid, if they did not become subject to the more active manifestations of chronic malarial
poisoning, so long as they remained exposed in the malarious country. Medical Inspector
W. H. MussEY, U. S. A., touches this subject in a report of an inspection of the Depart-
ment of North Carolina, dated April 13, 1863:
Much has been said upon tlie snliject of acclimation, which, in these localities, would lie nothing more :ior
less than a complete saturation of tlie system with malaria, so that intermittent fever would be the normal condition
of those acclimated. But there must be acclimation to the new life of the camp, and this is important. It is essen-
tial to keep the soldier up to the highest point of resistance to the malarial influences. Care in the <iuality of the
food, the proper mixture of vegetables, the cookery, the administration of prophylactics, attention to cleanliness,
raising the hed above the ground, avoiding unnecessary exposure in the night, wearing flannel, and the administra-
tion of coffee and a lunch, are the best means of securing this resistance.
Prophylactic use of Quinine. — The attention of the medical officers of uur armies
was directed to the prophylactic use of quinine at the very outset of the war. In the Raits
for preserving the health of the soldier, prepared by Dr. Wm. H. Van Buren of New York,
for the United States Sanitary Commission, and issued July 13, 1861, f the daily use of
quinine was recommended in localities where ague and fevers were prevalent. Later in
the year a pamphlet by the same authorj was also issued giving a digest of the evidence
on which the recommendation was founded.
This embraced the personal experience of the author in Florida during April, 1840, that of his friend Dr. J. S.
Newberry on the Isthmus of Panama and elsewhere, a letter from President David Hoadley of the Panama railroad
company, setting forth the beneficial results of an issue of quinine in wine to the crews of merchant vessels visiting
Aspinwall, a letter from William Laird of Liverpool, relating the successful nse of quinine as a prophylactic by the
♦Appendix to Part First of this work, p. 46.
f U. S. Sanitary Commission Doc. Xo. 17, reprinted in Military Med. and Surg. Essays, edited for tbe Commission b,v Wm. A. Hammond, Philadelphia,
1864, par. 2.5, p. 168 : " It is wise and prudent, when ague and fevei-s are prevalent, that every man sbonld take a dose of quinine bitters at least once
in twenty-four boui-s. This will surely serve as a sitfeguard against an attack of disease ; it bas been practised in Florida and elsewhere with undoubted
benefit."
t WiLLi.\M H. V.\N BcREN- — Qitwiiw as a Prophyiatiic aijaiusi Matariotis disease. Sanitary Commission Doc. 31, New York, 1S61, reprinted op. cit.,
last note, p. 93 et seq. From a note appended to the original pamphlet it appears that this essay was approved for publicatiuu September 30, 1861.
MALARIAL BISEARE. 167
crews of a line of steamers plying; between Liverpool and the coast of Africa, Iho testiiuony of Hrysou ' and llaviict
of the Eiinlish Xavy,Ue Saussuret of Charleston, S. C, and of several African travellers,^ besides sundry favoraldo
opinions and recommendations from various sources showing the confidence with which the measure was regarded
in various quarters. ||
ll was declared to be a fact well established in the experience of American physicians,
that the daily use of three to six grains of quinine by those who are exposed to the (lan<rer
of malarial poisoning will in most instances avert an attack, or failing this, will render the
disease milder and prevent the development of the malarial cachexia.
In accordance with these recommendations quinine dissolved in whiskey was fre-
quently used as a prophylactic by our medical officers, but no systematic records of the results
were kept; nor does it appear that the method was anywhere employed with persistence
on a considerable scale. The difficulty of transporting the whiskey needed for the purpose
often interfered with the continuance of the experiment, and at other times the quinia
itself could not be obtained in sufficient quantity. Many medical officers were led by
their observations to form a favorable opinion of the efficacy of this prophylactic method,
and in the Sanitary Commission's Memoirs may be found the testimony of Surgeons Isaac
F. Galloupe, S. B. Thrall, F. H. Milligan, S. W. Abbott, W. S. Willes, II. Z.
Gill and Professor Paul F. Eve.T[ Moreover, Dr. Flint expressly states that no testi-
• Alexandkr Bhysox — On the l*roph;tlactic iuflttence of Qiiinitie, Med. Times aurf G<lz., ISTj-I, Vol. I, p. C — refers to a Htatuliiig rule in the Xavy eiijuiiicd
ty the Oth article of the Surgeons' Instructions, that men seut on shore in tropical climates should take daily in the morning a drachm of powdcn-d Imrk
iu wiuu a;i a prophyhictic, and stalct* that this nieas'iin- had fallen into disust- partly on account of tlu' doubts of the medical offlcere and partly hccaiiHc
of thi" nausi-ous chanicter of the dose. Il<- then speaks favorably of the use of aniorphi.us quinine in wine, citing the reports of a number uf inediiMil
officers un the African station to the efiV-ct that boats' crews using this projihylactic either wholly esc^ipod or had milder attacks. lie admit** the tnuui-
BJonal failure of quinine-wine as a preventive of fever, but holds that it has been of most essential service. He had previously recommended its use, and
given some evidence in its favor in his lieport oh the Climate and I'riiuijud Duteases of the African skition. London, 1K47, p. 218.
t L. J, IIayne— Oh the Kudemic f event of Africa and Oie P)-ophtjlactic u»e of Quinine. Med. Times and Gaz., 1855, Vol. I, p. 280 — cites the case of a boat's
rrew ex|>osed on the Ponga river for two days and nights : 32 officers and men who used the prophylactic daily !iad but four slight cases of fever. As a
contrast to this he instances the exposure for sevt-n or eight days on the Lagoon at Lagos of 34 officera and men who only took the quinine every othrr
ilay. and had seventeeu severe cases ; while an otticor and man on shore at Sierm Leone for eight days took no quinine, and both had reiuittt'nt fever.
Bui it will be observed that the men who suffered least had been exposed the shortest time, aud that the hw^Hties were not the siune,
J ll. W. I)K S.M-SSVRE—Quiniw: os a Prophijla.tic of IntermiUeut and lirmittt-nt ftrcrti. Charleston Med. Jour, and Iteview, Vol. XV, 18G0, p. 4:i:t— testifies
to the succfgs of this measure on the rice plantations and elsewhere in South Carolina, citing the Knglish naval exiK-rience, and contrasting the fatality
of rvniittent fever in the first N'igor exploring exjjeditiou with the coniimrative good health of the second ex|M-'dition, in which quinine was used as a
prophylactic. An account of the first has been given by J. 0. McWilLIam— 3/e</. Hist, of the E^ipedition (o the yiijer during the years 1841-2, comprixinij an
acouHMl of the fern- trhich led to Us abrupt termination. London, 1843. The second has been chronicled by Wllliam Balfour Baikie — .Varrn/irc of an
Krplorituj votiayi- tip the rirerg Kico'ra and Bt'mie {commoidrf hiotPn as the Niger ami Diddda) in 1854. London, 1850. See Appendix O, p. 452, and also au
article liy the siune author— On liemUttnil fever, espectalht as it appears on the West coast of Africa, etc. Edinburgh Med. Jour., Vol. II, 1856-7, p. 803.
gSuch as W. B. Baikir, si.'e hist note. T. J. Hutchinson — Impressions of We-tlern Africa, London, 18.'>8, p. 229. The article on hUermitteiU fcr^r in
till" Kncijclopirdia Britannica, and I)u CnAll.l.u — Etjnalorial Afritn, Chap. XVIII, p. 31)9 — to which the editor has added a reference to the ob.se r vati on s of
MoiAT among the ,\iidaniau Islands — Annals of MHitanj and Xaval Suryen/and Tropical Mrdiiine, etc., London, 18(14, p. 193.
I lie cites Of.i'rge B. Wooii — .! IVeatisi^ on Therapentit-s, etc., Philadelphia. 18.55, Vol. I, p. 2W} ; and also the recommendations of several English anny
mtnlii-al offiw^ra of high position and reputation, whose views, however, do not ai)iK'ar to have been carried far eiiongh to yioUl definite practical refinUs.
Th»- first of these is the letter of Dinrtor-Cieuenil A. Smith of the Ai my Jledical I)ei>artment, July 27, 1S.'>5, to the Ins|)ector General of Hospitals in the
lYimea, n*c on unending the prophylactic use of quinia, and remarking : '* Having now at command snfticicut of this tlrug, siH'cially provided for that
•en'iw, Iu furnish five grains per dii-ni (o every n»'niber of a force of 35,(XM) men, I beg yon will take such measures as yon think propter with a view to
induce tin* nieilical officers to enipbiy that n-niedy."' — lieport of th« <_\}mmisK(oners appoiiittd to twiuire into tJif Itfijnlations afffctiny the SanUary condUion of the
Armii, etc., Louilon, 1858, .\ppendix 79, p. TO. The Med. and Surg. Ilislory of the British Anny which served in Turkey and tJte Criswa^ etc., Loudolk, 1858^
oiaki^s no mention of the adoptitui i-f this measuri'; but in the appendix to A'.d. I, p. .5ff4, Sir-TouN Hai.i.. Insi^'ctor (jeneml uf Hospitals, in reply to
urn* uf the qut-ries of tlu- I)in*clor tJciit-nil, wmle iu Jaunary, 18.57, that " In malarious distriits, ciuiniiie, or (piinoidine in sululion, which is prefemblo
from the form it is in, givt- n as a prophylactic in either wine or spirit, is very beneficial, but suldiel-s do Tint like it, and I have heani them dccdare that
it had occasioned the complaints they «ei-e laboring under at the time." The second is the recommendation of Director-General J. B. Gibson of tliu
Amiy Medical Department, submitted to the Minister of State for War during the preparation for hostilities in China in 1859, that a stock of quinine-
wiue be provided for issue during the unhealthy months, or when the soldiei-s are ivquired to proceed up rivers or to encamp in the vicinity of marshy
ground,— with the instructions to use quinine-wine contained iu ^ 8 of the New Medical Regulations for Field Service issued to the Expeditionary .\rmy
(In China) during the same year.— .Ir»»/ 3M/. hcpartmtiU, fHati^tiral, Sanilary and Medical Hr ports for the year 1H59, London, 18G1, p. 181. But in the vulnnie of
-the siiiie reports for Lstin, London, 1802, p. 393, is found an official statement of the Practical residts beariny im the Medical DepurtmejU deducible from the
oj»T«tiiins in China, from which we leurn : "That the ex|jerinient of quinine as a prophylactic agiiinst malaria was n()t tried in this campaign on a suffi-
ciently extended scale to warmnt reIiiiI)lL' ivsnlts." It is (rue tliat \Vm. R. K. Smart — (Jbs. on the f'limatoloyy. Topography and biseam-s of Hong-Kony and thr
CiiH/i.M nrer s/alion. Trans. Kpideni. So<-., London, A'ol. I, l.sOO-1, p. '.i-'ll— speaks uf the ''comparative exemption " securi'd by quinine for the crews of
the gunboat llotilla on the Canton river, but he gives nothing more precis*; than the statenient that " they seemed nut to suffer disproportionally from
uialarious fevers, excepting those of the intennittent type." It would ap|»t.*ar, too, from his remarks that the quinia was given **ou the slightest occa-
sions uf indisposition " nther than t»» the well men. The last of these eitjitions is a mere suggestion for the use of this meaaure by U. C. Keade—
Rruiark* on the Typography of the Mdilary /Nations in British Cuiana, etc., Voiunu? for 1859, cited supra, p. 243.
^ Sanitary Memoirs of the H'lir of the Uel'ellion, collected and published by the ll S. SaniUiry Commission. Medical,— (-dited by Austin Fl.lST, New York,
1867, p. i:i4. Si*e also an article headed i^ninine tw a Preventive of Malarial disease. Stin. Com. Bulletin, Vol. I, IHVA, p. 215 ; also .4»ier. Med. Times, Vol.
Vin, 1864, p. 248, iu which the inspector of the 8anitar>' Commission in the De|)artmeut of North Carolina and Virginia. J. W. Page, reports great benefit
from the isaue of a qoinine nition to regiments iu the vicinity of New Berne^ N. C.
168 PREVENTION OF
mony adverse to this method of prophylaxis had been received by the Commission.
Reports favorable to the issue of quinine were made to the Surgeon General's Office bj'
certain medical officers, and some communications were received by Dr. Woodward in
response to a letter requesting information on the subject. These are herewith submitted.
Surgeon C. N. Chamberlain, Wth Mass. Vols., Washington, Octohn- 1, 1861. — The fevers were of a liilious remit-
tent type, some rapidly assuming a typhoid form. At first they were of a very severe character, and four treated in
our regimental hospital jtroved fatal. One became convalescent and left the hospital for his quarters, but owing to
imprudence he sufiered a fatal relapse. Another was delirious from the first, his skin literally covered with petechia
and vibices; he had severe congestions of the head and bowels, and sank after an illness of ten days. The third
and fourth had all the phenomena of ordinary typhus fever, and both died of severe and repeated hemorrhages from
the bowels. As the epidemic progressed the type of the disease became milder, although we still have occasionally
cases of a severe character. The treatment employed has been usually a mild laxative of castor oil and oil of turpen-
tine, often preceded by five grains of blue pill; full dosed of cjuiuine, and an occasional Dover's powder, after the
operation of the cathartic. This has sufliced to arrest very promptly the large proportion of the cases, while it miti-
gated the others, excepting the few cases more emphatically typhoid in their tendency which ended fatally.
After witnessing the salutary effects of quinine as a remedy, I determined to employ it as a prophylactic, pro-
vided a sufiicient quantity could be procured. An appeal to the Sanitary Commission secured twenty-three gallons
of whiskey containing three grains of quinine per ounce of liquor. The men were allowed to take daily one or two
ounces, and I was happy to witness its results in reducing the morning report of the sick from tifty or sixty to twenty
daily. After the supply was exhausted the reports exhibited an increase of the disease. I am prepared to recom-
mend emphatically the use of quinine as a prophylactic under circumstances parallel to our own. A second small
supply, furnished also by the Sanitary Commission, has been of great service.
Medical Inspector J ohn Wilson, U. S. A., Army of the Potomac, Oc(o6er 31, 1864. — The ordinary endemic diseases of
the region have touched the Army of the Potomac [before Petersburg] with unwonted gentleness during the usually
sickly autumnal months. This, at least in a measure, is due to the vigilant surveillance kept over the police of the
camps and the cleanliness of the person of the soldier, and also to the excellent manner in which the army has been
fed and clothed. In the more malarious localities occupied by our troojis during the months of September and Octo-
ber, a ration of whiskey and quinine was given daily with excellent eti'ects as a prophylactic.
Asst. Surg. Alfred A. Woodhull, U. S. A., in charge of Battalion of '2d and 10th V. S. Infantry, Siplenihir 30,
1862. — The whiskey ration that was at one time attempted is, in my opinion, not. only unprofitable but absolutely
detrimental when it is issued indiscriminately, even under the worst aspect of military life on the Chickahominy.
It is unprofitable, because on those occasions when it would beof service, if at all, it is often impracticable to issue it.
If useful, it is chiefly in the depression and exhaustion induced by wet and cold, immediately after a fatiguing
march; but as these are the very times when the wagons are not up, it is impossible to obtain it until the occa-
sion for its use has passed. The transportation of the required amount would greatly burden the Quartermaster's
department, an item in the movements, and consequently in the health, of the army not to be overlooked. Its
habitual issue would uuciuestionably tend to the producticui of intemperate habits in some and foster those of others
that a campaign might otherwise dissipate. While accustoming men to a stimulant, to be deprived of at those times
they would most need it (as indicated above), would be doing a double injury. The addition of iiuinine does not
seem to counterbalance the evil, and so great a consumption of that valuable drug appears to be a waste which
nothing but the most certain benefits should authorize. To leave the issue of quinine to the legitimate channel of
the medical department is much more rational than its indiscriminate administration by battalions. Of course these
remarks refer to the circumstances of the Army of the Potomac, and not to those clinuites where perpetual cinchon-
ism is the condition of life to the white.
Surgeon J. G. BuAnT, 26/A Mass. Vols., Xew Orleans, La., March 31, 1863.— The rainy season continued through
the last quarter, and probably had an eft'ect upon the health of the regiment, as shown by a considi'rable increase
in the number of cases of intermittent fever. Wet days, followed by sudden changes to warm, muggy weather,
have invariably increased the prevalence of this fever; but all the cases occurred among men who had previously
sufiered from the disea.se. I consider that the city is comparatively free from the miasm to which nuilarial fevers
o«e their origin, and that these fresh cases are merely the reappearance of an old trouble which had been l.ving
dormant in the system. To test the value of whiskey and quinine as a prophylactic, I procured fifteen gallons
of whiskey and added one ounce of quinine to the gallon. This mixture was served out to the guard at night at
the rate of one ounce per man. In wet weather a ration was also served out at midnight. I am positive that it
prevented a great number of attacks of chills.
Surgeon David Merritt, 55th Fa. Vols., Beaufort, S. C, May 10, 1863. — The issue of a ration of whiskey and
<|uinine while the regiment was on Edisto Island was of great service to the health of the command. At Beaufort
the ration has only been issued to the men on picket duty. I am a strong advocate of the measure, and the oral testi-
mony of other medical officers corroborates my opinion.
A.ist. Surg. E. A. Thompson, 12th Me. Vols., Baton Houge, La., Fehruary, 1863. — Most of the cases of intermit-
tent fever which occurred during the winter were observed in the companies that were exposed to malaria during
last summer while on detached service at Lake Pontchartrain. We are now issuing rations of quinated whiskey to
the men on picket and extra duty with marked benefit.
MALARIAL DISEASE. IfiO
Medical Inftpector E. P. Vollvm, ('. S. .(., Louisrillc, Ki/., Diccmhir 31. IWJS. — I have to state that from my i-xiio-
rience with quiuiiie-whiskev as well a.s with simple iiuiiiiiu'. I am letl to believe that it is a prophvlactic- anaiiist
malarial levers. When troops are about to enter or abide in a region well known to be malarious, 1 would advise
the MH>derate use of <ininiue-whiskey, to be eontinueil in diminished i|Uantities as lonj; as it is evident that the
troops are in danger of attack: liut 1 would diseountenance its general issue exeept at snrh seasons and iu such
regions as are markedly nuilarions.
Medical Inspector A.C.Hamlin, I'.S.A., Wushiiiiitoii, />.('., .Yoreiii/iec, 18t>3. — My observations have not biM'u
conducted on an extensive scale, but the results have convinced me that the use of iiuinine-whiskey in pro])hylaciic
doses (iroduces a ])rompt and energetic action, and supports the organic forces in resisting the i>eruicious intluence
of malaria and neutralizing the paludal poison : but when iialiidal cachexia is oiu'e fairly established the adminis-
tration of i|uiuine seems to be without much force. 1 will also state that 1 consider the best mode of administering
this drug to be iu solution in the red wines, by reason of their tonic cti'ect upon the muscular libre : and I believe,
with the distinguished chemist Henry, that the red wines of liurgundy are best adapted to the jiurpose.
Suifieoii \. I'. Mwi.F.RT, V. S. )■(>/»., J.uiiisvillf. Ky., Xiiniiihrr I, 1X1)3. — I think that the issue of (|uinine or some
autiperiodic as a prophylactic would be uot only humane but an economical nu-asure for the (iovernnu-nt. Alcohol
is doubtless the best menstruum for its administration, and ]>ure old whiskey the best form of alcohol : Imt inasmuch
as it would be impossible to obtain the latter, I would recommend that diluted rectified spirits, i. c, pure diluted
alcohol, be used for this purpose. I regard alcohol when properly administered as ]>ropliy lactic to a limited extent,
Imt when imi>roiierly used, as is too often the case, its eft'ect is doubtless the reverse. I would therefore recommend
that iu any such combination the alcohol should bear as .snuill a proportion to the antiperiudic as may be.
SuriiKiii T. H. HvrilE, U. S. Vvlx., U'lixhiiiiiloti, D. C, .Yorcwi fcce 3, 181)3. — I know i|uinine-whiskey is of great n.se
as a prophylactic against malarial fevers. However, I am opposed to the mixture, and think its geneial issue would
cause much harm, owing to the fondness of many for whiskey. I am iu favor of a mixture without whiskey, though
I would in some cases have recourse to w hiskey as well as to quinine.
tiurgcon E. SwiKT, C S. J., Chester, I'a., Xocember 22, 18t)3. — In June, 1SI7, at \'era Cruz, Mexico, I recom-
mended two grains of sulphate of quinia in about two ounces of whiske,v, to be taken V)y the olticera every morning
at the moment of rising. This coulil not be administered to the men for want of a suflicient supply of the liquor.
The army was, however, generally healthy, and 1 did not discover any marked dilference between oHicers and men.
Ill Texas 1 frequently reconuiieuded this prophylactic iu malarious districts, and credited it with an intluence in
wardiug otf disea.se. So fully convinced was I of this that, as Medical Director of the Army in Kentucky in Decem-
ber. 18m, I urged (ieneral Mitchell to approve a daily issue of iiuinine-w hiskey, but the advance of the army into
IVnnessee prevented me from making satisfaitory observations. In a cir<iilar publishe<l to the Army of the Cnm-
li 'rland by order of General Kosecraus, I find- the following directions, viz: "Hot cotfee should be issued to the
.soldier immediately after rising in the morning, and in iuclenient weather quinine and whiskey iu the evening."
Favorable testimony is also i'ound iu some of the reports printed in the Appendix to
tlie First Part of this work,* and in certain articles published by army medical officers iu
the medical journals. f Unfortunately this testiniony is iu no in.stance based upon statistics
showing tht^ comparative eft'ect of like exposures upon commands using the quinine and others
not using if. On the other hand no reports condemning the propiiylactic use of quinine
have been published.;]; although doubts have occasionally been expressed as to its
♦See, for instance, tliat of Snrgeon 0. S. Triples, Mi-diral Director, Army of tile Potomac, pp. 47-8, in wliicli lie slates that, liaving n^ceiveJ
faTonttile report!* of tlie effects of quinine and wliislcey a.-^ thf result of au exi>erinieiital irwne made by liif* mediral offiei-rs. lie nfcommended il»* u«e lo
llioM- n.-i;iiii,-iits wh.ise (-oliilitiou s<H'iiied iiiotit tu deinaiiil it, and w:is indtK-fd tliereafliT to kt't-]) it (■i>nstaiitl>' on baud in tbe Purveyor' ;* store. See also
|.. (IT, wber»' :<nrKeon J. B. Brown, Medical Diivclor. 4tli .\nay t'cnl).-;, i-.\|iivsse!< liitnsi-If salisfietl tliat bad a libeml supply of quinine been obtainable
for propiiylactic piir|ioA>s and treatment, oiie-half of tlie sickness tliat prevailed in bis coliilnaiid during tlie advance on Williamsbiirt^, Va.. in ISfi'J, wonld
bav." iH-en preveiiteil. .\lso, on pp. T^lt, -\ssistalit Surgeon H.\uvi:Y K. Bkow.v, l". S. .\niiy, states tbat his regiment, tlie 7(ltli N. Y. Vols., while o i
tlie Peninsnln. was seriously tlireatened with inteniiittent fever, but tliat a liberal administration of quinine dissolved in whiskey lo the whole coln-
nialid checkeil the progn-s.s of the disease. .\lso. on pp. 232-.'i, Surgeon Geo. K. CtioPKR, IJ. S. .\rmy, after referring Ui the generally n*ceiveil opinion
tliHt while men could not live on the low marshy grounils bonlering the rivei-s of tin* sontlieasteru coast, ami to tin* feeling of anxiety coiiw*qneiit on
I'm- i.v»ui* of onlers to construct and garrison fortilicationson these bottom lands, states that : "The medical officers on duty in Ibe batti*rit*s wen* instructed
li. iwiie lo the men ipiiiiine and whiskey as a prophylactic ; and with beneficial effect it was used, as the statements of the medical officers infonned me.
W bib* nferring t<. the prophylactic use of quinine. I w,iiild state that in such casus as ca iiiuler my own .ibsiTvation I saw much boo<1 resnlliliK from
II Many men who seemed to In* iiniRTceptibly almost succumbing lo the malarious isjison were in a short time giving indications of isTfecl health.
I w.mld stn.ngly recommend its use in all malarious districts, for thougli the expense is considerftble the lienefit following will. I think, mon* than com-
|-*lit«ite for the outlay."
t See letter from Brigade Surgeon Geo. II. Lvsiax— Boston Med. ami Surd. Jour., Vol. LXV, 180*2, p. 312— in which the prophylactic use of ipiinine is
highly commended ; see also the same journal. I.X I X, ISlSl, p. 109, where Surgeon GeordI! Dehbv, '2M Mass. Vols., n*lates his experience with this ilrug
in his regiment at New B.^riie, X. C, and vicinity, and strongly commends il-s il.si* as a prophylactic.
t If we exctpt the following: A boanl of surgeons consisting of Drs. G. H. Cvv, (". I>. Homaxs, R. M. Hodoes, specially detaileil by tlie Governor
of M.*Ls^chusetts to insjieet the condition of the 5Ia.s.sachuw'tts regiments tif the .\niiy of the Potomac, then befoiv Yorktown. visitiil that army during
April. ISli2. and made a n*|M,rt. Ii',^n„ Sl-'-l. oivl Surg. J;iir.. \'ol. I.X VI. \StVl. p. -VA, to the Surgeon General of the State, in which tln*y n*mark : " Malaria
WHS Slid to Ik* ailing |n.werfiillr, and therefon* quinine must Ih* adiuiiiislen*il in large doB<*s. The ill effect from this large dosing was fouml to h.* uinrli
givab-r than tbat from any supposed malarial intltienin*. The improvement in every instance wheiv the quinine was either entin*ly stop|>ed or given
in greatly leilncwl ipianiities w.os Ivm. marked and too continued to leave a shadow of a doubt as io the exciting cause of the [lersistent headache and
di*rrb,ea. The g>»«I .*ir,cl of stimulants, liniiidy or whiskey, was immediately sien when we bad some to give," This paiugraph is cited by the editor
Med. Hist., Pt. HI — 22
170 PEEVENTION OF
value.''" In view of the general tenor of the testimony, it must be allowed that quinine
exercised a protective influence. Nevertheless, as the practice of administering it for its
prophylactic virtues was generally abandoned in the later years of the war, it must be
conceded that the results achieved did not equal the expectations which were at first enter-
tained. But a consideration of the well-known temporary action of the drug on the system
will readily explain its failure to protect where the exposure in a malarious country was so
prolonged as during our civil war. An intermission in the use of the quinine, by leaving
a command exposed to the miasm, necessarily put an end to the prophylactic experiment.
The sickness of those who became affected by the malarial influence and the idiosyncratic
immunity of others under similar exposures rendered unnecessary, in many instances, the
further expenditure of quinine as a preventive, and led to the gradual abandonment of the
method by our medical officers. Practically, therefore, the prophylactic use of quinine in
our armies was a failure; but it does not follow that the method, so far as employed, was
not of value. On tlie contrary, all who adopted it give positive evidence on this point.
Men were saved from attack and preserved in perfect health for the active service of the
time-being by the use of the drug. That it did not continue to save them after its use was
intermitted does not detract from the value of the protection already rendered. That it did
not save from attack every one to whom it was administered is no argument against its
prophylactic use. Its efficacy even as a remedy is unequal, some cases requiring more, some
less, for the suppression of the morbid phenomena, and in certain instances in which the
morbific influence is overwhelming, quinine, although well known to be of remediahvalue, is
unfortunately of no value. Its efficacy as a preventive may not be supposed to be more equable
than its remedial power. The malarial influence may be so overpowering that the prophy-
lactic dose maybe as inefficient for prophylaxis as the remedial dose for cure. From these
considerations it would seem that the quinine which was used with a view to prophylaxi
was of value in preserving health temporarily, and that the disuse of the method was due
not to a I'ecoguition of its want of value, but to the difficulty attending its successful prose-
cution in cases of prolonged exposure, especially as the periods of active service which
led tlie troops into dangerous bivouacs and surrounded them with predisposing conditions
were precisely those in which there was the greatest liability to a failure in the issue of the
prophylactic doses.
Nor must it be forgotten, in a discussion, of the prophylactic value of quinine, that
although, owing to conditions of continued exposure, the attempt to protect whole com-
mands was given up during the later years of the war, the protection of individuals from
relapses continued to be practised to the last, not by issues of quinine and whiskey, but
by the administration of the drug in repeated doses, covering several days at -a time,
or by larger doses given at specified periods. The success of this mode of treating
relapses, really a prophylactic use of the drug, bears strongly on its value when used under
favoi'able conditions for the protection of healthy men from the miasmatic influence.
of the Chicago Medicid Journal, Vol. XIX, 18G2, p. 416, wlio remarks : " Is uot this monstrous ' quinine propliylaxis nonsense about played out ' ? The
word of its promise is uot even kept to the ear, and the humbug proves dangerous as woil as expensive." The report of the Massachusetts physicians .
is not understood, however, to refer specifiwilly to the use of quinia as a prophylactic, but rather to its alleged abuse in the treatment of [he sick.
The prophylactic use is probably objected to in the remarks of Alex. Le B. Monroe — Lettfr lo the Snrf/toii General of the State of MoMachawttn, Bo^oii UTeit.
and Surg. Jonr., Vol. LXVII, 186*2-3, p. 21— who, writing of a brief tour of duty in the Army of the Potomac during June and .July, 18G2, says; " We found
a great many patients who had suiTered from over-dosing with iiuiuine administered in whiskey,"
* J. J. "WooDW-^RD — Outliuen of the chief t'awp Difea^tc, etc.. Philadelphia, 1S6.3, p. IGS et ncq. — speaks dunbtiugly of the prophylactic value of quinine,
first, on accouut of its failure to become an accepted method of prevention in the army, and secondly, on the claim thi:t its continued use establishes a
tolerance of the remedy by which its curative powers arc to a great e.\tent lost. " The general use of quinine-whiskey as a preventive of malarial disease
is therefore to be regarded as uuadvisabie. * * * Quinine should i>e reserved for employment as a therapeutic measure in the treatment of the actual
symptoms of malarial disoi-ders when they appear in iudi%idual cases."
S
MALARIAL DLSEASE. 171
The experience of the war appears to teacli that, when a command is to he temporarily
exposed in a specially dangerous locality, quinine should be issued for the sake of such protec-
tion as it may give; but that when the command is to be stationed for a lonir time in a
malarious section, prevention should be attempted by the judicious selection of camp sites
and the avoidance of predisposing causes, while quinine is reserved for remedial exhibition
oil the first manifestations of the malarial poison in the system, and for special prophvlactic
doses under conditions of unwonted exposure or in anticipation of relapses.
The whiskey ration is brought incidentally into question by its connection with the
quinine. Dr. Woodhull lias expressed the prevailing sentiment of our medical officers
with regard to it. As a matter of fact, the campaigns of the civil war were made on IkjI
cot!ee, with a rare issue of whiskey under special conditions of fatigue or discomfort. The
sanitary reports are therefore generally silent on the subject of the whiskey ration per se.
On the Confederate side attention was directed at an early period of the war to the
prophylactic use of quinine by Dr. Joseph Jones, who cited in support of his favorable
opinion the accounts of its successful employment by English naval vessels on the .'Vfrican
coast.* This essay was subsequently embodied, with some additional matter, in a report
made by Jones to the Surgeon General of the Confederate Army in August, ISS-i.f
From this report it appears that quinia had not been employed as a prophylactic to any
extent in the Confederate Army chiefly because of a scarcity of the drug. Nevertheless
it had been used on a small scale with decided benefit in certain malarious localities.
Ass't Surg. J. X. Wakken, 25th South Carolina,^ stationed on James Island, S. C, gave
four and a half grains daily to two hundred men of his regiment, from April to October,
1863. Four cases of malarial fever and one of typhoid occurred among these men. The
remainder of the regiment, between three and four hundred men, did not take the prophy-
lactic, and over three hundred cases of paroxysmal fever, with twenty-three of typhoid,
occurred among them. Surgeon Samuel Logan, § chief surgeon of the 2d and 3d Military
Disti'icts, Department of South Carolina, Georgia and Florida, tried quinia in four-grain
doses daily as a prophylactic during the summer and autumn of 1863, in portions of several
small commands stationed in malarious districts of South Carolina. The coast line is
indented with numerous havs, inlets and salt-water creeks, which contribute to the iVn-ni-
ation of a series of islands consisting of light sand supported by a clay stratum a few
'Joseph Jones — Snlvhale of quinia ttdmrnitiered m small doses during health the best meauM of prerentiag Chill and ferer, and Bilious feter^ and Co'v^tflireferer^
m tho$e espi)*e*l to the ttidtealihtf dtimUe of the rich totrtauds and siranips of the Sotithent t\mffdeTacy. SoMOiern Med. and Siirg. Jottr., Vol. XVIII, August. 18G1,
p^ 593. *• rnd^T Iht'Sf i-xoo8urfs I have found that sulphate of quinia. taken in fruiu :i to 5 grains twice during the day, would in most cases prevent thu
occurreore of malarial fe-er, and if it failed toward it off entirely thy attack would he of a verj- slight charact.T." In support of thisfiosition he cites the
prevalence and fatality of malarial fevers among Euro]H^ans in Africa before the iotroductiou of the use of quinia as a prophylactic, and contmsts this
with the cominrative ininmnity in the case of certain Eugliiih naval vessels on the west coast of Africa during 185)> and 1857. — See Slatifticnl report of the
ke^tk of the Rotjid Sary jur the year 1&56, Londou, IS58, pp. UH> to 116 ; also the same for the year 1857, London, 18a*i, pp. 78-85.
t QmiHhf tiA a I*itrj}hyhictic agaitiii Malarial fecer: being au appeiidiJ to the Third report oh T)fphoid and Malarial /erers, deUrered to the Surgemt
tiemeral of the bite C. S. A., Aiigtul, 18M. yatJiville Jour, oj Med. and Stirg., Vol. II, 18f.7, p. 441 el iteq. Dr. JoNRS adverts to the great prevalence of inter-
mittent and remittent fevers in the command i^tatiuned in and around Kurt Jackson on the Savannah river. This command hail a mean stn>ngth of 878
men, and during the twelve months " from October, 1SC2, to November. 18I>1, ^Z,S^^S■ cases of malarial fever were treated." He asaume-t that these men
' might have been protected at a cOj;t of &4,31K> by each using an ounce of quinine during the (M'riorl stated. On the other hand he suppos>-s that had nu
pniphylartit- l»eeu used tin- proper treatment of the casi'T* rx'ported would hav»- rronired tm an average 50 grains of quinia each, or about :i(N> ounces,
ciwting at $:. |nr ounce Sl.."rf«t. The additional cnst of the quinia n-qnind for |>roidiv)axis would thus be S2.8'.K»; but against this he ..frs.tj< the jiwy of
til** men un the sick-list. Asi^uniing 10(> nieii to !«• constantly off duty in tlie unprotecteil command, their jjay jht annum. eHtiinated at SM.'-i<M would
give a lialance of SUi,:ilO wn a saving to the t'oufedemcy by using the quinia Jis a pr<U)hylju-tic. Besides the reports of Surgeons Warrkn and LOOAN,
nientioned in the t*-xt. Dr. Jones reprint.s a report by Sui^eou Ocr.wiis White, ihited James Island, S. C, Slay 7. ISCJ, in which the writer refers to
the Knglish naval ex|n-rience. and recommends the prophylactic use of quinia by the troops on James Ittland and iu St. .Andrew's Parish ; aUo a letter
fnwn Dr. D. Dr Tke. da!e«l Nashville, Teou., May H», 1867, meutioning the case of si.\ individuals expt>se<l to malarial iuflueuces who attributed their
«c»pe from fever t«. the use of quinia.
I Surgeon W.vbke.n's ob^rvations were made at the instance of Dr. Jones.
gSAMiEL Loc.ix, P. A. C. S.—Prx>phylactic efftdg of quinine. Gmfed. States Med. and Sarg. Jour., Vol. 1, p. 81. This article was republished by its
author in the Hidimoud Med. Jour., Vol. II, 1SG6, p. 412.
172 PREVENTION OF
feet below the surface. Towards the interior the light sea-island soil gives place to level
tracts of stiffer earth, sandy, but mixed with red clay, on which the undergrowth is extremely
liixilriant. These lowlands are intersected by swamps, some bearing rice, and all composed
of an alluvium on blue clay. Beyond this the pine barren region, a dry, porous sand with
clay underlying it at a considerable depth, becomes gradually changed into the rolling
ground which leads up to the mountain slopes. Malaria prevails in the sea-islands, in the
low-levels and in the lower part of the pine barrens. The higher parts of the last, and
some of till' first are exempt from fevers; but as the Union troops occupied all the
healthy portions of the shore, the rebel lines of defence ran through the unhealthv low-
lands just within the belt of sea-islands. During the summer months most of the troops
were moved to the liealthy pine lands, but some, chiefly cavalry commands, were retained
fur outpost duty in tlie sickly low grounds. To these quinine was administered as a prophy-
lactic; but it was not taken b}' all, althougli all were exposed to similar influences. This
failure on the part of some to make use of the quinine gives a value to Dr. Logan's statis-
tics by permitting a comparison to be made between the sick rates from malarial disease
among those who did and those who ilid not use the drug. His results were as follows;
Total number who took uo iiuhiiiie 230: had fever 134; ratio per 1,000 of fever cases to patients .'i82.60, or 1 in
every 1.71 patients; ratio per l,000of severe cases to total cases313. 43, or 1 in every 3.19 cases. Total nunilier who took
quinine irregularly, 246; had fever 96; ratio per 1,000 of fever eases to patients 390.24, or 1 in every 2. .'16 ])atients;
ratio per 1,000 of severe cases to total cases 291.66, or one in every 3.71 cases. Total number who took quinine regularly
506; had fever 98; ratio per 1,000 of fever cases to patients 193.67, or one in every .5.16 patients; ratio per 1,000 of
severe cases to total cases 326.53, or 1 in every 3.06 cases. It would seem from these statistics that although not an
absolute prophylactic, the degree of protective power possessed by the agent fully warrants its use. If four-tiftlis
of the fever cases are prevented, it should surely be used. It may be well to explain that under the head of iiumher
who took (luiniiw irregular} tj are included those who would forget or neglect to take it some three or four days in the week,
or take it one day and forget it the next, or omit it for a week at a time.
On the other liaud it has been stated by Dr. Herrick of Louisiana, that cjuinia
was issued in a spirit ration to the crews of the Confederate fleet in Mobile Bay during the
summer of L863, by order of the Confederate States naval commandant, but tlie result of
the trial was not satisfactory and it was soon discontinued.*
It is not difficult to add to the list of authorities brought forward by Van Buren and
Jones in support of the prophylactic virtues of quinia. On this side of the question may
be cited the papers of Mekritt, Rogers, Herrick, Bartholow, Vivenot, Jilek and
Hamilton, and the favorable opinions expressed by Easton, Dutroulau, Rtille,
H. 0. Wood and Hertz.^ Moreover, favorable notices of the successful employment
of the measure on the West Coast of Africa may be found in the oIKcial volumes con-
taining the statistical returns of the health of the Royal Navy subsequent to those cited
* iS. S. Hkrrick — Qliinmf. as a therapeutic agent. Trann. Amer. Med. Asaocialioti, Vol. XX, 18G9, p. 618.
f.r KiNd Merritt — Quinine as a Prfypltijlaflie in Malitrionit retjimis. Amer. Med. Ti}ite.i, Vol. Ill, 18(51, p. SfWi. Stepiiev UncERS — The Prntecfii-e or
projihylactii' prei'entii'e tnid smne points in llie t^nrotire nses of Qtiinine, etc. Trans. Med. Soeiehi, N. Y. Slide, 1802, p. IHl ; alsii, Tlie I'rojdiiilitelir and the Tliera-
pentic uses ami abuses n/ Qninia and its salts. Triuifi. .inier. Med. .^ssoeiation, Vol. XX, 1869, p. 187. Both Meruitt and Ru(iKRS inatallL-c their experience ou
the Isthmus of Pauania as authorizing their favorable opinion. .S. S. Herrick — cited in last note. Roberts Bartholow — .inny hiiijiene. Prnceedinijs
Chnnecticnt Med. Soeiety, Vol. Ill, 2d series, 1868-71, p. 76 ; also, Quinine and its salts, in sjiiiie Vol., p. 96 ; also, .4 Praetival Treatise on Materia Mediea and
Therapeuties, New York, 1876, p. 1.11. Rliriol.F RiTTER VON VlvENOT, JUN. — Ueber die propii;ilakl.ische Auwendumj des tyaniu ijegen Malaria-into^iltatiou. Med.
Jidirb., Weiu, 1869, S. 39. In this paper the writer relies almost wholly on the essay of Van Bnren, cited note J, p. 166, siepra, and the English naval
experience, .which lie gleans chietly from the work of C. Friedel — Die Kranl-heiten in der Marine, tjeoyraplrisch niid slatisliseli, naeh den *^ Iteports uu Die Health
of the Uoiial Nary," dargestellt, Berlin, 1866. A. R. VON JiLEK — Bietrag zur Prophijlase gegeu Marlariafieher. n'oelienblatt der k. k. ilesellsehaft der Aerzte iu Wrin,
April 27, 1870 (Nol7), S. 177. J. Bl'Ti.ER B.^MtLTon— Remarks m, tlie ralue of Qnmiue as a Prwplajlaetie. Indum Med. Gar.., Vol. VI, 1871, p. 2:i3. This anthor
i-elates that at .Inljlinl pore, in 1866, he gave tlii-ee grains of quinine every second day to each of lli.'i men under his iuunediate charge ; few cases of fever and
no deatlis ttccurrcd among them, the average number in hospital not exceeding four percent, of the command. At the s;ime time and place .^)0U men of the
2.3d R. W. Fnsileers. who did not use the qninia prophylaxis, weiT attacked with severe remittent fever, having at one time as many as l-'jO of their number
sick in hospital, and 150 moiv convalesceut from the fever, eucamiied on the hill close by : "The number of deaths I cannot remember, but 1 thiidt
they were about 20." A. F. DuTROri.Al' — Trad.' des Maladies des Europ 'ens dans les pays chauds, 2* edit., Paris, 1868, p. 2.'>:1. .1. A. Easton — General obser-
rafi*im on poisons, etc. Glasgow Med. Jour., Vol. VI, 18.'>8. p. 27:i. Ai.FREO STiLl.t: — Therapeuties and Materia Mediea, 3d edit., Philadelphia, 1868, Vol. I, p. 454.
H. C. Woon — Treatise an Therapeutics, 2d edit.. Philadell>liia, 1876. p. 73. Henry Hertz — Malarial di^^eases, iu Zienissens (.'nch'piedia of the Practice of Med-
icine, Vol. II, Amer. transl., New York, 1875, p. 657.
MALARIAL DISEASE. 173
in the paper of Van Bukkn. These notices are indeed so laudatory as to warrant the
;uitici[>:iti(>n that the statistics would show a considerable and permanent rcductinn in the
tV(Hpii'ncy o( malarial levers among the sailors of this station after the general inlmduetion
of the prophylactic use of quinine under the auspices of Bkyson in 185-1; bui an examin
ation of the actual figures does not show any such reduction, although of late years the
mortality has been very materially diminished.
The shore operations of the Ashanti war led to a high rate of jirevalence of malarial
fevers among the men of the British Navy and undermined the faith of their medical
officers in the propliylactie virtues of quinine. StatT burgeon Thomson e.\pressed adouljt/'"
Stafl' Burgeon Lucas gave an unhesitating deniahf Surgcn^n Major Gork, on the staff of the
quartermaster general, declared that his unfavorable opinion was shared by European resi-
dents in West Africa,;|; and Sir Antho.w \l IIomk. prineipal nKnlical officer, regretted that
he had been unable to recognize any value in quinine given in prophylactic doses, for it
seemed neither to ward off attacks nor to mitigate their severity. §
MoREHEAD, from his (tbservations in India, entertained the opinion that the evidence
in favor of the power of quinia to prevent intermittents and remittents in malarious districts
was by no means conclusive. || LlyJ^M_;sTO^, during his expedition to the Zambesi river,
Ibund that those of his men who took quinine as a preventi\*e were attacked witii fever as
irequently as those who did not attempt thus to secure protection.^ Leon Colin's expe-
rience in Algeria and Italy led him to an equally unfavorable opinion. •^'■•' The method
was tried without success among the Russian troops in the Caucasus. -j-j- Vivenot's essayQ
suggested its use in the Austrian army and navy during the year 1869, when Jilek obtained
f Surgeon .James Thomson, of the Aiwth{st—Staii>^tml rfpnrt for 1S74, \}]t. 180 ami 184 — writes: " Wh.-tlii-r miy jiruphyliutir tniitiu'iit i;in Iif*
roiiiplolfly Micressful in tliis rlinintc is a proMi-ni for tho future. I confess to ronsidorablf; disttpjiointtMi-nl in tin- prt'st'nt cast-, althoiic'i I think it
prultMlilc that the daily ndniinistnition of fimr-gniiii dosus of .piiqine hiid a itmdifyin;: influence. It is, moreover, worthy of reniarlt that I )iav<- li.-ani
ornocHso liiivinga fatal termination. "'
fSiirgeon Lfonakd Litas, of t)n' Anjim — S/atifiicnl report /or ISui, p. VMi: "A tjuestiou arisps, diK-s <iuieiine j;iveu as a prophyhutie prevent a ii
jtriark of remittent fever? I unhesitatingly say no. Take the catJe of thow marines landed at Ehnina tn gnnni tlie plaw. Quiuiue was administerr'd to
them daily, yet within a month all these men i-eturned on bmnl with fever. It is true Fort St. .lago is unlit fur men to live in ; hut thnw l.illet"d in
llie rastle fared uo better. It d»H's not foMow that men landed for a day, wbi> hatl fjuinine before leaving their shi]t. esea[M'd fever in fonseqnenee. bcrauito
men have also been landed without any ipiinine and have fared equally well. It remains to be proved whcthei- its administmtion as a pruphylartii:
tends to render the attack of fever milder in cliar.uter."
I .\i.HF.RT A. OoRE— .1 1 'oulrihul'um f'> Ihf MrtU,,il Hinfoi-ij nf (hr W'M .\j'ri'aiTt''jiiipniiiiis, London, ISTtl. p. liVI— gives ^|M•^itic illustniti'-ti*. >•( th<- failun'
of ibe qninia-pnipliylaxis, as for inslarii-e : "giiininc was served out to llu- marines wlut started fur Klmina on the I2th .Inne— live gniiiis in half a gilt
t'f nun all round, the same quantity at daylight in jiorl wine ; all these men had t><_'Veie attacks of RMuittent fever. After wet and damp nights it was
always given to the sentries with no better etfect."
5. Deputy Surgeon (ieuenti Sir Anthonv D. Homh, K. C. B.. *i-. — .V'-«y(Vvi/ hiMnnf „( ihr Wm- in Ihe (inhi-rouKt l'r»h:h>ruU' in 1K7:!. .inin/ Mniinil Ifr^juirl-
m'hI ft'pori for Ihe year 187:1, Viil, XV, London, 1875, p. 220 : " With regret, and heartily wishing that my opinion may he overthrown liy tliose nf others,
I have lo eay that I did not recognize any value in quinine given propbyiartically; it neither seemed to wani off attacks nor to mitigat- the severity of
nialariouH fevers in those attaeked. With the exreption that in yome men a daily thiv?e-grain (h>se prmhired transient dcafne.ss, and in a few others
nauM'a, no untoward symptom followed Ihe nw <»f tlie medicine, iln tlie other hand I was unable to agree with the startling opinion seriously pro-
|K)unded lo nie by some men nf tin* West India regiment encauiped at Napoleon, that the quinine they took daily as a prophylactic had given iheni lln-
Ague from wliiili Ihey suffered."
|! euAiMFs MuRKllKAn— e/i.iiV.t/ /^w.(r./(/'« OH Dixms^x in huHu, 2d edit., London. iSflll, \\. H'.l— speaks of the alleged snecess of Iwo-gniiu doses of
quinine in pn-venting malarial fevers in the !t2d Highlanders during itswrvice in the jungly tracts along the southern base of the Saut|>noni hills rhiriug
Ni'VfudnT and DecemlK^r. ls5H, but shtiws that either detachments of the same exjiedition behmging to the l.sth Kuyal Irish, the ;{d Dnigoon (;uanls and
the Romliay Hunm' .\rtillen.- were equally fortunate, although they t«»ok nu quinine.
^\ I>AVii» and Charles Livin(;ston— .Y«rrfi/iV*' »/ an Ej-jjeditimi lo the '/jtmheKt, eU-., New Vork, IKOO, p. S2 : " Whether we took it daily, or omilli'd it
Altogether for months, made no difference; tlie fever was imiiaitial, and S4'ized on the days of qninin*; as rt^gularly and severely as when it renuiimrd
undistnrlied in tlie medicine ihest, and we finally abandoned the use of it ws a j)rophyIacticaltogetlicr.'' In a [wiper of earlier date by Paviu Livinuston
nnd John Kirk— ffciHdrA* mi the A/rienn /erer tm the hncer Zambesi Mrtt. Tinted find Guz.^ Vol. XIX, N. S., 1859, p. 47:J : "The result of our exiH'rienc; has
U* -u to discontinue the daily use of quinine."
**IjtON Coux — TmiU' der FuirreK lutrrniHtfulrn, Paris. 187<>, p, 424 ; also, < ''innifli'mtions gimralexmrVciinhujie deMjCrre* inter nittleiiieitf Arch. ile». de MM.,
M"" s^-rie, t. XV, 1870, p. S4. See also his nqKirt to the Minister of Public Works, April 4, 1881— BkH. d.- V Aeml. de 3/tV/,, t. X, 1881, ji. l.'V.W. He insisti*
tliat quinine is not pnqierly an "anti-niiusmatic medicine"; it only acts against certain symptonm of the nialarial intoxication, es[K'cialIy (Ih^ febrile
syniptouis. lit- recommends that it be reBer\ed for the sick, and given to them in sufficient doses. Acconling to B/;RKsr!ER-Fr,nAii) — Mabuliex des Knro-
fKetu lui S'w'ijul, Paris, 1875, t. I, p. 244 — the French military surgeons in Algeria are divided in opinion as to the prophylactic virtue of (jui.iia, some
beiDg for and some against it.
ttCoLix, in Bull, de F Ar^ul. de M^d., cited in last note.
j;S«e not« t, p. 172, eapra.
174 PKEVENXIOJSr OF
somewhat favorable results in a detachment of marines at Pola on the Adriatic;'" but a
similar experiment at the same time and place by the surgeon in charge of the 29th in'fantry
gave about the same proportion of cases among those who took the quinine as among those
who did imt; and equally unsatisfactory results were obtruned ui the cfise of several small
cavalry detachments on the Danube, as also, during the same year, among the troops form-
ing the large garrison of Komorn.f
The evidence bearing on the virtues of quinia as a [jrophylactic against malarial
fever is therefore by no means uniformly affirmative; Imt in tlie instances of failure or of
doubtful benefit there is always that prolonged exposure which, as we have seen, led to the
disuse of the method in our armies during the war. Berenger-Feraud recognized the
difference between temporary and prolonged exposures in this connection, and even specified
that if the exposure was to be continued for more tlian twenty days, prophylaxis need not
be attempted.^ Moreover, some of the instances of failure may perhaps be attributed to
the inadequacy of the quantity given. Quinine as a prophylactic has usually been adminis-
tered in comparatively small doses. A grain and half to three grains daily as used by
JiLEK, and two grains daily as at Komorn and elsewhere in Austria, might well be regarded
as inefficient; yet Hamilton, with three grains every other day, reports one of the most
brilliant instances of success. § Most of those who in this country liave recommended the
quinine prophylaxis have insisted on a daily c^ose of four or five or even more grains.
Herrick advocated the view that the most effectual plan is not to make daily use of
quinia, but to resort to it in decided doses on the first appearance of malarial symptoms. ||
This opinion, which was based on his exjjerience of intermittent fever in his own person,
corresponds with that which has been given above as to the proper mode of meeting the
dangers attending the prolonged exposure of an army in malarious districts.
Similar in principle was the plan pursued by the medical officers of the English army
during the war of 1879 in Zululand. Surgeon General Woolfeyes reports that during the
sickly season quinine was administered three times a week to all the debilitated men.^
The opinion expressed by Hamilton that quinoidine used for the purpose in view is
more efficacious than quinine, is not as yet supported by adet[uate evidence.**
Besides the doubts tliat have occasionally been thrown upon the ])ower of quinia to
prevent malarial fevers, the serious objection has been urged that those who take the drug
* Jli.EK — op. cU., note f, p. 172, supra. The quinia was given in 1J4 ^^* -i-ffiiiin doses daily in rum; 5U0 men toolt it from June 1 to September 20,
1881, among whom there were 91 eases, while among 23U men who did not take it there were 08 cases., Jilek thinks, too, that the cases among those
who took the quinia were milder than anuing those who did not.
f These facts are reported in an article Erfuhriwgeii uher die prophfthdlisihe Aiiirtmltni'i ton t'hhihi I'u I Est. uttvis fnniicie ij-'jcii M-ihiriti-liilnxikitiioncii,
-iWj. Millliiriirzllklie Xeiliiiiif, 1870, No. 10 u. 11, S. 7G ef. seq. Two grains were given dail.v in spirits of wine. At Komorn, between .January 1 and Augti.st
2,^1, ISHO, there were 1,449 intermittents in a mean strength of 5,3^)0 nn*n, or 270 ])er l,^M;to for the time named. This is spoken of as less than the usual
proportion of cases at the post, lint as there were neither floods nor prolonged heats du]-ing ISliO, it was considered doubtful whether the lessened
prevalence was really due to the quinine.
JL. J. B. B^RENGKlt-FfeRAun — Op. fit., note**, j), 173, aupm, t, I, p. 240.
g Hamilton — cited p. 172, supra.
11 Hekkk'K — I'ic i'H., note *, p, 172, supra, says: "In 1864 the writer had occasion to test the value of quinine as a i)reventive of intermittent fever
in his own person, and became convinced that the most efFectual plan was not to make a daily use of it, but to resort to it in decided doses on the first
warning. It is only necessary to exercise constant vigilance, for a paroxysm is generally preceded by unmistakable signs of malaise for a day or two
previously, and the attack can be warded off by a few timely lioscs of cpiinine."
1[ Surgeon General J, A, Wmi.TlllY.Si—MetlicalHisUirijofthfmir in Xiihiliiiid iu 1,S7H ; .\rmij Mrdital Diparliiieiil Eeporl, 1879, London, 1881, p, 299: The
strength of the regular troops of this connnand was 13,333 otRcers and men, of whom 2,941, or 220 per 1,000, were taken on sick report with fevers between
.lanuary 4 and October 3 ; the proportion of malarial fevei-s is not stated.
**.!. BuTLKR Hamilton — Ilrpmi mt the ai-tion of QuinokVme and Citickomuc an rcgardu Uieir iujlue}ict! on Midaritms ferers ; Tmliati Med. fio,:.. Vol. VI, 1871,
ji. .'io— gave to each soldier of a detach UH'nt of .somen at -Mlahabad, from August 3 to November IG, 1870, three grains of quinia daily ; to each of a detach-
ment of 07 men the same quantity of cinchouine, and to each of a third detachment, als-j of 07 men, the same quantity of quinoidine. In the lii-st
detachment there were 7 cases of ague, or 87 per 1,000 ; iu the second 13 cases, or 191 ^er 1,000 ; in the third .5 cases, or 77 per 1,000 ; whence he con-
cludes that quinoidine muks highest and quinine next in prophylactic virtue. On the other hand Oore — p, 104, op. eiA, note J, p. 173, je'j)r((— reliorts
Ihat the men of the West India regiment who occupied the camp at Najtoleon ilnring the .Vshanti war took daily a solution of quinoidine without
d -riving any particular benefit.
MALARIAL DISEASE. 175
habitually acquire in time a tolerance of its action, in consequence of which its power as a
renitMJy becomes lost.* But, as during our war there frequently occurred cases in whioh,
without the previous administration of quinine as a prophylactic, this remedy failed to lircak
up the paroxysms, necessitating arecourse to arsenic and other antiperiodics, it is possible
that this tolerance to the habitual use of the drug may have been really due to some pceu-
liarity in the individual or in the attack. It has also been represented that gastric and
intestinal irritation, loss of appetite, headache and even diarrhcea result from its continued
use:f but although these accidents undoubtedly occur in some highly susceptible indi-
viduals, it is not unlikely that in most cases the medicine is undeservedly blamed for symp-
toms referable to the coincident malarial and other morbid influences. This explanation
unquestionably applies to the opinion sometimes expressed by soldiers,| that the fevers and
other serious results of malarial intoxication from which they suffer are caused by the med-
icine employed to prevent them, — an opinion sustained by ^fALOXK and MoDanikl in
this country, and by the Sicilian physician Tomaselli and others, whose error has been
^sufficiently exposed by the criticism of Berenger-Feraud.§
Prophylactic Use of Other Medicinal Agents. — Several other medicaments have
been said to act as prophylactics against intermittent fever. The only one of these men-
tioned in the official reports as having been tried during the civil war was the bark of the
willow. Assistant Surgeon , Hunter, in a report of his inspection, August 31, 1864, of
certain regiments in camp near Thibodeaux, La., states that a spirituous infusion of willow-
bark had been used by the 33d 111. Vols, with fair success ;|| but the monthly report of
siek and wounded of this regiment, on file in the Surgeon General's Office, shows that dur-
ing the month stated no less than one-third of the men were taken sick with intermittent
or renuttent fever.^
In the Confederate armies the Cormts jlorida or dogwood was used in some instances
* Still£ iu his Therapeufic* and Materia .Iftv/trti, Philadelphia, 1874, Vol. I, p. 519 — refers to this toleration of tlie medicinf and its loss of remedial
power n» liantjer? inherent in daily doses continued for any length of time, and quotes Dr. Ghaves (Dubliu Quarterly Jour., February, 1S46, p. ~2) as [kt-
hH|Kt the first to call attention to this subject. Dr. Graves, after a comiwrative trial of several methods of administering quinine in a oise of obstinato
qtiurtan ague, concluded that it was best to withhold the remedy until i)ivmoiiitiona of a fit occurred, and then to give it iu large doses ; for if continued
ttiniughout the apyretic interval "the system becomes accustomed to its impression and is less powerfully affected than when it is taken only at such
tinn's an thi? derangement which it is adapted to remedy is ab(1ut to occur." It appears to the writer that the tolerance and loss of powi-r are by mr
means provini by Dr. Gr.vves's experiment. The allowable conchisJon does not reach further than the gn.'ater efficacy of large as compared with small
«nd nqvated doses, which is now a well recogiiizi.'d fact iu all malarious districts. See, for instauce, a reference to Dr. Ciiarles MrCttRUicK's e.\jMTienc<r,
now^i III) p, 179, infra. Kor does Dr. Woodward give any ground for the assertion as to the loss of antijieriodic power. J. J. Woodward— OiiZ/meji »»/ the
i'kir/ f'luap hiM-oM^ Philadeli)hia, 18G:i, p. 171 : ''The system in time ac<iuires a tolerance of the action of quinia, and when acute malarial affections
BUpepene, as they frequently do, the grand therapeutic agent on which the surgeon relies is found to have lost its curative power to a great extent."
Baktholow — Army hygiene, cit*Mi note f, p. 172, unpra — says : " Quinine loses its power by long continued use ; itsantiperitnlic power is not exhibited satis-
fsrtorily in cases of chronic malarial p<»ison, and hence its prophylactic power is feeble in the same morbid state." Koueks — jyans. Anier. jl/cff. Ask.,
I'i'W. p. "^iK), — expresses the opinion that insusceptibility to the therajM-ntic effects of quinia is seldom met, except in thus*- who have ns*'d it coiiliu'
uou!*ly. ami nH-onunends, therefore, that ''considerable intervals of abstinence" should Ik* practiced by those who employ it prophylactically. Stirgmn
.V. G. !>KLUEc.E, of the British navy, who had charge of a detachment of Royal marines landed at Cape Toast Castle during the Ashauti war i>f I87.'i —
JS/ii/jWifYif Wc/M.rf, 1873, p. 2(M>, — states that the officers of the Army Medical Staff who had served for long iK'riods on th(? coast advised him to give quininu
as » pmphylactic only to those of his men who wen' especially exjwsed, as by its constant use " such a tolerance of it wus created that when attacked
with fever it would require enonnoiis doses to produce any effect." Gore — p. 104, op. cU., note J, p. 173, aqyra — states that it is a general idea among
the English residents in West .\frica *' that when taken de die in di^m it loses its power as a remedy."
t Such symptoms were referred to the quinine in the report from Komom, ciUnl p. 174, mpra, although only two grains daily were given.
I As for example by the English soldier? in the Crimea, ac<;ording to Sir John Hall, cited in not** fl, p. 167, mpra, and during the Ashauti war,
acconling to Sir Anthony Home, note §, p. 173, mipra.
^ Mal'ine and XcDamel expressed the belief that while quinine did not cause malarial ha?maturia it determined an attack or recurrence in those
liable to the affection from continued exposure to the malarial influence. See note on hemorrhagic mahriai /ever, nupra, p. 128 ; and also Salvatore Toma-
selli— L' iiiiiivirazifme rhinica, etc., Catania, 1877 — abstract»-d in the linU. dr V Arad. de Mid., 2*s6rie. t. VI, 1877. p. 756; O. H. 1'(;hetti — I." iutofMntzinnr dtinira
* Infdhrt biUoM emalnrictt, Lo i>prrimnitale, 1878, p. 614 ; and the pai>er of KARAMJrrZAS in the Bull, of the Medical Society of Athens, session of Nov. lS-.'iO,
1«7S. BtRENGER-FtRAl'D — L' iiifo ricn/irtii tptinijpte rt riufection paliuirr, Archireit dtr Mid. ttarale, t. XXXI, 1879, p. 3.VJ — has thoroughly exploded this
charge, anil shown that the untoward symptoms attributed to quinia are really those of ha.>maturic remittent fever. A similar explanation of the views
cxpre^tA'd in Tomaselli's i>ai»er was offered in the Acad, of Medicine, Bull., vol. cited mipra, p. 778, by Le Rcjv de M^kicovrt.
I See his report, p. l.Vi, mpra.
■"The ref»ort is signed l>y Assistant Surge^.n H. T. Antis, of the .1.td Illinois Volunteers: Mean strength of the command 6.11 officers and men ; V.*7
caws of intermittent fever and 20 of remittent are reported— total 217 ; of the iutermittents 5 were congestive, and two of these died.
176 TREATiMKNX OF
instead of quinine as a prophylactic. Circular No. 12, issued i'roin tlieir Purveyor's Office
August 22, 1862, refers to an arrangement by which whiskey medicated with dogwood
and other indigenous barks was to be used by the troops as a protective against malaria.'"'
r*r. Joseph Jones reports that this compound tincture was issued by the purveyors to
troops serving in swampy districts, and was employed with good effect in preserving them
from malarial fevers.f
VII.— TREATMENT OF MALAEIAL DISEASE.
General Considerations. — Prior to the introduction of cinchona bark into medical
practice the system by which these fevers were treated was palliative and uncertain,
depending chiefly on the special symptoms manifested by the individual case. Tlie
primary congestions suggested the propriety of bloodletting, but the subsequent deterioration
of the blood, so marked as to have originated the ivdme putiHd fever, caused much opposi-
tion to this measure. The introduction of cinchona as an element in the treatment was
opposed by those who considered bloodletting essential, and advocated by such as looked
specially to the putrescent character of the developed disease. At first the bark was
regarded ^^^ an antiseptic, and was given in conjunction with camphor and wine; but, as
early as 1765, Dr, James Lind trusted to it alone as a specific antidote to the disease-
poison. J Its value was also urged by Hunter, Clark and others. § But in 1804 its use
*This circular is quoted, from Dr. Jones's article cited in the next note : "Although no orders have been issued to that effect, some of the purveyors
ai>p*'ar to he under the imprcssinn that they should make a mixture of the indigenous harks (dogwood, Ac.) and whiskey. The arrangement intended
by tiie Surgeon General and (.'nnimissary General is, that the dimniiesjiry Department sliall furnish the whiskey to the troops, giving each man one drink
a day. The Purveying Department was to furnish the harks to mix with the whiskey, to make u species of army bitters, as a preventive against malaria,
&c. The arrangement is merely an issue of whiskey by the Commissary Department to the troops, and the Purveying Department furnish the bark to
mix with it. This office has not yet been instructed whether the mixture is to be made at the purveying depot or at the commissary depot. Therefore
whiskey will not be issued in other than the medical preparations that have beiMi or may be ordered as regular issues."
t As. for instance, to the Eutaw {25th South Carolina) regiment, whilst it was encamped upon James' Island, in a notoriously malarious locality.
This regiment had a mean strength of about eight hundred officers and men. During the summer and autumn of 18112 one-third of the command was
at times upon the sick-list with the various forms of malarial fevei'. "The assistant surgeon of this regiment, J. AV, Warren, of South Carolina, com-
municated to the author, during his inspeetion of the sick upon .lamee' Island, some interesting facts upon the prophylactic powers of certain indig-
enous remedies. \ eom|Hiund tinrture, or medicated whiskey, prepiircd hy the Medical Purveyor from the dogwood, cherry, poplar and willow barks,
was administered daily, in tlie pr.iportion of one-half to one gill to each man during two weeks in the month of September, 1862. Tnder the use of this
tonic mixture the number of new cases of malarial fever diminished one-tialf, although as the autumnal season advances upon James' Island malarial
fevers increase in number and severity. The supply of this medicated whiskey being limited, at the end of two weeks it was exhausted, and in the
course of eight djiys the cases of malarial fever had increased from thirty-six to eighty. A fresh supply having been obtained its use was again commenced,
and in the coui-se of tive days the uundier of cases of malarial fever fell to the original number." Dr. Joseph Joxes — I»digenons remedies of the Sontheni
Stales, ff-c, No. 2, Dogu-ootl.Sf. Lotiis Me,l ffepnrtcr, 18(i8. p. 30H.
XAn Essaif on Diseases iuddenfal to Enropemm ui Hot *'Umale.\ by .Iames LiNr', M- D., F. R. S., Sixth Ed., London, 1808, p. 323 et seq.: "The prepara-
tion of the body requisite ])revious to the administration of the bark is not coiisidenible. It is sufficient to cleanse the stomach and alimentary canal hy
an emetic or purge. * * * The bark may bi- administered at any ijeriod of the disease. When the ague is slight it need not be given till a second fit
has evineed the tnie nature of the rljsease ; but when the ague is severe there is frequently an absolute necessity of administering it upon the first inter-
mission, even with scarce any preparation of the body : instances have occurred, on unhealthy spots in England, of agues liaving lieen so malignant
jifter hot summers that a return of the fit sometimes proved fatal." * * * After adveiting to the opinion that an ague must continue some
time before it is completely formed, and that till such time it is liighly dangerous to apply any remedy, he continiies : "The advantage of administeriDg
the bark as early as possib!e in the disease fully ap|>eared in the year 17(i4 and the two following years, during an uncommon iin-valence of remittiTig
anri intermitting fevers, which spread themselves over the greater part of England and furnished me with a nimiber of patients laboring under all the
synijitonis nf those diseases. * * * i never prescribed the bark until the patient was free from the fever ; and then without regard to a rough or any
other chronical indisposition I ordered it to l)e given in large doses. I have given the tiark in ivery circumstance attending intermitting fevers during
their remission, but in-ver gave it during the fit."
^JouN Hunter — Ohsen-a/lotis on (he Diseases of the Aruiii in Joinuiat, London, IT.sy^speaking of the cure of intermittents, says, p. 208: "When
the intermissions were complete the bark was given directly without any previous evacuations in order to cleanse the stomach and bowels,
which is to ho considered as rather recurring to an old than giving in to a new practice. There was no inconvenience arose from omitting the vomiting
and purging, usually made to precede the bark ; on the contrary it was so much time gained." Hunter refers to Sypenham's use of hai'k in this man-
ner. John Clark — Observation on the DtseaseJt which prevailed iu long voijuges to hot cmmtries, particidnrly mi those in the Eavl Indies, — London, 1801 1 :
"As soon as the intestinal canal has been thoroughly cleansed the cure [of the remittent fever] must entirely depend on giving Peruvian hark in as
large doses as the patient's stomach will bear, without paying any regard to the remissions or exacerbations of the fever. If the remissions be distinct
the bark, indeed, will have a more speedy effect in subduing the fever; but even if it Jiecome continued, by a regular and steady perseverance in tha
Hicdicine it will be effectually prevented from growing dangerous or maliguaut."
MALARIAL DISEASE. 177
was checked by the experience of Dr. James Johnson,* who, finding that his first ciise of
remittent at Calcutta rejected the remedy and died with an engorged Hvor and conf^ested
brain, liad recourse in his succeeding cases to venesection and evacuants. Moreover, the
beneficial effects of twenty-grain doses of calomel taken by hiniself during an attack accom-
panied by dysenteric symptomsf led him to urge this practice, which for many years
afterward sent Europeans back from India with their constitutions shattered by repeated
salivations.
As the evils of the mercurial sy:^tem were developed, bleeding was resorted to freely
and repeatedly as the only efficient remedial measure. Meanwhile, in 1S20. quinine was
discovered and its use introduced into England and Fraiice, but several vears elapsed before it
was employed by the Indian practitioners in those dangerous reniiitents for wliich bleeding
to relieve congestions, free purgation to remove vitiated secretions, and calomel and opium to
act on the secretory and excretory functions, constituted the st-andard treatment, although
Sir J. Annesley and TwinikgJ made use of small doses of quinine, when full remissions
• The Influence of Tropical dmnUe* oh Biiropemi Omtlitntiow^ by Jaues Johnson, M. D., Second Ed., Luudoii, 1818, p. 48 — after rfferring to the instnic-
tious for treatment pivcn iu the works of I>rs. Ci.aijk and LiNit, lie descril»es hi$ first caw as follows: "A yomig nian, of u jrinxl conntitiition, in the
prime of life and health, had liefM assisting with several ntber^ to navigate an Iiidianiaii through the Hoogly. The day after he returneil he was seized
with the Uffual symptoms of this ftver. 1 did nut see him till the culd stage was past ; but the i\'aclion «-as violent ; the headache intense ; ^k^n Imniing
hot : great i.>i>pression about t!»o pn*vonlia, w ith quick hani pnlsi* ; thirst and nausea. An emetic was prescribed, and t»>wanls the cUise of its ojiiTatiun
dii^'barged a quantity of ill-conditioned bile, bulb upwards and downwanls : soou after whicli a perspiration bruke out, the febrile symptoms subsided,
and a rvmission, almost amounting to an intemiissiun, foliowivi. I now, with an air of confidLnce. beg-an to •' thruw in " the Itark. quite siuguine in
my exjxHtations i>f stnin checking this fonaidable disease. But, alas '. my triumph was of very short duration : for in a few hourv the fevt^r returned
with incrca&ed violemv. and attended with such ohstiuato vomiting that although 1 tried to push on the bark tbrt>ugh the luruxysiuii, by the aid oT
opium, efferrceiciug draughts, Ac it was alt fruitless ; fur everj" dose was i\"ject«-d the momeul it was swallowed, and I was forced to abandon the only
n>eans by which I had hoped to curb the fury of the disease."
t Op. rit., in lart note. p. 2rtS ; '* I was bled, and took an ounce of castor oil immediately; a few hours after which six grains of calomel and one of
opium were taken,* and repeated every five hours afterwards, with (Occasional emollient injections. The day pas;*ed mtlier easier than the preceding
night ; the tormina wen* somewhat moderated by the medicine ; but I had considerable fever, thirst, restlessness and cuutinual <:;ills to stoul ; nothing,
however, coming away but mucus and blood. As night closed in the exacerbation was great. Tlie opium lulled me occasi«tnalIy, but I wa* again delir-
ious ; and the phantoms that haunteil my imagination were worse than all my corporeal sufferings, which were, in themstdves, inde:K-rihably tonnentiug.
The next day I was veri* weak ; and so inceftsiint were the griping and tenesmus that I could hardly leave the commode. The tenesmus was what I
could not War with any degree of fortitude ; and, to procure a momentary relief from this painful sensation, I was forced to sit frequently in u~anu
water. The calomel and opium bolus was now taken ever?* four hours, with the addition of mercurial frictions. An occasioual lavement was exhibit<-d,
which gave much |ain iu the *-xhibition, and I eacii day took a dose of castor oil, which brought off a trifling feculence, with inconsiderable relief. My
fever was higher this day than yesleixlay, with hot, dry, constricted skin. As night approached my debility and apprehension of the usual exacerbation
Itrougbt on an extreme degree of mental agitation. The surgeon endeavored to cheer me with the hope of ptyalism. which, he assured me, would alle-
viate my sufferings — I had then no local expterience in the complaint myself. As the night advanced all the symptoms iKH-ame aggravated, and I wa**
convinced that a fatal termination must ensue unless a speedy relief could be procured. I had no other hope but in pt.valism ; for luy medical friend
held out no other prospect. I sent for my assistant and desiivd him to give me a scruple of calomel, which I instantly swallowed, and found that it
produced no additional uneasiness ; on the contrary I fancied it rather lulled the tormina. But my sufferings were great ; my debility was increasing
rapidly, and I quite despaired of recovery ! Indeed I looked forward with impatience to a final release ! At four o'clock in the morning 1 n-jvated the
dose of calomel, and at eight o'clock (or between 60 and 70 hours from the attack) I fell, for the first time, into a profound and refreshing sleei), which
Usted till near midnight, when I awoke. It was some minutes before I could bring myself to a perfect ivcollection of my situation prior t(» this repose;
but 1 feared it was still a dream, for I felt no pain whatever: My skin was covered with a warm moisture, and I lay some considerable time uithout
moving a voluntary muscle, doubtful whether my feelings and senses did not deceive me. I now felt an uneasiness in my bowels and a call to st<K>l.
Alas, thought I, my miseries are not yet over ! I wrapin-d myself up, to prevent a chill, and was most agreeably .suqirised to find that, with little or no
griping. I ]iast<ed a copious, feculent, bilious stool, sucoeded by such agreeable sensations— acquisition of strength and elevation of spirits— that I ejacu-
lat.^ aloud the most sincere and heartfelt tribuU- of gratitude to Heaven for my deliverance I On getting into I>ed I perceived that my gums were much
swollen and that the saliva was flowing from my mouth. I took no more medicine, recovered rapidly and enjoyed the l>est state of health for some time
afterwards."
JJ.viirjs Anxeslet, of the Madras Medical Establishment— 7fe«arcAesii»/o (Ac Oiw««, KaHuv and TrecOmetd of the mare pretxdent Dimueso/ India and tearm
climntfx (/nt^rrJ/i/, London. 18'.iS. Vol. H, p. 4CM) ei ftp*/-— ri-commends in agues the moderation of the cold stage, if severe, by the hot or vapor Iwith, frictions
and the internal administration of camphor, amuiouia. ether, wine, brandy and water or other stimulant^?. When the vascular excitement of the hot stage
is excessive, general or local bleeding is suggested, esi>erially in thr jilethoric and when accompanied with determination to the ht-j«l and delirium, or
to the liver and spK-<-ii, with symptoms of inflammatoiy action in those viscera. Cooling diaphoretic's as the nitrate of potash, acetate of ammonia. «uii-
l«hor juleji, antimonials, etc., are also recommended as promoting the speedy supervention of the sweating stage. When the jiaroxysm has C4-ase<l an
emetic i? given, and its operation encouraged by the five use of diluents, after which a full dose of calomel, fifteen or twenty grains, is administen-d.
followed by a jmrging draught, and if these fail to act within a few hours, their operation is assisted by a cathartic enema.. "Having thus promoted
discharge of the morbid secretions and fa>cal accumulations, and nmoved local congestions by bloodletting, we may resort to the exhibition of Imrk
wi as to prevent the accession of the jiaroxysm. Vnless purgatives have been cn>ployed previously to the exhibition of bark, so as effectually to
carry off mori>id accumulations, and unless local determinations of blooil and congestions are removed by general or Kx^l depletions, we shall nsort to
thisnu^t valuable medicine to little purpose; for it will either not U- retained on the stomach, or it will fail of producing its febrifuge effects if reiaim-d,
and .icca^ion oltstruction and enlargement of the liver and sjileen." tjuiniue, although in use in England, had not been introduced into medical prac-
tice in India at the time Axneslev w r.te. Similarly in nniittent fever : ■' Bark may be resorted to in the remissions. But care should ^»e bad not to
give this medicine during active demonstrations to the head, liver, lungs or splten until such complications have been removed by vascular depletion,
either general or local, and by the judicious employment of whateier means the i«rticular circumstances of individual cases may require."— On IherftxiK
of BioodJfOi^y in the roll rtaoc o/ Int>^tiUmi fever, by W. TwiMNC, Eiiq.. TVoitf. Med. trnd Phi/sical Society of CclcuU,i, 1S31. Vol. V, pp. 5&-100. Twixing
adopted and advocatt-d the mLth<.Ki iutrodaced by Mackistosh of Edinburgh, of bleeding in the CQld stage to relieve the bemt and Urge vewelfl from
Mep. Hist., Pt. UI— 23
178 TREATMENT OF
were established, to prevent a return of the paroxysm. Even as late as 1861 Sir J. R.
Maktin gave the administration of quinine a secondary place in the list of remedial
agents.* But during this time Dr. Hare was urging the antidotal power of quinine in
tliese malarial fevers. He obtained successful results from thirty-grain doses, and from an
extensive and systematic experimental practice of this method, advocated its use in the
pernicious fevers of India to. the exclusion of other remedial means excepting the occasional
use of small doses of calomel when there was gastric irritability .f Nevertheless the value
of the treatment by quinine may not be considered as fully established in Indian practice,
for HoRTON, in 1879, did not consider the remedy admissible until portal and abdominal
congestion and epigastric irritation had been relieved and the febrile action moderated. J
In France, Maillot, from an experience of many thousand cases of pernicious inter-
mittents, urged an immediate recourse to quinine in large doses. § But perhaps to American
medical men is due the credit of having been the first to use quinine in large doses and irre-
spective of preliminary evacuant treatment, as antidotal to the malarial poison ; for Perrine
their state of engorgement, to unload the lungs and remove congestion of the brain and spinal marrow ; but as he did not consider that venesection
superseded the necessity of using other remedies, according as the nature of the existing symptoms and the course of the disease might demand, he
occasionaliy used the sulphate of quinine or powdered bark combined with purgatives. See also his Diseases of Bengid, Calcutta, 1832, p. 627, where he
says: "In every description of remittent fever we must watch the changes which take place; and when the pyrexia abates administer sulphate of
quinine for the purpose of preventing a return of the exacerbation ; in most cases where the cerebral symptoms are not urgent and continued the
effect of this remedy is undoubted."
* Sir J. R. Martin — The Injiuence of Tropknl Climates, London, 1S61. p. 430 : "Quinine, the great febrifuge, justly administered acts purely as a nerve
tonic to the cerebrospinal and visceral sympathetic system. Exhibited in extravagant doses it is toxical and not therapeutic." And again, on page 360 :
"Subject only to the limitations already stated, bleeding — early bleeding — whether general or local, ami always practised at tfte very outset of the stage of
reaction, is very generally necessary in the severer foims of Bengal remittent fever; then come full doses of calomel and sudorifics, short of producing
salivation, with saline purgatives, antimouials and refrigerants, and quinine in the inten'als."
fE. Hare — On the Treatment of Malarioiif ferers. Meil. Times and Ga::ette, London, 1864, p. S40 : " In 1843 I was sent to Segowlie, on the borders of
the Nepal Terai, the most deadly in India, and there remained for four years. I was called to a distance on one occasion to see a medical gentleman
with cliolera. He died, and left me a valuable medical library, in which I found the now scarce works of Lind and Hunter. Their practice was new to
me, and I read them with eagerness. I had seen enough of the standard practice to be dissatisfied with it. especially in gome recent cases I had treated
of the Terai fever. They all died. So remission took place ; there were head symptoms, and I durst not give quinine. In fact, it was so utterly for-
bidden by all authorities that it never occurred to me to give it. I tried to salivate, but the fever was so active that my patients were dead before the
mercury had time to affect them. It then struck me as remarkable that since the discovery of (jninine no one had tried it in the same way as Li.nd and
Hunter had used bark, from the dn-ad of increasing congestion and inflammation, and a case (piite hopeless under the common treatment soon offered
itself to me, and I determined to try quinine. * * * i found a young lad of about 20 lying quite insensible on a native bed. The natives said that ho
was traveling on a puny in tlie Terai, hail fallen off insensible in their village, and fearing he should die then^ and cause suspicion they had brought him
to the nearest doctor. I immediately mixed one scniple of quinine in some wine, and by giving him a teaspoonfui at a time made him swallow the whole
of it. I repeated it every four hours three times that day. Early in the morning he was sensible. I gave him another dose and some arrowroot and
milk. He took the same doses througliout this day, with some soup, and the next to my delight he was out of danger, having taken two and a half
drachms of quinine in forty-eight hours, and without much inconvenience. * * « In the first place, no blood was drawn either by lancet or leeches.
Bleeding, therefore, is not necessary, and the disease not inflammatory. No opium ; no purgative to bring away bad secretions ; no drug of any kind is
required, except quinine, for t!ie successful treatment of malarious fever. Quinine also may be given in the largest doses, whether there are head symp-
toms, delirium, coma or pain in the liver, ^\'hether it be in the hot stage or cold quinine is not only safe for all forms of malarious fever, but its certain
cure ; and in cases where there is danger to life the earlier and the larger the doses of quinine which can be given to the (^latient the better. * * * *
Quinine, therefore, may witli reason be pronounced as a direct antidote to the poison of malaria, and not simply as an antiperiodic and adapted only to
stop periodicity, for it always cured equally well those fevers in which there were no periods, but which continued without the slightest remission during
the twenty-four hours."
J J. A. B. HoHTON — The Diseases of Tropical Climates and th^ir Trpntment, London, 1879 — speaking of quinine as useful in preventing the recurrence
of the paroxysm, says, p. 93 : "This valuable remedy requires some caution in its administration in this disease ; in large doses it should on no account
be given when the paroxysm of fever is on the patient, and more especially when there are sigus of gastric or cerebral inflammation or congestion,
with scanty or depraved secretions, full and hard pulse, as it may lead to the fixing of the inflammatory and congestive tendency to the bra,in. Quinine
18 safe, and should be administered when there is a complete remission ; when there is no sign of venous congestion ; when the pulse is reduced in fre-
quency and force ; when the skin is moist and the secretions free."
§ Traite desfievres on irritations cer&>ro-spinah:s inlermitletUes d'apres les observations recueiUics en Fratice, en Corse et en Afritpie, par F. C. Maillot, Paris,
1836. See pp. 360 et seq., where he speaks to the following effect : Many practitioners, still under the influence of obsolete ideas, are accustomed to use
laxatives and purgatives to prepare the stomach for the reception of quinine. This custom is generally followed' in Italy and in several marshy districta
of France, Holland and Germany. Torti, in ajiplying this method, acted consistently with his principles; in a great number of cases, however, he was
forced on account of the gravity of the symptoms to expedite matters and give quinine without employing this hackneyed preparation ; which fact, it
seems to me, ought to have put him in the right path, or, at least, shown him the uselessness of this medication. In ordinary' intermittent fevers the
employment of laxatives sometimes suspends the attack, but more often its only effect is to put off for a time the use of quinine — which must always be
had recourse to in the end. The more energetic purgatives and emetics increase the congestions which take place in the disgestive mucous memlirane
of which the coating of the tongue is merely an indioauon ; they may rapidly raise these irritations to a higher degree — to inflainmation. * * * lu
fact while laxatives are being administered pernicious attacks often take place ; but even admitting that purgatives and emetics do not increase the
gastro-intestinal irritation, they have the greater inconvenience of jjermitting attacks to occur, which by their violence and continuance always add to
the dangers of the disease and to the difficulty of its treatment. It is clear that when our predecessors used purgatives and emetics to prepare the stomach
to receive quinine, they followed rather their medical theories than the teachings of experience. * * * Ha\ing observed several thousand cases, I
think that immediately after and sometimes before bleeding, suiphate of quinine ought to be used whatever may be the symptoms. Neither the persist-
ence of the arterial excitement nor the signs of gastro-euteritis ought to bar its employment. All the morbid phenomena will disappear as if by enchant-
ment in a few hours,
MALARIAL DISEASE. 179
in 1826 advocated the employment of large doses at any period of the fever,* and this
practice was common among our army medical officers during the Florida war.f
During the War of the Rebellion quinine was the sine qtia non of treatment for
malarial disease. Other drugs and remedial measures were used as called for by particular
cnnditions of system; but other antiperiodics were seldom employed except in cases in
which quinine after a fair trial failed to eradicate the disease.
In addition to the notes of treatment found in the clinical and post-mortem records
sulitnitt('d in this chapter, and to the references which appear in Uie sanitary and special
reports already printed,;]; the following extracts are presented as bearing on this subject:§
AssH Surg. W. W. Cjuangek, 3rf Mo. Cav., Holla, Mo., October, 1862. — Our cases of intermittent ("over, both (juo-
tidiau and tertian (except two), have yielded readily to quinine coinltined with capsicuin in e(|iial proportions. In
the two e.xeeptional cases the system, through tViMHieut use, had apparently lost its susceptibility to the etlects of
<|uinine, either alone or in combination with stiiinilants or opiates. These cases linally yielded to emesis, induced
an hour or two in advance of the expected chill, and followed as soon as the stomach would tolerate it with one-
fourth of a strain of sulphate of morphia, two {grains of ca])sicum and one-fourth of a fjraiu of sulphate of copper,
j;i\ en every three hours duriuf; the intermission. One of the cases presented thi^ unusual ]>lienomcuon of iu\ ersion of
symptoms, that is, the precedence of the hot stage, followed by the cold. I think decided advaiitane resulted in
this case from the use of (piinia alone in the intermission, and the administration of capsicum in ten-y:rain doses as
soon as the sweatinj; stage arrived, continuing every hour till the chill had pa.s.siid off.
There were si.Ktcen cases of remittent fever, twelve of which began with languor and indisposition to action,
consti])ation, full and frequent pulse, dizzy sensations, pain in the head and, as the patient expressed it, in the bones
and tlesh generally. Five of these experienced much restlessness during the later stag(^s. Convalescence was reached
in from four to sixteen days and was rapid in nearly every case. Treatnu?nt consisted of a purgative of calomel
and powdered rhubarb, followed in six or eight hours by castor oil and turpentine or salts, when necessary. After
free evacuation, quinine in full doses was administered during the remission ; and during the accession bathing, cold
or tepid as proved agreeable, Dover's powder, nitrate of potash and sweet spirit of nitre were relied on with satis-
factory results. I found nothing better than cold or tepid sponging as a sudoritic, aiujdyne ami refrigerant in
remittent fever; and when the fever was associated with irritation of the kidneys, a <-old wet cloth over the lum
bar region acted satisfactorily as a diuretic. In cases characterized by much restlessness, sponging was an efficient
anodyne, and almost indispensable when cerebral disturbance contraindicated the use of opiates. Under this course
the remissions became longer, the febrile accessions lighter; the circulation resumed its natural character, the akin
♦Henry Peruini: — F<t<t treated tcUli lartje ilo»ee of Qninine iii Adams couidi/, iietir yalchez, Mississijqii. I*hdtidelphia Jour. Mvd. and Plti/fi. tici., 1826, Vol.
13, pp. 36-41 — rt'Iatos several cases of remittent fever treated by bleeding and quinine, tlie latter iu eight-grain doses, repeatx'd ut intervals; in one ease
ctianieterized by stupor and inseusibilit.v 64 gruius were taken in the twenty-four hours, and apprehensions of danger were roniovod. Ileconeludes:
"My observations so far, exhibit the following as one of the successful modes of treating our autumnal fevers, wheth4;r congestive or inflammatory.
Bleeding whenever the s}-mptoms n-ijuire it. A dose of from 6 to 12 grains of sulphate; of tpiinine every two or three hours, at any period of the fever,
until its symptoms in the pulse and skin are subdued. Then purgatives to obtain eopi()US consistent evacuations from the bowels, until they regain their
usual power. Subsequent attempts to form fever should l>e coutiteracted by a large dose of quinine."
t The Siidisiical lit-piM on the SUhtem and Mortaldij in the Ann;/ of thf ritUt'd Sl<dfn, by K. II. Cool,n»(;E, Assistant Surgeon, I'. S. A., Wasflington,
1856, gives, p. 6.38 el scq., a special report l)y Cilikles JIcCoemick, dated October 11, 1841, in which ho brings to the notice of the Surgeon General's
Office liis treatment of iutemiittent fever by large doses, fifteen or twenty grains, of quinine administ«red inunediatidy after the sweating stage, with the
view of suppressing the occurrence of further paroxysms. Two years before the date mentioned he had been so unsuccessful in arresting int(rrmittent
INtroxysms with the sulphate of quinine in two-grain doses every hour, although as nuudi as twelve, eightcien and twenty-four grains bad been taken during
the apyn'xia. that he gave up its use and resorted to relaxants, such as tart;ir emetic, ipecacuanha and opiinu. lint soon tlu-reafter ho resumed ttie
use of quinine, giving it iu from four to six grains every hour until its peculiar efTecta on the brain were produced, when he found himself invariably
successful ill contndliug the intenuittent. This led him to give it in single doses of ten, fifteen or twenty grains, according to the violence of the symp-
tom.s. He used it in similar doses witli benefit iu remitt*Mits, claiming to have given it at all times of the paroxysm iu many hundreds of cases without
witnessing any alarming or dangerous effects from its .administratiou iu this manner. The practice of using quinine in such large doses, and during the
stage of febrile excitement, having excited much attention, and the propriety of such treatment having been questioued, Surgeon General L.iwso.v issueil
a circular t() medical officers of the army asking for their experience of this metluxl of treating malarial fevers. Fifty-seven replies testified to the value
of tin- metliufl. Some of the replies, as those of B. F. H.\rney, It. S. Satterlee, K. C. Wood, Burton Kanuai-i., .1. .1. B. Wright, U. >I. Byrne, J. II.
Bailey, I>. C. DeLeon, T. V. Maoison, R. F. Simpson and .Iohn Byrne, are published in the Statistical Iteport above mentioned. See, also, an article
t-hi the Trvatmnd of Intermittetd fever, by AcsTiN Flint, in the .■fmericaH Jonr. Med. Sci., Vol. 11, New series, 1841, pp. 277-292. Dr. Flint gives an
analysis <tf 'Si ca-ses occurring in soldiers lately from Fort Cnitiot. Michigan, in whicli he gradually increased the dose of quinine until twenty, tliirty
and in one caw- forty grains were administered within half an hour. He gives also a inunber of cases from civil jiractice illustratiug the efilciency of this
mettiotl. He argues that the system n-quires no preiaratory process for the reception of the (juinine, and that " the most rational policy is manifestly
to strike at once at the foun et oriijo of the diflicnlty."
{See in the .\ppeudix to the First Part of this work the reports of Hand, p. 239; Hewitt, p. 313; Frink, p. 318, and Whiteiiili, p. 334; also in
tho present Vol. those of Gaije, p. 12:i ; Peck, p. 124 ; IIcntinuton, p. 12.^ ; Merritt, p. 142 ; Galloupe, p. 144 ; TowLE, p. 153 ; etc.
gFew articles on the treatment of malarial fevers appeared in the journals during the war. Thomas T. Smiley', writing from Hilton Hea<l,
S. C, October 1.1, 1802, furnishes the following paragraph on IntermiUenlfevem in the Boston Med. andSunj. Jotir., Vol. IVII, 1862-63, p. 270: "The cases
admitted into the hospital have not been numerous, and have presented no aggraY-ated features. After a proper attention to tho stomach and liowols,
they haY-e generally yielded si)eedily to the exhibition of ciuiniue, in doses of from three to five grains, re]>eated more or less frequently, and combined
with alcofiolic: stimulants, or not, according to the previous habits or condition of the patient. In a few cases the disease has assumed a congestive
form, when quinine was administered in much larger doses." S. S. Thorn, in a letter published in the Med. and Surg. Reporter, Vol. VlII, 1862, p. 280,
refeta to the treatment of intermittents.
180 TREATMENT OF
its moisture and the system its tone. Aromatic sulpliuric acid was used as a tonic. Tlie four remaining cases dift'ered
in having no constipation at the heginning, and in greater mildness throughout, yielding in from four to six days
to quinine during remission, and five grains of Dover's powder during accession, given every five hours, and fol-
lowed by the acid tonics during convalescence.
Surz/ron Ezra Read, 21.it. Ind. Vols., Canq) Dix, Baltimore, Md., Scjjtemhcr 5, 18()1. — In the treatment of intermits
ting fever I have relied upon sulphate of quinine in full doses, giving from one to two scruples in twenty-four hours
to arrest the periodicity. During convalescence I have continued the same in five-grain doses every morning, and
have had no relapses and no unfavorable results from visceral enlargements.
Swrr/eon JNO. "W. Scott, 10th Kansas Vols., September 30, 1862. — As was to have been expected, most of the cases
were malarial fevers, chiefly of a remittent type; a few assumed a decidedly typhoid character, and to these was
due most of the mortality. Pure intermittents were of rare occurrence, there being in almost every case more or
less febrile action in the intervals; but this, as a rule, occasioned no delay in the administration of antiperiodics,
as the combination of diaphoretics with quinia sufificed to counteract any unduly stimulant effect of the hitter, — and
the cases yielded to treatment with the usual facility. The fevers, remittent and intermittent, have shown during
the past summer a much slighter tendency to relapse than usual ; and we have met with none of those cases of
enlargement of the abdominal viscera and general deliility which are so often the result of continued attacks of
autuiimal fevers in this climate. Doubtless this marked exemption from the usual sequela^ of ague has direct rela-
tion to the fact that so few cases of the disease have occurred. The cause which produces by its intensity a great
number of cases mu.st, by its persistent action, occasion relapses in constitutions debilitated by previous attacks.
Surgeon D. W. Henderson, 96th Ohio Vols., Louisville, A'//., Xovember 19, 1862. — The regiment left Camp Bates
[four miles from Covington, Ky.] October 8, 1862, marching to Falmouth, Ky. * * * In all cases of intermittent
fever larger doses of quinine are required here than north or in home practice, twenty-five to thirty grains being
generally needful to accomplish the desired object.
Surijeon David Meruitt, 55/7i Pa. Vols., Beaufort, S. C, Mail 10, 1863. — We have had in the regiment very many
cases of intermittent fever which have yielded promptly to the following mode of treatment : First, I give an emetic
consisting of two grains of tartar emetic and twenty of powdered ipecacuanha in conjunction with capsicum. Then, as
soon as the stomach becomes quiet, I administer ten grains of calomel combined with twenty of jalap. After the
bowels have been freely opened I give large doses of sulphate of quinia, which generally arrest the paroxysms
sjieedily. In some cases I have given the solution of arsenite of potassa to ward off the hebdomadal chill and its
sequences, but generally I keep on with the suljihate of quinia in two-grain doses three times daily, or it may be in
larger doses and oftener, knowing well that the mere arrest of the paroxysm is only an apparent and not a real cure.
I may also mention that in several eases of intermittent fever I have cut the chill short and prevented a paroxysm,
both since being with this regiment and when in Iowa (near the Mississippi river above Dubuque), by the mere
administration of the emetic above mentioned, with the exception that in these ca.ses more of the capsicum was
added to the other ingredients. I have frecjuently given quinine in twenty-grain doses since arriving at this place
with theefiect of a speedy arrest of the intermittent paroxysm, and then, by continuing the remedy in smaller doses,
have been mucli gratified with the result. With regard to the sulphate of cinchonia I cannot bear very favorable
testimony, and would much ratljer depend upon the sulphate of quinia, with which, if it produces gastric distress, I
administer a few drops of tincture of opium. We have also had in the regiment numerous cases of lemittent fever,
many of which have been complicated liy periodical congestion of the bowels, manifested by mucus and bloody
stools, in some cases simulating dysentery. The uncomplicated cases have been mild, and readily yielded to treat-
ment. An emetic was first given, if indicated, then a mild cathartic, followed by blue mass and Dover's powder,
neutral mixture or a solution of acetate of ammonia, and finally sulphate of quinia.
Surgeon B. F. B.AnmS0Ji, Independent Battalion, X, T. Vols., Morrix Island, S. C, Jaiiuar;/ 9, 1861. — [This bat-
talion arrived at Hilton Head, S. C, February 1, 1863, and subsequently, to the date of the report cited, served in
the Department of the South.]
There is probably no point in which the medical history of the battalion is more peculiar than in the small
amount of quinine which has been used. I commenced my service with it at Yorktown, Va., on August 18, 1862.
At that time intermittents prevailed, and no quinine was on hand. I borrowed one ounce, and before the first of
January, 1863, had obtained thirty ounces from the medical purveyor. Since the commencement of the year (1863)
to the 16th of November, I obtained thirty ounces more from the purveyor, and of this we have now fourteen
ounces on hand, so that not more than forty-six ounces have been consumed during fifteen months, whilst at the
same time there have been regiments in the field by the side of us, doing no harder service and having no greater
number of men than ours, which have used an ounce a day for a considerable portion of this period. In one regi-
ment in particular, which was in camp near us in Virginia, and has been with us almost constantly since, there were,
according to the sick reports, three or four times as many cases of intermittent fever during the month of October of
this year as we had. This and many other circumstances have convinced me that the consumption of quinine in the
army is larger than is useful, and perhaps, even injuriously large, as well as a source of large and useless expendi-
ture. I never give quinine as a prophylactic in a case where the paroxysmal character of the disease has not been
distinctly manifested. My practice is, when the intermittent paroxysm has once exhiliited itself, if the patient is
still in the cold stage, to give half an ounce or an ounce of whiskey with some hot drink, and, if there are no vio-
lent symptoms, to let the paroxysm pass, modifying or assuaging some of the most uncomfortable manifestations as
may seem necessary. About two hours before the next paroxysm is expected I give eight or ten grains of quinine in
one dose; and if the paroxysm is kept oif, I give two or three grains less two hours before the next paroxysm is
MALARIAL DISEASE. ISl
exproii'd: ami if that does not oootir T again diminiBli the dose li.v Iwoor three grains, and again repeat two hmirK
hcfore thi' ni'M jiaroxysni is expected, and thus give from two to fivo doses, hy whieh time the' illNcasf' lias usually
disa]ii)eareil. Hut I am not always so fortnnate as to eontrol the disease in this ]>roiiipt and rasy mannrr, and sonic-
timrs twi'lve grains are neeessary to 'Mireak the eliill;" and oltcutimes the system is out of order in other ways, the
tongue eoated, the ap])etite gone, the digestion disordered, and in other respeets the jiatient may he sutlering from
eondiltons whieh shi>ul<l lie attended to; all the functions should he hrought into the most healthy condition.
Siiniiiin ('l.Ainoi'HN'K ,1. Wai.tox, 21k/ hi/. I'd/.v., Ariiii/ of lliv TninfmiiT, Ilriimliir'iM, 18(>2. — The intermittent and
remittent fevers observed in this reginu-nl have yielded readily to the use of iiuinine. Twenty grains given at one
dose usually ])revent the return of tlu) paroxysm in intermittent cases. The sanu^ iiuantily given in live-grain doses
during the twenty-four hours (without regard to the remission) and continued in some eases for two days, with or
without mercury, is snflicient to relievo a remittent.
Snrijiitn .Toiix Wkic.iit, 107(/i //(. VoU . Elizohc.lhtown, Kij., Decemhcr 31, 1K(')2. — The intermittent fevers observed
iu this ri'giment have heen generally treated with untiperiodic doses of (julnine, preceded hy a cathartic in cases of
constipation, and associated with opium in eases of diarrlxca. Sixteen to twenty grains of quinine, given during
the int<'rmission, suOiced to prevent a return of the chill. Remittents have been treated on the same ]dan, the
i|uiuine being given during the remission, and with favorable results, the remission in a f<^w days bei'oming an iut<?r-
mission. Occasionally there has been great irritability of the stontach; in such eases large dos<'s of laudanum
appeareil to answer well.
Iu Intermittents the sulphate of quinine was usually administered in dosew of lIutc
to Hve grains, repeated every few hours during the intermission. Where the disease was
eominon and deaths from sudden congestions rare, these doses were given threu or four
times a day, with the intention of favorably modifying and ultimately suppressing the suc-
ceeding paroxysms. But where the occasional occurrence of fatal congestions infused into the
case a possible danger to life, the remedy was administered witli especial intent to immediately
suppress the morbid manifestations. To this end the dose was repeated at such intervals
tiiat ringing in the ears or other symptoms of cinchonisni might be produced, or failing
this, that a specified quantity might be taken, before the time when the next paroxysm was
conceived to be due. Thus, in case 55, five grains were ordered for administration at 8,
10, 12 and 2 o'clock, to antici])ate a paroxysm expected at 3.30 p.m. The quantity need-
ful to effect this object varied with tlie section of the country which gave rise to the disease.
Thus, while Wright says that sixteen to twenty grains, given during the intermission, were
sufficient to prevent a return of the chill, Henderson states that twenty-five to thirty
grains were generally required to accomplish this. But tlie quantity varied also in indi-
vidual cases, some requiring more some less ; and these peculiarities becoming known in
primary attacks, dictated the quantities prescribed in subsequent relapses.
The danger attaching to tlie recurrence of the chill led to the very general adoption of
the practice of giving one or more large doses as being more efficient than the repetition of a
smaller dose. The large dose was usually administered early in the intermission, that time
might be ttfforded for its full absorption and eflicient action before the period of the expected
return. Thus the medical officer of the 19tli Mass. Vols., in cases 5, 13 and 41, gave
fifteen grains at once, and continued the remedy thereafter in three- or five-grain doses at
intervals. Peck gave fifteen to twenty grains morning and evening; Merritt, Walton
and others twenty grains. Harrison, who comments on the unnecessary expenditure
of quinine in some commands, states that a practice leading to economy of the drug in
his own charge consisted in the exhibition of ten-grain doses to ward off expected chills;
but lie allows that lie was not uniformly successful, and that twelve grains had some-
times to be given. A few reports referring to methods of administration speak of the use
of evacuants prior to the exhibition of quinine; but that this was not usual in practice
may be gathered from the clinical records, where the remedy is generally ordered at once
and unaccompanied by a cathartic. When called for by the condition of the tongue or
182 TREATMENT OF
bowels, blue pill and opium were combined with the quinine, or a mercurial was given,
followed by Epsoin or Rochelle salts, or the citrate of magnesia; capsicum was frequently
used as an adjuvant, especially in the Western armies. Emetics were seldom given; but
Merritt and Granger refer to their successful use in preventing recurrences. When
gastric irritability interfered with the administration of quinine, opium was considered of
value; Hoffmann's anodyne, ice and sinapisms were also used to overcome occasional
vomiting. Diarrhoea as a complication was treated with Dover's powder, opium or aromatic
powder in conjunction with quinine or camphor, or with opium combined with acetate of
lead or nitrate of silver. During the j^aroxysm little was done other than to make the
patient as comfortable as possible and to abridge the febrile stage by the use of hot drinks.
Quinine was used as freely to prevent anticipated relapses as to suppress expected
paroxysms after the relapse had occurred. For this purpose small doses were occasionally
continued for several days; but more generally the patient was directed to report at
the end of the first, second and third weeks for the administration of a large dose in antici-
pation of a relapse at those periods ; or he was cautioned to be on the outlook for premoni-
tory symptoms and instructed to report for treatment immediately on their appearance.
An occasional dose of blue pill, when the tongue was furred, was also given as a part of
this prophylactic system.
Strychnia was sometimes employed in obstinate cases, as in case 4, in which it was
combined with blue pill and capsicum. But when quinine failed to prevent relapses,
medical officers generally had recourse to Fowler's solution, which was often found bene-
ficial. After the paroxysms were controlled quinine was not unfrequently resumed in
roborant doses with other vegetable tonics and the tincture of iron; or the citrate of iron
and quinine was employed. Surgeon Towle considered the removal of the patient from
the malarious atmosphere of the greatest importance in treating obstinate fevers, and urged
the advisabilitv of having such cases removed from the exposures incident to camp life in
tents, stating that many cases in his practice which had proved refractory to quiiiiiie
recovered when the patients were ti'anferred froni a tent to the better protection of a house.'^'
Remittents.- — In the treatment of remittents the sulphate of quinine was generally
used, often with capsicum or blue pill and opium, in five or more grains, repeated four or
five times in the twenty-four hours. Frequently a mercurial' cathartic, followed liy a
saline, was given; but the administration of quinine was not delayed for the action of the
bowels. The specific remedy was prescribed during the pyrexia! periods as well as during
the remissions, but when the latter were well marked, larger doses were administered during
their continuance, while acetate of annnonia, spirit of nitre and neutral mixture were
employed during the exacerbations. Local congestions were not permitted to interfere with
the administration of quinine, as they were believed to originate in the miasmatic influence,
and were found to be relieved when the latter became counteracted or modified by specific
medication. Turpentine emulsion was frequently used in the diarrhoea accompanying these
cases. Dover's powder was often given to restrain the bowels, promote perspiration and
secure rest. In some instances of hemorrhage from the intestines, enemata containing
persulphate of iron were employed. Vomiting was controlled as in the intermittent fevers.
* S. K. Towle, Surgeon 30th Mass. Vols. — Notes of Praciire in V. S. A. General Hospital, Batou Rouge, La., during the year 1863. Bo^on Med, anil
Surg. Jour, Vol. LXX, 1864, pp. 4'.»-56. "While on the Potomac I was so well pleased with the progress of typhoid cases in hospital tents that I thought
them as good as bouses j but since being in this department I have become convinced that cases of malarial disease do very much better in buildings
than in tents — the canvas protecting the imtients much less than boards from the two great excitants to the action of miasmatic poison, the beat of the
sun and the chilly heavy dews of night."
MALARIAL DISEASE. 183
Sinapisms or blisters were applied on account of pjiin in the hvpocliomlriac or uiiil)ilic;il
regions; and calomel, opium and taraxacum were administered when indications of jaundice
appeared. Active catharsis, as by calomel, rhubarb and salines, was used in the few sthenic
cases which occurred, in conjunction with low diet, cold to the head, mustard to tlii> feet,
and very exceptionally, bloodletting. Digitalis was sometimes employed with the quinine
when there was much cardiac excitement. Aromatic sulphuric acid was used to restrain
excessive perspirations, and carbonate of ammonia and alcoholic stimulants when the
prostration was great.
Congestive fever. — In congestive cases .the sole reliance was on quinine. Dr. Gal-
LOUPK* expressed the general opinion in saying that in these cases no treatment was (jf any
avail ("xccpt. that by quinine; and that when cinehonisra was rapidly produced tlie disease
was promptly and almost invariably broken up. Large and repeated doses were civen.
irrespective of the condition of the patient as to collapse, fever, intermission, head symp-
toms or intestinal inactivity or derangement. Other measures were employed as adjuncts
during the stage of collapse, as mustard emetics, capsicum, alcoholic or ethereal stimulants,
stinmlating enemata, hot frictions and sinapisms or the hot bath. Hewitt recouimended
the application of iodine to the spine, wliicli was assumed to do good by relieving passive
congestion of the cord, thus enabling tlie organ to generate and transmit power sufficient
to remove local obstructions and restore integritv of vital function, f
Chronio malarial poisoning. — Quinine was also given in cases of chronic malarial
poisoning, but in tliese it was by no means so efficacious as in the acute manifestations of
tin' disease. D'AviGNON, speaking of such cases at New Berne, N. C, says that the ordi-
nary remedies were of no avail; and in case 52, reported above, iodide of potassium, iron
in \arious forms, vegetable bitters, mineral acids, stimulants, counter-irritants and anodynes
were employed for three and a half months, during which the patient seemed rather to
decline than improve. Removal to a non-malarious climate was apparently essential to
recovery from this condition of clironic poisoning. The deteriorated blood had to be
improved before the gcuiTul hcahh could be re-established, and this could not be effected so
long as the individual remained expo-sed to the influences which had caused his disability.
This was well recognized bv our medical officers, and furloucjh, discharge from service or
removal ior treatment to some northern hospital was their usual prescription. Iodide of
potassium internally and iodine applied to the region of the sjjleen, with tincture of iron
an<l small doses of quinine, or the citrate of iron and quinine, and the best diet procurable,
constituted the routine treatment of such cases, special symptoms receiving attention as
they becaine prominent. At the Satterlee Hospital, Philadelphia, Fowler's solution suc-
ceeded in allajang supraorbital neuralgia in several instances in which quinine gave no
beneficial result,^ while extract of belladonna applied locally was a means of temporary
relief. At Quincy, 111,', this neuralgia was favorably affected by forty grains of chlorate of
potash, twelve of citrate of quinine and iron and two of capsicum, given in four doses
during the day.
Untoward effects of quinine. — The medical records of the war make no mention
•See his report, mif, p. 144.
tSct! his report in the Appendix to the first part of tliis work, p, 313.
J .\n .\ssi8talit Surguon (mime not given) — Effetrtu nf Itilfttt Malaria, roxued into aciii-Uy bi/ a» ercUing cauM. Metl. and Surg. Reporter, Vol. X, 1803,
|i, 1INI — describes sevtrml caM's of periodic nenratgia in soldiers brtmglit to hospital from tho Army of the Potomac, in which arsenic succeeded after
,auiniahad failcil. See, also, letter from Surgeon George 11. \Vll.i,so\, Si aiicli. Vols,, from Camp Michigan, Va., Feb, 2.'., 1S02, Boi/on -Wed. and Surg.
Jour.. \ ol, LXVI, 1862, p. 1(19, — in which he describes some ca^es of periodic neuralgia relieved by quinine and some by Fowler's solution.
184 TREATMENT OF
of harmful effects from the use of large doses of quinine in suppressing malarial fevers.
Giddiness, deafness, ringing in the ears and even temporary prostration were frequently
experienced, but these were regarded as desirable symptoms, indicating that the remedy
had been absorbed and was pervading the system with its antidotal influence. Nausea was
sometimes produced, but was considered as of little moment in comparison with the great
benefit to be derived from the administration. The absence of specially dangerous symp-
toms or undesirable sequelae attributable to quinine might well be accepted, in view of its
extensive employment during the war, as establishing the harmlessness of the remedy when
exhibited in large doses in malarial fever.* It must be admitted, however, that large doses
may be a source of danger by the direct sedative action of the drug on th^ nervous and
circulatory systems, especially in cases having a tendency to heart-failure from temporary
enfeeblement or degeneration of tissue. Dr. D. S. Lamb of the Surgeon General's Office,
U. S. Army, published recently the case of a child of three years, in which, at the end of
the first week of a mild attack of typhoid fever, death was caused in little over an hour
by syncope following the ingestion of forty-two grains of quinine.f Stille cites several
cases of death from quinine, in which the autopsy showed congestion of the brain and lungs,
and in some degree also of the stomach.J The toxical effects of quinine must therefore
be held in view; and their notable absence from the records of the war be attributed to
that judicious use of the remedy which relieved diseased conditions and even recovered the
patient from impending death without injuring the system by an excess.
Other remedial agents. — The sulphate of cinchonia was occasionally used during
the war, but no systematic observations were made on its efficacy as compared with that of
quinia. The opinion formed was unfavorable to its use. Surgeon Merbitt, for instance,
states that he preferred quinine to cinchonine, but does not give the grounds of his prefer-
ence. Certain experiments in this country, and recent observations in India, lead to the
belief that cinchonia is energetic and in adequate doses a sure remedy. § Nevertheless, from
*The Diedical officers mentioned iu note f P- ^'i^ supra, were requested to tt-stify on this subject. The 7th inquiry of General Lawson's Circular
was as follows : " Since the piuctical introduction of quinine in large doses, the statistics of this bureau exhibit a much higher ratio of diseases of the
bowels — as, for instance, diarrhceii and dyeentei-y, — and also a much higher average of mortality from the s.ame diseases. It remain.? therefore to be deter-
mined how far this result is due to tins cause, or to the operation of other agents." In rejjly, Surgeon R. C. Wood stated that — "I have always been
opposed to the administration uf quinine in very large doses, and have no doubt that dysentery and diarrhiea have been aggravated by tlie excessive use
of this remedy." But theexfK-rieuce of the others did not sustain Dr. Wood's opinion. They attributed the.increase in the bowe! affections to the condi-
tions existing during the Florida war, and conceived tliat quinine was efficient as a remedy in those diseases. Thus Surgeon R. S, .Sattkrlee reported :
"I have not the least hesitation in saying that the constant and long exposure of the soldiers in Florida to the influence ()f malaria, and their suffering
from fevers, both remittent and intermittent, was the cause of the great mortality as well as the great number of cases of dysentery and diarrhrea that
occurred there, and by no means the use of quinine ; oti the contrary, I have often seen iiitermitti^ut and chronic dysentery, I'utli in the wime case, at
the same time checked by that remedy.'' Assistiint Surgeon li. M. lUiiSK is the only officer who icfers to otherevil effects from the use of (|uinine: "I
have, however, met with i^^veral cn&ea of nervous affections, which cviili-ntly resulted from the administration of large quantities of this medicine, I
have witnessed four aises in which partial deafness was experienced for upwards of three months ; one in which the deafness was jjwmaiiCH/; and one in
which almost total blindness was occasioned for several days, and in whidi perfect vision was not restored for some months. These cases were all clearly
attributable to the administration of quinine in large quantities, I have, besides these, met with numerous other cases of nervous derangement of a
chronic character, such as slight spasmodic affections, frequent attacks of vertigo, palpitation uf the heart, cephalalgias, nervous tremors, &c., which, it
appeared to me, could be fairly ascribed to the same cause. In nearly all these cases the remedy had been e.xhibited in doses uf from t<-ii to thirty grains;
and in several of them, as high as two hundred gmins had been administered within ten days."
■fNew York Med. Jour., Vol. XXXIX, 1881, p. 5-1:0.
I Therapeutics and Materia Medica, by Am'REU Stilli^, M. D., rhiludelj)Iiia, Pa., 1S74, Vol. I, ji. 200.
§ Obsf.rrntU}us upon one hundred i-ases of intennitteut ft^ccr in iciiith tin- sulphate of Chichoma mts n»ed as ti subslilulc for qnhua, by A. Paih. Tur.VEE, M. D.,
Am. Jovr. Med, Sciences; New Series, Vol. XLVII. 1Sr>4, p. :M>IJ. Dr. Tuuneu, Jifter referring to MAGENniE, Gittermann, Chomel and others who, after slight
inquiry rejected the pretensions of cinchonia as a febrifuge, cites Bally, who, in 182.5, succeeded in immediately checking twenty-five out of twenty-seven
intermittents, while the refractory cases yieldt;d on a judicious perseverance in the remedy. He recalls the favt»rable oitinions of Mariant, Wutzer, Duf-
RE.SNE, PoTiER and Bardsley, and invites special attention to Professor William Pepper's success in promptly checking eleven out of fifteen cases, two of
those remaining having yielded to a second administration of the remedy. Of his own cases seventy-nine had no paroxysm after the first exhibition of the
medicine, fifteen had one paroxysm but not two, four had two but not more, one had three or more paroxysms, and in one the cinchonia, as administered,
was without effect in averting the disease. The maxiinimi quantity used during a single intermission was thirty grains, and the largest dose given at
one time was fifteen grains. It was usually given in three-grain doses every hour during the intermission, until about twenty grains had been taken.
Vertigo and buzzing in the ears were observed in most of the cases ; nausea and vomiting occurred in five and cephalalgia in six. See, also, Heporl of 57
cases of iiUermiUent fever treated hij the sulphate of cinchonia, — J. C. Wells, — Cincinnaii Med. Observer, Vol. I, 185fi, p. 15, and Table of 102 cases of intenntUmt
fever treated with the eidphate of cinchonia, — G. Martin, in Trans. College of Phydciam, Philadelphia, 1853-'56, Vol. II, pp. 434-430. Joseph Douoall, M. D.»
MALARIAL DISEASE. 185
the slow progress made by this remedy into public favor, it seeins unlikely that it will
displace quinine as the special antidote to the poison of malarial fever.
The case-books of the Pettigrevv hospital, Raleigh, N. C, Surgeon E. Burkk Haywood
in charge, give the details of the treatment of intermittents by turpentine applied to the
chest over the fourth and fifth ribs. The application was made an hour before the acces-
sion of the cold stage, with a view to prevent tlie recurrence of the paroxysm. Mention
has occasionally been made in the medical journals of the internal use of turpentine in
intermittents;* but there are few references to its use as an external application. Neverthe-
less its employment in this way was advocated by some Southern practitioners, as appears
from a letter written in 1855 by K. A. Fontaine of Georgia.f in which he reports the
successful treatment of an intermittent by anointing, the entire chest, stomach and axillae
with turpentine, as recommended by J. C. Nott of Mobile. Prior to its use at the Pettigrew
ho.<pital it had been employed at Savannah, Ga., in 1862, by Stiles Kennedy,! with
very successful results. The patient was directed to appear at the steward's tent forty-live
minutes before chill time, when a bandage of cotton cloth eight inches wide, soaked in
turpentine, was wound around his chest; his linen was buttoned closely down over the
bandage, after which he was wrapped in a blanket and kept under medical supervision.
At the time this practice was begun there were sixty-two intermittent cases on the register.
Of this number fifty received immediate relief — that is, the expected paroxysm was sup-
pressed; nine resulted in cure on the second application, and three on the third; but during
these three days eight new cases were reported, all of which were cured on the first appli-
cation. Fowler's solution was administered in each case to prevent relapse. In his sub-
sequent experience Dr. Kennedy found the tui|>entine a prompt and efficient remedy when
used in this way. In some instances failure occurred from irregularity in the return of the
chill, as when, by anticipating the period of its recurrence, no time was given for the pre-
ventive treatment by turpentine. In two cases of failure the oil made no impression on the
skin, and in four or five cases remittent fever supervened.
It appears that the favorable results obtained by Surgeon Kennedy, when reported to
Surgeon SladrasArniy — Thu Jebrifngc pmpcrtU* of Uie I'inrliotia alkttloula — cini-Jionitt, iiitinitlia and dii'-lioiiidut. FAlinhnrf/li Mfd. Jour. VyI. XIX, Part I, 1873, pp.
I9:j-2U9. From oliscrvutioim on lOS iuti'rniitti'nt cases Dr. DorGALL concludes that after quinine, quiuidia is the most powerful as an antiperiodic,
> itichonidia next to it, and cinchonia the least active ; but that even cinchonia is energetic, and in adequate doses a sure remedy. In the first trials the
lilkaloids were given during the intermission. "En" long they were given indiscriminatt'ly during paroxysm and intermission. .\t length it became
»Pinr<>nt that they werti most serviccabh? when administered during the iwiroxysni only." Head symptoms were less common than with quinine; but
naus<^ and bilious purging were frequent concomitants, the latterappearing to facilitate the cure. It does not appear from the history of the ciises that
menurials or other evacuants were administered. The doses were usually live gniius, with an occasional large dose of twelve grains. See also a
Ri-juTl (.n, iiiui Stuluitititt dfliiitit o/, the trtatriieid of tflr liitiidrrd atxex^ iif malarioltit ffrer, In Unr lihnpat liitttalinn Hftnpilaly by cincliimn fcbri/ttge or mirtd atkalablU^
by K. Onr.VAlNE. hiditm Mediod UtizfU^, IHTS, Vol. XIII, p. 00. The maxinnun quantity administered in twenty-four hours in any one case was twonty-
'■ne grains, which was usually given in three doses. The average quantity for all the e:jises from the commencement of treatment to discharge was .'ilj.oll
grains. The maximum number of days under treatment was thirty-three, the minimum one, and the avemge 4..^5 days. Of the total 4ti6 were quoti-
dians, no tertians, 1.5 fpiartans and :t remittents ; and the average numlxT of grains used in each case of the first variety was .'17.20 ; of the second .13.68 ;
of the thinl 3.x:j.3, and of the bust ->4..3:l. But the antiperiodic was continued on the avonige in each case I.G5 days after the arrest of the paroxysm, and
as for this protective purp(iS4> an average of 14.88 was used, the average quantity which sutliced to anrst the paroxysms amounted only to 21.71 gmins.
This quantity of the mixed alkaloids was estimated to contain only 1.3.5 grains of quinine ; wheua.' it was assumed that the combination of the alkaloids
^vo rise toan increa.s<.d s|iecific effect. In tertians ami quarterns Fowler's solution was given on the days of intermission, the cinchona febrifuge having
been used only on the lUiys of exiwcterl jKiroxysms. The mixed alkaloids did not cjiuse nausea, vomiting or heail symptoms in a larger number of cases
than occurs with quinine. The writer's small experience of cinchonia is not so favorable jis that noted above ; In l.SOS be supplied a detJichment of
troope at a malarious station in the San Pedro bottom, .\rizoim Territory, with sulphat<' of cinchonia. in the absence of the quinin siilt. The men, who
were accustomed to the use of the latter, pronounced against the new medicine as prone to cause vomiting and as being less efficacious than quinine.
•M. F. CoLBV — Fj^efU o/Spiritg of Tttrpeittine in a caw of itii£rmiUeitt. Bonlon Mi;d. ami Sur<j. Jour., 1828, Part '2, Vol. I, p. 712— gave two-thirds of a
tablespoonful of turpentine in molasses at the beginning of the cold stage, which was immediately suspended ; vomiting occurred, and the hot and sweat-
ing stages were not distinctly marked. On subsequent occasions the remedy was followed by suppression of the paroxysms without nausea or other
aopleasant result.
tSee Allattlic Mrdkal and Surgiad Jounud, 1858-511, Vol. IV, p. 444.
} THrpaOine ok a remedial aijenl by Stiles Ken.nedv, M. D., of Hallstown, Del., in the Med. and Surg. Reporter, Philadelphia, 1807, Vol. X^l, p. 4,58:
"A» to the mode of action of the oil of turpentine, I submit, 1st. The |siin produced by it calls the whole attention of the mind. 2d. The impression on
tbe nervous centres. 3d. The stimulant effect." Mustard was frequently used by Dr. Ki.n'SEDV, but ho found that the skin became sore, swollen aud
irritated under its use, while the turpentine yielded no such undesirable results.
Med. Hist., Ft. Ill— 24
186 TREATMENT OF
the Surgeon Greneral, C. S. A., led to a series of experiments on this mode of treatment in
several sections of the Confederacy. Seven cases were reported in the Confederate States
3fedical and /SurgicaUournal, January 7, 1864;* in these the expected accession was pre-
vented, but the chill recurred on the seventh or fourteenth day. The Journal, the official
organ of the Surgeon General, expressed a desire for a larger experience of this economical
method of treatment, and requested that reports of cases be promptly forwarded. In
response to this, seventy returns, involving over 400 cases, were received from different
hospitals and posts, and the announcement was made that with few exceptions the remedy
was regarded by the reporters as one of great power, if not positive efficiency, in prevent-
ing a return of the paroxysm. Nevertheless, in a later issuef the editor hesitated to accept
these favorable experiences, considering that the turpentine had no special advantage over
other powerful revulsives, such as blisters, alcoholic stimulants, narcotic medicines, sudden
shock as from a plunge in cold water, exciting news, etc., which sometimes stave off chills,
although they are seldom used for this purpose therapeutically. The results at the Pettigrew
hospital were not so satisfactory as those reported by Kennedy; but whether this was
owing to the smaller surface exposed to the action of the turpentine or to a difference in
the character of the cases is unknown ; certainly in many instances the failure was not due
to irregularities in the type of the disease. A report from the Chimborazo hospital, Rich-
mond, Va., shows that this mode of treatment was employed in its wards, and proved
successful in some cases, although in many others it merely retarded the access.
At the Pettigrew hospital there was also tried a mixture of tincture of opium J and
solution of ammonia as a substitute for quinine in the treatment of intermittent fevers. A
draught containing thirty drops of each was given a short time before the expected onset.
Of thirty-three cases detailed below thirteen were treated by turpentine applied by means
of a roller bandage around the chest; one of these was successful on the first application:
Case 1. — Private J. B. Kelly, Co. F, 50th N. C, had a quotidian chill Nov. 7, 1864, at 8 p. m. Next day at 7 P. M.
the roller was applied for an hour, and there was no chill. The operation was repeated on the 9th and 10th, and
there was no recurrence of the chill. Three ounces of turpentine were used without injury. He was returned to
duty on the 28th.
Three were successful on the second application :
Case 2.— Private D. D. Stuhbs, Co. F, 2l8t S.C, had a quotidian chill June 28, 1864, at 3 p.m. At 1.30 P.M.
the next day turpentine on a roller bandage was applied and continued for three hours. The chill however recurred.
The application was repeated on the following day, and the chill was sujipressed. No strangury or injury to the
tissues resulted. Three' ounces of turpentine were used.
Case 3. — Private M. B. Manners, Co. K, 10th N. C, had a tertian chill Sept. 7, 1864, at 7.30 A. M. The applica-
tion was made on the 9th at 5.30 a.m. and continued for two hours. A slight chill occurred; hut after a second
ap])licatiiin there was no recurrence. No injury to the tissues or other had effect followed. Two ounces of turpen-
tine were used.
Ca.se 4.— Private M. Steen, Co. A, 13th Art'y Batt., had a ciuotidian chill Sept. 19, 1864, at 11 a. m. At 10 A. M.
next day the application was made and continued an hour without success; hut after the repetition of the applica-
tion on the 21st there was no chill. Five ounces of turpentine were used.
One on the third application :
Case 5. — Private CM. Dowd, Co. H, 1st Junior Eeserves, had a tertian chill Sept. 20, 1864, at 3 p.m. On the
22d at 2 p.m. the application was made and continued for one hour; it was repeated on the 24th, with partial suc-
cess. The chill recurred on the 26th. The application was renewed, and there was no chill thereafter. Six ounces
of turpentine were used.
* Confederuli: Stales Med. and Surg. Jottnmly Richmoud, 18G4, Vol. I, p. 7; — On the eriemal applicalum of the oil of tnrpenliiie <i.f a mtbslit'ite for i/uininr in
iiilirmitlent fever, tmUi report of cases.
t Op. ct/., last note, Editorial, p. 119.
J Opium has been frequently used iu conjunction with quinine to relieve the patient from the head eymptoms occaBionally produced by tlie latter,
to restrain the bowels when diarrluna or dysentery accompanied malarial fever, or, as we have already seen, to allay gastric irritability which might
threaten the rejection of quinine. But it has sometimes been used alone, as for instance : Eiijhl cases of simple intermittent and sUc of remittent fever successftiHy
treated III/ the ejlnbitimi of parliallij demmotized opium.— W. S. SlNN of Ohili, Hancock, IW.— Nashville Med. Jour., 1864, Vol. VII, p. 379.
MALARIAL DISEASE. 187
While in eight it was found advisable to liave recourse to quinine :
Case 6.— Private H. L. Lawsoc, Co. I, IStli S. C, had a tertian chill at iioou of .Iniio 8, 18&1. On the 10th at
ll.\. M.a roUer haudajje wet with turpentine was applied and eontinueil tor three lionrs. The chill, however, continued
to recur every second day. The amount of turpentine used wa.s ten ounces. No injury to the tissues or strangury
occurred. He was iinully treated with ([uinine.
Case 7. — Private I». W Greenlee, Co. K, 50th X. C, had a quotidian chill Nov. 8, 1861, at 6 a. m. Next day at
5 A. M. the roller was ap])lied for an hour and no chill occurred. On the 10th a chill occurred at 2 a. .m. Quinine was
administered on the 11th and 12th, and there was no recurrence of chills. He was aniemic, and was therefore given
tincture of iron and infusion of quassia. Two ounces of turpentine. He was returned to duty on the 27th.
Case 8. — Private H. . I. Pollard, Co. D, oOthN.C, had a quotidian chill Nov. 7, 1861, at 9 a.m. Ne.\t day at 8 a. m.
the roller was applied for one hour, and repeated on the 9th, and no chill occurred. On the 10th the roller was not
applied, and a chill occurred at 10.30 a. M. He was then given quinine until the ]>aroxysnis ceased, aftd was continui^d
on tonic treatment for debility. Two ounces of turpentine were used. He was furlouglied on the 1 Ith forsi.xty days.
Case 9. — Private T. J. Turner, Co. V, nOth N. C, had a ([uotidian chill Nov. 7, 1864, at 2.30 i'. m. The paroxysms
were so irregular that the roller was applied Imt once, cm the 9th at 11 a.m.. for one hour, one ounce of turpentine
lieing used. .V chill had occurred on the 8th at 12.30 r >I., and recurred on the 9th at 3 r. M. Quinine was then used
and the paroxysms ceased. He remained under treatment for diarrlicea.
Case 10.— Private H. W. Cani.sse, Co. G. 50th N. C had a quot idiaii chill Nov. 8, 1864, at 2 a. m. On the 9th at
1 A. M. the roller was applied for an hour. At 1 r. M. the chill recurred. The operation was repeated at noon on the
10th, hut a chill occuned at 10 p. M. Two ounces of turpentine were used. On account of the irregularity of the
chills, quinine was given, three grains every two hours, and a cure eflfected. He was retained on tonic treatment
because of debility following intennittent fever.
Case 11.— Private J. C. Hutchings, Co. G, 50th N. C, had a quotidian chill Nov. 7, 1864, at 11 a.m. The chill
recurred irregularly. The tir.st application was on the 8th. at 10 a. .M., for an hour. He was treated in the same
manner as Canisse. Two ounces of turpentine were used. He continued in the hospital taking tonics for debility.
Ca.se 12.— Private G. L. Hlack, Co. G, 50th N. C, had a tertian chill Nov. 8, 1864, at 1 r. M. A quotidian char-
acter was afterwards assumed. The roller was applied on the 10th and 11th for two hours, without success. Two
ounces of turpentine were used. Quinine w.as then resorted to. He remained under trc^atineut for debility.
Case 13.— Private J.C.Strickland, Co. D, 11th S. C, had a quotidian chill Oct. 8, 1864, at 10 a. m. Next day
at 9.30 A. .M. the roller was applied for half an hour. A chill, however, occurred. The application was rei)eated on
the 10th and no chill occurred. Next day he had fever, which continued several days. He was given quinine, two
grains everythree hours, and the paroxysms were finally chec^ked. On the 18th a chill occurred at 9 r. M. The
roller was applied at 8.30 p. M. on the 19th, 20th and 21st, without success, but on the 22d the chill was arrested and
did not recur. Kight ounces of turpentine were used without any injurious etfects.
Of the twenty remaining cases one was treated successfully by turpentine with the
subsequent addition of opium and ammonia:
Case 14.— Private K. Clarke, Co. D, 9th Pa. Reserves, had a quotidian (-11111 Nov. 9, 1864, at 10 a.m. Next day
at 9 A. M. the roller was applied for an hour, and there was no diill. On the 11th laudanum and ammonia were used
in addition to the roller. No chill occurred. Having chronic diarrlnea he was retained in the hospital. Two ounces
of turpentine were used.
Two were treated with success by opium and ammonia without the use of the turpen-
tine bandage :
Case 15. — Private .Jacob W. Cobb, Co. H, Bonaud's (Jeorgia battery, had a chill .luue 6, 1864, at 6 P. M. Next
day at 5..30 p.m. laudanum and solution of ammonia, of each thirty drops, were given. The chill did not recur.
The dose was repeated on the 8th, and there was no further recurrence of chill. A tablespoonful of infusion of dog-
wood was given every three hours through the day. He was returned to duty, cured, on the 16th.
Case 16.— Private G.G.Davis, Co. H, Bonaud's tJeorgia battery, had a chill .June 6, 1864, at noon. The next
day at 11 a. m. thirty drojis each of laudanum and solution of ammonia were given, and the chill did not return.
Infusion of dogwood was administered every three hours.
8ix were treated at first with the turpentine bandage; but the chills persisting, opium
and ammonia were resorted to with beneficial results:
Case 17.— Private .1. B. Woodliss, Co. E, 1st N. C. Cav., had a iiuotidian chill Oct. 2, 1864, at 1 p. M. Next day
at noon the usual application was made and continued for one hour: but the chill recurred. On the 4th the operation
was repeated an<l laudanum and anmionia in the usual dose administered, after which the chill did not recur. There
Were no injurious effects from the turpentine, two ounces of which were used. He was returned to duty on the 15th.
Case 18.— Private George W. Thompson, Co. F, 2d Junior Reserves, had a tertian chill Oct. 15, 186-1, at 8 a. m.
On the 17th at 7 a.m. the roller was applied and continued for an hour. On the 19tli a chill occurred. The roller
was repeated and laudanum and ammonia administered. No further chills occurred. Two ounces of turpentine
were used, without injurious eft'ect. He was returned to duty on the 24th.
Case 19.— Private Wm. S. Davis, Co. G, 50th N. C, had a quotidian chill Nov. 10, 1864, at 11.30 a. m. Next day
at 10.30 a. m. the roller was applied for one hour over the fifth and sixth ribs, and was repeated on the 12th
1S8 TREATMENT OF
\rithonT snccess. On tbe 13th landanum and ammonia -were administered, after wliicli there was no recurrenc* of
chill. Three otinces of tnrpentine were used without injury. He was returned to duty on the 30tb.
Cask 30. — Pri-rate G. W. Wren, Co. A, 50th X. C. had a quotidian chill Xov. 7. l!*t>l. at noon. Xest day at 11 a. m.
the roller was applied for an hour. A slight chill occurred. The same treatment was pursued on the 9th and 10th.
a chill occurring each day. On the llth laudanum and ammonia were added. There were no further chills. Four
oonces of tnrpentiue were used. He was treated for anaemia with muriate of iron and infusion of quassia.
Cask 21.— Private J. C. Snead. Co. A, 13th X. C. Arty, had a quotidian chill Sept. 20, 1864. at 1 p. M. The
roller was applied at noon and continued for an hour. It was repeated thus for four consecutive days, hut without
preventing the recurrence of the chill. On the 24ih laudanum and ammonia, of each thirty drops, were given wlule
the bandage was on. A slight chill occurred. On the 2oth this treatment was repeated, and there were no chills
afterwards. Ten ounces of turpentine were used. Oct. 14. at 5 a. m. he had a tertian chill. On the 16th at 4 .\.m.
the application was made and continued for one hour: at the same time laudanum and ammonia were given. Xo chill
occurred tbereaiier. One ounce of turpentine was used. He was returned to duty on the 19th.
Case 22.— Private W. P. Wilson. Co. I, 1st X. C. Reserves, had a quotidian chill Sept. 20, 1864, at 2 p. M. Xext
day at 1 P. M. the application was made for one hour, and repeated daUy till the 24th, without snccess. On the latter
date the usual dose of laud.inum and ammonia was given, and the chill did not occur. This treatment was repeated
the next day, and there was no chill afterwards. Ten ounces of turpentine were used.
In /?*e cases treated by turpentine externally, in conjunction with opium and ammonia
internally, four were successful on the first day and one on the second day :
Cjisk 23.— Private W. H. Boherts, Co. D. 20ih Ga, lottery, had a tertian chill Aug. 31. 1861. at 10 a. m. At 9.30
A.M., Sept. 2. the roller was applied for an hour over the fourth and fifth ribs, and at the same time were given
laudanum and solution of ammonia, of each thirty drops. The chill did not recur. The roDer and the landanum
and ammonia were repeated on the 4th. Xo further chills occurred. There was no injury to the tissues nor other
bad effect from the turpentine. The amount used was ten ounces. He was returned to duty on the 23d.
Cask 24. — ^Private James B. Dean, Co. B. 1st Junior Beserves. had a quotidian chill Oct. 24. 1864. at 3 p. m.
Xext day at 2 P. M. the roller was applied for an hour, with the laudanum and ammonia internally. The chill did
not recur. The same treatment was repeated on the 26th. and there were no chills afterwards. Two ounces of
turpentine were used. He was furlonghed on the 29th.
Cask 25. — Private J.S.Tribble, Co. B, Sth Georgia, had a tertian chill Oct. 2, 1864, at 6 p.m. On the 4th at
5 P. M, the roUer was used for one hour, in connection with the landanum and ammonia. The chill did not recur-
One ounce of turpentine was used. He was much debilitated from diarrhcea.
Cask 26.— Private J. M. WU.son. Co. H, 50th X.C. had a quotidian chill Oct.. 3, 1864, at 2 r.-M. Xext day at
1,30 P, M. the roller was applied for half an hour, and laudanum and ammonia used. There was no chill. The treat-
ment was repeated at the end of the week, and there was no recurrence of chill. One ounce af turpentine was used.
As he was ansemic he was given Vallet's mass and quinine for a week. On the 20tb he was returned to djity.
Case 27. — Private John Broadbent. ChappeU"s Train Guard, had a quotidian chill Oct. 2. 1864. at 3 a.m.
Xest day at 2.30 a. M, the roller was applied for half an hi>ur without, however, preventing a chill. Laudanum and
ammonia were also used. On the 4th the treatment was repeated, and there was no chill, Xo injurious effect followed
the nse of the turpentine, of which two onnoes were nsed. He was returned to duty on the 18th,
And in six recourse was had to quinine after a conjoint trial of the new methods ;
Case 28, — Private J, S. Inge, Chapman's Guard, had a quotidian chill Oct. 1, 1864, at noon. At 11.30 a.m.
nest day the roller was applied for half an hour, in connection with laudanum and ammonia internally : a chUl
occurred. Xest day it was developed an hour earlier. On the 4th it occurred at 10 .\, M.; the treatment having been
commenced at 9 A, M, 5th. The chill occurred at 10 a. M.: treatment repeated. 6th. The chill, which was less severe,
occurred at 10.30* a. m„ the same treatment ha^-ing been pursued. 7th. The laudanum and ammonia were omitted.
The chill began at 11 a, m, and receded half an hour daily untU the lOlh. On that day fifteen grains of quinine were
given hut without success. Next day three grains every two hours were given imtil eighteen grains had l>eon taken.
and there was no chill. Sm.xUer doses of quinine were used until the 15th : no chill. Twelve ounces of turjientine
were used without injury to the tissues. He was returned to duty on the 18th.
Case 29. — ^Private J. G. Stephenson, Co, D, 50th X,C,. had a qnotidian chill Xov, 7, 1864. at noon. Xext day
at 11 A. M. the roller was applied for an hour, and the chill did not recur. On the 9th the application was repeated.
There was no chill, but some fever. A chill occurred on the H>th. The application was repeated at 10.30 a. m. of the
llth, and at the same time laudanum and ammonia were given, but without success. 12th, Two grains of quinine
. every two hours were given, A chill occurred, 13th, The treatment was rej>eated and no chill occurred. Four ounces
of turpentine were used without injury. He remained an*mic for some time, and was given infusion of quassia one
ounce three times daily: 23d. he was returned to duty.
Case 30,— Private J, O, Woodall, Co, C, 50th X", C had a quotidian chill Xov. 7, 1864, at 4 p. M. At 3 p. M. the
nest day the roUer was applied for two hours, but the chill occurred at 9 P. M. On the 9th the application was made
at 5 P. M.: there was slight fever afterwards. On the 10th the treatment was repeated, but the chill occurred, receding
three hours, llth, Laudantun and amiuonia were added, but without effect. 12th. Quinine was given, and there was
no chill. He was anfemic, and was retained in hospital. Five ounces of tnrpentine were used.
Case 31, — Private S, Laws, Co. I, 1st X. C. battery, had a quotidian chUl Xov. 7, 1864. at 9 P. M. Xext d.<iy at
8 p. M. the riilVr wa^i 3ririli.^-i f«T mtih b.i-ir. but the chill occurred at 11 P. M. On the 9th and ll>ih tbis treatment was
MALARIAL DISEASE. 189
repeated without preventing the chiJl. 11th. Laudanum and ammonia were added •writhout effect. On the 12th and
13th quinine was employed, and no chill occurred. Four ounces of turpentine were used vrithout injury. As he was
au:emic tincture of muriate of iron, twenty drops three times daily, was given.
Case 32. — Private 'William Huntingdon, Co. I. .5C»th X. C, had a quotidian chill Nov. 7, 1864, at 10 \. M. The
next day at 9.30 a.m. the roller was applied for one hour. The treatment and results were as in the case of Laws.
Four ounces of turpentine were used. He was returue<i to duty on the 27th.
C.tSE 3.S.— Private A. Britt. Co. D. .TOth X. C. had a quotidian chill Nov. 7, 1S64, at 1 P.M. At noon next dav
the roller was applied for an hour and there was no chill. On the 9th and 10th the application was repeated, and a
chill occurred each day. 11th, Laudanum and ammonia were added to the other treatment, bnt without avail. On
I lie 12th and 13th quinine was used. An infusion of quassia, one ounce three times daily, was given for seven davs.
Three ounces of turpentine were used without injury. He was returned to duty on the 20th.
In addition to these the records of the Pettigrew hospital state that —
A number of cases ■were treated with the turi>entinc roller as an adjuvant to quinine, greatly reducing the
<|uantity of the latter administered.
The following is from the case-book ol the Chimborazo Jiospital, Richmond, Va.; the
writer's name is not given:
Intermittent fever, the common ague of this country, has been qtiit« prevalent this winter, and quinine,
:iluiosl the only remedy employed against it internally, has not prevented relapses. The turi>entine stupe has
jiruved useful in some cases, applied an hour before the expected paroxysm, but in many others it has only retarded
ihe access of the paroxysm. The acetates, citrates and tartrates of soda or potash, so highly commended as adiu-
vants to the antiperiodic treatment by Ciolding Bird, have not been 'employed, nor has sufficient care been taken to
repeat the antiperiodic remedy, whether quinine, arsenic or other, at intervals of seven days. The individual cases
have presented no points of particular interest except that of Pitts, who died of the congestive or pernicious form.
He was a fine, tall, robust fellow, recently from the Army of Virginia. He was rational but taciturn on admission,
aud though without typhoid symptoms, gave the idea of a profound cerebral impression. Each evening he was
seized with what was spoken of as convulsive movements, quite violent, during which he struck to the right and
left and had to be held by main force! it was supposed that he .sought to jump out of the window. This maniacal
delirium was succeeded by intense fever. After a few nights he became very cold at the evening access and shook
violently. During the intervals he remained taciturn and did not seem to recognize his friends. The treatment
employed was insignificant. A few small doses of quinine, cupping to the temples, a blister to the nucha, etc.
Nothing made any impression, and he died within a week.
The prevalence of malarial diseases in the Confederate Armies, together ■n^th the
scarcity of quinine resulting from the blockade of the Southern ports, gave origin to a con-
tinued effort to utilize such indigenous remedies as were popularly credited with anti-
periodic powers. In fact, in the first year of the war Dr. Joseph Jones called attention to
the advisability of investigating the properties of native plants with a view to finding a
substitute for quinine.* Of these the Pinekneya piibens or Georgia bark and the Cornus
jiorida or dogwood, had an extensive trial. The former is a small tree closely allied to
the cinchonas, growing on the wet and boggy margins of the streams which intersect the
pine barrens from l^ew River, S. C, to Florida. Dr. Jones reports it as having been used
in conjunction with dogwood and wild cherry as a tonic and antiperiodic. In view of its
reputed virtues the Surgeon General, C. S. A., directed his medical purveyor to have it col-
lected for experiment. The only published report on its use, that rendered by Medical
Director A. M. Faustleroy, does not sustain its claim for notable febrifuge powers. f
• Indijenctu rrmedie* of the Sotdhcrn Conffdemcy, vhkh may he employed in thr trralmerU nf malarial fever. SotUhem Med, and Surg. Jour.,, Aug;uEtaL, Ga,
1861, Vol. XVn, pp. 6^ asd 753. In this yaper Dr. JoxES insists on the examioAtlon and employment of Southern remedies, not as a temporarj expo-
<\wnt in the absence of quinine, bnt as a permanent advance toward the Cf^tablishment of absolute independence. He reviews the variou!; remedies
which ma; be employed in the treatment of the most common aud important of Southern diseases, citing the evidence on which the reputation
"f ' I. h has U-en established. As of value in malarial fevers, the following remedial means and measures are discussed : The inner hark of the Ptndbw^
; «'-..» or Georpia bark; the bait of the root, stem and branches of Ckmrnt JIarida or dogwood; the bark of other species of dogwood, a« C cirdnaSa, the
Fvi!;: i!.-aT. i ilojr^ood. and C. ifricea, the swamp dogwood : the bark of the poplar or tulip-tree, Ltriodatdron tnUpifera : the bark of certain magnolias, as the
^iiiiill !!..(_-:.. lia or sweet bay, Jlaffjtolia jfiauoa; the encumber tree^ if. aaunmata; big laurel, M. grandijiora^ and umbrella tree. .V. tripctala; the l>ar^
of till' I- r-:inmon, Itiofpyrnf. Vtrginiatyi; the Imrk of the caTaliM, Hi^inonia caUdpa; Virginia snake-root, Aru^dodiia ncrpentana: Indian quinine or ague
wewi, Uentiaaa qmutqvffolia ; tlioroughwort, boneset or Indian sage, EHpatariMun, ptrfcAiatam and wild borefaound, E. rottuidifoUHm ; willow hark, SaUx aSha
aod S. nigra; the root of the yellow jestsamine, GtUeminvm tmiprrrirtrw; the root of milkweed, AscUptas tyriaca: chloride of eodium ; hydrochlorate
of amm<»nia ; nitric acid ; arsenioos add ; ligature of the extremities and cold afiiisions and douches,
• A. M. FArNTi.EE0T. Medical Director, Wilmington, K. C. — Brport of additional cascn of fd»ris ialcrmiilenK treated wUh the extract of Pineibnttya pvhau.
Confrdmtjf :ituU* Jklr^L oful Surg. Jour.,, Vol. I, p. l?A — concludes thus: "The extract has undoubted antiperiodic prtijK-rties; still it is too slow in
itsactioD to be used as a substitute for the sulphate of quinine. It has, with one exception, always produced diaphoresis. Its therapeutical action
190 STATISTICS OF
The Cornus jiorida, a small tree common on moist gravelly soils in the Northern and
Middle States and along the borders of swamps and bottom lands in the South, was also
emjDloyed under official auspices.* Dr. Jones says lie used the decoction and tincture to a
considerable extent during the war, and found the remedy of value in the treatment of malarial
fever. In severe cases the paroxysm was arrested by quinine and the treatment subse-
quently continued with dogwood. Its use is incidentally mentioned in some of the cases
given above from the records of the Pettigrew hospital. But it does not appear that any
formal reports testifying to its efficacy were rendered; for as these were requested by the
medical authorities, it may be assumed that, had any such been returned, they would
undoubtedly have been published. The uiedical journals are also silent on the subject.
We may therefore conclude, with Dr. Kennedy, that although the dogwood and other bitter
infusions furnished by the Confederate States iVrmy Medical Purveying Department possessed
an antiperiodic power which, under favorable conditions, would cure ague, there were certain
objections to their use, and in no case could they be valued as a substitute for quinine.'j"
CHAPTER IV.— ON THE CONTINUED FEVERS.
I.— THE STATISTICS OF THE CONTINUED FEVERS.
I.— IN THE UNITED STATES ARMIES.
Prevalence and Mortality. — The uncertainties attaching to the statistics of the
Camp Fevers from the abolition of the term common continued fever , and the institution of
the new term typho-m^alarial, have already been indicated. J The figures representing the
typhoid cases of the later years do not comprise the whole of the cases that occurred in the
commands from which they were reported, for some were certainly included in the typho-
malarial statistics. Indeed, in accordance with the intent of the new term, each case reported
under it should have been essentially- a typhoid case. But a comparison of the rates of
fatality of the two series of cases manifests that in its acceptance by the profession the new
term had a more extended signification than was purposed by its author. The percentage
of deaths in typhoid cases among the white troops was 35.90, among the colored troops
is principally that of a tonic, and it deserves a position in the front rank of vegetable tonics. From the tardiness of its action, and its effect upon thn
vascular system, together with its manifest invigoration of the digestive organs, I am induced to think its energy as an agent is displayed through tin.-
organic nervous system."
* A circular from the Surgeon General's Office, C. S. A., dated Dec. 5, 1862, printed by Jones in his article on Indigenous Remedies of tlie Soutiiern
StaJett — Si. Louis 3l€divut Reporter, 1868, Yol. Ill, p. 261 el seq. — gives a formula "for a compound tincture of the indigenous barks, to be issued as a tonic
and a febrifuge, and substituted, as far as practicable, for quinine. * * * Dried dogwood bark, .30 parts ; dried poplar bark, 30 parts ; dried willow
bark, 40 parts ; whiskey 45 degrees strength. Two pounds of the mixed bark to one gallon whiskey. Macerate fourteen days and strain. Dose, one fluid
ounce three times a day."
t Dr. Stiles KE^'^'EDY gives his opinion of these indigenous remedies incidentally in introducing the subject of turpentine exlenially applied.
See note supra: "While in .Savannah, November, 1S6*3, I assumed control of the medical department of the 47th Georgia regiment in order that its
surgeon might visit bis sick wife in Griffin. Several companies of this regiment had been exposed during the summer months to the elTluvi.i of the rice
fields on the Savannah river, and at first ' sick-call ' I found over one hundred cases of ' chills." No quinine was being issued at this time by the Confed-
eiBte purveyor, but instead of this potent remedy, infusion of Pitickneya pubcns. Spanish willow and dogwood were sent in large quantities with full
directions for their use, and the hope was expressed that I would be able to return a favorable report of their eifects. And 1 will state here.'that when
the patient is in comfortable quarters in town, away from exposure and malarial influences, with sufficient tone and calibre of stomach to bear repeated
drenchings of these nasty iufusions, there is no difficulty in curing intermittent fever. But my troops were in the field and on picket-duty every day.
* * * The infiisions failed during a severe trial."
I Supra, p. 75 el se*^.
THE C0NTINX7ED FEVEES.
191
7. Duriiitc
55.69, while in typbo-malarial cases the corresponding rates were 8.1-i and 17.2
the fourteen months, July, 1862, to August, 1863, inclusive, following the introduction of
the term, and while yet in ignorance of the value intended to be officially attached to it,
medical officers of white troops reported 27,399 cases, or more than one-half of the total
number of cases, 49,871, embraced in the statistics; of these only 1,585 died, or 5.08 per
cent. Had enteric fever been assuredly present in all these cases a further deterioration of the
blood by a coincident malarial fever must be regarded as a desirable complication in typhoid
epidemics. But, after the public announcement of the intent of the term, the suddenly
increased gravity of the cases reported under it must be understood as moaning that a
certain proportion of the medical officers of the army became aware of the \alue intended
to be attached to typlw-malarial, and restricted its use accordingly to cases which appeared
to them to present a specific typhoid element. The 22,472 cases reported subsequently to
August, 1863, included 2,474 fatal cases, the percentage of fatality being 11.01. The
probable proportion of true typhoid cases embraced by the typho-malarial statistics will be
suggested hereafter when the clinical and pathological features of the cases thus reported
have been submitted and fully considered.* But although the whole of the typho-malarial
cases were not typhoid fevers modified by coexisting malarial influences, they were probably
all of a more or less continued type; and while their statistics have been presented in con-
nection with the paroxysmal fevers in view of their malarial element, it seems proper to
again submit them in the present connection in view of their continued, if not in all cases
truly typhoid, character.
The following table summarises the reported statistical facts :
Table
Statement of the Frequency and Fatality of the Continued Fevers, ffivivg the totals reported from May I,
1861, to June 30, 1866, among the White Troops, and from Jxdy 1, 1863, to June SO, 1866, amuny
the Colored Troops; with the ratio of cases to strength and to cases of all diseases, and the ratio of
deaths to strength, to deaths from all diseases, and to cases of the continued fevers.
SPEcmED Fetebs.
Number reported
during the period
stated.
Ratio per 1, 000
of strength.
11
L. ao aa
ill
1"
8 !
u
E,
Oases.
Deaths.
Cases.
Deaths.
Among White Troope from May 1, 1861, to June 30, 1866 :
75,368
11,898
2,501
49,871
27,(66
147
850
4,059
1T.1
57.78
13.90
2.19
.46
9.19
-
209.11
1.14
6.57
31.37
1
35. «l
1.24
33.99
8.14
2i , .31
6
US
1.82
8.67
T^phn-Xftlllrill T^^^T
Tnt.1
139,638
32,112
324
68.58
25.74
248.19
23.00
.^mong Colored Troope from July 1, 1863, to June 30. 1866 :
Typboid FeTer ______
Typhiu Te\^T. . .__
Tjp>>n.MA)an«1 F^vr
4,094
123
7,529
108
1,301
oT
2
123
1.69
20.35
6.77
.20
12.44
82.91
3.33
47.31
55.69
1
87.80
17.27
TnBil
11,746
3,689
192
57.71
19.41
134.15
31.41
* See w/ro, p. 375.
192
STATISTICS OF
Among tlie wliite troops there were reported 139,638 cases of the fevers specified, and
of these 32,112 were fatal, making 324.0 cases and 68.58 deaths per thousand of strengtii
present during the five and one-sixth years covered by the statistics. AUhough the cases
formed only about one-fortieth of the total cases of disease, 25.74 per tliousand, their
fatality was such that the deaths constituted one-fourth of the deaths from all diseases, or
248.19 per thousand. This was due to the relatively large proportion and grave character
of the typhoid cases. Tlie percentage of fatal cases among those reported as typhus was
large, 33.99, but the number of cases being compai'atively small, this fever was charged
with only 6.57 of the 248.19 deaths from continued fevers presented by every thousand
deaths from all diseases. The cases of typho-malarial fever, on the other hand, assumed
an importance from their number, although they furnished only 31.37 deaths as compared
with 209.11 caused by typhoid in every tliousand deaths from disease.
Among the colored troops nearly two-thirds of the total numbei', 11,746, of cases of
continued fever were reported as typho-malarial fever. The ratio of typho-malarial to
typhoid cases among the white troops cannot be obtained from the upper division of the
table, as the periods during which the cases occurred were of unequal duration. But a
Table XL.
Expressing the Frequency and 3Iortality of the reported forms of the Continued Fevers as percentages
of the total cases and deaths caused by such fevers.
WHITE TROOPS.
Specified Fevers.
s
'o
1
a
3
1
■s
a
•a
o
S
a
3
Percentage of —
■S"5
.H 3 1
May 1, 1801, to Juno 30, 1862—
Typhoid Fever . _
22,062
841
11,898
5,665
204
147
63.4
2.4
34.2
94.2
3.4
2.4
Common Contiuued Fever .-
Total of specified forms ..
34, 801
6,016
100.0
100.0
July 1, 1862, to June 30, 186&—
Typhoid Fever
53,301)
l.GCO
4'J,87l
21,391
646
4,059
50. 8
1.6
47.6
82. CI
2.5
15.5
Total of specified forms _ „ _
104,837
26,096
100.0
100.0
COLORED TROOPS.
July 1, 1863, to Juno 30, 1866—
4,094
123
7,529
2, 280
lOS
1,301
34.9
1.0
64.1
61.8
2.9
35.2
Total of specified forme
11,746
3,689
100.0
100.0
TITK CONTINUED KEVKRS.
193
reference to Table XL, on the opposite page, wil! sliuw that during tlie tliree years inwhieh
both typho-inalarial and typhoid cases were reported tlie former constituted less than one-
lialf of the total. It will be seen hereafter that this greater prevalence of typho-malarial
fever among the colored troops was associated with a diminished prevalence of typhoid, the
average annual number of cases of continued fever among tliem having been nearly the same
as among the white commands. Hence the deaths from typho-malarial fever constituted a
larger proportion of the deaths iVom continued fever, and of the deaths from all causes,
among the negroes than among the whites, and the deaths from typhoid fever a smaller pro-
portion, although the percentage of cases that terminated fatally was considerably greater
among the former than among the latter. It will be observed also that among the colored
troops the deaths from the continued fevers constituted a smaller proportion of the deaths
from disease, 134.15 per thousand, than among the whites, 218.19 per thousand, notwith-
standing the similar rates of prevalence among both and the larger rate of mortality among
the negroes. This may be seen, by Table II,''' to have been caused by the relatively greater
mortality from diseases of the respiratory organs.
Paring the period when common continued fever held a place in the official nosological
system typhoid cases formed 63.4 per cent, of the continued fevers among the white troops,
typhus 2.4 and common continued fever 34.2 per cent.,"j" while typhoid was charged with
94.2 per cent, of the deaths; subsequent to that period typhoid contributed a little more
and typho-malarial a little less than one-half of the cases, typhus forming only 1.6 per cent.,
while the deaths attributed to typhoid were reduced to 82.0 per cent, of those from the
contiimed fevers by the substitution of the larger percentage from typho-malarial fever for
the smaller percentage formerly referred to common continued fever.
Among the colored troops 64.1 per cent, of the febrile cases were reported typho-
Table XLI.
Relative Frequency of Qises of the Continued Ferers, and of Deaths occasioned by them, during the
xereral years of the war and the year following the war, expressed in annual rates pei thousand
of strength present.
WHITE TROOPS.
Diseases.
lSGO-1.
1861-2.
1862-3.
1863^.
1864-5.
1865-6.
Cases.
Deatlis.
Cases.
Deaths.
Cases.
Deaths.
Cases.
Deaths.
Cases.
Deaths.
Cases.
Typhoid revcr,-
Typhus Fever
U.OO
2.89
2.46
.43
78.62
2.94
48 IS
19.55
.69
.51
62.36
1.55
38.00
15.89
.57
1.78
16.32
.56
18.93
6.63
.18
1.71
16.96
.57
22.91
8.99
.19
2.27
12.97
.32
6.23
.21
16.62
29.91
2.54
Total Cuntinued Fevers
35.62
2.89 1 123.69
20.75
91.91
18.24
35.81
8. .52
40.44
11.45
8.98
COLORED TROOPS.
I
Tjphoid Fever
41.67
1.66
56.16
16.35
1.30
10.85
20.24
.55
37.47
13.34
.46
6.61
9.74
.13
34.21
5.99
.12
5.49
Typhus Fever
■ Typho-malarial Fever
Total Continued Fevers .
99.39
28.ii0
58.21!
1 1 :l
11 1- 11.60 1
1
• Page 11. sufrn. \ The relative freqiK-iicy of the reported forms is jfiven with more of detail in Table XLVII.
Mei>. Hist., Pt. TIT— 25
194
STATISTICS OF
malarial, 34.9 typlioid and 1.0 typhus, while the deaths under these headings were respec-
tively 35.2, 61.8 and 2.9 per cent, of tlie whole number attributed to these fevers.
Table XLT, presented on the last page, shows the annual variations in prevalence and
mortality. The columns for 1860-61 may be overlooked, as their figures are based only
on the reports for the last two months of the fiscal year.
As the war progressed these fevers became less frequent among the white troops. The
first year gave 123.69 cases per thousand of strength; tlie last year of the record gave
only 29.91. But this decline suffered, in 1864-65, a slight interruption, specially marked
among the typho-raalarial cases, and probably due to the substitution of fresh troops for
men who withdrew to their homes on the expiration of their term of service. The death-
rate was similarly interrupted in its fall from 20.75 to 8.98 per thousand of strength.
No interference occurred in the gradual subsidence of these fevers among the colored
troops from a rate of 99.39 per thousand strength in the first year to 44.08 in the last, nor
in the fall of the mortality-rate from 28.50 to 11.60.
But although the annual mortality expressed as a ratio of the strength present dimin-
ished with the reduction in the number of the cases, the decrease of the one was not
exactly proportioned to the other. ' , Nor was this disproportion due to the association of
lessened virulence with diminished prevalence. On the contrary, the gravity of the cases
increased to the close of the war. During the first complete fiscal year 17.4 per cent, of
the febrile cases among the white troops terminated fatally; during the last year 31.8 per
cent.; during the year following the war 30.9 per cent. . Table XLII illustrates the increas-
ing gravity of the individual cases during annual periods which, according to Table XLI,
were characterized by a diminution of the prevalence of these fevers and of the mortality
caused by them in the army as a whole.
Table XLII.
Showing the Annual Percentages of Fatality of the Continued Fevers.
WHITE TROOPS.
Teak ending June 30—
1801.
1862.
1863.
1804.
1865.
1866.
Rates for the
whole period.
Typhoid Fever
17.5
15.0
0.0
25.7
24.5
1.2
32.6
39.7
44.2
36.2
59.5
37.8
49.4
67.8
35.90
33.99
1.24
8.14
Typhus Fever
Common Coutinued Fever
5.0
9.9
11.2
16.7
Total
8.1
17.4
21.3
25.9
31.8
30.9
23.00
COLORED TROOPS.
Typhoid Fever
40.3
85.7
19.9
70.3
89.1
16.7
63.2
100.0
16.6
55.69
67.80
17.27
Typho-malarial Fever ..
Total
29.5
35.3
27.1
31.41
The rates here presented cannot be accepted as accurate. The want of relation
between the cases and deaths borne on the reports has already been explained. The cases
that occurred in the large population of the general hospitals were not taken up on the
THE CONTINUED FEVERS.
195
reports, but all the deaths were noted. The mortality among this unknown number of
cases adds considerably to the calculated rates of fatality. The limits of the error may be
fairly defined for certain diseases, but in the instance of typhoid fever, other cases than
those that originated in the hospitals were unrecorded. Vast numbers of ailing men were
sent to the general hospitals from the field, especially when the army was on the eve of a
move. Few of these were entered as typhoid fever on the field reports, although had they
continued longer under observation this diagnosis would have been autliorized; and in
many instances, unfortunately, opportunity was afforded after death for its verification.
Tlie number of these unreported cases must have been very large, for the experience of
medical officers in charge of general hospitals near the base of operations of troops on field
service testifies to the frequency with which typhoid fever reached their wards without
appearing on the antecedent records. In view of these unregistered cases, which contributed
largely to the recorded deaths, it is impossible to ascertain the actual percentage of fatality
of the continued fevers.
The ratios of typhoid fever are modified also by the withdrawal of so many of the
cases into the typho-malarial group, while those of the typho-malarial fevers are valueless
from the uncertainty as to the nature of the fevers thus reported and the certainty that,
as may be inferred from the ratios themselves, not all of the cases possessed a typhoid
element. The comparatively small percentages of fatality sometimes recorded for typhus
are explained by the entry of the cases in accordance with the diagnosis under the typhus
heading, and of the resulting deaths, in view oi post-mortem revelations, under the heading
typhoid — the typhoid rate thereby becoming augmented at the expense of the other.
But although of little value as indices of the fatality of the continued fevers, the ratios
presented above are admissible evidence of the increased gravity of the cases as the war
progressed; for the statistics from which they were calculated were gathered under similar
conditions.
The average annual rates per thousand of strength show, in Table XLIII, a similarity
Table XLIII.
Comparison of the Frequency of Cases of the Continued Fevers, and of the Deaths occasioned by them,
among the White and the Colored Troops, as shown by the average numbers annunlly recorded,
reduced to ratios per thousand of strength; the figures for the [VJiUe Troops based on the statistics
of the period May 1, 1861, to June 30, 1866, and those for the Colored Troops on the statistics of
the three years July J, 1863, to June 30, 1866.
DISEASE.
White
Troops.
l.'uLi'l;):!
1 KU.JJ'.-.
Cases.
Deaths.
Cases.
Deaths.
Typhoid Fever
33.83
1.12
37.07
26.15
11.18
.35
.44
1.95
22.32
.67
11.89
.56
Typhus Fever
Common Continued Fever .
Typho-malarial Fever
41.06
6.79
Total Continued Fevers
62.67
13.27
64.05
19.24
L^
196
STATTSTTi '
OF
in tlie rates of prevalence among the white and the colored troops, 62.67 and 64.05 per
thousand respectively; but tlie mortality was greater among tlie colored than among the
white men, 19.24 as compared with 13.27. This increased mortality was caused by the
typho-malarial cases, they having occasioned 6.79 deaths per thousand of strength as
against 1.95 among the whites. The mortality from typhoid was similar in both, but the
cases having been less numerous among the colored men their larger percentage of fatality,
already noted, is explained. The slight prevalence of cases reported as typhus, 1.12 among
the white and .67 among the colored soldiers, accounts for an annual mortality which was
less among the white troops than that from common continued fever, notwithstanding the
high rate of fatality that attended the typhus cases.
Prevalence as related to Season and Locality.— To reduce the size of Table
XLIV, and at the same time to simplify figures, the data on the seasonal and regionic
prevalence of the fevers reported typhus have been consolidated with the statistics of the
typhoid cases. This might have been done with propriety in all the tables of this section;
for, as will be shown hereafter,* the greater number of the cases reported as typhus were
in reality cases of typhoid fever; but it was deemed advisable to present in certain of these
tables the rates of the reported cases of typhus by way of intimating to some extent the
modification of the typhoid cases by crowd-poisoning, as the typho-malarial cases similarly,
but perhaps less certainly, indicate their modification by the malarial influence.
Table XLIV.
Showing the Variations in the Prevalence of the Continued Fevers among White Troops in the various
Regions during the years of the War and the year following the War, expressed in monthly ratios
per thousand of mean strength.
YEAR ENDING JUNE 30, 1862.
1861.
1862.
Disease.
Regions.
a
g
<
1
u
a
O
g
m
a
1
S
<
g
■4
<
K
pa
a
■<
IS
p.
<
<
H
P
Typboid iiiid cases rei>orted as Typhus
Atlantic
2.3
4.C
5.8
7.1
9.1
8.3
5.8
4.0
3,2
0.0
5.9
7.8
74.0
Central
1.8
2.8
9.4
12.1
l.'i.2
9.8
10.4
7.1
0.0
0.9
8.7
0.3
99.8
Pacific
.2
2.5
1.4
1.0
.3
.5
.8
.4
8.1
81.0
In all the regions .„ _
2.0
4.0
6.5
8.6
10.2
8.5
7.0
6.1
3.9
6.3
7.2
7.0
Atlantic —
Central
3.4
1.0
4.6
2.7
4.2
4.0
4.7
6.1
5.3
4.3
2.3
.3.7
2.4
2.2
2.0
1.7
2.4
1.7
3.5
3.0
3.5
4.8
4.3
4.9
41.4
46.2
Pacific
.4
.9
3.8
1.2
1.0
.8
.6
1.1
1.3
.7
4.1
3.3
16.6
In all the regions
2.1
3.9
4.2
6.0
4.8
2.8
2.3
2.4
2.2
3.6
4.1
4.6
42.1
All the Contiuued Fevers
Atlantic—
5.7
9.1
10.0
11.8
14.4
10.6
8.2
7.2
5.6
9.5
9.4
12.1
11,1.4
Central .._
2.8
5.5
13.4
18.2
17.5
13.6
12.6
8.8
7.7
10.5
13.5
11.2
145.0
Pacific
.6
.9
3.8
3.7
2.4
1.8
.9
1.0
2.1
.7
4.1
"
24.6
Id all the regions
4.1
7.9
10.7
13.6
15.0
11.3
9.3
7.5
6.1
9.8
11.3
,...
123.7
' Ili/ra, p. 324.
THE CONTINUKD FEVEBS.
197
YKAK- ENDING JUNE 30, 1863.
1>
:J.
1.-:..:.
1
Disease.
Kegions.
i
•-9
s.S
i
<
tt.3
u
a
£
u
-
2.8
ad
a
7.4
U
a
SI
1
7.4
•X
S
a
6.3
<
1
5.5
<
U
i
i
•<
3.0
•<
s ■
2.6
bi
•-s
2.4
=
m
TypUoiti aud cases rv|H<rti'«l ns Tyiilnis
.\IUilitic_ .
4.8 1 4.8
01.7
I'eutral .__
* 4.7
4.6
3.5
4.4
4.6
4.6
4.8
4.9 1 4.8
3.6
2.4
1.8
48.1
I'nciSc
^'2
2.3
3.1
2.7
2.1
.7
1
.0
.4 ' .3
.3
13.0
In all tli.> n-giiins
6.7
5.3
3.1
. >
."'. s
5.4
5.1
4.8
4.7
3.2
2.5
3.6
42.3
Tvpho-inalarial Fevor
Atlantic-..
6.1
4.1
3.3
3.4
3.8
3.8
4.2
2.9
2.7
2.5
2.7
Central ...
4.8
4.5
3.2
3.2
2:3
1.9
2.8
3.9
3.3
2.C
2.1
2.0
34.8
Pacific
2.0
2.3
1.6
2.'.;
■ •'
::. 4
.2
.8
.7
1.3
.7
2:3
2.2
2.0
18.0
In .ill the regions
5.4
14.6
4.3
10.4
3.2
3.3
3.0
2.9
3.4
3.4
3.0
2.6
38.0
AH tlie Coutiuued Fevers
Atlantic
6.1
10.8
11.2
10.1
9.7
7.7
7.5
6.5
5.3
6.9
IM.O
Central
9.5
9.1
0.7
7.6
6.9
6.5
7.6
8.8
8.1
6.1
4.6
3.8
82.9
Pacific
2.2
4.G
9.6
4.7
4.9
3.0
4.1
.8
1.2
1.0
1.3
.7
2.6
31.0
In all the regions
12.1
6.3
9.1
8.8
8.3
1 8.5
8.2
7.7
5.8
4.8
4.6
91.9
YEAR ENDING JUNE 30, 1864.
1
180.3.
1864.
<
Disease.
Regions.
2.9
i
o
•<
in
a
e
n
<
p
'A
4
>•
<
i
e
u
»4
1
i
<
<i
K
p
•-s
p
a
19.0
T>i)ht)id and cases reported as T.vpiius
,\tliintic
XO
2.8
2.0
1.5
1.2
1.3
.9
1.0
1.0
.9
1.4
Central ...
2.0
2.2
1.9
1.3
1.1
.9
1.2
.7
1.0
1.0
1.0
1.6
15.7
Pacific
.3
2.3
.;i
.1
1.0
1.3
.3
.4
.2
.2
.5
.3
4.8
2.5
2.2
1.5
1.3
1.0
1.3
.7
1.0
1.0
1.0
1.6
10.9
Typho-ma la rial Fever
Atlantic
4.4
4.:;
•i.^i
::. 6
1.8
1.-2
1.3
.7
.7
.9
1.2
3.1
24.0
Central
2.9
3.2
1.9
1.4
1.-
.6
.5
.7
.7
1.0
I.-.
''■•'
Pacific
.8
.2
.3
.1
.4
1.4
1.0
.8
.4
. 1
.1
1.9
.2
I.O
2.1
.1
3.0
In all the regions .. . . ..
3.4
S.5
2.3
1.9
2.0
18.9
44.2
.\ll the Cuntinumi Fevers
.\tlantic —
7.3
7.2
6.8
4.8
3.3
2.4
2.G
1.6
1.7
4.5
Central ...
4.9
5.4
3.8
2.7
2.3
1.7
1.8
1.2
1.7
1.7
2.0
3.0
31.8
Pacific
1.1
.5
.4
1.1
1.7
.5
2."
1 .0
.6
.3
.1
.7
.4
7.8
5.7
6.0
4.5
3.4
2.x
■.'. 1
1.3
1.7
1.7
2.0
3.6
35.8
1
198
STATISTICS OF
YEAR ENDING JUNE 30, 1865.
1864.
1865.
<
Disease.
Regions.
i
<
cs
u
Ba
S
a
n
H
a
»
>
a
n
s
n
<
P
A
<
X
<
S
a
<
i
Typhoid and cases reported as Typhus
Atlantic
2.9
2.9
1.7
1.9
1.9
1.5
1.6
1.6
1.2
1.0
1.3
1.6
20.4
Central
2.1
2.0
2.4
1.4
1.2
1.0
1.3
.8
1.0
.7
.7
.8
15.8
Pacific
.3
.1
.8
.7
.3
.4
.6
.3
.2
.4
.5
.3
4.8
2.4
2.2
2.1
1.6
1.5
1.2
1.4
1.2
1.1
.9
1.0
1.2
17.5
Typhn-malarial Ffivers . , .
Atlantic
7.6
6.6
4.8
4.0
2.9
1.6
1.4
1.3
1.5
1.4
1.7
1.6
34.4
Central
2.1
2.3
1.7
1.2
.7
1.1
.8
.4
1.0
1.2
.8
1.4
14.9
Pacific
.1
.1
1.1
.5
.2
.4
.1
2.6
In all the regions
4.2
3.8
2.9
2.4
1.6
1.3
1.1
.8
1.2
1.2
1.2
1.4
22.9
All the Continued Fevers
Atlantic
Central
10.5
4.2
9.5
4.3
6.5
4.1
5.9
2.6
4.8
1.9
3.1
2.1
3.0
2.1
2.9
1.2
2.7
2.0
2.4
1.9
3.0
1.5
3.2
2.2
64.8
30.7
Pacific
.3
.2
1.2
1.8
.8
.6
1.0
.3
.2
.5
.5
.3
7.4
6.6
6.0
5.0
4.0
3.1
2.5
2.5
2.0
2.3
2.1
2.2
2.6
40.4
YEAR ENDING JUNE 30, 1866.
1865.
1866.
<
Disease.
Regions.
1
1
<
«
aa
a
1
g
O
o
i
1
1
i
<
A
1
5
<
g
>
<
S
SS
o
Typhoid and cases reported as Typhus
Atlantic-
1.7
1.9
1.7
2.6
1.5
.8
.5
.6
.7
.4
.4
.4
17.9
Central
1.2
1.2
1.2
1.2
.6
.3
.3
.4
.4
.3
.5
.3
11.2
Pacific
.4
.7^
.5
.8
.3
.2
.3
1.0
.7
1.3
1.0
.5
7.5
1.4
1.4
1.3
1.7
1.0
.5
.1
.6
■ .6
.6
.6
.4
13.3
Typho-malarial Fever
Atlantic
1 4
1 7
1 6
1 7
.5
2
.3
.1
.2
13.0
Central
4.5
1.7
1.0
1.1
.9
.3
.1
.1
1.2
22.5
Pacific
.6
,1
.2
.1
.1
.1
.5
1.5
3.1
3.1
1.6
1.1
1.2
.6
.2
.1
.1
.1
.7
16.6
All the Continued Fevers
Atlantic ___
3.6
3.3
4.3
2.0
1.0
.5
.9
.7
.4
.5
.6
30.9
Central
5.Y
2.9
2.2
2.3
1.5
.6
.4
. .4
.4
.3
.6
1.5
33.7
Pacific
1.0
.8
■ .5
.8
2.9
1.0
.3
.3
1.0
.7
1.4
1.1
1.0
9.0
4.5
3.0
2.4
.7
.."i
.7
.6
.6
.7
1.1
29.9 :
i
The striking irregularities in the monthly rates of prevalence of the continued fevers as
a class may be more readily observed by means of the plate facing page 199 than by the
tabulated figures. There are six notable prominences on their line of prevalence: one,
the highest, culminating in November, 1861 ; the second, less acute, spreading over the
months of May, June and July, 1862; the third, still more obtuse, covering the last
h
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Sep.
Oct.
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Jan
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Mar
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THE CONTINUED FEVERS. 199
three months of 1862 and January and February of 1863; the other three prominences
are acute and cubninate in August, 1863, and in July of 1864 and 1865.
Evidently something more than mere seasonal change was involved in tlie production
of the first of these waves of prevalence, for while in September, 1861, the line tends to
the summit of the first elevation, in September, 1862, it forms the angle of the deep sulcus
between the second and third, and whilst it falls in the winter months of 1861, the
corresponding months of 1862 sustain it on the crest of the third epidemic wave. On
the other hand, the prominences occurriiii;- in July and August of 1863, 1864 and 1865
suggest by their regularity a seat^onal iuHiuMU'i'. wliich is seen by the green line to have
been due to the prevalence of typho-malarial fever.
The elevations of the line indicating typhoid fever show that the poison of this disease
was the principal cause of the irregular waves of febrile prevalence during the early period
of the war. The sudden aggregation of young men in camps where they were exposed to
influences favorable to the spread of this disease accounts for its rapid increase from May
to November, 1861. During this period the troops which furnished the statistics were
increased from sixteen thousand to three hundred thousand men, under President Lincoln's
call of April 15 for 75,000 men for three months and the closely following act of Con-
gress, approved July 22, calling for 500,000 men for three years. This suggests the expla-
nation of the irregularities in the second and third prominences of the line of prevalence
of the continued fevers. In November, 1861, the epidemic among those who responded to
these calls was at its height, 15.03 monthly per thousand of strength, after which it sub-
sided rapidly to 6.14 in March. 1862. But meanwhile the army became augmented in
response to a requisition for 300,000 three-years' men; and this second aggregation was
followed by a second epidemic which, as the volunteers responded less promptly than on
the first call, had a less prominent but more prolonged acme, yielding in May 11.30, in
June 11.55 and in July 12.11 cases in every thousand men, after which the disease again
subsided to 6.33 in September. About this time the call for 300,000 nine-months' men
occasioned the third epidemic wave by the fresh material thus brought into the camps;
but as the men arrived more slowly than on the former requisitions the monthly rate during
the acme in October, 9.07, was not so high as during the previous visitations. Nevertheless
the susceptible men of the new levies did not escape, but were seized with fever as they
arrived, giving monthly rates of 8.80, 8.29, 8.52 and 8.22 for the four months next follow-
ing. In March the epidemic began to subside, and as no large bodies of new troops were
added to the army after this date until the expiration of the term of service of the three-
years' men, the only prominences in the line of prevalence are those already noted as
occurring towards the end of summer, and evidently occasioned in great part by the malarial
element of the fevers reported as typho-malarial. It is probable, however, that into the
first of these, that culminating in August, 1863, there entered febrile cases from the regi-
ments that responded to the call issued June 15, for men for temporary service in protecting
Maryland and Pennsylvania from invasion; and it is equally probable that the high rates
ot July and August, 1864, were in part the effect of the replacement of discharged veterans
by fresh levies.
It appears, therefore, that outside of the influence exercised on the rates of prevalence
of the continued fevers by the absorption of certain malarial cases the statistics afford no
information concerning variations due to seasonal changes. If any such were present they
200
PTATISTTCS OF
were of so slight a character as to be swamped in those arising from the one great cause of
variation — the number of men present susceptible to the action of the febrile poison.*
From this view of the line of prevalence of the continued fevers, and from what has
been said of the increasing gravity of the cases as the war progressed, it will be readily-
understood that the line of mortality, while presenting prominences similar to those on the
line of prevalence, would not, if drawn, be separated from that line thi-oughout its course
by the same multiple of its own height, but by a lesser multiple at points near the end
than at points near the beginning. The monthly variations in the mortality rates from
typhoid fever have already been illustrated on the tinted diagram facing page 20.
The lines of prevalence and mortality among the colored troops are traced on the
plate facing this page. Tyj^hoid cases formed a larger proportion of the strength present
at the beginning of the term of service than at subsequent dates; but the line of preva-
lence is irregularly elevated as fresh regiments were mustered into service. The line
expressing the prevalence of the continued fevers as a class presents three very notable
seasonal prominences, due principally to the presence of fevers reported as typho-malarial.
In treating of the paroxysmal fevers the seasonal variation was emphasized by con-
solidating the rates for the corresponding months of the several years into a line expressing
the average rate for each of the months or the average annual curve; but in the case of
the fevers now under consideration the prominences due to the aggregation of susceptible
material are the main factors in determining the contour and level of the line obtained by
such a consolidation. The average line for the white troops, as shown on the diagram on
the opposite page, exhibits a notable elevation in July, 7.14 per thousand strength, due to
themalarial element of the fevers, and a smaller elevation stretching over the months of
October and November, due, so far as shown by the data, to the incomplete levelling of the
epidemic prominences.
The average annual curve of prevalence among the colored troops presents a marked
elevation in July, August and September, 9.31, 9.45 and 8.64, respectively, per thousand
men present. This is evidently due mainly, but net wholly, to malarial influences; for
while typho-malarial fever certainly contributed to the elevation, typhoid fever was also
more prevalent then than at other seasons. In view of the greater prevalence of typhoid
in the first July of their service, as delineated in the plate facing this page, the composi-
tion of the prominence under consideration may be appreciated.
* There are many observations in the
literature of typhoid sliowiiig its in-
creased prevalence in the kite aiituuin
and winter niontlis, itsdiininislied prev-
alence in the spring and its presence at
all seasons: but in tliis country there
have been few st.atistics gathered on
the large scale. The National Hoard
of Health collected and published
weekly mortality returns during the
period from January, 1880, to Maj-,
1882. Cities and towns aggregating a
population of about eight millions were
represented in these returns. Ttie ab-
solute ilgures as reported in the in-
stance of typhoid fever have been
converted into monthly rates expressed
as annual rates per tliousand of popu-
lation, and from them the a<-company-
ing diagram has been drawn.
BtAGRAJvt showing by annual rates Jter thousand the seasonal varialimts in the mortality, and hence in the prevalence of
t/iphoitl ffrn; among n T^niifd Slatm poptiUithn of about eight minions.
188 0.
18 8 1.
18 82,.
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Monthly rates of the fn-crs as n rlas.'i .
, „ „ TvpJin nmtariul Fei-ej-.
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Death Rntex Prom, all the Fexrrs-.
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THE CONTIXrKI) KK.VKRS.
201
Di.vcuAM showing Ihe ai'cnigi' (inniial iiinm 0/ prfruliiur and morliililij nf innlinnid fivers.
Thp up|wr Tinhrokon liiu- sliows tlio rale of prt>viilonco of the fovoiff M u class, tlio lower tlu* iU>j)lh-mtoi4 rjiut<4>tl hy tlioiii. Tlic ilottoil lino n>pn>K*'iilii
tlio pn-valeuco of tJ^lho-maltt^iul fever, and the space Iwtweeu it and the line nhove it the prevalence of typhoiil fovt-r.
WHITE Tuoors.
« OI.OKEl) TItOOPS.
Il4-I44^l;t§l=^4l4!
10.0
10.0
9 6
9.5
9.0
9.0
a. 5
8.0
8.5
8.0
7 5
7.8
7.0
7.0
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\
6.5
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s
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10. 0
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The data from whic-li these curves have been constructed are submitted in the two
tables which follow:
Table XLV.
Seasonal Variaiions in the Prevalence and Mortality of the Continued Fevers among ihe White Troops,
ej^presned in average monthly rates per thoiisand of strength, obtained by the comolidation 0/ the
figures for the coi-responding months of each of ihe years covered by ihe statistics.
Diseases.
>•
g
a:
(<:
t.
u
QQ
a
a
0
ES
u
a
>
0
0:
n
i
<
•A
<
<
1
0
a.
-<1
•A
hi
Y.
('asea of—
Typhoid Fevor (a)
2.98
2.80
2.61
3.50
3.78
3.4:j
3.22
2.04
2. 40
2.35
2.33
2.40
.15
.12
.08
.09
.09
.07
.08
.08
.10
.09
.08
.III
1 jp \ i
2.1a
4.07
3.92
3.52
4.14
2.64
5.02
2.45
4.82
1.98
2. 76
1.71
2.33
1.85
2.33
1.66
2.20
1.05 •
3.49
1.50
4.14
l..'.l
l.''."i
4.56 ^
2.04
4.S9
Tvplionialarial Fever (p)
Vil thA rontinuod Fever8(d)
7.U
8.47
5.47
G. ;;.".
li. ::4
:^. 37
.'.. 1.\
4.48
4.28
4.2'.
I>tiiili> from—
Tvphoifl F<'V4T{rt)
1.34
1.2n
.89
.91
1.00
.96
.89
.85
.84
.84
.86
.03
Typhus Fiv.r .n __
.m
."■.
.02
.02
.03
.03
.02
.04
.05
.03
.03
.03
Comiiion r»uitimK'd Yi'wv (&)
.02
.04
.OS
.03
.02
.08
.02
.01
.09
.06
.10
Typho-malurial Fevcr(c)
.27
.30
.27
.18
.14
.10
.13
.12
.13
.10
.10
.16
All the Contiuued Fevers (*f)
1.64
1..51
i.u;
1.09
1.16
1.08
l.o:v
.,,.,
I.I.I
. '.*T
.98
1.10
(aiTliH niI.-8 fur lyi.hoiil uii.l typliiis iire th.- iiverage nitr-K .if til.- live y.-ar» .Inly 1, I.m.I, 1.. June 30, 1806.
(f.) Tlie ('..ninion cliliiiued fever rates are those for the year eiuiin^; June 30, 1K62.
(.) Til., lypho-malarial rates an> III.- averae.-s of the fonr years .Tuly 1, ISOi, 1.. .June .TO, 1866.
oOTlie ratis for theBe fevers as a class are th.- averages of the facts recorded ilnring the fivi- years af.vresaid ; they are of necessity not
rates of the s|»-<ifled fevers, as neither c.iinmoii continued fever loir typho-iualarial fever was rciHirted dnring the whole of the Bvo years.
Med. Hist., I't. 111-20
the "uai of tho
202
statistics of
Table XLVI.
Seasonal Variations in the Prevalence and Mortality of the Continued Fevers among the Colored Troops,
expressed as average monthly rates per thousand of strength, obtained by the consolidation of (he
figures for the corresponding montlis of each of the three years, July 1, 1863, to June 30, 1866.
Diseases.
<
n
g
O
«
>
1
pa
P
<
<
fa
o
<
n9
s
CI.
<
Cases of—
2.94
.03
6.34
2.55
.03
6.87
2.40
.14
6.10
2.14
.07
4.44
1.46
.02
1.89
1.47
.04
1.67
1.82
.04
1.97
1.18
.05
1.56
1.45
.00
2.13
1.34
.02
1.95
1.61
.09
2.95
1.97
.08
3.29
Typho-malarial Fever
All the Continued Fevers
9.31
9.45
8.64
6.66
3.37
3.18
3.83
2.79
3.61
3.31
4.65
6.36
Deaths from —
.08
1.02
1.23
.07
1.11
1.22
.07
.87
1.14
.01
.97
.69
.01
.38
.68
.02
.30
.89
.02
.27
.84
.02
.28
.68
.06
.22
.88
.07
.45
.86
.08
.48
1.21
.06
.46
Typho-malarial Fever
All the Continued Fevers
2.68
2.41
2.16
2.12
1.08
1.00
1.18
1.14
.96
1.40
1.42
1.73
The regionic figures in Table XLIV show that the lines of prevalence in the Atlantic
and Central regions conform in their general course to that already submitted from the
array as a whole. Each presents three irregular prominences in the earlier part of its
course not referable to seasonal or regionic influence, but to the aggregation of men under
the calls for troops; and each shows subsequently three other prominences, apparently
seasonal in their recurrence, and corresponding with an increase in the typho-malarial rates.
The line of jirevalence in the Pacific region is less regular, but even in it the general con-
tour of the line of the army may be observed. These have been traced on the diagram
which faces this page.
The highest I'ate of prevalence in the Atlantic region was 14.6, in July of the second
epidemic wave; the highest in the Central region, 18.2, was in October of the first epidemic
wave; the highest, 4.9, in the line of the Pacific region, was reached in October of the third
wave. Although the Central region contributed the highest monthly rate and the highest
annual rates during the first and last years, the high annual rates furnished by the fevers
of the Atlantic region during the three intervening years gave that region the highest
average rate.
The inconsiderable number of troops in the Pacific region, 10,172, when the maximum
rate was yielded, is naturally suggested as a possible cause of the small size of this maxi-
mum and of the generally low level of the line of prevalence in that region. But the
Central region furnished its maximum of 18.2 when only 81,387 men were present, while
the maximum of the Atlantic region was only 14.6, although the strength for the month
amounted to 227,419 men. Again, the annual rate for the first year was greater in the
Central region, 145 per thousand of strength, than in the Atlantic region, 115.4, although
in the latter the average strength was 176,650, as compared with 105,108 in the former.
The mere aggregation of troops in a region has therefore apparently but little influence on
the prevalence of these fevers. Nor does the narrowing of the limits from the region to
My
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C/3
THE COUTINUKD FKVERS.
203
the department develope in the statistics of the latter any special influence of locality or
of aggregation on the occurrence of the continued fevers. It is evident that for an expla-
nation of all the facts we must go behind these aggregations to the susceptibility of the
material of which they were composed.
Table XLVIT.
Showing the relative Frequency of the reported forms of the Continued Fevem among the White Troops
in the several Departments and Begions during Vie four years of war service from July I, 1861
to June 30, 1865.
o
III
i|
■35
1. 3
E3
3 O
ao
o o
2|
a 1
m
<
Koportcd fonns of Foveroa iwiroiitagcs of the li)tal num-
hor of cases.
Depaktmkxts and Reoioks.
DuriiiKtbp.ViMrcndinK.IiiiU'
3", 1.S62, when 4'<iiiinion
f'ontiuued Ffvor was rp-
port^d.
During the Ihroo joars from
.luiic :)», 1S02, tu Juno 30.
1865, whon Typho-umlarial
Fcvorwas rpport4Ml.
Tj-phoid.
Typhus
Common
continued.
Typhoid.
TypliUB.
Typho-
nularial.
Department of tho East
Middlf Department _.
Department of tho Shenandoah
2(1, 3d & 4th
Ist,2<i, 3d&4»l.
1st
4th
2d, 3d k 4th
1st, 2d, 3d & 4th
1st
1st, 2d, 3d * 4th
1st, 2d, 3d & 4th
Ist, 2d, 3d & 4th
909
3, 28r>
1,114
1,C54
10,818
37, OS)
1,385
7,182
4,713
4,664
71
69
35
105
84
62.1
60. 0
6.4
1.6
31.5
32.4
78.0
73.9
49.5
56.7
48.4
3.6
6.9
18.4
20.2
Middle Military Division
Dei«rtmeDt of Washington
2.1
1.0
1.0
48.4
42.3
60.6
Army of the Potomac
Department of the Rappahannock
64.0
60.9
1.4
7.2
4.9
1.5
.5
34.6
31.9
40.5
32.7
53.9
i,:i 54.6
40.9
43.2
31.0
.6
1.7
.6
58.6
56.1
68.4
102
72
65.8
45.6
Department of the South.. __
j
72,777
79
62.1
2.0
3.'i.9
49.7
1.3
49.0
Department of the Korth west
Northern Department
1 -t, 2d, 3d & 4th
2d, 3d & 4th
Ist, 2d & 3d
Ut, 2d, 3d & 4th
2d A 3d
1st, 2d & 3d
1st, 2d & 3d
4th
4th
2d&3d
1st, 2d, 3d A 4th
799
1,581
6,091
5,310
2,968
13,327
15,467
3,928
1,599
1,801
. 10,145
40
41
99
53
56
62
63
36
18
33
82
67.1
36.7
7.2
84.0
64.3
68.5
61.1
64.3
61.0
60.8
48.3
38.8
39.7
38.4
2.4
1.4
3.2
1.4
1.3
1.8
.5
.7
2.8
2.9
14.0
33.3
SO.l
35.7
34. S
37.7
47.4
61.2
60.5
57.5
68.7
Department of West Virginia
70.1
62.9
2.3
3.8
27.6
33.3
Department of Missouri.
Deimrtment of tho Oliio
De|iartment of tho Cumberland
68.9
67.8
2.7
2.0
28.4
30.2
Department of tho Tennessee _
Militarr Division Slississippi, Part T
Militarr Division Mississippi, Part H
Deportment of Arkansas
.31.2
7.3
61.6
Department of the Gulf
fVntrhl RAginn
63,016
56
66.0
2.8
31.2
62.6
1.9
46.5
Department of Now Mexico. . . _
let, 2d, 3d & 4th
Ist, 2d, 3d & 4th
284
352
19
15
15.7
42.4
1.9
M.3
65.7
40.6
62.0
1.9
4.1
87.6
43.9
Department of tho Pacific ._
I'Aciftc Begion
636
r :
1.1
67.1
46.7
3.1
60.2
1
1 Total in all the BeKiona
136,429
65 63.6 1
2.4
34.0
61.1
1.6
47.3
L— 1
1
On account of the greater prevalence of the continued fevers during the early period
ot the war, comparisons in this connection can be instituted with propriety only on the
statistics of those departments that were kept intact during the four years of active war
204 STATISTICS OF
service. It would be iuaduiissible, for instance, to contrast tlie annual rate of 18 per
thousand among the veteran soldiers of the Military Division of the Mississippi, who
marched from Atlanta to the coast, with the 72 per thousand furnished by the troops who
operated on the seaboard of the department through which the march was made, because
the latter rate includes the larger figures of the early period, while the former is unaffected
by them.
Looking only at those de2:>artments from which reports were furnished during the whole
period of active operations, the rates of 69 in the Department of Virginia, 84 in the Arinv
of the Potomac and 102 in the Department of Jforth Carolina, all of which commands
were contiguous geographically, indicate that departmental locality exercised no marked
influence on the number of cases.
Again, as to aggregation in the departments. The comparatively low rate in the
Department of the Northwest, and the small number of troops operating within its limits,
support the idea suggested by similar conditions in the Departments of the Pacific region,
especially in view of the larger' rates, already instanced, in departments which contained
a larger number of men. But when the statistics of these are compared with each other
it is found that the fever rates did not increase in proportion to the strength present. In
the Army of the Potomac, with an average strength of 109,734 men, the average annual
rate of prevalence was 84 per thousand, while the adjoining territorial command, the
Department of jSl^orth Carolina, gave a rate of 102 in a strength of only 15,541 men.
The consolidated statistics now under consideration are incompetent to show precisely
whether concentration in a locality exercised an influence on the prevalence of the fevers.
As the rate was greater in the Department of North Carolina than in the Army of the
Potomac it would seem that local conditions were more efficient than mere concentration
in promoting their spread; for the small number of troops in the department mentioned
rendered impossible such a concentration of forces as was found in the camp of the Army
of the Potomac. But the influence of susceptible material in the ranks was so great that
conclusions drawn from figures merely are necessarily of doubtful value. This influence
has been seen in the elevation of the line of prevalence following the arrival of fresh troops.
It may also be observed in the table now submitted, by comparing the rates in the Depart-
ment of the Shenandoah, 69, and in the Department of the Eappahannock, 98, gathered
during the first year of the war, with the rates in the Middle Military Division, 35, and in
the Military Divisions of the Mississippi, 18 and 36, collected during the fourth year of
service. The highest rate, 105, in the Department of Washington, appears exceptional,
as it does not include the records of the first year. But this department was in a measure
a camp of organization and equipment for new and undisciplined regiments, which were
subsequently transferred, as the occasion required, to other points for active service. Young
soldiers passed through it on their way to the front; hence the high rates yielded by its
reports. The rate in this department during the fourth year, 73.6, was higher than that of
the Shenandoah in the first year of the war. In tlie third year, when there were fewer
changes in the personnel, the rate fell to 63.8. The rate for the second year was 151.0.
During the first year the reports from the troops in Washington and its vicinity were con-
solidated with the returns from the Army of the Potomac, which furnished a rate of 126.2
per thousand of strength.
In tlie other columns of this table may be observed the relative frequency of the
THE CONTINTTKB FEVERS. 205
reported forms of fever expressed in percentages of the whole number of febrile cases.
During the period when the term common continued fever was in use typhoid fever consti-
tuted nearly two-thirds of the cases except in the Pacific region and the Department of
the Gulf, where, on the contrary, common continued fever formed this proportion of the
whole. During the period when the term typho-malarial was in use, about one-half of the
febrile cases were reported as typhoid. A small percentage, larger generally in the earlier
than in the later years, appeared as typhus. The unusual percentages of typhus and com-
mon continued fevers returned from the Department of the Northwest during the first year of
the war originated in the inconsiderable number of cases entering into the calculation, only
fourteen, of which five were said to have been typhus and one common continued fever.
It is worthy of note, as bearing on the disposition made of the continued febrile cases
after the term common continued fever was removed from the reports, that those depart-
ments from which a large percentage of that form of fever was reported were subsequently
characterized by a large percentage of typho-malarial cases. Thus, while common continued
fever formed 34.0 per cent, and typho malarial 47.3 per cent, of the reported forms in the
Army as a whole, the Departments of the South, the Gulf, Virginia and New Mexico gave,
in both instances, percentages largely in excess of the average. Nevertheless, a high
percentage of common continued fever in the Department of the Pacific was not followed
by a correspondingly high typho-malarial figure; and, on the other hand, as equally excep-
tional, a high percentage of typho-malarial fever in the Army of the Potomac and in the
Department of North Carolina was not preceded by corresponding figures under the head-
ing common continued fever.
Lastly, variations in the percentages of typho-malarial fever may be noted as having
been wholly unconnected with the prevalence of the continued fevers as a class. This may
be illustrated by taking as a standard the figures furnished by the Army of the Potomac.
In that army 84 febrile cases occurred" annually in every thousand men, and of these 50.6
per cent, were typho-malarial cases. But in the Departments of West Virginia and North
Carolina a greater number of cases than 84 occurred annually, while the percentage of
typho-malarial cases in the one department was greater, and in the other smaller, than in
the Army of the Potomac; and on the other hand, in the Departments of Missouri and the
South a number of cases considerably less than the standard, 84, occurred annually, while
the percentage of the typho-malarial cases, as in the other two departments instanced, was
in one greater and in the other smaller than in the Army of the Potomac.
The statistical relations of typho-malarial fever to the purely malarial fevers have
already been shown in Tables XXXII and XXXIII.
II.— IN THE CONFEDERATE ARMY.
Evidence has already been cited in Table XIV establishing the fact that i„ the early
period ot tlie war the Soutliern troops operating in Virginia suffered more from the continued
fevers than the soldiers of the Army of the Potomac opposed to them, the annual rates of
cases per thousand of strength having been respectively 275 and 125. From the follow-
ing table, which contrasts the prevalence of these fevers in the two armies during a period
ot nine months, it is found that the monthly average of cases in each was about the same;
but as the United States Army had more than twice the strength of the other the ratio of
cases to strength was correspondingly smaller, 10.4 monthly per thousand as against 22.9 in
206
STATISTICS OF
tlie Confederate ranks. Tt may be observed also tliat this greater ratio in the rebel army
was due chiefly to an epidemic that prevailed during the months of August, September,
October and November, following the increase of the strength present from 21,577 to 58,918
men, and that at the close of the record in March, 1862, the rate of prevalence was small
atid almost identical in the two armies. Both commands during this period were composed
of raw levies unaccustomed to camp life. Both were similarly rationed, quartered and
disciplined, for the officers who organized them had been comrades in their military educa-
tion and experiences. It would seem, therefore, that local conditions were not responsible
for the greater prevalence of fever in the Confederate camps.
The U. S. Army of the Potomac was largely recruited from the urban population of
the New England and other Eastern States. In its ranks there was certainly a larger pro-
portion of city men than in the Southern Army. This appears to have a bearing on the
greater frequency of typhoid fever in the latter, in view of the well-known facts that'a
majority of the enteric cases in cities occur in young people recently from country districts,
and that an army encampment is in many of its sanitary relations an extemporized city.
Increased rates prevailed also in the Union Army as its strength was augmented by
the arrival of fresh troops, but the monthly rate did not rise above 15.9, while in the Con-
federate camp the rate in September was 45.2 per thousand of strength.
Table XLVIII.
Number of Cases of the Continued Fevers in the Confederate and Federal Armies of the Potomac from
July 1, 1861, to March 31, 1863, with the ratio per thousand of mean strength for each month.
Months.
CONFEDEEATE TeOOI*.
United States Troops.
II
0**
-■§
Number of cases of—
1
•s
b
o
•a
a
i
o
EH
1"
c a
Number of cases of —
1
a
a
a
5
J
is
•a
:§
i
Eh
g
o
n
o
'S
■a
a
i-
o »
t
July, 1861
21,577
60,525
68,360
58, 918
55, 099
.56,700
67, 089
54,810
31,470
190
1,716
1,801
947
853
566
398
283
86
2
4
299
221
132
77
38
39
1
31
390
546
437
370
307
215
160
88
223
2,110
2,646
1,605
1,355
950
651
482
175
10.4
41.8
46.2
27.2
24.6
16.8
11.4
8.8
5.6
17,709
60,608
85,408
113,204
133,669
152,759
167,267
153,308
126,588
39
311
5(M
818
1.456
1,351
1,098
772
360
6
1
50
34
13
32
17
12
8
101
317
437
520
663
341
384
423
310
146
629
991
1,372
2,132
1,724
1,499
1,207
678
8.2
12.4
11. C
11.2
1..9 '
11.3
9.0
7.9
5.4
August, 1861 . _
September, 1861
October, 1861
November, 1861
December, 1861
FebruarT, 1862 j
March, 1862
Monthly average
—
49,394
760
90
283
1,133
22.9
111,169
745
19
388
1,153
10.4 j
The only other figures that reveal the numerical status of the continued fevers in the
Confederate forces are certain monthly rates calculated and published by Dr. Jones.*
These are submitted in juxtaposition with the rates of the white troops of the U. S. Army
for the same monthly periods, typho-malarial statistics being included after June, 1862.
' Page 666, Vol. I of his published Memoirs.
THE CONTINUKD FEVERS.
207
Table XLIX.
A Comparison of the Prevalence of the Continued Fevers in the Union and Confederate forces during
the nineteen months, January, 1S6J, to July, ISO'S, inclu^-ive, expressed in monthly ratios per thou-
sand of strength. Typho-malarial cases are included in the statvitics of (lie Union Armies after
June 30, 1862.
MONTHS.
Cases ur the Continued Feveus expressed
IN MONTHLY UATVi* PER 1,1X10 OF STRENGTH.
MONTHS.
Cases OF THE Continued Fevers expressed
IN MONTHLY RATES PER 1,000 OF STRENOTH.
Confodorate.
Foderal.
Coufcderate.
Federal.
13.8
11.7
11.6
14.4
13.7
30.2
27.8
18.3
8.5
8.2
9.2G
7.4G
0.14
». 77
11.30
11.. M
12.11
9.63
0.3:!
0.O7
6.1
10.7
8.9
0.1
8.1
11. 0
9.0
0.4
9.9
7.9
8.80
8.29
8.62
8.22
7.71
&.80
4.80
4.01
5.27
11.2
Febniarj-, 1S62
Man-b, 1SC2
April, 18G2
Mav, ISfiff
Fcbruiiry, 1803
March, 1803
.\pril, 180;t
Jnlv 18tj2
May 180:i
AofUBt 1862
June, 1803
Seliltniber, 1862
OcIoUt, 1802
Jiilv, 1803 -
Average monthly rates..
These figures, so far as they go, strengthen the conclusion derived from the statistics
of the Confederate Army of the Potomac, that the Southern troops suffered more from the
continued fevers tlian the Union Army during the epidemics consequent on the aggregation
of susceptible material. Tlieir high rates during the months of June, July and August,
1862, followed the Conscription Act of the Confederate Congress, passed April 16, calling
out all white men between the ages of eighteen and thirty-five. Their lower rates during
the later months cited above, and the lessened prevalence of typhoid in our own camps
towards the close of the rebellion, sustain Dr. Jones in his assertion that "typhoid fever
progressively diminished during the progress of the war, and disappeared almost entirely
from the veteran armies."*
The Confederate death-rate from these fevers cannot be obtained for comparison, but
it must of necessity have been considerably higher than the Union rate. While in each
camp nearly the same number of cases (see Table XLVIII) were reported as typhoid, the
number of cases of common continued fever was smaller and of typhus larger in the Con-
federate than in the Union Army. Thus, in the former a hundred cases of fever consisted of
67 of typhoid, 25 of common continued and 8 of typhus; in the latter the percentages were
64.6 of typhoid, 33.7 of common continued and only 1.7 of typhus cases. Moreover, it has
been shown in Table XIII •}■ that up to December 31, 1862, the number of fatal cases among
the Confederate forces was 33.27 per cent, of the whole, as against 22.28 percent, among
the Union troops during the same period. This, in connection with the greater rates of
prevalence in the Southern camps, indicates with certainty that the mortality rates, if
known, would be considerably higher than those calculated from the Federal statistics.
In fact, if the rates of fatality just cited be applied to the rates of prevalence in the Armies
of the Potomac, the average mortality rate in the rebel army will be found to have been
<.62 monthly per thousand of strength, as compared with 2.32 among our Northern troops.
The number of cases that terminated fatally in the Chimborazo hospital, Richmond,
* Op. cU., p. 665.
^Sujpra, p. 31.
208
STATISTICS OP
Va., was 885 or 41.11 per cent.* of the total of 2,153 febrile cases with known results,
typhoid fever claiming 661 deaths or 47.6 per cent, of 1,388 cases, and common continued
fever 224 deaths or 29.3 per cent, of 765 cases.
m.— AMONG THE UNION SOLDIERS, PRISONERS OF WAR.
It has already been shown that at Andersonville, Ga., the rate of prevalence of the
continued fevers, 77.4 annually per thousand men present, was higher than the average
annual rate among our white or colored troops, and that the mortality rate, 20.5, was nearly
double that among our white troops. Nevertheless the rates among the prisoners were
very much lower than those calculated for our army during the early periods of epidemic
visitation.
The 753 cases and 199 deaths in Table XVIf consisted of 126 cases reported /e&?'('.s
continua communis, with 10 deaths, equalling 7.9 per cent, of fatality; 155 reported febr'is
continua simplex, with 4 deaths, equalling 2.6 per cent., and 472 rejsorted /'e6?'w fi/phoides,
with 185 deaths, equalling 39.2 per cent, — the whole equalling 26.4 per cent.
The cases in Table XV, J 281, of which 241 were fatal, were distributed thus:
Returned to Prison. Transferred. Died. Total Cases.
Fever, Continued, ...-6 .- 3 9
" " Common, 1 .. 18 19
" Typhoid, 32 1 220 253
Total, 39 1 241 281
No case of typhus fever was reported.
* .See Table XII, p. 30, supra, — Dr. JoSES. page 6G4 of his Medical and Surgical Memoirs, Vul. I — has published some figures coDcerniDg typhoid
and common continued fevers which are reproduced in the following tabulation ;
Statistics of the Continued Fevers in certain of the Confederate General Hospitals.
Name of Hospital.
Period covered by the Statistics.
Typhoid and
Common Con-
tinued Fever.
(^ a
1:1
i
H
si
it '
lis
HI
|£l
Cases.
Deaths.
General Hospitals in Virginia out of Richmond .
January, 18B2, to February, 1863
September, 1862, to April, 1863 ,„
6,245
1,619
25.90
26.31
17.78
2;i.86
45.59
17.57
10.48
5,516
2,705
868
333
125
46
293.5
249.4
188.2
360.6
279.3
336.0
239.1
General Hospitals in Rii-hniond, Ya
General Hospitals in Virginia^
April, 1SR3, to .\ugust, 1863
2,863
1,312
204
2.39
105
509
313
93
42
11
July, 1861, to September, 1803..
Decemljer, 1861, to January, 1804
June, 1862, to January, 1804
General Hospital, No. 1, Savannah, Ga
May, 186-2, to .lanuary, 1804
Tota!.
10,968
2,587
23.59
9,593
269.7
These rates of fatality have absolutely no value. They vary from 10.48 per cent, in one hospital to 45.59 per cent, in another; the experience of
seven hospitals averaging' 93.59 per cent, of fatal cases. It is to be remembered, however, that the cases enumerated were not bojm fide cases, but in
many instances duplications of case* already recorded. On the transfer of a man from hospital to hospital his name was entered as anew case on tlie
register of the hospital to which he was transferred. The influence nf this duplication may be in part appreciated when it is known that for every case
recorded as sent from the field to the general hospitals there were more than four admissions on the hospital registei-s. Dr. JONES in the Richmfmd and
Lonisrilh Medical Journal. Vol. VIII. p. 347. acknowledges that: " The large number received into hospitals, as shown by these returns, can only l»e
accounted fur in tlie repeated transfers of patients during convalescence, from one hospital to another.*' To calculate rates of fatality when the deaths
are unmodified facts and the cases a multiplicaticm of facts by an unknown number, is manifestly absurd. These registers should have been carefully
revised, excluding all admissions, which were merely transfers, from the list of cases, as was done at this office with the records of the Chimborazo Hos-
pital. It is impossible to tell how many of the 10,968 cases of fever in the seven hospitals were due to transfers during convalescence; but were the
number known and deducted from the total the percentages of fatal cases would no doubt be very different from those tabulated. The figures in the last
column are of little value for purposes (tf ci)mparison, as deaths from wounds, of necessity a very variable number, are included in the thousand deaths
which fo-m the basi.'* of the calculation.
t Siq>ra, p. 35. t Supra, p. 34.
THE CONTINUED FEVERS.
209
IV.— AMONG THE CONFEDERATE SOLDIERS, PRISONERS OF WAR.
In Table XIX '=' the annual rates of prevalence and mortality of these fevers among
the rebel prisoners were stated as 31.4 and 13.6 respectively per thousand pi-isoners. But
these numbers do not include the fevers reported as typho-malarial. When the 37.6 cases
and 4.8 deaths returned as the annual prison rates of this fever are added to those of
typhoid, typhus and common continued fever, the rates for these fevers as a class become
69.0 and 18.4, smaller than the average annual rates of the rebel troops on active service
but larger than those of the Union forces.
The following table exhibits the statistical relations of the continued fevers at certain of
the prison depots:
Table L.
Number of C hses of the Continued Fevers, loith the resuUhu/ Mortal ity, reported from the prindi>al Prison
Depdts as having occurred aviong Confederate Prisoneis of War, with the annual rates pei- 1,000
of strength.
e 3
to
—"5
ll
= g
rt o
Is
a ^
In
1}
.£'3
!■?
,52
0^
A e
0 3
4
0 a
^1
§■
00
s
-3
•sS
£§
u
<1
n
It
a
if
il
5,361
!, ■
■ ' tw
2,865
2,114
3,570
6,591
6,406
9,610
40,815
Owp8:
1,114
185
6
51
1
54
1
93
115
235
4
414
WIS
266
2
2,526
31
3,069
5,628
Common Continued
2
16.3
722
10
506
54
3
2
1,674
35
302
Total Continued Fevers
1,279
912
(a) 62
561
147
118
241
2,006
Dcfttbs from—
Tj-phoid _
Tvphns
3oI
67
3
122
f>2
2
12
41
1
98
26
53
140
156
216
1
1
218
1, 102
7
389
Typho-malariaL
51
4
9
1
91
402
192
(a) 66
140
30
62
141
247
1,498
Xumcrical ratio per 1,000 of strength for the cases of—
Typhoid (including Typhus and Common Continued)
Typho-malarial
Total Continued Fevers
60.9
8.9
66.5
252.8
6.1
1.2
9.2
84.8
21.1
12.3
22.7
.6
36.3
.3
35.2
128.2
15.1
2.0
31.4
37.6
69.8
319.3
7.3
94.0
33.4
23.3
36.6
163.4
17.1
69.0
Fur the draths from —
Typhoid (including Typhus and Common Continued)
Typho-malarial.
Total Continued Fevers .
19.2
2.8
24.5
42.7
6.3
1.4
7.0
16.4
5.9
.9
10.4
1.8
21.2
.2
12.7
7.4
12.3
.1
13.6
4.8
22.0
67.2
T.7
23.4
6.8
12.2
21.4
20.1
12.4
18.4
(a) The number of cases registered on admission as ague, bronchitis or other slight febrile affection and credited to the continued fevers on th«
occoirence of a fatal issne, has more than riffset the rc'covci-ie-s among those admitted originally as cases of tlie continued fevers,
(M In the>!(; casos tln> deaths, in nccurdaiice with 7M>K/-m'«r/<fni rt-vdations, were charged to typhoid, the diagnosis on the record remaining unchaiig<-d.
* Suprti. p. 47.
Med. Hist., Pt. Ill— 27
210 CLINICAL RECORDS OF
Of the 5,628 febrile cases noted in this tahle 44.9 per cent, were reported t3'phoid,
54.5 typho-malarial and only 0.6 typhus. Of the cases reijorted as typhoid and typhus
43.3 per cent, were fatal; of those regarded as typho-malarial 12.7 per cent.; of the whole
number of febrile cases 26.6 per cent.
Typhoid, notwithstanding the smaller number expressing the totality of its cases, was
the prevailing fever at two-thirds of the depots. Typho-malarial predominated at Alton,
Camp Morton and Fort Delaware; but on account of the uncertainty attaching to the nature
of these cases the large annual rates at Alton, 319.3 cases and 67.2 deaths per thousand of
the average strength, cannot be accepted as indicating a typhoid epidemic of unusual viru-
lence within the walls of the prison. The frequent changes in the constituents of the
average number present must be remembered, in connection with these high rates, as
modifying and materially reducing them.* The deaths, which numbered 16.9 per cent, of
the typho-malarial and 36.8 of the typhoid cases, imply a doubt of the presence of typhoid
in many of the cases of the former series. Indeed, had this camp experienced an epidemic
of typhoid or other continued fever due to its insanitary conditions, the fatality of its febrile
cases would have been greater instead of considerably less than that of the continued fevers
in the prisons generally. The percentage of fatal cases at Alton was 21.0; in the nine
prisons tabulated the percentage was, as already stated, 26.6. But as malarial fevers were
prevalent at this point, in the apparent absence of local conditions for their development,
it is probable that many of the tj^pho-malarial cases, which constitute nearly four-fifths of
the whole number on the record, were adynamic remittents imported from southern fields
of service.
The comparative infrequency of the continued fevers among the prisoners on both
sides, notwithstanding the insanitary elements of their environment, which included the
presence of the typhoid poison, must be ascribed to the same cause that preserved the camps
of the veteran armies from visitation — a want of susceptibility on the part of the individuals
composing the aggregation.
II.— CLINICAL EECORDS OF THE CONTINUED FEVERS.
The clinical records of the continued fevers are, as might be expected, contained prin-
cipally in the case-books of the various general hospitals. Field reports treated of such
cases only in exceptional instances, as when, during winter quarters, a medical officer
retained his typhoid cases rather than expose them to the dangers attending transportation
to a distance. Usually, however, cases of enteric fever wex"e sent from the field on the first
favorable opportunity.
The recorded cases, as a rule, are more or less imperfect. On arriving at the general
hospital the patient was frequently unable to give an account of the early history of his
. case. In some hospitals no attention was paid to the clinical records. In others the case-
books were kept, but in so perfunctory a manner that thev show little to indicate the nature
of a particular case other than the entry of the disease as determined by the examination
on admission and some fragmentary details of the medication prescribed. Fortunately,
however, some of these books were carefully kept, and from them ample materials may be
gathered for a representation of the continued fevers as they were seen and treated by our
* See siipra, p. 62.
THE CONTINUED FKVERS. 211
medical officers during the war. But to obtain a clear view of the subject the study of a
large number of cases is needful, not only to supplement the incomplete details of one case
by those of another, but chiefly because of the variety presented by the cases. A certain
aggregation and sequence of symptoms might be selected for presentation as illustrative of
a certain grade and type of the febrile manifestations, but such an arrangement would be
]iurely artificial and arbitrary. Some medical officers refer briefly to their cases on the med-
ical descriptive lists as having been typical instances of the fever as diagnosticated. This
'vas due either to a limited experience or to preconceived views of the general course of the
disease. There were in fact no typical cases: the fevers presented an infinite variety. As
has been seen, even the line separating the paroxysmal from the continued fevers was not
defined, and among the latter every gradation was found, from the mild attack in which
the patient hardly recognized that he was sick, and the abortive case with its early con-
valescence, to that in which a fatal issue appeared from the beginning to be the only
probable termination; and from the cases which progressed with some regularity toward
their favorable or unfavorable ending, to those which were beset witli alternations of hope-
fulness and uncertainty, prolonged for months by the continuance of intercurrent or the
supervention of sequent disease. Only a few of the mild or abortive cases are detailed in
the case-books. Such cases were treated in the field, where clinical records were not kept.
When they occurred in the general hospitals they seem, owing to the prevalence of more
serious cases, to have reached their termination without attracting special attention, and
the diagnosis ii/phoid, entered probably on a mental review of the history, constitutes their
only record.
L— COMMON CONTINUED FEVER.
To the same causes which possibly account for the absence of details in mild cases of
typhoid fever may be attributed the absolute want of clinical records in cases of common
continued fever. Although no less than 11,898 febrile cases, 147 of which proved fatal,
were reported under this heading during the first fourteen months of the war, no official
record has been preserved of the symptoms and progress of any one of them. When details
of febrile cases are recorded in the case-books, the diagnosis is typhoid fever. But among
the Medical Descriptive Lists there is one case which appears as simple continued fever.
Remissions are definitely acknowledged as having occurred in this case.
Privat* William R. Snyder, Co. G, 2(1 N. C. Battery, was admitted August 8, 1863, as a case of simple continued
fever. He had been left on the field at Gettysburg as a nurse when Lee's army retreated. About August 1 he was
seized with severe headache and loss of appetite. On admission he was very feeble; pulse 120 and weak; tongue
moist but with a browu fur in the centre; skin hot and dry ; bowels constipated. On the 15th the fever subsided
by the occurrence of remissions; the patient's bowels were alternately loose and constipated. By .September 1 he
was considered fit to be sent away, having been able to walk about the grounds for the previous ten days. lie was
treated with small doses of quinine, s))irit of nitre and blue-pill. — .l.vs'( Sunj. II. C. M<iij, Uoth X. X, Vols., Hospital,
Gettynhurg, Pa,
There are also on these lists thirly-iseven febrile cases whicli were reported as continued
fever* These are all of a later date than the order calling for the disuse of the term coyn-
mon continued f eve)', and may therefore be regarded as contributions to the clinical history
of that fever furnished by officers who were unacquainted with the requirements of existing
orders. Unfortunately most of the descriptive lists are barren of information except as to
•To ttiese may Im> jii1i1(h1 ttie case whicti, from tho sufti-uinp: of tlie mucous membrane of the hirgc intcHtiiio, wuh i^ubmittCMl by Dr. VVnonwARP aa
So. 4"o ..f the iliarrhuiil wrios, p. ];i3 of tlie .S<conil Part of this work, anil also the cases 24'J, 288 and 3U1 of tlic iioal-morlcm records of the cODtJBued
fcwni lobe horeaflir |>reecuted. lu these the cbanuteristic lesions of lyiilioid were obsened.
212 CLINICAL EECOEDS OF
dates of admission and of recovery or death, with or without notes of treatment. Of these
cases seven, which give more or less testimony as to the condition of the patient, are here-
with submitted:
Case 1. — Private Benjamin Midler, Co. 6, 147tli N. Y. Vols.; age 10; was admitted Juno IX, 1863, with a severe
attack of continued fever whicli had lasted two weeks. He is rejiorted as improving slowly on t he 2t)th ; as markedly
improved ou July 2, and as returned to duty Augusts. — Act. Ass'i Surg. T. Turner, U. S. Army, Sd Division Hospital,
Alexandria, Fa.
Case 2. — Private J. E. Vosburg, Co. II, 137th N. Y. Vols.; ago 18; was admitted June 17, 18G3, in the advanced
stage of an attack of mild continued fever. On the 20th the tongue, which had been slightly brown and dry, became
clean, the febrile excitement abated and the appetite returned. He was returned to duty July 1.
Case 3. — Private Charles Robinson, Co. I, 137th N. Y. Vols.; age 21; was taken while in camp, June 7, 1863,
with continued fever of a mild type. On admission on the 17th he complained of severe headache, and hi^ tongue
was slightly brown in the centre and red on the edges. On the 21st be had diarrhoea; but was convalescent on the
26th, and returned to duty July 6. He was treated with diaphoretics, opiates and astringents. — Act. Ass't Surg.
Benjamin Wilaon, U. S. A., 3d Division Hospital, Alexandria, Va.
Case 4. — Ass't Engineer Jas. Flinn, U. S. Navy; age 22; was admitted July 14, 1863, having been sick for
fourteen days with continued fever. He had slight delirium at night and a diarrhtca of six or eight light-colored
stools daily; but there was no tenderness of the abdomen. The tongue w.as white furred; appetite deficient; he had
a slight bronchial cough. He took a mixture of dilute phosphoric acid and ipecacuanha, and was sponged over the
whole surface of the body twice daily with cold sea-water. He was able to be up on the 18th, and was returned to
duty August 1. — Act. Ass't Surg. T. H. Lichold, U. S. A., Hospital, Point Lool-out, Md.
Case 5. — Private Sherman Hopkins, Co. L, 6tb Mich. Cav.; age 30; was admitted September 8, 1864, with con-
tinued fever. On the l2th the patient is reported as presenting all the symptoms of typhoid fever and as being uuich
reduced. He had muttering delirium, slight diarrhoea and great tenderness over the abdomen; tongue thickly
coated ; teeth covered with sordes ; pulse 136. He seemed tp improve a little for a day or two ; but during the after-
noon of the 11th he began to gasp for breath and his extremities became cold. He died next morning. — Act. Ass't
Surg. TV. Kempstcr, X7. S. A., Patterson Park, Baltimore, Md.
Case 6. — Private Benjamin Shuester, Co. D, 2d Mass. Cav.; age 23; a paroled prisoner from Savannah, Ga.,
was admitted December 19, 1864. He vy^as much emaciated, aud complained of headache and soreness in his bones.
He had a chill on the 25th ; was restless during the night, and uext day his bowels were loose ; pulse 125; eyes red;
face flushed; skin dry; tongue coated and tremulous. The diarrhoea continued severe until the end of the month
aud was accompanied with much abdominal paiu. Ou January 2, 1865, the patient became drowsy; on the 5th a
lictechial eruption was observed ou the chest anol abdomen; there was much tympanites and great tenderness of the
liowels ; pulse 120; respirations 38. On the 8th the tongue was dry and covered with sordes and thin watery passages
came from the bowels. He became delirious ou the 11th, and from the 12th to the 15th, when he died, he was moan-
ing constantly. — Act. Ass't Surg. H. A. Maughlin, U. S. A., Annajjolis, Md.
Case 7. — Private J. L. Austin, Co. D, 37th N. C; age 25; was admitted from Fort Delaware October 16, 1863,
having been taken sick with continued fever about a week before his arrival. He suffered from pains in his right
foot and thigh, probably connected with an open sore of gangrenous appearance near the roots of the toes; these
pains occurred iu severe paroxysms and prevented sleep. By the 28th the local inflammation was subdued, but the
fever became aggravated in the evenings. After this he became much debilitated; his tongue was moist but red in
color, subsequently becoming dry and brown; and he had a diarrhoea of about three stools in the twenty-four hours.
By Noveml)er 16 he was greatly emaciated, and on this day he had twitcliLngs of the muscles and involuntary dis-
charges. Death took place on the 19th. — Act. Ass't Suj-g. W. A. Harney, U. S. A., Point Lookout, Md.
n.— TYPHO-MALARIAL AND TYPHOID FEVERS.
The bedside records of typho-malarial fever are represented in the case-books by but
three cases, which, moreover, do not appear characteristic of the diseased conditions for
which the name was suggested; for in the first there is, in view of our knowledge of the
symptomatology of malarial fevers, a remittent fever with nothing to indicate a specific
typhoid, in the second, another remittent, but of a graver type, and in the third, as will be
seen hereafter, a typhoid fever with nothing in the record to indicate a malarial complication.
Case 1.— Sergeant Egbert H. Little, Co. A, 38th Wis. Vols.; age 20 ; was admitted July 26, 1864. About July 1
he contracted diarrhoea, which yielded to treatment ; on the 14th he had severe headache followed by a decided chill,
and afterwards by high fever, which recurred daily for a week. Ou the 17th he was admitted to the 3d Division
Hospital of the Ninth Army Corps, and ou the 22d transferred to this hospital, arriving as above stated. He was
very feeble, and had a tendency to low fever every afternoon ; his bowels were coristipated and appetite lost. A
ten-grain dose of blue-mass was given ou admission, aud three grains of (juiuiue with tincture of iron were pre-
scribed for administration three times a day. On August 7 he continued to have headache and fever every afternoon,
THE CONTINUED FEVERS. 213
and liis bowels were constiiiatcd and appetite poor. On the 21st the quinine was oniittcd; three compound rhubarb
pills were given, and neutral mixture and acetate of ammonia prescribed for use every three hours. The diaphoretic
mixture was omitted on the 25th, and the iron and quinine resumed, .\fter this the patient improved gradually
and was returned to duty October 18. — Satlvilee Uonpilul, Philadelphia, I'a.
Cask 2. — Private William Smith, Co. K, l,>lth Ind. Vols.; ago 24; was admitted June 21, ISO.'i, with typlio-
malarial fever, lie had been sick for ten days with constant nausea an<l frequent vomiting of dark-green bile, head-
ache, pain in the loins and diarrhcva: his tongue was large, llabby and coated with a thick brown fur; pulse 1)0, soft
and compressible; skin dry. The diarrh(V>a continued, coma supervened, and on the 30th convulsions were followed
by death. — Cumherland Hospital, 3Id.
C.\SK 3. — Private David Jlarkly, Co. A, 126th Ohio Vols.; age 23; was admitted September 3, 18(53. He was
attacked with typho-malarial fever in camp at Castlo Garden, Now York, on August 31, but the symptoms were not
very marked. Quinine and milk diet were ordered. A diarrhoea of live or six stools daily set in on the 4th, and
slight delirium on the t>th. .Sudamina appeared on the 9th, on which day there was bleeding from the no.se. Milk-
iniucli and beef-tea were prescribed. There was a slight papular eruption on the 10th, and rose-colored spots on the
13tli. The diarrho-a had meanwhile abated and the general condition of the patient improved. Convalescence was
uninterrupted; he was returned to duty November 29. — Central Park Hospital, X. Y.
In lulilition to these there are among the medical descriptive lists thirty-seven cases
reported as typho-malarial fever. Twenty of these are destitute of value as they give no
statement of the actual condition of the patient; the others are given below. In 1 and 2
the fever had subsided before admission, as also in case 3, in which a diarrhoeal sequel
proved fatal. Cases 4-8 were mild febrile attacks which, before the introduction of the
new term, would have been recorded as common continued fever: there is nothing in the
record of case 4 to exclude a diagnosis of mild remittent fever, especially if the patient had
been exposed to malarial influences; but cases 5-8, in the Central Park Hospital, were evi-
dently mild attacks of typhoid fever. The Fairfax Seminary cases, 9-12, represent the last
stages of typhoid fever or of an adynamic remittent without the presence of specific typhoid,
if the existence of such a diseased condition be admitted. Cases 13-16, in the Douglas
and Stanton Hospitals, show more distinctly the presence of a malarial element. Case 17
was apparently a pernicious malarial fever.
Case 1. — Private R. L. Keeth, Co. D, 7th Conn. Vols., was admitted Sept. 28, 1863, with typho-malarial fever.
When admitted he was weak, but the fever had subsided, the tongue was cleaning and the appetite improving. Ou
October 14 he was placed on light duty and recommended for transfer to the Invalid Corps on account of an oblique
inguinal hernia.
Case 2.— Private B. Earl, Co. H, 142d N. Y. Vols., was admitted Oct. 1, 1863, with typho-malarial fever. The
fever had subsided but the patient was greatly debilitated, and there was general oidenia and effusion into the peri-
toneal and pleural cavities. One grain of iodide of iron and two grains of powdered squill were given every si.x
hours in the form of pill. This course was continued until November 1, when the patient was reported as doing
very w('l — his l)owels regular, secretions normal, appetite good and effusion removed. He was returned to duty
November 2i. — Charles T. Jieber, Act. Ass't Surg., U. S. A., Hospital So. li, Beaufort, S. C.
Case 3.— Sergeant Thomas Julien, Co. I, 62d N. Y'. Vols.; age 27; was admitted June 14, 1863, with typho-
malarial fever. He had diarrhoea and was somewhat emaciated, but slept well. On July 20 the diarrhoea became
aucontrollable, the matters passed being thin and slimy. Death occurred August 2. — Act. Ass't Sury. M. H. Picot,
v. S. A., Lincoln Hospital, Washington, D. C.
Case 4.— Private John Roach, Co. C, 26th Pa. Vols.; age 16; was admitted Oct. 9, 1863, with typho-malarial
fever. He complained of weakness, loss of appetite, pains in the back and limbs and fever at night; his pulse was
feeble, tongue coated and bowels regular. He was able to be up on the loth, and was returned to duty on the 27th.
Treatment consisted of tonics, quinine and milk diet. — J. P. Iiossiter,Act. Ass't Surg., U. S. A., 2d Division Hospital,
Jlf-iandria, fa.
Case 5.— Private Elam Dye, Co. H, 126th Ohio Vols.; age 21; was admitted Sept. 5, 1863, with typho-malarial
fever, with which he had become affected seven days before admission. His fever was continued. He had no chills
nor eruption; his tongue was furred but moist: skin hot and dry; bowels constipated. He had headache but his
mind was not affected. A slight bronchitis retardec^his convalescence. He was returned to duty November 29.
Cask 6.— Private Hector S. Hunt, Co. D, 126th Ohio Vols.; age 22; was admitted Sept. 5, 1863, with typho-
malarial fever. A week before this date he had been attacked while in camp at the Battery, New York, with fever
followed by diarrho-a. The fever lasted only for two or three days after admission, but the diarrhoea continued
until the 10th. After this he wa.* placed on light duty. He gained strength rapidly, and was returned to field
service October 15.
Ca.«e 7.— Private William Craig, Co. H, 126tli Ohio Vols.; age 21; was admitted .Sept. 5, 1863, with typho-
malarial fever, having had continued fever without diarrhoja for eight days before his admission. He had slight
214 CLINICAL RECORDS OF
headache and much pain in the back and limbs; his skiu was hot and dry; tongue moist aud lightly furred; pulse
88; bowels regular; there was no eruption. He had some delirium during the night on the 8th and 9th, but after
this his case progressed favorably. He was treated with quinine, pills of rhubarb and soda, milk-punch, and tepid
sponging of the body aud limbs. He was returned to duty November 29. — S. Teats, Act. Jss't Surg., U.S.A., Vtntral
Park Hospital, X. Y.
Case 8. — Private David A. Maskley, Co. A, 126th Ohio Vols.; age 23; was admitted Sept. 3, 1863, with typho-
malarial fever. He liad been sick in camp at Castle Garden for seven days before admission. He had diarrhoea from
the 4th, and afterwards slight delirium. Epistaxis occurred on the 9th, on which day sudamina appeared. A slight
jiapular eruption, which faded somewhat under pressure, l>ut which did not seem to be the specific eruption of
typhoid fever, was discovered on the 10th. The typhoid eruption, however, was well marked on the 13th. The
diarrhtea ceased on the 17th, after which convalescence was progressive. He was treated with quinine, camphor
and opium, and milk-punch. He was returned to his command November 29. — <S. Smith, Act. Ass't Snrg., XJ. S. A.,
Central Parle Hospital, A". Y.
Case 9. — Sergeant William H. Smith, Co. B, 6th Md.A'ols.; age 25; was admitted August 19, 1863, as a case of
typho-malarial fever. He was much exhausted by the fatigues of his journey to hospital ; pulse 120, feeble and
vibrating ; skin dry; bowels very loose, bat not tender; lips and teeth covered with sordes. Delirium and subsultus
tendinum set in on the 22d, with involuntary passages and some tenderness of the bowels. Ou the 26th he appeared
to be improving, being at times rational, but the prostration increased and death occurred on the 30th. The treat-
ment consisted of the administration of neutral mixture, acetate of lead and opium, small doses of quinine, turpen-
tine emulsion and milk-punch: the general surface was sponged repeatedly with diluted alcohol, aud mustard was
applied to tlie abdomen.
Case 10. — Private (Jeorge W. Hamilton, Co. G, 6th Md. Vols.; age 22; was admitted August 19, 1863, in a
dying condition from typho-malarial fever. He had diarrha?a with involuntary stools, fulness and tenderness of the
abdomen and sordes on his lips and gums. He became delirious ou the 21st and much prostrated. He died next
day. Neutral mixture, astringents, stimulants and sponging with warm water and alcohol were used in the treat-
ment.— George S. Bennett, Act. AdhH Surg., U. S. A., Fairfax Seminary, Va.
Case 11.— Private Alfred Chase, Co. F, 35th N. J. Vols.: age 19 : was admitted May 16, 1865, with typho-
malarial fever. He had been ailing for some days prior to admission, but had not been confined to bed. In a few-
days, however, cerebral symptoms set in, accompanied with a profuse diarrhiea, aud the patient sank rapidly,
dying on the 23d. He was treated at first with acetate of ammonia aud afterwards with moderate doses of quinine,
opiates and stimulants. — J. D. Smith, Act. As.9't Surg., U. S. A., Fairfax Seminary, Alexandria, Va.
Case 12. — James McQueen, uiiassigned recruit, was admitted May 19, 1865, with typho-malarial fever. He was
received from the provisional cam]', Virginia, in a critical condition. His sickness had lasted ten weeks. When
admitted he was under the influence of a chill, which was followed by fever and profuse perspiration. He was
delirious most of the time. His tongue was coated and very red: bowels regular; pulse 110 and feeble, and he
experienced much difficulty in urinating. Three grains of quinine and Dover's powder were directed to be given
every three hours, and twenty grains of calomel at night, followed by a full dose of castor oil and opium in the
morning. Brandy was added to the treatment on the 22d, ou which day the fever and perspirations continued, with
difficulty of swallowing and much gastric irritability. Hiccough and subsultus tendinum appeared on the 23d, with
increasing perspiration and involuntary passages on the 26th. He appeared a little better on the 27th, taking some
nourishment, although the delirium and the involuntary passages continued. Death took place on the 29th. — Fairfax
Seminary, Va.
Case 13. — Private Daniel McCumber, Co. H, 26tli Mich. Vols., was admitted November 4, 1863, with typho-
malarial fever. The patient was incoherent, constantly endeavoring to get out of bed. He had fever of a remittent
type and diarrho'a; pulse 120; respiration feeble. He perspired freely at times, but the delirium continued, the
pulse became weaker, and deatli took place on the 13th. — P. II. Holly, Act. Ass't Surg., TJ. S. A., Douglas Hospital,
Washington, D. C.
Case 14. — Sergeant Horace Hammond, Co. F, 124th N. Y. Vols.; age 36; was admitted Jujie 14, 1863, with
typho-malarial fever. The patient had sulfered with slight chills aud feverishness, recurring several times duriug
the day, for several days following June 8. On admission he had no intermittent symptoms and the case was sup-
posed to be incipient typhoid, but its mixed character soon became evident. He was treated with milk-punch and
beef-essence, to which, on August 22, quinine was added at the rate of sixteen grains daily. At the end of three
weeks he was able to walk about, although weak and having a slight diarrhoeal tendency. He was returned to duty
August 24. — C. C Lee, Ass't Surg., TJ. S. A., Douijlas Hospital, Washington, D. C.
Case 15. — Private James Wheeler, Co. I, 141st N. Y. Vols.; age 29; was admitted July 26, 1863, with typho-
malarial fever, having been sick since the 19th with fever of a typhoid type. The tongue was red and moist; the
pulse frequent aud feeble; the bowels loose and tender. He was treated with opiates aud aromatic sulphuric aeid.
On August 2 there was a distinctly marked remission ; but the diarrhoea continued and the patient became enfeeliled.
Quinine was given. Perspirations aud remissions recurred, but delirium set in on the 7th and death took place ou
the 10th.
Case K!.— Corporal N. K. Stille, Co. A, 168th N. Y. Vols.; age 19; was admitted July 28, 1863, with typlio-
malarial fever. He had been sick since the 22d with headache, pain in the back and bowels, and diarrhtpa. His
pulse was frequent aud full and tongue coated and dry, but with red edges. He had remissions with profuse per-
spirations at the end of the month, having been taking quinine meanwhile in doses often to thirty grains daily; and
during the first week of August he had some febrile movement every afternoon ; but his tongue became moist and
THE COKTINUED FEVERS. 215
clean iukI his bowels constipated. On Avigiist 22il ho was scut to New York lor muster out. — Giunje A. JIursick,
.Id. .tsx'l ^Hi;;., r. .S. J., Slunlon Hospital, }l'a>ihiii<ilon, 1>. C.
C.\.sE 17. — Private John Ennis, Co. E, Stth X Y. C'av.; ajje lil; was admitted on the afternoon of May I, 18(>l,
with tyiiho-malarial fever. Surgeon E. M. I'K.vSE of the 9th N. Y. Cav. stated that the patient liad heen sick for
three days. He had delirium with stupor ancl suhsultns tendinum: his pulse was rapid and full and his tonj;ue
coated with a long yellow fur. He eontiuTied in low delirious conditiou until death at 3..'i() A. M. of the (ith. Stlmu-
hiuts and beef-lea were given, and a Hy-blister was ai)plied to the uapo of the neck. — J. M. Il'ulltick, Act, Ass't Swy.,
V. S. A., HospiUil \o. C, BeiiiiJ'ort, S. C.
Outside of these cases, and a few clinical notes to be presented hereal'ter in connection
with the post-mortem records, there has been filed in tliis office notiiing that will indicate
the prol>able history of the 57,400 cases (white 49,871, colored 7,529) reported as typho-
inalarial fever during the period extending from June 30, 1SG2, to .Tune 30, 1866.
Seminary Hospital cases. — The case-books of the Seminary Hospital, Georgetown,
D. C, were kept with much care during the autumn and winter of 1861, while the estab-
lishment was under the supervision of Surgeon Juskph 11. Smith, U. S. A. These books
contain an admirable series of fever cases receiveil from the Army of the Potomac. As the
term typho-malarial had not been introduced at this time, the cases were entered on the
record as typhoid or remittent, in accordance with the views then held by the attending
>urgeons as to the symptomatology of the camp fevers. Later in the war the relative pro-
portions of these fevers became changed, the percentage of pure typhoid cases undergoing a
diminution, partly from an actual decrease in prevalence and partly from the complication of
tiie typhoid manifestations with those due to a more extensive prevalence of malarial dis-
etise among the troops; but there are no grounds for supposing that the fevers whicli occurred
immediately after June 80, 1862, differed in type from those that occurred immediately
before that date. An examination of the records of the Seminary Hospital will therefore
j^liow, among the typhoid and remittent fevers, those which at a later date would have been
reported as typho-malarial, in accordance with the views of the late Dr. Woodward.
The case-books contain the histories of one hundred and twenty -three cases of fever.
The entries were made daily, and in some instances twice a day, at the morning and even-
ing visits. The utmost care appears to have been taken in recording every thing of note
in connection with each case; but this veiy care renders the records unpresentable in their
original form in a work of this kind: the continued repetition of the condition of the skin,
tongue, pulse, etc., and the persistence of cerebral, pulmonary and intestinal symptoms,
day after day on the records, while giving the cases their value, render them unnecessarily
tedious. As presented below they appear in a condensed narrative form, care having been
exercised to omit no statement which tends in any way to convey an appreciation of the
patient's condition. They have been arranged as follows :
Fifty-one c<isi« of fever, entered as typhoid, in which there is no ground for acknowledging the presence of a
prominent nuilariai complication. Ten of these were fatal.
.Scrcii c((«(» of fever, entered as rrmittint, in which there is nothing to indicate the presence of the typhoid
poison. None of these terminated fatally.
Thirly-Jivr cases of fever, entered as typhoid, in which the records give more or less evidence of the coexistence
of malarial disease. Seven of these were fatal.
Klti( H casts of fever, entered as typhoid, in which intermit tent fever |)receded the devolopnuMit of t he symptoms
which authorized the diagnosis. Seven of these were fatal.
Kiijhl cnsis of fever, entered as typhoid, in which remittent fever seemed to precede or accompany the typlioi<l
manifestations. One of these proved fatal.
Eiohl ciiscs of fever, entered as rimittint, in which the records give more or less evidence of the coexistence of
the typhoid poison. One death occurred among these.
Tiro idm.iof feviT. entered as typhoid, but in which the malarial disease only is prominent.
One cast, entered as typhoid, but which was probably a case of pericarditis.
216 CLINICAL RECORDS OF
This classification of the fever cases of the Seminary Hospital is the result of a careful
analysis of the history of each. The symptoms apparently regarded as characteristic of
typhoid fever by our medical officers were separated from the aggregate, while holding in
view tlie clinical jjlienomena of malarial fever as deduced from the cases presented in the
third chapter of this volume. A defined periodic character of the chills, fever or perspira-
tions, epigastric pain, gastric irritability, hepatic tenderness, jaundice, densely coated or
large and flabby tongue, constipation or, concurrent with diarrhoea, an umbilical or general
abdominal tenderness, and a manifest influence of quinine on the febrile condition, were
regarded as indicating the presence of the malarial poison in the system. Certain symp-
toms in the Seminary Hospital cases appeared common to both forms of fever, either as the
result of the febrile action or of the specific influence of its cause. Increased heat, circu-
latory excitement, diminished secretions, cerebral disturbance amounting to delirium, stupor
or coma, hemorrhagic extravasations or other general manifestations of a depraved condition
of the blood, were therefore excluded from consideration as indefinite in their indications.
There remained a set and sequence of symptoms, to be particularized hereafter, which our
medical officers evidently regarded as pathognomonic of typhoid fever.
Of the one hundred and twent3'--two cases in the records of this hospital, excluding the
case of mistaken diagnosis, one hundred and seven were regarded as typhoid and fifteen as
remittents by the physicians in attendance. But on arranging them in accordance with a
typho-malarial symptomatology, there are found to be fifty-one cases of typhoid fever,
seven of remittent and sixty-four of typho-malarial fever, fifty-six of the last having been
drawn from the record of typhoid cases and eight from that of the malarial fevers.
The fifty-one typhoid cases furnished ten deaths or 19.6 per cent., and the sixty-four
typho-malarial cases sixteen deaths or 25.0 per cent.; none of the pure remittents died.
These results diff'er markedly from the percentages obtained from the numerically reported
cases. As may be seen by Table XLII, typhoid fever during the war gave a mortality of
35.9 in every hundred cases, while typho-malarial fever was credited with only 8.14 per
cent, of fatal cases.
Although fifty-six of the sixty-four cases of typho-malarial fever were reported as
typhoid, it is evident, from the record of treatment, that the medical officers were not
ignorant of the presence of the complication nor of the importance of removing it by specific
medication. But as malarial fever gave a small mortality and typhoid fever a large one,
the more dangerous disease was naturally entered on the record as the diagnosis. These
cases illustrate the true typho-malarial fever of the autumn of 1861, as well as those which
occurred at a later date ; but it is manifest, from the mortality rates to which reference has
been made, that they do not give information concerning all the classes of cases which
were after waixls reported as typho-malarial.
Fifty-one Typhoid Cases.
Case 1. — An incomplete record. — Private Henry A. Hitchcock, Co. B, 3(1 Vt. Vols.; age 25; was admitted Oct. 1,
1861, as a case of typhoid fever. On the 2d he was dull, stupid, deaf, and had fulness of the head, tinnitus auriuni
and some delirium and subsultus; his skin was hot and dry; tongue pale, red at tip but coated gray in the centre;
he had also some diarrhoea, slight tympanites and acute iliac tenderness. Quinine was given. Next day the skin
was moist and but one stool was passed; the acute tenderness continued. He was returned to duty on tlie 28th.
Case 2. — A lu/ht febrile attack, unmarked hi; specific symptoms. — Private Fospeld Black, Co. C, 1st Long Island
Vols., was admitted September 14, 18(il, having been sick for twelve days. The disease began with chills, whicli
were followed by fever, pain in the head and bones, buzzing in the ears, epistaxis, anorexia and weakness. On
admission he slept well after a bath, and next morning his tongue was coated yellowish-white, skin hot but moist,
bowels regular; he was a little drowsy and had some cough. Dover's powder was given at night. He rested well,
THE CONTINUED FEVERS. 217
and on tlio Ifith had a good appetite and cpiiet bowels, liut his toiiguo was white. Castor oil produced two stools.
No further niedieatiou was required. His tongue hecauio clean, lie was returned to duty on the 30th.
Case 3. — Sliijht inti>:linal aiimptomn and rose-colond sjioln, hut proiinss not rcpoittd ill (Uttiil. — Private Joseph Cald-
well, Co. K, 9tli Pa.: age 21: was admitted September lit. IStil, as a ease of typhoid fever. He had been sick for a
week, at first with eliills and afterwards with pain in the head and bowels, diarrho'a and fever, which Last was worse
in the evening and on alternate davs. lie had taken but litlb' medicine. On tlie day of admission he had six stools,
with tenderness in the right iliac region and rose-colored spots on the chest and abdomen, disappearing on pressure;
the pulse was 74 and strong: the skin warm and nmist: the tongue smooth, fissured, red, dry, quite clean anteriorly
but with a brown fur posteriorly. On the 20th the eyes were sufiused, the cheeks Hushed, the pulse 80 and full, skin
dry and warm, the tongue dry. brown and fissured; epistaxis, anorexia, thirst, one thin fietid siool and slight tender-
ness of the abdomen are also noted. The details of the case are not recorded. The patient was returned to duly
October 20.
Case 4. — JTeakniss, iii<liliini<ft, droirsiness, perspiration, siDlumiiia and rose-colored xpots. — Private James F. Tomb,
Co. H, 12th Pa.; age 19: had headache, weakness and diarrha-a on August 28, 18G1, and was admitted September 4
as a case of typhoid fever. On the morning of the 5th there was slight fever, the pulse 80, weak, the skin dry and
hot, the tongue red, flabby and coated. Quinine was ordered with Dover's powder at night. He rested well during
the night, and next day had no fever; pulse 72, tongue heavily coated, skin warm aiul moist, Iwwels slightly
relaxed: nor did the fever recur in the evening. The following is the daily record of observations in this ease: 6th,
Morning: rested well; pulse (32; tongue heavily coated; skin warm and moist; one stool: no fever. Evening: pulse
72; skin warm and dry: tongue very red, coated white; one stool; no fever. Gave ten grains of Dover's powder.
7th, Morning: rested well; pulse 76; drowsy; tongue coated brown, red at tip; skin warm, natural; bowels quiet;
appetite fair. Evening: pulse 60: skin warm and moist; no fever; tongue slightly coated; bowels quiet; appetite
good. 8th, Morning: rested well; drowsy; pulse .56, weak ; tongue pale, slightly coated white; skin cool, moist;
no fever; giddiness; bowels quiet; appetite fair; walking about. Evening: pulse 50; tongiu' coated, pale; skin cool,
moist; appetite good; stronger; bowels quiet; sleepy. 9th, Evening: sleepy : pulse natural; tongue pale; one thin
small stool; skin natural. 10th, Morning; rested well; slept much ; pulse U)2, strong; tongue coated white, moist;
skinmoist, warm ; rose-spots; profuse sudamina : bowels natural, (iave wine of cinchona. Evening: pnlse85wlien
standing; skin warm and dry; tongue slightly coated; profuse sudamina; one large stool. 11th, Morning: rested
well: pulse 88, sitting; tongue pale, coated at base; skin cool; sudamina profuse; three stools ; no pain ; appetite
good; no rose-spots. Evening: walking about ; some weakness; profuse sudamina. Ordered rest. 12th, Morning:
rested well; pulse 78, quick, compressible; tongue slightly coated gray; skin warm, moist; no fever; p-ofuse
sudamiiui; no tenderness ; one large stool; walking around: weak. Evening: pvilse80,sitting; tongue pale, slightly
coated grayish : skin natural, covered with sudamina ; one natural stool ; appetite good. 13th, Transferretl to hospital
at Baltimore, Md.
C.VSE 5. — The mind continned affected after the other mjinptoms had dimppeared. — Private Charles Whitfield, Co. B,
Ist Mich.; age 25; admitted March 2,1862. Diagnosis — typhoid fever and chronic bronchitis. On the 1th he was
quite deaf, drowsy and delirious; he was hoar.se and had a fre<iuent cough with free expectoration; his cheeks were
hot and tiushed, and he had much thirst; pulse rapid and weak; tongue somewhat dry, quite red and with enlarged
papilla-; stools not frecjuent but loose; abdomen tender. Two watery stools were passed on the 5th. The tongue
became moist on the 6th, the appetite returned and the bowels were quiet, but the other symptoms remained unchanged.
On the 7th the deafness lessened and the hoarseness and cough diminished; pulse 90, good ; skin natural; tongue
moist, fissnred, clean; bowels unmoved; but the mind continued alfectcd for some time longer. On the 13th he
replied naturally to questions, but had curious hallucinations which returned occasionally for several days after
this, and the deafness continued for some days longer. During this time the bowels were regular or Inclined to con-
stipation. Milk-punch and tincture of iron were used. He was able to walk about on the 27th. On April 26 he was
discharged for disability.
C.tSE 6. — Deafness; successive crops of rose-red eruptions; hoieels quiet but for castor oil; skin moist; date of onset
undefined. — Private Charles Cheney, Co. G, 9th Pa. Vols. Admitted Sept. 19, 1861. Diagnosis — typhoid fever. No
note of the ca.se was taken until the 23d, when the patient was reported as quite weak and without appetite; his
pulse 85 and quick; face flushed; eyes sutt'used ; sense of hearing somewhat dulled; skin natural, showing an eruption
which was not considered characteristic; tongue brown in the centre and moist at the edges; bowels quiet. Tinc-
ture of iron was ordered three times dail.v, turpentine emulsion every three hours, and Dover's powder at night. He
slept sonu- during the night and perspired towards morning, when the eruption of the previous day was found to have
disappeared and been replaced by an abundance of rose-colored spots; there was some borborygmus, but no stool
and no tenderness or tympanites of the abdomen. The patient was thirsty and his tongue red, dry and slightly
furred, but there was less deafness. In the evening castor oil was given, after which he slept badly and had five passages
from the bowels during the night with some umbilical pain; he perspired towards morning. Next day the tongue
was red, dry and glossy, and the eruption fading. On the evening of the 2oth acetate of lead and tannin were given
with Dover's powder. On the 2Gth the pulse was 80, the skin soft and natural, the eruption disappeared, the tongue
.vellowish and slightl.v furred, the appetite improved and the bowels quiet. Some ro-se-spots appeared on the 27tli
and 28th, disappearing on the 30th. The bowels remained unmoved from the 26th until the 30th, when there was
ouc stool: after this they continued unmoved until Octol>er 3, when the record closes, — the ])atient'8 skin being in
natural condition, his tongue clean but a little dry in the centre and his appetite good. He was transferred to
Annapolis, Md., on the 10th.
Cask 7. — Ihuirsiness ; abdominal symptoms slightly marked; rose-colored spots on 6lh day; conraleseent on the loth. —
Mei>. Hist., Pt. Ill— 28
218 CLINICAL RECORDS OF
Private li. W. Beemau, Co. A, Ith Mich Vols.; age 19: was admittfd Oct. 30, 1861. Diaguosis — typhokl fever.
He had chills on the 25th, followed by fever and diarrhoea, for which quiuine had been given. On the evening of
admission he was drowsy, his face slightly llushed, jiulse 85 and of good strength, skin dry and warm, showing a few
rose-colored spots on the abdomen and chest, tongue red, smooth, dry and glossy, teeth blackened with sordes, bowels
quiet; he had no appetite, some abdominal tenderness and gurgling, but no meteorism. Milk-punch, turjientine
emulsion and beef-essence were prescribed on November 2. The skin became co%-ered with sudamina on the 4th and
the appetite was improved. A full dose of castor oil on this day produced one large evacuation. On the 7th the
Ijatieut was looking liright and lively, and on the following day was up and walking about. He was transferred to
Annapolis Md., on the 18th.
C.i-SE 8. — Heudiiclie aud dhziness ; bowels quiet notwithstanding purgnti re niedicinex, hut right iliac region tender; roxe-
sjjols on the nth day, u-ith eonralescence sneceeding. — Corporal B. F. Gale, Co. A, 4th Mich.; age 20; was seized about
Sept. il, 18(jl, with weakness, pain in the head and Ijack aud fever, and was admitted as a case of typhoid fever. In
the evening his pulse was found to be 92, quick and strong, skin natural, tongue red at tip but coated slightly in the
middle, bowels quiet aud appetite poor. Ten grains each of calomel aud jalap were given. Next day the pulse was
74, the skin natural and moist, the tongue white in the centre and red at the edges, and the bowels quiet. Quinine
was ordered. In the evening the xjulse was 66 aud the skin and tongue unchauged. One stool was passed in the
morning; no tenderness. The patient had slight headache and dizziness. The bowels remained quiet during the
following days, but some tenderness was manifested in the right iliac region. The skin continued warm and moist
and the tongue unchanged, although the patient developed some ajipetite. On the 20th he was sitting up. On
the 21st he had tinnitus aurium and some thirst, but the pulse was 64, tongue clean and appetite good. On the
22d a few rose-colored spots appeared, the patient's condition otherwise remaining unaltered. He was improving gen-
erally when, on October 1, he was transferred to hospital at Annapolis, Md.
Ca.sk 9. — Deafness; dizziness, but mental faculties clear; diarrhoea; rose-colored spots on the lOlh and 12th days,
fading on Hlh, when convalescence followed ; to duty on 2'th dug. — Private George N. Barber, Co. C, 14th N. Y.; age 18;
was admitted .Sept. 20, 1861, having been taken sick a week before with weakness, pains in the head, back and bowels,
aud epistaxis. Diagnosis — typhoid fever. On admission the pulse was 114, the skin hot and moist, the face flushed,
the tongue gray in the centre aud red at the tip and edges; there was diarrhoea, with irritability of the stomach and
much tenderness in the right iliac region; the patient was sometimes afl'ected with dizziness, but his mind was clear.
Blue-pill was given. On the 2l8t he had five stools with persisting tenderness and gurgling, anorexia, a slight cough
epistaxis and deafness ; his face was flushed, skin hot and moist, tongue red at tip, whitish-gray at base. On the 22d
the epistaxis recurred; the tongue was dark-red at the tip, brown at the base, and its papillie were prominent; the
skin was warm and dry and jiresented one or two rose-colored spots; one stool was passed and the tenderness con-
tinued; pulse 76. Quinine in eight-grain doses was given three times daily, with morphia at night. The eruption
faded next day, but appeared again on the 24th. The tongue began to clean on the 22d and the skin softened on
tlie .same day, after which, although the bowels continued relaxed and tender for a few days and the throat became
slightly sore on the 27th, there was a steady improvemeut, and the patient was returned to duty October 9.
Case 10. — Deafness; muscular twitchings; rose-colored eruption; abdomen tender, scujihoid : improrement after the
second week. — Private William Patterson, Co. K, 6th Wis.; age 28 ; was admitted Oct. 2, 1861, with typhoid fever. The
condition of the patient is not stated until six days after admission, when his pulse was weak and compressible, 110;
countenance haggard; cheeks sunken; eyes suffused; tongue slightly coated brown aud very dry and fissured, as the
mouth was open much of the time; he was very deaf and difficult to arouse; he spoke with much effort, aud had
exquisite tenderness in the epigastric and right iliac regions and spasmodic twitchings of the arms. Whiskey-punch
was given every hour. Next day the eruption appeared over the abdomen and the tenderness was very much lessened ;
sinapisms were applied where the tenderness had been acute. The abdomen became scaphoid on the 10th, the tongue
clean and very red, the face much sunken and the eyes suffused and surrounded by dark areola?; pulse 104; the
patient had much thirst, cough and hurried respiration. Next day the countenance was more natural and the tongue
moist. On the 12th the expression was better, the eyes clearer, and there was less epigastric and umbilical ]iain. The
sinapisms were repeated on this day. After this the patient gradually imjiroved, although for some days the skin
continued dry aud husky, the bowels somewhat relaxed, about two thin stools daily, and the right iliac region
slightly tender. On November 1, when he was transferred to Annapolis, Md., his pulse was natural, appetite good
aud bowels regular.
Case 11.— Bronchitis j»-omi«e«(.— Private J. Little, Co. H, 3d Mich. Vols.; age 26; was admitted October 19,
1861. Diagnosis— bronchitis. About October 12 he was taken with pain in the head, neck, back and limbs, and with
loss of appetite. Throughout the progress of this case there was cough with nuich yellowish expectoration and some
dyspnoea. Rose-colored spots appeared on the day of admission, and continued to erupt until the 30th. There was
headache with dizziness, ringing in the ears and for a short time deafness; the tongue was moist, white in the
centre and red at the tip and edges; the pulse was usually 80; the skin hot; the bowels relaxed, two to four stools
daily being passed ; the abdomen tympanitic and tender, especially in the right iliac and umbilical regions. On the
31st, on the disappearance of the eruption, the skin was of the natural temperature, so recorded for the first time;
the tongue coated, Ijut the appetite good ; one stool was passed : there was slight headache, and the cough persisted,
with asthmatic paroxysms at night. He was transferred to Annapolis, Md., on November 1, and discharged on the
13tli on account of "fever."
Cask 12. — Symptoms generally not strongly marled ; free rose-colored eruption from 7th to ISth day ; dysuria from
20ih to2Sth day; eonralescence rapid. — Private J. E. HoUom, Co. H, 6th Me.; age 22; of large frame aiul stout habit,
was taken about Sept. 3, 1801, witli pain in the head, back aud shoulders, slight fever, epistaxis and diarrhcEa. He
THE CONTINUED FEVERS. 219
was a<linitte(l on the 9tli as a case of typhoid fever. Tlie patient wa.s weak ; his tongue coated at tlie base, pale at
tip and moist; skin hot and dry, showing a profnsion of rose-eolored spots; his cheeks were Hushed, tjuite red, and
he had cough and hoarseness, hut his bowels were quiet. Dover's powder was given. He rested well, but next morn-
ing the fever ran high; pulse 104: skin hot and dry: face much tlushed; tongue purple at the tip, coated, pale;
large numbers of rose-spot.s on the abdomen, thighs and back, disappearing on pressure ; one thin stool ; borboryguuis ;
anorexia. Siiuill and tartar emetic were giveii to allay the cough. In the evening the tlushed condition of the face
continued and the patient became drowsy, — pulse 108, liut the skin began to be moist ; four .small thin stools were
passed: but there was no abdominal jiain, tenderness nor borboryguius. Next day the skin was perspiring and
covered with rose-spots, the pulse had fallen to Mi?, and the patient "s drowsiness was dissipated and his cough lessened;
he had epistaxis. In the evening he sat up for a short tiuu-. On the 12lh he had four small stools and some tym-
panites, but no pain nor tenderness. In the evening the face was tlushed, eyes injected, skin hot and dry, but the
mind i>erfectly clear. The diarrhcea abated gradually, and on the I'ltli he had one natural passage; on which day
the skin was in natural condition, the ti>ugue dark-red and slightly coated and the min<l clear: the patient's face
was tlushed, and he had some cough and hoarseness; the rose-spots continued on the surface and did not disappear
tiually until the 20th. On the 22d the patient complained of dysuria, occurring suddenly after beginning to urinate,
and accompanied by the passage of a few drops of blood and pain in the end of the penis ; this continued more or less
until the 30th. On October 2 he was employed in light duty about the ward, and was returned to duty on the 20th.
C.vsE 13. — DizzhieDS and drousiness : intestinal si/niptoms alight ; no ronc-colond spots; defervtsi'iiicc ithoul end of seeond
week; com-alescence OH 24t/i dui/. — I'rivate W. T. Smith, Co. C, 1st Long Island Vols.; age 20; was admitted Sept. 14,
IStil. Diagnosis — typhoid fever. Ten days before admission he had chills, followed by fever, increasing debility, pain
in the head and bones, anorexia and slight diarrluea. He rested well after a l>ath and Dover's powder, and on the
irvth the pulse was 88, tongue moist, red at the tip and sides, brown in centre, bowels regular, skin dry and warm.
In the evening he was drowsy and had a sense of heaviness over the eyes; the bowels were nuiet. Sulphate of
magnesia was given with the eft'ect of moving the bowels twice. After this the bowels renuiined (|uiet, but with
some tenderness and gurgling in the right iliac region. The tongue became somewhat dry on the 18th, but regained
its moisture in a few hours. The skin became moist on the 20th, the appetite returned, and the sense of heaviness
in the head was removed. On the 22d turpentine emulsion and one ounce of brandy were ordered for administration
every three hours. Ho rested poorl.v ou the 24th and had some nausea and less apjietite. Castor oil was adminis-
tertd, and repeated ou the 26th and on the 2i)tli, after which one drachm of extract of senna was given daily for
some days on account of headache and dizziness. He was able to sit up on the 27th, and was transferred to Annap-
olis, Md., on October 10th. No rose-colored spots were observed in the case.
C.VSE 14. — Headache; no diarrhaa ; successive crops of eruption ; convalescence foUotoing free perspirations on the21th
day. — Corporal Joel E. Yaw, Co. 11, 1st Long Island ; age 19; had chills, fever and headache on Sept. 9, 1861, and was
admitted ou October 1st as a case of typhoid fever. Ou admission his pulse was 95, full and strong; skin slightly
above the natural temperature and covered with elevated rose-colored spots on the chest and abdomen ; tongue moist
and heavily coated brown in the centre: appetite poor. Quinine was given on the 2d, tincture of iron ou the 3d,
au«l turpentine emulsion, three times daily, on the 4th. One stool was pas-.d daily. On the .5tli he was per-
spiring freely, and the chest and abdomen were covered with rose-.spot8 and sudamina; on this and the following
day lie had a slight diarrha-al attack. After this he gradually improved and was transferred to Annapolis, Md.
Case 15. — Mental dulness; delirium; eruption; diarrhaul affection not prominent as a si/mptom; skin moist; date
of onset not defined. — Private Frederick P. Seclor, Co. A, Dth Pa.; age 24 ; had suB'ered from fever and ague in June,
1861: but since then had done his duty uninterruptedly until September 19, when he was admitted as a case of
typhoid fever. In the evening the patient was weak and had headache; the bowels were ijuiet, but there was some
tenderuess in the right iliac region and intestinal gurgling; face Hushed; eyes bright; breath offensive; pulse 88;
skin hot and moist: head cool and sweating; tongue grayish-yellow in the centre, red aud clean at the edges. Ten
grains of calomel and Jalap were given. Next day, with a continuance of the symptoms stated, the patient became
dull and stupid and had mu.sc;e and tinnitus. On the night of the 21st there was delirium, and the characteristic
eruption appeared on the 22d. on which day also he had twostools with some tympanitesand tenderuess; histongue
was black at the base, reddish-white in the centre and red at the tip. Turpentine emulsion and wine were given.
Next night he was again delirious, aud on the 23d dull, the skin unaltered save by the fading of the eruption from
the chest and abdomen, the bowels <iuiet, slightly tympanitic but free frcm tenderuess, and the tongue cleaning.
Dover's powder was given in small doses, with stimulants. An enema was administered ou the 24th, with two grains
of blue-pill and one of (luinine every three hours. Uy the 26th the eruption had disappeared, bnt the patient con-
tinued dull: the skin was moist, the tongue cleaning. The bowels were moved once on this day and on the 27tli,
and some tenderness and tympanites remained; but after this the tongue became clean, the appetite good and the
bowels natural. The patient was returned to duty October 20.
Case 16. — Date of onset not specified; delirium; rose-colored spots; diarrhwa persists after the occurrence of prof use
penpiratioHs. — Private Harrison Woods, Co. K, 5th Wis.; age 26; was admitted October 1, 1861, with typhoid fever.
He had been taken abcmt September 1 with diarrhtea followed by fever. On the day after admission his face was
flushed, eyes injected, pnl.se 100, skin hot, covered with perspiration, tongue moist, reil, appetite not wholly lost: he
had some headache but no diarrha-a nor cough. Tincture of iron was ordeied three times daily. Ou the 3d rose-
colored spots were noticed; the skin continued moist but the tougue was dry, red and glossy. Emulsion of turpen-
tine was given. Next day sudamina appeared, and the patient was dull nieutally, quite deaf and at times delirious.
Rose-colored spots were very numerous ou the 6th and 7th. The bowels were moved two or three times daily, and
there was more or less of right iliac, umbilical aud even general abdominal tenderuess and meteorism. The tongue
220 CLINICAL RECOEDS OF
became moist on the lOtli, the fece less flushed ami the eyes clearer. The delirium disappeared on the 12th, hut the
deafness and tinnitus aurium, together with the diarrhoea causing three to five stools daily, continued up to the time
of the patient's transfer to Annapolis on November Ist. A large crop of rose-colored spots appeared on the 20th and
a few more on the 24th. [This patient was returned to duty November 9.]
Case 17. — Deafness and iii/]i(iiiiii the jirominent symptvms; diarrhaa ; rose-colored spots on the Gth dnt/ ; improvement
on the 21st. — Private W. H. Harrington, Co. G, 22d Mass.; age 19; was taken sick March 1, 1862, with headache,
nausea, debility, pains in the limbs and diarrhoea, and was admitted next day as a case of typhoid fever. No details
are given until the 6th, when he was reported as weak, dull looking, very deaf and aphonic; he had epistaxis, cougli,
accompanied with epigastric pain, and rose-colored spots on the abdomen and chest. His skin was hot and dry; face
congested; eyelids pufty; tongue moist and coated; stools fre(iuent and watery. Quinine was given. The symp-
toms continued, being at times more or less aggravated, until the 2lst, when the deafness was much diminished, the
voice nearly recovered, the tongue cleaning and the bowels regular. A discharge issued from the left ear on the
night of the 16th. On the 27th the general health was improving rapidly. On the 29th the patient was walking
about. On April 15 he was discharged from the service on account of a contusion, the particulars of which do not
appear on the record.
Case 18. — Cerebral symjytoms slight; diarrhwa abated after occurrence of perspirations ; rose-colored sjwts on 13th
and 15th days and on nth and 22d, accompanied iy sudamina and followed iy convalescence. — Private Joseph Husang, Co.
E, 19th Iowa ; age 19 ; had a chill followed by fever on August 27, 1861, and was admitted Sept. 4 as a case of typhoid
fever. On the morning of the 5th he had slight fever and anorexia; pulse 84, skin dry, tongue coated brown in the
middle and dry; the mind was clear. Quinine was given. In the evening there was moderate fever, the pulse 84
and strong, face flushed, skin dry and hot, tongue very red, flabby and coated white, appetite poor, bowels moved
four times; the patient was weak and dizzy and had headache. Dover's powder was ordered. No marked cliauge
took place on the two following days; the face became flushed towards evening. On the 7th the skin was somewhat
moist, and next day an eruption of rose-spots was observed. On this day, the 8th, he had six thin painless stools;
he became restless, talking in his sleep, and in the evening drowsy. Pills of acetate of lead and opium were admin-
istered. On the 9th a slight cough was developed with mucous and sibilant rales; the abdomen became somewhat
tender and the rose-spots disappeared. In the evening the pulse was 68; the tongue moist and heavily coated brown
at the base; the skin warm and moist; the bowels were moved once during the day without pain, but some tender-
ness was present; anorexia continued and epistaxis was noted. Next day there was one painless stool; a few rose-
spots appeared; and in the evening, while the skin was perspiring the tongue became dryer aud there was some
cough, flushing of the face and headache. Friction with alcohol was applied to the skin. The perspiration con-
tinued on the 11th, during which there was one stool at night and one during the day, and the patient became weak
and exhausted. Aromatic sulphuric acid was ordered and the body sponged with alcohol and nitro-muriatic acid,
(in the r2th the skin became dry and a profuse characteristic eruption appeared. The lead and opium was omitted.
Next day night-sweats were reported and some imj>rovement in the appetite; but the tongue continued dry and
brown. Blue-pill three times dailj- and oil of turpentine were ordered. On the 14th the tongue was cracked, and
although there had been no night-sweats, the skin was warm and moist; the bowels were quiet and the appetite
improved; in the evening there was a slight cough with diminution of the appetite. The night-sweats returned on
the 16th, when also the tongue became moist and less coated, the bowels remaining quiet. Whiskey-punch was
ordered. Next day the skin and tongue again become dry; rose-spots and sudamina appeared and the bowels were
moved twice ; a slight flushing of the face was noted in the evening, as also on the evening of the following day.
On the 19th the tongue assumed a gray, moist coating; the skin was warm and sweating; the bowels moved once;
rose-spots were present but no sudamina, no tenderness nor tympanites. From this time he gradually improved.
Thus, on the 24th, the report is as follows: Rested well; pulse 9S; tongue red, moist, slightly coated; bowels regu-
lar; appetite good. He was able to walk about on October 1 and was transferred to Auuapolis, Md.
C.\SE 19. — Admitted delirious and in low condition about the21st day ; free pers]>irations occurred two d^iys later, after
rchich convalescence was gradually established. — Private John Cross, Co. E, 14th N. Y. State militia; age 23, and of stout
habit ; had been sick three weeks when admitted Sept. 14, 1861, with typhoid fever. He was delirious and aft'ected
with great muscular debility and twitchings; pulse 120; skin hot and moist; face hot and dark-red; tongue coated
brownish-white and fissured; body emitting a peculiar odor. Next day there was less delirium; but the subsultus
continued with great roaring in the ears; the pulse was 104, tongue brown and slightly fissured, teeth covered
with sordes, skin hot and dry, face flushed, on one side purplish-red, and abdomen tender on pressure. Turpentine
emulsion and stimulants were ordered. In the evening the tongue was dry and coated posteriorly, and the delirium
and subsultus persisted. Dover's powder was administered. On the 16th copious perspiration, with subsidence of
the delirium and subsultus and increase of appetite was noted; the patient was weak and had great thirst, dryness
of tongue and some incontinence of urine. In the evening the skin was warm and perspiring, the mind much
clearer, the subsultus absent, the pulse 104, the tongue cleaner and moist and the bowels quiet. The Dover's powder
was continued. He rested well, and on the 17th the tongue was white, pulse 100 and skin moist. Aromatic sulphuric
acid was given. In the evening the pulse was 100, the tongue white and less fissured and the bowels regular. Next
day sudamina appeared with free continued perspirations, great thirst for acid drinks, high-colored nrine aud
regular bowels. After this the daily record varies but little, showing a good appetite, tongue moist, clean or with
yellow or brown patches, the skin natural or moist, the bowels quiet except when sometimes moved after the admin-
istration of extract of senna, and the sleep sound. Some deafness and tinnitus were noted for a day or two. The
patient was transferred to Annapolis, Md., October 1, where he was entered as a case of continued fever, and
whence be was returned to duty October 21.
TSE CONTINUED FEVEES. 221
Case 20. — UtrnrH commrmHng about thir(l irfft; prrcpiraiions accompanying fiiihsi^cnre of the fever. — Private P. P.
Sniilcy. Co. F. Iltli Pa. C'av.: a^e Ut; was naid to liave contracted diarrhtra on Sept. 9, 18<>1, and was admitted on
the 3(>tli. l>ia^nosis — typlioid fever. He was weak, had a slight cough, a diarrha-a yielding two stools daily and but
little appetite: pulse 100 and quick; skin natural; tongue moist, liut coated in the centre. Next day he was dull :
had some headache and tenderness in the right iliac region. On October 2d the tongue was dry, lirown and fissured
in the centre. No change was noted on the 3d, hut on the 4tli his pupils were dilated; he was delirious and had a
wild look. The delirium aViated somewhat on the (illi : the tongue liecanie dry, red and fissured by the 10th, but the
appetite improved and the bowels continued unmoved for several days, the pulse beating 7.5 to 80 per minute, although
there was some abdominal tenderness and tympanites, with fljished checks, injected eye.s and nocturnal delirium.
The patient perspired during the night, and next morning the tongue was red at the tip and edges and coated white
in the centre: there was less delirinni and the appetite was good. On the 12th the tongue was moist and clean but
for a yellowish streak on each side of the centre. One stool was obtained on the 14th, after the administration of
two compound cathartic pills. The tongue on the 17th was moist and clean but for some white patches. The patient
steatlily imiiroved and was returned to duty November 13.
Case 21. — Ilcadachc ; cpistaiie : ddiriitm ; sordes and rose-i-olored spoU on the \2th day; pvrnpirationii and conia-
IrfccHCf on the 2i^lh. — Private Jno. Stoddard, Co. A, 13th X. Y. Vols.: age 25; was admitted Nov. 1, 1861, having been
sick for a week before iidmission with headache, epistaxis, anorexia, thirst and cough. On the 2d the patienfs eyes
were suffused, face congested, pulse 100. full and strong, skin hot, tongue red at the tip and edges and coated yellowi.sh
in the centre; appetite poor; he had epistaxis during the day and one pa.ssage from the bowels, which gurgled and
were tender on pressure, particularly on the right side; he hadalso some cough with yellowish blood-streaked sputa.
The epistaxis did not recur, and next day he had headache, which was accompanied by mental hebetude on the 4th
and by delirium on the 5th. An eight-grain dose of quinine, turpentine emulsion three times a day, and six grains of
calomel with one of opium at night, were prescribed on the 4th. Rose-colored sjiots appeared on the chest at this
time, as also dryness of the tongue and blackening of the teeth and lips from sordes. Tlie delirium lasted only one
day, but the dulness of mind persisted. A diarrh<pa of three or four stools daily was perhaps due to the calomel,
which was repeated on the otli. Much abdominal tenderness and tym]>anites were also preseut; the appetite, how-
ever, continued good and the thirst was lessened. The tongue became moist and covered with white patches on the
6th, swollen and coated on the 7th and 8th and clean ou the 10th; but the skin did not become moist until the 21st.
On the 22d there was profuse per.spiration. Complaint Avas made of earache on the 2.">tli. Tlire* days later the
patient was able to leave his bed. On December 3, when transferred to Baltimore, Md., he had tinnitus aurium
and cough and his bowels were slightl.v relaxed.
Case 22. — Date of onset unrecorded: cerebral, pulmonary and intestinal symptoms : rose-colored spots ; conralescence. —
Farrier -Vlexander Wenrich, Co. K. 2d Pa. Cav. Admitted Nov. .5, 18fil. Diagnosis — typhoid fever. On the day after
admission he was delirious and slightly deaf; had frequent and involuntary stools, some cough and the respiration
Increased to 22; his eyes were injected: face congested; pulse 100, quick, bounding and intermittent: skin hot;
tongue red and slightly coated yellowish-white. Hoffmann's anodyne, tincture of valerian, turpentine and .istringents
were prescribed, with morphia at night. Sordes appeared on the teeth ou the 7th, on which day two stools were
passed: beef-essence, punch vid morphine were ordered. He was stupid on the 9th ; had headache and tinnitus on
the 10th, two stools and -slight tympanites and tenderness in the right iliac region, but the tongue was moist and
cleaning and the cough slight. Rose-spots appeared on the chest on the 11th. The delirium did not quiet down
until the 16th. after which he slept well and had a good appetite. He was transferred to Alexandria, Va., Dec. 20th.
Case '2'A. — Deaf nesn and mental dulnesn; intestinal symptoms ; perspirations and rose-colored sjiots on 19tli day : sordes
aad delirium on the 20th and 21s/ ; conralescence- on the S3d day. — Private William O'Brien, Co. (J. 13th N. V.: age 20 ; con-
tracted typhoid fever Oct. 15, 1861. and was admitted November 1. Next day there was headache and deafness,
tinnitus and hebetude; the face was congested: pulse 78: the tongue was dry, swollen and coated yellow ; the i)atient
had no appetite, much thirst, relaxed bowels and some tympanites and abdominal tenderness: profuse sweating had
occurred during the night, and on the chest and abdomen a few rose-colored spots were discovered. On the 3d sordes
appeared on the teeth, and on the 4th delirium supervened, the patient making frequent attempts to leave his bed;
the tongne became red at the tip and edges. There was less deafness, and the mind became clearer on the 6th, but
the delirinm did not entirely subside until the 11th. On the 16th the tongue was clean, pulse 75, and there was no
altdominal tenderness. The case was treated from the 3d with milk-punch, beef-essence and emulsion of turpentine.
He was transferred to Annapolis, Md., on the 18th [and returned to duty Dec. 16].
Case 24. — Fresenting delirium, unconsciousness, Hoecitatin, subsultus, slight diarrhera, rose-spots, sudamina, bed-sores
and ribicrs. Improrement manifested about 35th day. — Private William E, Thompson, Co, C, 9th Pa. Vols.; age 19; was
taken about .\ugust 22, 1861, with pain in the head and back, ejiistaxis, chill, fever and diarrhtea, and w.is admitted
.September 12 as a case of typhoid fever; pulse 100, quick: skin hot and dry; tongue dry at the tip and coated gray
at the base: the patient was dull-looking and had subsultns, relaxed bowels, right iliac tenderness and intestinal
gurgling. Dover's powder was given. On the 13th the skin was hot but moist with perspiration ; rose-colored spots
appeared. Next day the skin was again hot and dry, but covered with profuse sudamina; the cheeks were flushed,
the tongue dry, smooth, cracked and protruded with difliculty, and the yatient stupid but restless. Toward
evening on the 15th a few more rose-spots came out: sorde.s appeared on the teeth; the bowels continued slightly
relaxed and there was right iliac tenderness; the patient was haggard: he turned his head from side to side,
muttered, and had snbsultustendinum. No change occurred on the 16th, but on the 17th more rose-spots made their
appearance and the patient became drowsy. On the 19th his pupils were dilated and he was unable to articulate.
Next day the pulse was 112, irritable and full; the skin dry and husky : the rose-spots and sudamina had disappeared;
222 CLINICAL RECOEDS OF
the tongup was nuigli, dry and lirowu; the gniiis and teeth covered with sordes; right iliac tenderness, meteorism,
gurgling and relaxation of tlie bowels continued, and the patient muttered and groaned, hut had no sulisnltus.
He was greatly emaciated and prostrated, and for some days lay on his back with his eyes half-closed; souietinies
jiartly delirious, picking at the bed-clothes, and at other times unconscious. Meanwhile the pulse became more rapid,
rising to 128 on the 23d, and the circulation of the skin languid. He vomited on the evening of the 22d, and after
this his bowels became more quiet. Bed-sores apjieared over the sacrum. Turpentine, Dover's powder, astringents
and stimulants had been used in the treatment. On the 2oth the pulse was 114 and stronger, the tongue cleaning
and the mind clearer, liut the skin continued hot and dry, and vibices appeared profusely on the chest ; the
bowels remained quiet. The patient was sponged with alcohol and turjientine; warm bottles were applied to the
feet and soft pads to the sacrum over the sores. In the evening the eyes became brighter and the skin moist, the
pulse having meanwhile fallen to 100. Next day the patient was tranquil, the tongue moist and cleaning at the
edges ; the bowels were moved by an enema. A purulent discharge came from the right ear. The left ear became
similarly affected on the 28th. The appetite returned on the 29th, and after this improvement continued. The pa-
tient was furloughed October 31.
Ca.se 25. — DeVmum; hirolnntdnj stools; sordcx; rose-colored spots ; conralcsciiicc coincidnii with fnc perspiration. —
Private W. H. Barnett, Co. D, 14th N. Y.; age 26; was admitted Oct. 2, 1861, as a case of typhoid fever. On the 6th
he was reported as weak and having suffused eyes, quick pulse, 11.5, hot and dry skin, moist, brown and slightly
fissured tongue, anorexia, relaxed bowels and iliac tenderness. Turpentine emulsion and camphor with sweet spirit
of nitre were ordered. Next day the patient was quite delirious and had three involuntary stools; sordes ajiiieared
on the teeth and six rose-colored spots on the skin. Milk-punch and tincture of opium were ordered. On the 8th
the rose-colored spots increased in number and the delirium was somewhat les.seued ; the five stools passed were not
involuntary; some irritability of stomach was manifested. Sudamina ai)peared on the 10th with a fresh crop of vose-
colored spots, and the tongue became red at the tip and edges. On the 11th epistaxis occurred and the patient was
stupid. Next day headache accompanied the delirium, the other symptoms continuing as already stated. On the
14th the tongue was somewhat moist and the ai)petite improved. On the 15th the pulse had fallen to 80, the diarrhoea
lessened, epistaxis recurred and the patient was more rational. Next day there was only one passage from the bowels,
l)ut the right iliac tenderness continued with some tympanites and gurgling. Rose-colored spots appeared on the
18tli and again on the 21st; on the former day the headache and delirium were greatly lessened, and on the 19th the
tongue was clean and the api)etite good; but some general tenderness continued in the abdomen an<l there was some
cough. A free perspiration occurred during the following night, after which the progress of convalescence was
steady. He was transferred to Annapolis, Md., November 1 [whence he was returned to duty on the 22d].
Case 26. — Cerebral and intestinal si/wijjioms; rose-colored sjjotsfrom the 11th to the 3ith day ; inqirovement on the 2Glh
da;/, coincident with subsidence of febrile heat and appearance of moisture on surface. — Private Hugh Murphy, Co. I, 3d
Vt.; age 22; had measles in July, 1861, and on Sept. 25 was taken with a heavy cold, chills, headache and diarrhoea.
On admission, Oct. 3, his case was diagnosed one of typhoid fever. He slept well, but his eyes were suffused and
he had some pain in the head, anorexia and slightly relaxed bowels; his tongue was moist and coated yellowish in
the centre; skin natural; pulse 90 and full. Rose-colored spots appeared on the chest and abdomen on the 5th and
were very profuse on the 7th, when the skin became hot and dry, the lips parched and the tongue red and glossy at
the tip and edges and dry at the base and centre; five stools were passed on this day, and there was much tympan-
ites but no tenderness. By the 10th the eyes had become injected, the cheeks flushed, the tongue dry and dark and
the teeth covered with sordes; the patient was stupid and at times delirious; meteorism and borborygmus accom-
panied the diarrhoea. Up to this time emulsion of turpentine and Dover's powder had been used in the treatment:
quinine was now given in two-grain doses every hour. The bowels were moved nine times on the 11th and the
right iliac region was markedly tender. Tincture of iron was given on the 12th. Deafness was noticeable on the
13th. This condition of mental hebetude, deafness, occasional delirium. Hushed face, hot and dry skin with erup-
tion of rose-colored spots, dry and dark tongue and marked diarrhipa contiuiied until the 20th, when the skin lost
its heat, the tongue its dryness and the stools became less freciuent; the patient was troubled with some cough
during this period. The skin was reported moist for the first time on the 24th. The eruption did not disappear
until the 28th. The tongue continued moist and but slightly coated, the skin natural, the appetite good and the bowels
moved but once daily until Nov. 1, when the patient was transferred to Annai)olis, Md. [whence he was returned
to duty on Dec. 2].
Ca.se 27. — iJiurrha-a ; nuitterinij delirium; coma vigil; sordes; dark-red sjwts, persistin;/ under pressure, on the lllh
day, after which improrement was proyressire.- — ^Private Andrew Scriber, Co. C. 14th N. Y.; age 22; was admitted Sept.
20, 1861, having been taken sick two weeks before with chills, pains in the head and bones and great n\uscular
debility. Diagnosis — typhoid fever. His pulse on admission was 118 and soft, face flushed dark-red, countenance
anxious, skin hot and dry, tongue thickly coated gray in the centre, red at the tip and sides, gums and teeth covered
with sordes; there was some diarrhcea with tenderness of the abdomen and tympanites; the patient lay with his eyes
and mouth partly open, muttering incoherently when roused. On the 21st he was dull, stupid and difficult to arouse ;
pulse 90 and quick, skin hot and moist, tongue brownish-gray. He had six stools during the day, accompanied with
gurgling but no tenderness. Turpentine emulsion and enemata of laudanum were ordered. On the 22d he was rest-
less; pulse 112, small; skin hot and dry, with here and there dark-red spots which did not disappear on pressure;
tongue Iirowu and dry in middle, moist and red at edges. The diarrhcea was checked by the enemata, but there was
some tenderness of the abdomen and intestinal gurgling. Brandy was given. On the 23d the eruption had disap-
peared; two stools were passed; the sordes persisted about the lips, but the tongue was cleaning from the edges.
The sordes disappeared on the 25th. Next day the tongue was clean ; there was some appetite, and the patient looked
THE CONTINUED FEVERS. 223
and sai<l bo fi'lt well; lint lie wns losllrss and wanted to go out. IIo had tliroo stools; ]nilse SI. In tlu> cvtninj; tho
|)iilsi' rose to 100, the face was flushed, the skin liot and dry, and there was borhorygmus with right iliae tenderne.s.s
and one stool. On the morning of tho 28tb the pulse was 82; the skin warm and moist ; the tongue moist, red at tlu)
tip and slightly coated. His appetite was good on the 29th. He had four stools on the 30th, but no tenderness; bis
countenance was natural, his skin warm and soft, and he was gaining strength. Ou October 20 ho was detailed
on extra duty.
Case 28. — Dhiincss ; deafness; diaiThccu; eriiptiim on the 9th daij, net disuppcariiiij aii pressure; manifest improvcnieiil
roineidriit with epistaxis on llith duij ; hemorrhage from boweh on liUh dm/, leilh siihseqnent injiitmmiitorij action in the pnlmo-
Hurij and urinary onjans, and delirium lastinii until the 33rf da;/, when improvement was aijain manifested. — Private .lames
•Seotheld, Co. K, tith Wis.; age 20; beeanu- subject about Sept. 25, 18(il, to faintness and feelings of weakno.ss, eliills,
fi'ver.diarrhu'a, pain in the head and back and anorexia. He was admit ted October 2 as a case of typlioid fever. His
face was tluslied darkly; eyes sulfused ; expression ilull and heavy; pulse 100, strong and full; skin hot, dry, smooth
and without eruption; tongue slightly moist, red at the liji and thickly coated grayish wUiti' in the centre; bowels
relaxed but not tender; he was somewhat deaf and had a slight cough. Next day tlu' patient was drowsy and had
headache with di/ziness and increasing deafness; the skin hot and sliglitly moist, sliowed a few spots whi<'h didnot
disappear on pressure; the bowels were moved four tinu"S and were tender. No change took ))lace until tlie 7th,
when tinnitus aurinni and epistaxis were noted, the tongue having beconu- clean, dry, red and tissnred. On tho 9th
the tongue became very rough, red and grayish- white in the centre: epistaxis recurred ; four stools were passed, and
there was slight tenderness in the right iliac region; the uriue w-as scanty and very dark-colored. Next day epis-
taxis again occurred, the pulse was 100 and strong, the skin soft although hot and dry; the expression was less
anxious, the eyes clearer, the hearing improved and the tongue nu)ist and cleaning in the centre, but tlu; patient
coniplained of headache and pain in the back and side, a dry hacking cougli and mucli thirst : he had two thin stools
with iinuh tenderness and gurgling and slight meteorisni. On the 13tli a profuse hemorrhage occurred from the
bowels; the jiatient became very pale and stuiiid. ])ulse 120, skin hot and husky, tongiu' moist, fissured and slightly
coated; the abdomen was soft and tender. Next day the pulse was 101, the skin dry and husky, thi' tongue dry,
dark, cracked and rough, the countenance pinched and somewhat anxious, the teeth and gums covered with sordes;
the bowels nu)Ved three times during the night, about eiglit ounces of blood coming away with one of the passages.
No henu)rrhagc took place on tlie l.'ith, but the jiatient liad subsultns teiidinum aiul some brouchitic congli. His
expression on the llith was wild: he was very wakeful and complained nnich of pain in his heels and legs. On the
17th he perspired profusely and had frequent epistaxis but no stool; the liladder was so distended ;is to re(|uiro
the employment of the catheter; the tongue was dry, furred and scaly ; pulse 112, feeble; mind dull: countenance
anxious; respiration normal. Two stools were passed on the 18th; the bowels were tyini)anilic and acutely
tender; the skin was dry but at times moist and perspiring; the delirium present was not of a violent character.
Krom this date until the 27th tho patient was dull, drowsy and more or less delirious, sometimes crying out loudly;
the skin was dry and husky but occasionally moist; the tongue dry, fissured and scaly and the teeth black with
sordes; two or three stools were passed daily, and there was much right iliac and hypogastric tenderness, with
meteorisni and borborygmus; the catheter had to be used, and the urine withdrawn was strongly alkaline, con-
taining blood, mucus, pus, epithelium and excess of phosphates. Some sibilant rales were heard in the upper parts
of both lungs, and the respiration at one time became incn'ased to 28 per minute. He was emaciated and very weak ;
but on the 27th the mind became clearer. On the 28th the eyes were bright, the skin warm and sweating, the tongue
moist and cleaning, the bowels (luiet, the abdominal tenderness much diminished, but still acute in the riglit iliac
and hypogastric regions. On the 29th some ajipetite was manifested. The teeth anil gums were clean on NovemI)er 1.
Micturition was free and natural on the 4th, but for .some days after this he had at times much pain in the jienis
and bladder. On the 9th bed-sores are mentioned ; the skin was hot and dry ; the tongue dry, smooth .and fissured;
the bowels were quiet, but tenderness continued in both iliac regions; the appetite was good. No further record
was made except that ou the 20th the patient was transferred to Annapolis, Md. This case was treated with turpen-
tine emulsion on October 7th. Dover's powder on the 9th, acetate of ammonia on the lOtli, extract of bnclui on the
11th, and thereafter with quinine, opium and stimulants.
Case 29. — Deafness and headache; abdominal tenderness and ti/mpanites, hut no movement except by castor oil ; rose-
cotored spots on the I2th to '2lst day : defervescence by free perspirations on the '27th, and convalescence on the 3fi(/i day. —
Private F. Klnssman.Co. I,3.")th Pa. Vols.; age 23: was admitted Oct. 30, 1801. Diagnosis — typhoid fever. His illness
began on Oct. 20, with chills and fever, anorexia and thirst. Ou the 31st he was very weak and did not sleep, tho
eyes dull, cheeks tlnshed, pulse 8."i. skin hot, chest and abdomen covered with a profuse rose-colored erujition, tongue
red at the tip and edges but coated white in the centre, teeth covered with sordes; he was deaf and had tinnitus
auriuni, anorexia, thirst, extreme tenderness of the abdomen and tympanites althougli but one stool was passed;
there was also some <-ough. Quinine and turpentine emulsion were jircscribed. Next day the tongue became dry in
the centre; on thi-2d there was epistaxis, and on the 3d headache and inability to sleep, the tongue having meantime
become dry. swollen and fissured at the edges. Beef-essence and milk-punch were prescribed, and as there had been
no movement of the bowels for some days, castor oil was given ; the abdomen was tympanitic and tender and gurgled
under pressure. The tongue became moist on the 6th, the skin moist on the 7th, but free perspiration did not occur
nntil the 16th, when the appetite returned. The headache became relieved about the 10th, at which time the last
crop of the eruption faded. The patient was able to be \i\> on the 25th. and was transferred to Baltimore on Dec. 3.
Except on thedayofadmission.no passage was obtained from the bowels of this patient without the aid of castor oil.
Case 30. — Delirium, diarrhtra and rose-colored spots; improvement daliny from the 38//i day, uhen the tongue became
moist.— Private .Andrew .Schick, Co. E, 1st Pa. Art., was taken about jVug. 20, 1801, with a cold; he sufiered for a
224 CLINICAL RECOKDS OF
week frniii dianlifoa with severe pain in the head, and fever which became aggravated in the middle of the day.
He was admitted Sept. 19 as a case of typhoid fever. The patient was stupid, deaf and delirious; the stools thin;
the right iliac region so tender that he objected to having the abdomen touched; the pulse 128, small and feeble;
the skin hot but soft and presenting an occasional rose-colored spot with sudamina on the neck; the tongue red
at the tip and gray in the centre and at the ba.se. A half-ounce of castor oil was given. Next day three stools were
passed, the skin was hot and dry, and there was much tliirst; otherwise little change was jireseuted. Quinine waa
given on the 27th. Next day there was less fever: the pulse fell to 9.5 and was stronger; the tongue was moist, but
the skin continued dry; the mind became clearer. The improvement progressed on the 29th. The pulse on the 30th
was 106: the tongue clean; appetite good; bowels quiet and natural. Whiskey-punch was given. The patient was
returned to duty November 1.
Case 31. — Date of onset unrecorded; rose-colored spots; delirium; chest complications interfere with defervescence
about end of ith week, and prolong the case for two or three ivceks. — Private Christian B. Krieger, Co. I, 4th Mich.; age
22; admitted Aug. 31, 1861. Diagnosis — typhoid fever. He was weak and feverish, and had diarrhcea, tympanites
and well-marked rose-spots; pulse 110; tongue dry and brown but red at the tip; teeth covered with sordes.
Brandy-punch, beef-essence and astringents were given. Next day he was slightly incoherent, and on September 4
delirious. The record does not again state his condition until the 13th, when tliere was fever with much thirst,
delirium, tinnitus aurium, muscie volitantes, a moist brown tongue and dry hot skin. Dover's powder, beef-essence
and brandy were given at this time. On the 15th, the patient's general condition remaining the same, liis pulse rose
to 106, his tongue became dry, and in the evening his urine was passed involuntarily. On the 16th the presence of
bronchitis was reported. Next day his tongue began to clean in patches, and on the 18th was moist, glos.sy and
nearly smooth, the appetite improved and the bowels quiet; but the delirium did not abate until the following day,
when in the evening it recurred, accompanied with abdomiual tenderness and tympanites, some cough, hurried respi-
ration, 30, and dryness of the tongue, which was protruded with difficulty. On the 21st he rested well ; his face was
pale and sunken but bright ; his tongue remained dry, red and glossy, and was slightly coated in patches ; the teeth
were covered with sordes; the cough continued; but the hearing was good, the bowels quiet, the urine normal and
the appetite good. Next day delirium was again added to these symptoms, and on the 23d some deafness and sub-
sultus tendinum. On this day the tongue again became moist, but dried on the 21th in the centre although remaining
red and moist at the edges. Turpentine emulsion was ordered. This condition continued until the 26th, when the
delirium became lessened, the face and lips pale, the expression anxious, the eyes clear and bright, the pulse 96,
the skin dry and husky but of natural temperature, and the tongue clean, soft and moist, but with some sordes
remaining on the teeth. Some perspiration is mentioned on the 27th as occurring on the skin for the iirst time in
the history of the case. Delirium recurred on the 29th, with slight failure of the appetite and cough, the tongue
remaining moist and the bowels undisturbed. After this the skin was natural, moist, or occasionally dry, the
tongue clean or slightly patched with yellow, the pulse from 72 to 96, the appetite good; but the bowels became
relaxed, yielding two, three or four stools daily. While in this condition he was transferred to Annapolis, Md.,
October 10. [This man ultimately recovered and was returned to duty with his regiment.]
Case 32. — Muttering delirium ; sordes; intestinal effusion ; rose-colored spots on Uth daij; petechite on loth ; pains in
the feet ; slight improrement on the nth, but record incomplete. — Private C. D. Emons, Co. D, 7th Wis. Vols.; age 18; was
admitted Oct. 30, 1861. Diagnosis — typhoid fever. He was taken sick about the 22d with diarrhcea, chills, weak-
ness and loss of appetite. On admission his face was flushed, pulse 100 and of fair strength, skin hot and dry, tongue
thickly coated, teeth black with sordes, breath very offensive; he had much thirst, relaxed bowels and some tender-
ness in the right iliac region, with borborygmus and tympanites ; he muttered in his sleep. Oil of turpentine, com-
pound catechu powders and whiskey-puuch were prescribed. Delirium became a prominent symptom for a few days,
during which the pulse was strong and slightly above 100, the face dusky, the eyes much injected and the tongue
red at the tip, blackened and fissured ; but on Nov. 4 the delirium lessened, the pulse fell to 86 : he slept well during
the previous night, the teeth and gums were cleaner and the skin was soft and presented a few rose-colored spots.
On the 5th the pukse was 88 and feeble; petechial spots appeared on the skin; the tongue was very dry and thickly
coated brown. The patient was drowsy and difficult to arouse; one stool was passed, and the bowels were tender
and gurgled on pressure. On the 7th the mind Ijecame clearer and the eyes were less injected, but otherwise there
was little change in the condition; he complained t>f pain in the feet. The record gives no further details. He
was transferred to Baltimore, Md., on December 3.
Case 33. — Muscular p)ains as a sequel of the fever. — Private Benjamin F. Reynolds, Co. K, 86th N. Y.; age 29;
admitted Feb. 18, 1862. Diagnosis — typhoid fever. On March 5 he was dejected and languid, complaining of rheu-
matic pains in the lower extremities; his skin was natural; pulse 90 and good: tongue moist and clean; bowels
unmoved. Stiffness and pain in the legs increased until the 10th, the bowels meanwhile requiring aperients for their
regulation. After this date he improved and was transferred to Annapolis, Md., on the 24th.
Case 34. — Date of onset undefined; mental dulness; eruption; sordes ; perspiration followed by delirium; improce-
meut, but record unfinished.— Friy ate Henry Klummer, Co. I, 35th Pa. Vols.; age 20; was admitted Oct. 30, 1861, as a
case of typhoid fever, presenting dulness of mind, dull and somewhat injected eyes, congestion of the face, a full
strong ])ulse beating 90 jier mbiute, a hot skin showing a few rose-spots on the chest and abdomen, a dry, fissured
and brown-crusted tongue, sordes on the lips and teeth, anorexia, thirst and some tympanites. Beef-essence, quinine
and tur])entine emulsion were prescribed. No change took place until November 2, when the skin was bathed in
persj)iration and some deafness was noted. Delirium set in on the 3d, on which day the patient had three stools.
The tongue seemed cleaning on the 7th and the delirium lessened, but the condition otherwise was as related. On
the 9th, after passing a better night than usual, he showed a return of appetite. Next day he was intelligent. On
THF, CONTINUKP KKVKKS. 225
till' mil till' ti)ii};m' was vvd ;it llif tip ami cU^is, diy anil liiowu in tim cuiilrt! and Iho skiu was hot, hnt tlio patii-nt
slept well, ha(\ a ;;o(nl appetite, and his bowels were (|niot. The leeord gives no fnrther details, lie was Iranslened
to Haltinioie, Sid., on Decemlier U.
(.'.V.SK 3.5. — G'u'inii a view of Ihr jiiiliail fur liii ilni/.-i (liiiiiiij lOuniliKcTiicf from ii jirotriKird iiUiick of firir — I'livale
Alfred (i. Rates, Co. A, Sd Mich.; a-je 21 ; lieeanie alleeled with typhoid lever in .June, lS(il, and was a<lniitled .Sept. 28.
lie fell pretty well, tint lie had some eongli with exjieetoration, and pain in the he.id, hack and limlis; his face was
slightly llnshi'd and his eyes dull ; pnls(> !lti, fnll and strong; skin hot and soft; tongno white in centre; appetite
snnill; howels iiniet hnt somewhat tender and tynipanilie. lie sh'pt jioorly the lirsl night, lint very well after that.
His tongne was more or less coated white or yellowish in the centre and red at the tip iind edges; his appetite
improvi'd. His liowels were not relaxed; small doses of lihie-pill and compound ixiraet of colocynth, castor oil
and sniphate of magnesia had to lie inescrilied to move them. .\l (Mie time he had some ditiiculty in mietnrition.
WIu'Ii transferred to .\nnapolis, Md., on October 10, his skin was of the normal temperature, tongne moist and
clean, appetite good and bowels ijiiiet.
C'.\SE 36. — Diliriiiiii ; diurrhaii ; rose-spots, rihiiTs and hcd-soris ; pneumonic compliailions deluij conealeseencc until
nfirr the iOth day. — Private George Felter, Co. H, Pth Pa. Vols.; ago 22 ; was taken sick abont Sept. I, 1861, and
admitted on the l!lth with typhoid fever. The notes of the ca.se on the 20th are: jinlse i)6; skin hot and dry; high
fever; tongne coated white in centre, red al lip aiul edges, slightly moist; acnte iliac tenderness; tympanites; con-
stipation: e:ilargement <if the thyroid gland. Ordered: iMU'ina of .s<iaiisnds ; emulsion of tnr]ieiitine ; Dover's pow-
der at night. On the 21sl : pnl.se 120, fnll and soft ; skin hot and moist,; tongne daik -red at the margins, dry and
brown in the centre; characteristic rose-spots: no sndamina: less tympanites; tendiMin'ss of alidomen on pressure;
borboryginns ; snbsnltns; delirium; drowsiness: deciiliitns ilorsal : rispiration 30. (iave wine whey four times daily
with beef-essence. On the 22il, morning: delirinm; snbsnltns: pulses 118, full and soft; few rose-spots; skin hot
and dry; tongne very red and nuiist ; respirations hurried; snbmneons and sibilant rales in upper part of both lungs ;
tleenbitns dorsal; acute general abdominal tenderness: tymjianitcs less; borborygmns; one stool. Ordered: one-
funrtli of a grain of inorpliia; cold ajiplications to hea<l. Kvening: pulse 120; face Hushed; skin hot and dry;
tongue dry; rose-spots; high fever; delirium : deafness. No change took place until the 2lth, when there was some
diarrhiva. On the 25th the tongue became slightly moist and cleaner, the delirium gave place to dulness, vibiees
appeared on the chest, the urine and fieces were passed involuntarily and a large bed-sore formed over the sacrtiin.
The tongne became again dry on the 2(ith, and the lungs were found con.solidated in their lower ]iortions. On the
27tli tin' pulse was 113 and strong, the lace flushed, the skin hot and ilry, the respirations 10, with snbinucovis and
sibilant rales in the upper part of the right lung and a short dry cough. A blister was applied to the npiier part of
the chest. The bowels were (iniet on the 28tli. The tongne became moist on the 2i)th, red at the tip and gray in
the centre; the skin was warm, dry :ind soft; the bowels were qnii't, lint there was tenderness on both sides, w itli
tympanites and borborygmus: the .sacral sore was healing and the jialii'iit rational. The chest was again blistcri'd ;
tonics .'Mid stimulants were administered. The stools became involuntary on the 30th, with acute right iliac tender-
ness and some anxiety of expression ; ]iulse 106; surface circulation sluggish; respirations 10; some cough and much
dyspniea. The p;it lent became restless on Octobi'r 1. \ibices ap|ieai<'d on the abdomen on the 2d ; some diarrlnca
occurred, the stools lieing involuntaiy; delirinm (x'casionally returned at night. On the Ith there was sonui improve-
ment in the chest-symptoms. I In I lie 7th the face was slightly flushed; the pulse IM, steady; the skin hot and dry,
moist in some places: the tongue moist, red at tip, coated in centre; the bed-sores showing points of granulation; the
stools involuntary at long intervals, with borborygmus and some tympanites but no tenderness; micturition invol-
untary. On the 8th, 9th and 10th the pulse fell respectively to 108, lOfi and 100, one or two stools o(^curring daily
with some tenderness — the skin luniiuiiing lint Miid dr\. but the tonglu^ becoming cleaner and its edges moist. On
the lOtli the eyes were bright and the countenance <liccrful. The piilsi^ fell to 90 on the 11th; the condition of tin'
tongue improvi'd and the appetite returned. On the ITtli the tongue was clean and moist but rediler than natural;
the bowels were regular: the appetite good: a slight cough yet remained. The record, which is continiiedin detail
up to the 27th, shows the occurrence of an occasional thin stool but the tongue preserved its clean and red condition,
the appetite was good and the sleep sound at night; no further reference is made to I lie licaliiig of the bed-sores.
This patient was transferred to hospital at Alexandria, Va., December 20.
C.\.SE 37. — Skin iirnerallij moist and intestinal siimptoms not iiroiiiin( nt: some delirium and pulmonari/ troulile; crops of
rose-eolored spots from Villi to 3]st diiji; conriilesccnee on the'Allh day. — Private Martin A. Stowell, Co. A, 3d Vt.; age 21 ;
was admitted Oct. 1, 1861, having been sick since September 21 with pain in the head, back and limlis, and diarrhira,.
Quinine had been taken. On the day after admission he was looking natural although his face was somewhat con-
gested; pulse 100, full and strong; skin hot and moist; tongue moist, white at the edges, dry and brown in the
centre: he had some headache and abdominal tenderness. Spirit of nitre, camphor and tincture of iron were ordered.
■\ six-grain dose of blue-]iill wa.s given on the following day, and repeated on the Ith, with two grains of extract of
colocynth. On this day there was some delirium : the tongue was moist and yellow coated and the skin covered with
perspiration. This was followed by freiiuent stools on the ."ith, but the diarrhiea did not persist. During the remain-
der of the patient's sickness the bowels were moved twice daily for two weeks and once daily thereafter to the
ivrminalion of the record. Rose-spots appeared on the chest on the titli, the tongue became red at the margins and
lirown-coated in the centre, and there was slight tendiMiiess in the right iliac region. More rose-spots erupted on the
8th: the tongue became dry, red and cracked, and there was tenderness in the left iliac and umbilical regions w ith
borborygmus. On the Ilth a few rose-spots appeared. On this day turpentine emulsion was prescribed. Deliriiiiii
returned on the 13th and continued at times until the IXth.iln ring which time the tongue, skin and jiiilse were unallereil,
although a slight cough was develo|ied. Hut on the 18th the tongue became slightly moist, and next day it was
Mkii. Hi.st.. Pt. 111—29
226 CLINIOAL REOOKPS OF
moist auil clean, the pulse 72, regular, the skin of natural ttniiicrature although still showing, some rose-colored
spots, the appetite good, the abdomen tender and tympanitic over the transverse colon. Some rose-spots appeared
on the 24th. On the 30th the patient was dressed and sitting iij). On November 1 he was transferred to Annapolis,
Md. [whence he was discharged on the 29th because of debility].
Case 38. — Dcliriitm and roxc-colorrd spots on thf Qlh and foUowin;] dai/s; intestinal si/nqttoms not si fire. A favorable
change on the 16/A dui/ is interrnjttcd hy the occurrence of jtneKnioiiin; improrenient on the 3'2d day. — Private Hiram Billing-
ton, Co. F, 2d Me.; age 29; admitted Oct. 7, 1861. Diagnosis — typhoid fever. He was taken with headache on Oct.
1 and with pain in the back on the 3d, but had no chill, diarrho-a nor eruption. On the evening of the 7th he was
somewhat dull, his face flushed dark-red, i)upils dilated, head hot and painful in the temporal regions where the
arteries throbbed strongly; tongue red at the tip and coated in the middle; skin hot and moist; he had pain in the
back, slight congh, abdominal tenderness and slight relaxation of the bowels; pulse 100. Cold water was applied
to the head and live grains each of calomel and jalap given at once. Next day he had two thin stools, his tongue
was cleaning and his pulse lowered to 90, but to the headache, flushed face and other symptoms of the previous day
some deafness was added. Quinine was ordered. The dilatation of the pupils continued on the 9th with increasing
dinmess of vision and nuiscic volitantes ; the patient muttered in his sleep, and even when awake his mind was at
times disturbed; he had a dry cough and pain in the chest, bnt lii.s respiration was not accelerated; his bowels were
nujved twice, and he had acute tenderness in both iliac regions but no borborygmus nor tympanites; his skin was hot
and moist and showed a few rose-colored spots on the chest and abdomen ; his tongue was ijuite red, moist and clean,
and he had anorexia and great thirst ; pul.se 88 ; urine chemically and microscopically nornuil. He was very drowsy on
the loth and had violent delirium in the afternoon. Next day a few more rose-spots came out, the skin became n arm
and dry and the tongue very dry, hard and fissured; two thin stools were passed w ith gurgling but no tympanites.
On the 12th the red spots had become darker in color ; there was less delirium, but the eyes were somewhat suffused and
the expression stupid. Turpentine emulsion and spirit of Mindcrerus and of nitre were given. On the 13th the
mind was clear and the countenance natural, but there was some dizziness at times; iiulse 80, steady; skin soft and
warm ; tongue dry in the centre, moist at the edges, quite pale and slightly coated ; the anorexia continued, but the
thirst was lessened; three stools were passed. The bowels were moved but once on the 11th and were ([uiet on the
loth, on which day a few more rose-spots appeared. During the night he slept well, and on the lt)th the skin was
moist and warm ; the tongue cleaning from tip and edges but still coated in the centre; the bowels continued quiet.
Citrate of iron and <iuinine was given. During the ten days which followed there was but little change in the
patient's condition ; the bowels were (juiet or moved once daily, with more or less of tenderness ; the skin was warm
and moist in the day-time and frequently bathed in pers]>iration at night, and the tongue was moist; but on the
25th, after a sleei>less night, the tongue became dry and fi.ssured, and complaint was made of cough and pain in the
pracordia, near n hich submucous and sibilant rales were heard. A blister was apjilied, and on the 27th one drachm
of Epsom salt and a half grain of tartar emetic were given three times daily. Next day there was mucous expectora-
tion withdulness over the lower i)art of the left lung, and the patient bt^came delirious. Brandy -punch was substi-
tuted for the tartar emetic mixture. On the 29tli the jiatient was very drowsy, moaned frequently and muttered in
his delirium; his tongue was coated with scales, dry in the centre, pale and moist at the edges; the teeth and gums
were thickly covered with sordes; the skin was hot and moist; pulse 96; respiration 33, short, quick and somewhat
labored ; riiles were heard in the lower jiarts of the lungs, and to a less extent in the upper parts ; the expectoration
was rust-colored; the bowels were moved twice and were tender and tympanitic. Calomel and opium in repeated
doses were ordered on the 30th. On the 31st there was much cough with rusty sputa. A slight improvement was
manifested on November 1. He slept well during the following night, and on the morning of the 2d looked bright
altliuugli very weak; some thirst continued, but there was a slight appetite, and the teeth, gums and lips were
clean ; the tongue was moist, deeply fissured and covered with white patches; the urine contained a trace of albu-
men. Slight salivation occurred on the 4th, on which day the urine was found to be normal. The last entry with
regaril to the case, dated on the 7th, shows the patient as having rested well during the preceding night and as
l>eing bright and cheerful at the morning visit, the pulse 88 and of good strength, the skin soft and warm, the
tongue soft, moist, fissured and coated ; some cough continued and the bowels were moved twice, l>ut there was no
tenderness. He was transferred to hospital at Alexandria, Va., on December 20.
C.\SE 39. — Pneumonia occtirrinij after the appearance of profuse pernpirution and rose-spots. — Private Warren G.
Butler, Co. I, 2d Me.; age 22; was admitted March 2,1862. Diagnosis — pneumonia. This man had measles with
severe sore throat in September, 1861. On the 4tli he had headache and deafness ; his cheeks were flushed and hot;
])ulse weak and ra])id; skin hot and moist, showing on the abdomen some erui)tion, which disappeared on pressure;
tongue dry and coated; two watery stools were passed; cough was troublesome, the respiration natural. Next
day there was profuse perspiration and great thirst, the tongue renuiining dry and coated; the bowels were con-
stipated and the patient suffered from tormina and frequent nausea, tinuitus aurium and dizziness; the breathing
liccame rapid and the cough aggravated. Ten grains of calomel were given with three of jalap. On the following
day there was much tendency to stupor; four watery stools were passed during the night, after which the bowels
became quiet. Little change occurred during the next two or three days. On the 10th profuse perspiration occurred ;
the expectorated matters were exceedingly viscid. Milk-punch, cod-liver oil and carbonate of ammonia were given.
On the 11th the skin was natural, the pulse rapid and weak, the tongue moist, clean and tremulous, but the appetite
remained poor ; three watery stools were passed and the cough continued. During the next two days the quantity
of the sputa diminished. On the 13th there was occasional nausea, and on the 14th the deafness was increased,
although otherwise the patient seemed better, as the bowels were regular, the skin natural, the cough lessened and
the sputa less viscid and more frothy. The deafness increased until the 19th, after which it lessened; the cough
THE CONTINUKT) FF.VERS. 227
prevented slei-p at night and the appetite did not return ; the tongue was clean but uunaturally red iu cci.or. On
the 25th, the last day on which the symptoms wore entered, tlie appetite was improving. The patient was fur
loughed on Ajiril 8.
Cask Id. — J'niumoiiin j)rec(tUs tin- fthrilc attack, which is not characlciicid hij urerc symptoms. — I'rivate Elijah
Marsh, Co. ]J, 7th Wis. Vols., was admitted Oct. 30, 1861. Diagnosis — typhoid lever. On October 1) he had pain in
the bowels bnt no diarrluea. pain iu the chest and cough with rusty sputa. On the L'Ttli he had a chill I'ollowcd by
some fever, bnt without licadache or confusion of mind, cplstaxis or diarrluva. On admission the skin was husky,
tongue dry and smooth, teeth blackened, puKse 80; there was dilliculty of swallowing from soreness of the faiu-cs; he
hud two thin yellowish stools with acute tenderness in the right iliac region, but no tympanites nor gurgling: he had
little appetite and was very weak; some cough was also present. Turpentine emulsion and whiskey-punch were
prescribed. Next day he had soreness in the bones, occasional dizziness and mental dulness. On November 1 the
tongue became moist, clean at the tip and edges but covered with a grayish fur at the base: on this day he expec-
torated some blood. There was some headache on the 2d; but the patient slept well on the 3d, aiul next day there
was moisture and sudaniina on the skin, while the tongue had again become dry and brown and there was much
abdominal tenderness: two stools were obtained on this day by uu'ans of castor oil. The tongue on the 6th becanui
again moist and clean at the tip and edges and the skin dry ; two oH'cnsive stools were passed ; there wits some cough
and the resjurations at this time were increased to 31 per minute; two rose-colored spots were discovered on the
chest. The record gives no further details, closing « ith the statement that the patient was returned to duty on
December 1.
Case 41. — Increasing drowsiness ; deafness; delirium; relaxed howels ; no eruption. Killed on the 12th day by spri/iging
from a window to the ground. — Private Henry Hickman, Co. Ii.83d Pa. Vols.; age 20; was admitted March 2, 1862. Diag-
nosis— typhoid fever. He became sick on February 23 with headache, chilliness, cough and pains in tlii' limbs, for which
Epsom salt was given. On admission he had much pain in the right side ; he slept fairly at night, but was drowsy
during the day ; he had much thirst, slightly llushed cheeks, dejected countenance, full and rapid pulse, hot and dry
skin, a moist tongue coated in the centre and one thin scanty stool ; liis respiration was hurried. A blister was
applied over the right lung; three lifths of a grain of calomel and one-tenth of a grain of opium were given every
hour. The drowsiness increased on the 5th and there was some deafness. Twenty-four grains of quinine were
directed to be taken during the day. He became delirious on the 6th, aud at night rose from bed, sprang from a
window and was killed l)y the fajl.
Case 42. — Deafness; delirium : diarrhoea ; cough ; eruption ; death on 20th day from })ulmonary congestion. — Private
C. A. Hartlette, Co. H, 5th Vt. Vols.: age 23: was adnutted Nov. 1, 1861. Diagnosis — typhoid fever. His illness
began about October 15 with pain iu the back and limbs, aiu)rexia and diarrhiea. On Novcml>er 2 he was wakeful,
his eyes dull, face c<iugested, pulse 100, skin hot and dry, showing the characteristic eruption, tongue dry, red at the
tip aud edges and coated yellow in the centre; he was very deaf and had buzzing in the ears, much right iliac ten-
derness and some cough with yellowish sputa. Next day he was stupid and delirious, frciiueutly :ittemptiug to
leave his bed: his i>ulse was impercejilible and his breathing laborious. He died on this day. Turpentine, milk-
punch and beef-essence were prescribed, with sinapisms to the abdomen.
Case 43. — Delirium; diarrhaa; iliac tenderness ; no rose-colored spots; coma; death on 29th day. — I'rivate William
Etzel, Co. C, 2d Pa. Cav.; age 2it; was admitted Nov. 5, 1861. Diagnosis — typhoid fever. He had been in good health
until October 22, when he was seized with chills followed by fever, epistaxis, pains iu the back and limbs, lassitude,
anorexia and thirst. On the 6th his countenance was anxious, eyes dull and sutfused, face congested, pulse 1)5, skin
hot, tongue slightly moist, red at the tip and edges, coateil white in the centre, appetite gooil, thirst cousiderable;
he was somewhat deaf anil spoke in a whisper; one stool w.is passed during the previous twenty-four hours, and
there was much iliai' tenderness with some tympanites: the respirations were 20 per minute aud there was some
cough. Oue drachm of emulsion of turpentine was prescribed, to be taken every four hours. On the 8th the tongue
was dry aud yellow in the centre an<l the teeth covered with sordes; he slept well aud had a good a|>petite.
He liecame dull and stupid on the 10th and had three stools with much tenderness and tympanites, but no cough.
On the 16lh he was delirious aud <i>nstaiitly picking at the bed-clothes. The diarrhn-a continued, the tongue being
moist and yellow-coated, pul.se 90. skiu hot ; coma supervened, followed by death on the 19tli.
Case 44. — Date of onset not defined; diarrhiea; headache; wakefulness ; mental dulness; eruption; cough; iuflam-
matioH of parotid: death 13 days after admission. — Private John Kueuzle, Co. I, 35th Pa. Vols.; age 21) ; was admitted
Nov. 5, 1861. Diagnosis— typhoid fever. He had been attacked some tinui before with chills followed by fever, head-
ache, anorexia, thirst aud diarrluea. On the 6th he was wakeful, eyes suffused, cheeks slightly injected, pulse 100,
skin hot and showing a fi-w ro.se-spots (ui the chest, tongue dry and coated brown in the centre, teeth black with
Bonles: his a|ipetite was jioor aud he had slight headache and tcmlerncss in the parotid region; the bowels were
relaxed and tin- abdonu-n tympanitic. Emulsion of •urpentine was given every four hours; twelve grainsofiiuiniue
and astringents were ordered, with Dover's powder at niglit Next day the tongue was retl at the tip ami edges,
brown iu the centre anil slightly moist: the i|uinine was repeated. He continued iu this condition and under treat-
ment by i|niiiine until the loth, when .some cough was recorded. Next d,-iy he was dull nu-ntally, aud the cough w.is
acconi]iaiiied with white frothy sputa. No further details are given. He died on the 17tli.
Cask ir>. — Diarrhna ; cough; sordes; rose-spots on Hth day, succeeded by others on the llth, \ith and 17//( days;
deafness; delirium: epistaxis; otorrhiea on 22d day, with relief to all symptoms; death from pneumonia iiu the '.ilst day. —
Private Z. McLaughlin, Co. A, .3d Pa. Cav.; age 18; was admitted Oct. 20, 1861. Diagnosis— typhoid fever. He
had lieen healthy until Oct. 14, when he was seized with chills followed by fever and sweating. On admission he
had epistaxis. diarrhuia, anorexia, thirst and cough. Next day his eyes were dull and slightly injected ; pulse ill and
228 CLINICAL RECORDS OF
quick; skin hot and dry, presenting a profusion of colored spots on the chest and some on the abdomen; tongue
slightly moist, red at the tip and edges but coated white in the centre; lips l>lack with sordes; two stools were passed
during the twenty -four hours; there was some meteorism and also a slight cough. Tincture of iron was prescribed.
Next day eight stools were passed, and there was some cough with expectoration of tenacious mucus. Turpentine
emulsion, lead, tannin and opium were prescribed. The diarrhoea, which was attended with much tympanites,
became checked in the course of a few days and the bowels thereafter remained quiet or with notmore than one
movement daily; the skin continued hot and dry throughout. Fresh crops of rose-colored spots appeared on the
24th, 26th and 30th, and were reported on November 2 as lading and unelevated; but on the 3d and 5th the chest is
noted as covered with sudamina. Deafness was recorded on October 2t; buzzing in the ears on the 27th; cpistaxis
and delirium on the 29tli, the former recurring on the 31st and on November 3 and 4. On October 30 the patient
was kept from sleeping bjf the cough, and there was much delirium, deafness and tinnitus; at this time the tongue
was dry and its papilhv prominent. On November 1 the tongue was swollen, dry and lirown. On the 3d the deaf-
ness was very great, but a discharge occurred from the ear, and with this the tongue became moist and the deafness
lessened. On the 4th, when the last attack of epistaxis occurred, the pulse became so faint that it could scarcely be
counted; but the appetite improved. On the 5th the tongue was moist and yellowish, pulse 100 and feeble; there
was no abdominal tenderness and less cough. On the 8th the pulse was 105 and the respiration 22. Next day the
pulse was 120. Death took place on the 12th with pneumonic symptoms.
C.\.SE 46. — Dinrrluca; (lioic>iiius>i mid deafness; brmtchiaJ and pneumonic accomj)animents ; rose-colored spots on I'th
and rihices on 2otli day; otorrhtra ; pains in the legs; death on the 122d day. — Private Mark Warner, Co. E, 1st Pa. Ait.;
age 26; was taken sick Sept. 1, 1861, w ith pain m the back and bones, headache and chills, and was admitted on the
16th. Diagnosis — typhoid fever. On admission his pulse was 94 ; tongue smooth and dry in the middle, moist at the
edges; skin hot and moist; cheeks flushed; eyes dusky; bowels loose and tender; he had headache and was dull
mentally. Catechu was used. Next day the characteristic rose-colored spots appeared on the chest aiul alidonien
and sibilant and sonorous rales were heard over the chest, especially on the left side. Whiskey-punch and turpentine
emulsion were prescribed. On the 18th the patient was drowsy and had acute tenderness in the abdomen and tym-
panites, although the bowels weie quiet. An enema of soap-suds was administered. On the 19tli the skin was moist
and the mind less obtuse, the bowels loose, the tympanites reduced, but the tenderness was not lessened. The respi-
rations were increased to 30 on the 20th; bronchitic sounds were heard over the w hole of the chest, and a part of the
lower lobe of the right lung was consolidated. Dover's powder was given. On the 21st the pulse was 108, soft and
weak, skin hot and dry, showing a few fresh rose-colored spots; decubitus dorsal with flexed limbs ; tongue smootli,
glossy, dry; bowels relaxed, tender and tympanitic in the iliac regions; the patient was somewhat deaf, and com-
plained of pains in the limbs. Vibices appeared on the skin on the 25th and 29th, sudamina on the 27th. The tongue
became clean on the 26th and the appetite returned on the 30th, the chest symptoms meanwhile gradually becoming
relieved; the pulse, however, continued accelerated, 100 to 112. On October 7 a discharge from the ear was treated
with a solution of nitrate of silver; but it became more profuse and persisted up to the close of the detailed record.
On the 9th the patient sutfered much from pain in the legs, which were greatly emaciated; sponging with alcohol
gave temporary relief; this pain also continued to the close of the record on October 17. After this date the only
entry made was the announcement of death from typhoid fever on December 31.
Ca.se 47. — Severe diarrhira at the onset; delirium and great prostration; improrement on the 12th day coineident with
eruption and epistaxis; recurrence of severe Kym2>ti>ms on the 33rf day, and death on the 36th. — Private F. Taylor, Co. I,
2d Mich. Vols.; age 23; was admitted Aug. 16, 1861, with rheumatism. He improved rapidly till Sept. 6, when he
was seized with a severe diarrhcea, fever and pains in the head and bones. Sugar of lead, tannin and opium were
prescribed. On the 11th tinnitus aurium, musca' volitantes, slight deafness and headache were among the symp-
toms; the skin was hot and dry, pulse 116 and weak, tongue coated; seven stools were passed. On the 12th emiilsiim
of turpentine was prescribed. C)u the 13th the tongue was dry and brown and the patient muttered in his sleep.
He complained much of rheumatic pains in his bones; his bowels were moved five times during the night and nine
times during the day. Beef-essence and brandy were given. He perspired much on the 15th, and the urine passed
involuntarily. On the 16th he was very weak and had a cadaverous look; his tongue was dry, brown, glossy and
red at the tip; the diarrbira continued. On the 17th he was much prostrated, somnolent and inditi'erent to sur-
rounding objects, but the bladder was more under control and the stools less frequent. He had epistaxis during the
night, and next day the tongue becariie moist and clean in patches and some rose-colored spots appeared on the abdomen.
He was brighter on the 19th, free from delirium, but with some headache, dizziness and deafness; the tongue was
clean, dry, glossy and protruded with difficulty. On the 20th the eyes were bright, face pale and sunken, piil.se
90 and weak, skin warm and moist, tongue dry and brown but red at the tip and sides, teeth and lips clean; he had
some appetite; one stool was passed and the iliac regions were tender. He continued in this condition, the bowels
comparatively (juiet, — ^occasional headache, dizziness and slight deafness being the only cerebral symptoms until
October 8, when diarrhiva again set in with delirium, dulness, deafness, great prostration and profuse sweatiug.
ending in death on the 11th. A copious eruption of rose-spots appeared on September 24, vibices on the 28th, with
fresh and numerous outcrops of the latter on October 4 and 8.
Case 48. — I'rolable relajyse four months after primary attucl: Diarrhaa; abdominal tendirness: eruptions: sordes;
delirium: death.— Piivate William Boardman, Co. D, 1st Pa. Rifles; age 29; was admitted Oct. 10, 1861. He stated
that he had been sick since June, when he had an attack of enteric fever. On admission he had headache and was
anxious looking, his eyes dull, cheeks flushed, pulse 90, quick and feeble, skin hot and dry, tongue slightly moist,
red at the tip and edges, black and fissured in the centre; his appetite was fair. Dover's jiowder was prescrilied.
Next day he was reported as having had four movements of the bowels; his tongue had become white in the centre
THK CONTINUED .FEVERS. 229
and his skin covered profusely with an eruption tlie character of which is not stated. Punch and tincture of iron
were given. The eruption is mentioned on tlie following day and again on the 21st. During the ])rogress of the case
the bowels were relaxed, two stools being passed daily. The appetite continued good until the day of death. There
was great tenderness in the abdomen, which was at first especially marked in the left iliac region, but afterwards
became associated with various regions as the epigastric, umbilical, the track of the transverse and descending colon
and on one occasion the right side; the tenderness was usually accompanied by meteorism and gurgling. The skin
was hot and dry throughout excpt on one or two days, when it was reported as very dry but not hot. The tongue
was dry, red, fissured and glazed, the lips covered with sordes and the teeth with tenacious mucus. On the lUth
there was some headache with occasional delirium of a mild character, which afterwards became more contin-
uous. On the L'.Stl the jiatient is reported as having slept well as usual; his countenance was pale, face pinched, lips
parched, skin aiul tongue dry. pnlse !»."> and feeble, the abdomen flat. Turpentine emulsion, cod-liver oil and (juiuiue
were prescribed, lie died during the night.
Case 49. — IMapse. Head symptoms not marked; rose-spols from the ilst to the 59th day; vibices on 50th; bowel
affection not promunni until cessation of perspirations ; returned to duty in IGO days. — Private M. R. Taggart. Co. A, 9th
Pa. Vols.: age 34: was admitted Oct. 10, 1861, having bBen sick since Sept. 1 with what had been regarded as enteric
fever, for w liich quinine had been given. On admission his eyes were dull, face congested, pulse 110, ijuick and full,
skin luit and dry, tongue nu)ist, red at tip and edges, coated white iu the centre, appetite poor; he had some cough.
Dovers jMiwder was given, lie slept badly during the night and next day was stupid aiul dull-eyed; a few rose-
colored sjiols w ere found on the chest and many on the abdomen : the pulse was 100 and feeble ; his bowels had not
been moved. Tincture of iron was ordered to be taken three times daily and extract of senna in the evening. He
slept well, and on the uuirning of the 12th the pulse was found to have fallen to 90; the eyes were bright and the
flush had di.sappcarcil fnuu the face: the bowels had not been moved, but there was much tenderness in the right
iliac region. On the IStli the patient was covered with a profuse perspiration; pulse 120 and feeble; a slight epistaxis
had occurred and one stool had been obtained. Tincture of digitalis and sweet spirit of nitre were ordered to be
taken four times during the day. The perspiration continued on the 14th, and the appetite was found to be improved.
Five grains of <|uiniue were given every two hours. On the 15th the pulse had fallen to 90 ami was more regular,
the skin was hot but somewhat moist, the tongue dry. the appetite poor; the bowels had been moved twice. On the
nuuning of the Itith the skin was dry, but there had been a profuse perspiration during the night ; the tongue was red
and clean but dry. and the appetite poor: one stool was p.assed, and the patient was troubled with cough. Profuse
persjiiration recurred nightly until the 22d. On the 17th the tongue became moist and covered with w liite patches.
Next day a few rose-spots appeared on the abdomen : two stools were passed, and there was slight umbilical tender-
ness. On the 19tli the profuse perspiration continued during the day; the pulse rose to 120; tymi)anite8 and bor-
borygnuis were jire.sent but no stool waspa.ssed. Several rose-spots and vibices api)cared on the abdomen on the 20th:
pulse 8»); two stools were passed. The skin was soft and natural on the 21st, and next day the tiuigue was clean and
moist and the appetite good. During the following week an occasional nocturnal perspiration was noted, but other-
wise the condition of the patient was good. On the 29th some rose-spots appeared and three stools were passed.
Four stools were recorded cm the following day, and on the 31st nine stools, with dry tongue, heat of skin and accel-
erated pulse. Twelve stools were passed on November 1, on which day the patient was transferred to .Vnnapolis, Md.
[where his case was diagnosed typhoid fever, and terminated iu a return to duty on March 19, 1862].
C.^SE 50. — Diarrhaa ; rose-rash ; delirium; parotid inttamiiiatiou; coma rigil; return of consciousness before death at
rnd of third ircek. — See case of Private Oscar Snow, Co. H, 3d Vt., No. 31 of the post-mortem records.
C.VSE 51. — Chills: epistaxis: iliarrhaa ; tympanites ; rihiees ; deafness, but no delirium or notable cerebral implicutiun;
temporary improremint folluuid by bed-sores, and death probably from pulmonary engoryement. — See case of Pri\ ate Ueu-
jamin Cunniughani, Co. D, 86th N. Y.. No. 31 of iht' post-mortem records.
Seven Remittent Cases.
Cask 52.— Private ,Iames Brown, Co. B, 26th Pa. A'ols.: age 38; was attacked .\ug. 20, 1861, with headache,
chill and pains in the biuies, ami admitted Sept. 4 iis a ca.se of remittent fever, presenting constipation, anorexia
and epistaxis, with high fever, the pulse being 100, the skin moist and the tongue heavily coated and of a yellowish-
browu color. A dose of Kpsom salt was taken at once, and (luinine orderedthree times daily. The bowels were
moved twice during the night and once next morning, after which the pulse was found lowered to 60, the .skin
natural, the tongue pale, flabby and coated, and the abdomen sore. Dover's powder was given at night. The fever
ilid not recur. The tongue continued pale, flabby and somewhat coated, hut the appetite returned, and he was sent
to duty on the 11th.
Case 53,— Private James Baker, Co. D, 19th la. Vols., was admitted Sept. 4, 1861, having had a chill fol-
lowed by fever without diarrhoea. Diagnosis— remittent fever. On the morning of the 5th his pulse was 70; skin
moist and cool; tongue pale, flabby and slightly coated, and bowels loose from the action of Epsom salt; he had a
dry cough with pain in the chest. Quinine was given. In the evening there was some heat of skin, but otherwise
the condition of the patient was unchanged. The cough was somewhat troublesome on the 6th, but there was no
fever. The tongue continued jiale, flabby and more or less coated, but the appetite returned and on the yth he was
able to walk about. His bow els did not remain loose after the purgative action of the salt had ceased. No eruption
appeared on the skiu. He was returned to duty on the 14th.
Ca.se 5-1.- Private Frank Teats, Co. C. 5th N. V. Cav.; age 22: was taken sick Sept. 19. 1861, w iili gi.Uliuess,
chills, epistaxis and pain iu the back, and admitted on the 23d as a case of remittent fever. His face was flushed,
230 CLINICAL RECORDS OF
eyes siift'used, pulse 85, quick and strong, skin liot and moist, tongue sliglitly wiiite in the middle and red at the
edges, appetite lost, liowels unmoved. He had headache, a slight cough and hurried respiration, 25 per minute.
A small dose (one and a half drachms) of sulphate of magnesia with one-eighth of a grain of tartar emetic was given,
and Dover's ])0wder ordered to be taken at bedtime. He rested well, had one stool during the night, and next morn-
ing his countenance was natural. In the evening the face was again flushed, the eyes dull, pulse 92, tongue moist
and white but with the papillie at the tip projecting; appetite small. He had headache, cough with difficulty of
expectoration, and a pain in the chest and abdomen from having taken capsicum by mistake. Six grains of (luinine
and three of Dover's powder were given every two hours until three such doses were taken. On the 25th there was
no fever nor headache ; the skin was warm and moist, the tongue moist and coated light brown, the pulse 98; the
bowels were moved once; there was epistaxis at night. Next day the ]>nl.se was 78, and there was one stool with
gurgling in the right iliac region and dysuria, but the cough had ceased and the appetite had returned. Extract of
Imchu was given. He was returned to duty on the 30th.
Case 55. — Private Samuel Cunningham, Co. H, 12th Pa. Vols., was taken about Sept. 1, 1861, with weakness,
headache, nausea and pain in the bones, and wa^ admitted on the 5th as a case of remittent fever. His tongue was
flabby, white-coated and red at the edges, pulse 90, face flushed, skin moist and hot, bowels constipated. His fever
was reported to be worse in the morning than in the e\ ening. A dose of Epsom salt was followed by six large thin
stools. Quinine was given. Next day he had two small stools, and on the 7tU his bowels were (|uiet. On this day
the morning pulse was 84, the evening 68, full on both occasions; and there was headache with flushed face, a pale
white-coated tongue and anorexia. Dover's powder was given at night. On the 8th the morning pulse was 66, the
tongue coated white in the middle, the face slightly flushed and there was some giddiness. In the evening the pulse
had risen to 71, the tongue was clean, and an eruption, stated as owing to the poison of the rhus toxicodendron,
appeared in confluent patches. After this he rested weii and had no fever. Bicarbonate of soda was applied to the
eruption, which faded in four or five days. On the 12th the patient's appetite was good and he was walking about.
On the i;ith he was transferred to hospital at Baltimore, Md.
Case 56. — Private John Hoadley, Co. B, 12th Pa. Vols., was taken with headache and pain in the bones about
Aug. 29, 1861, together with a daily recurring chill and fever, and a diarrhoea causing about six stools daily. He
was admitted September 5 as a case of remittent fever. The tongue was pale, flabby and coated, the face flushed,
the skin warm and moist, the pulse 86, the bowels loose. A small dose of tincture of opium was given. Next day
((uinine was ordered, with Dover's powder at night. He had no chill after admission, but there was an evening
exacerbation of fever, which on the 9th and lOth was accompanied by drowsiness and stupidity. On the morningof
the 11th the remission was very marked, and in the evening the appetite became improved. On the evening of the
12th the tongue, which had been flabby and coated hitherto, became clean. The bowels were relaxed throughout
the attack, but there was no tenderness except on the 9th, in the umbilical region. On this day also there was a
slight ciragh with a stitch in the right side. The diarrhcea abated with the decline of the fever and the cleaning
of the tongue. The patient was transferred to hospital at Baltimore, Md., on the 13th.
Ca.se 57.— Sergt. Byron Ilinman, Co. U, 24th N. Y. Vols.; age 24; was admitted Sept. 25, 1861, with remittent
fever which he had contracted about four weeks before. He had headache with flushed face, suti'used eyes, a (|uick
pulse, 82 i>er minute, and a warm but moist skin, a slight cough, anorexia and moist yellow-coated tongue. A six-
grain dose of blue-pill was ordered, with Dover's powder at night. Next day there was some umbilical tenderness;
sixteen grains of quinine were given in the forenoon and a small dose of castor oil; two stools were passed. On the
27th the face was not so much flushed and there was some return of appetite. The patient was dizzy and in the after-
noon had a free perspiration. The quinine was repeated on the 28th, but the headache, anorexia and foul tongue
were not removed until October 1, after a second mercurial dose with castor oil. He was returned to duty on the 9th.
Case 58. — Private H. Hardridge, Co. F, 6th Wis. Vols., was admitted Oct. 30-, 1861. Diagnosis — remittent fever.
Since 0(!tober 23 the patient had headache, weakness, pain in the back, some loss of appetite and much thirst. On
the day of adnussion he had a slight chill followed by fever. Quinine was given. He rested well but not until
after midnight, and next morning the skin was warm and nuiist but jaundiced, and the tongue soft, pale, moist and
coated, the pulse 86 and bowels quiet. Calomel and morphia were given three times during the day. Quinine in
six-grain doses three times daily was substituted on November 1 and continued until the 7th. The patient was
returned to duty on the 15th.
Thirty-five Typhoid Fever Cases with more on less Evidence of the Existence of Malarial Affection.
Case 59. — Relapse manifested hi/ tliarrhau, eruption, wakefulness and increased temperature. — Sergt. George M. Cook,
Co. 6, 3d Mich. Vols.; age 23; was admitted Oct. 19, 1861. He had previously suffered from rheumatism, inteimit-
tent fever and enteric fever, and while convalescing from the last, about October 14, he was seized with a chill
followed by fever and perspiration, wakefulness, thirst, diarrhoea and pain in the bowels. His case on admission
was diagno.sed tyjihoid fever. On the 20th he was wakeful, his eyes dull, cheeks not flushed, pulse 66, full and strong,
skin somewhat above the natural temperature, tongue red, slightly moist and with a few yellowish patches in the
centre, apjiet ite poor : he had six stools with some general abdominal tenderness and tympanites. A few rose-colored
spots appeared next day, but otherwi.se his condition w.as unaltered. On the 22d he slept well; the pulse ro.se to 74
and was regular and strong; the skin was of the natural temperature; the tongue flabby and patched with a white
fur: the appetite continued poor and the diarrhoea active, the abdominal tenderness being more marked on the right
side. After this the diarrhffia grrdually lessened, the tongue became clean and the ajipetite good. Up to the end of
the month he was troubled with a slight cough with yellowish expectoration. He was returned to duty Nov. 7.
rilK CONTINUED FK\-ERS. 231
Case 60. — Liiilil frhiilc nlliul; follouiiig intcnnitlntt fiver, hiil iwl iiijliicncad sj)eciall!i ^!l "'" action of llii- maltiriiil
poison; dvhilili/, liiowsiiwaa iiml diarrhwa. — Teamster Edward C. Led ley, 2d Micli.; age 23; had cliills and fever with
diarrhoea since the middle of August, 1861, bnt attended to his duty as an anihulance driver until September 6,
when he was admitted as a case of typhoid fever, presenting chills, increased local and general heat, anorexia, mus-
cular dehility ami pain in the head and bones. On the Mth be was drowsy and had headache; pulse 78, tongue
moist, red at the tip anil brown in the centre, ajjpetite returning. Next evening the heailachc continued and he bad
two stools: but after this the bowels became regular, the skin moist and warm, the tongue moist and clean, the
pulse natural, the slec]) sound and the apjietite and strengtii improved. He was returni'd to duty on the MOIli.
Dover's powder and turpentine emulsion, with <iuinine towards the end, formed the medication.
Cask 01. — I)i:;iiiiss. if(ikifiiliiix!<, runi'-culond xpolx iind (liitrrhiia ; inij>rofcmrnt ahoul end of 2d wick. — Private A.
A. Rich, Co. (i. .">tli Vt. \'ols.: ago 17; was admitted Nov. 1, INil. Diagnosis— debility. He bad been sick about a
week, first with chills, afterwards with fever. On admission he was wakeful and had headache, dizziness, buzzing
ill the ears, amirexia, thirst, vomiting, diarrluea an<l cough. Next day the wakefulness continueil; pulse 100, quick,
full and firm: skin hot and presenting a few rose-i oloriMl spots on the chest: there was slight headache with tinnitus
aurium; the tongue was slightly moist and furred while, but red on the tip, edges and central line; the a])petite was
good, but there was considerable thirst; the bowels wore slightly rela.ved, tympanitic and tender on pressure in the
umbilical aud left iliac regions; there was also some cough with frothy sputa. Ifo slept well during the following
night, and on the morning of the 3d the pulse was reduced to XO, but otherwise the symptoms lontinued as alreatly
stated. TieatnuMit was by snlpliate of quinine and astringents. On the 0th the diarrliu'a became suddenly aggra-
vated, five stools having been pa.ssed in tin' twenty-four hours, accomjianied with abdominal tenderness and gurgling.
Next day three stools were jjasscd anil on the Xth one stool. Improvement was i)rogressive after this, but on the
ISfh, when the |iatlent was transferred to Baltimore, Mil., there was still some beat of skin, with slight abdominal
tenderness and some cough. (He was returned to duty .Ian. 27, 1M02.1
Case ti2. — N7i;;/i( diiinhmi : di:ziiiexs: rosi-xj/ots on Wlhthiii; improreminl til end of 2d nnk.— \'i\\;\ti.' (ieovgeW .
iMney, Co. .\,4th Mich.: age IS; became sick about Sejit. 0, 1M6I, with weakness, head.icbe, diarrlnca and slight fever
without chills, ami was admitted on the 16th. Diagnosis — tyi)lii>iil fever. He bad ejiistaxis; his pulse was 70 and
full: skin warm and moist; tongue pale, flal>by .and slightly coated white; bowels quiet. Ten grains each of calomel
and jalap were jirescribed. He had three passages from the bowels during the night, and next day the skin was
warm aud sweating. Rose-colored spots appeared on the ISth, and the tongue began to clean; there was some
dizziness but no mental dulness; two thin largo stools were passed, aud there was tenderness in the right iliac
region. On the 19tli the pulse was 70; tongue tremulous, pale at the edges and coated in the middle ; bowels quiet ;
skiu hot aud moist. Quinine was given. Next day the skin was natural ; there was no tenderness nor tympanites;
the countenance was |>Ieasan1 and the eyes bright. A few dark rose-colored s))ots ap])eared on the 22d. The bowels
remained quiet until the 23d, when they were moved .seven timers, but there was no iiccompanying tenderness,
iiieteorism nor gurgling; the apju'lite was good, the tongue pale, gray in the centre but cleaning at the tip. Ojiiate
enemata controlled the diarrhiea and the patient inii)roved on tonics and stimulants. He was able to walk about
on October 1, when he was transferred to Annapolis, Mil.
Case 03. — Menial dnlnexs; rose-spnis on llie it//i din/, disiijipenrini/ nn Ihe 10(/i; hoieel iiffieHdn sliijlilh/ niitrkrd. —
Private .lolin Dickerson, Co. A, Itli Mich.; age 21; was t.iken about Sept. 0. 1801, wJtb pain in the bones, back and
head, fever which was said to be worst at noon, and diarrhiea. He was admitted on the lOtli. Diagnosis — typhoid
fever. In the evening the finer was slight; pulse 71 ; skin warm and dry; face flushed; tongue red at the edges,
coated yellowish at the ba.se and in the middle, moist and with prominent papil he; a bitter taste was felt in the month ;
one stool was passed during the day, and there was some umbilical tenderness. Two grains each of calonud and
jalap were given. Next day the ])ul.se was 70 and small; the skin dry; the tongue dry, licavily coated and brownish ;
the cheeks Hushed ; the patient was weak and dull ; his bowels had been moved once ; a few characteristic rose-spots
were seen. . Quinine was ordered. During the next week there w.as little change in the patienfs condition ; his eyes
were injected and half clo.sed and he was dull and drowsy, answering questions in a low tone; the face was flushed
aud the skin hot. dry, husky and profusely spotted with the rose-colored eruption ; tlie tongue, heavily coated and
brown, became moist on the litth: the bowels quiet and neither tender nor tympanitic; there was some headache
with dizziness at this time. On the 22il the patient was dull : his ])nlse 80 and feeble; face flushed ; skin hot. moist
and spotted : tongue red at tip and gray in centre ; he vomited once during the day and had one stool. Next day the
pulse was 82 and weak, the eyes sufl'uscd, the skin warm and moist, the tongue gray in the centre and red at the tip,
the bowels quiet and not fender. On the 24th the pulse was 78, the skin warm and soft, the tongue nu)ist and
slightly coated gray, the aiqictite good. Wine was occasionally given. He was returned to duty October 24.
Case 64. — Onset obsciind hi/ presence of tonsillitis ; headache, deafncsa and tinnitus; disease marked chiejii/ bij abdomi-
nal sijmptoms: diarrhwa allernatiny irilh jjercjjira/ioHs.— Private G. W. Conger, Co. B, lOtli Ind.; age 20; was admitted
Sept. 4, 1861, with a high grade of inflammatory fever, presenting marked remissions and accompanied w ith flushed
face, bloodshot eyes, hot and moist skin, yellow-coated tongue, regular bowels, anorexia and slight tonsillitis.
Quinia and a gargle were ordered. On the 7th the fever lost its remittent character and was accompanied with head-
ache, dry tongue and frequent stools; pulse 80. Turpentine emulsion, beef-e^ence and milk were substituted for
the quinine. On the llth diarrhiea, tympanites and tinnitus aurium were noted; pulse 88. Dover's powder was
given at night. The patient rested well and had sonui appetite next morning; the bowels were quiet, but the skin
was hot and dry aud the jmlse 108; a slight eru|)tiou had api)eared on the penis and scrotum. In the evening the
pulse was 100. the tongue moist aud slightly coated: the ]);iticnt had two stools and some tympanites during the day.
The Dover's powder at night was continued. On the li'.th the liowels were regnbn ami there h;is some apjiitite;
232 CLINICAL RECORBS OF
pulse 75 and skin moist. On the 17th the tongue was cleaning, the appetite good, the pulse 80 and the bowels
regular. Dover's powder was continued. On the 18th the report is varied by noting abdominal tenderness with
one stool, and on the 19th by dryness of skin, the tongue continuing moist, slight deafness, cough, respiration
increased to 24 per minute and bowels tympanitic, slightly tender in the right iliac region and moved twice. Twelve
grains of (luiiiine were given. Copious sweating occurred during the night and svidamina appeared, the bowels
again becoming regular and the respiration natural. On the evening of the 22d pain recurre<I in the abdomen with
two stools, dryness of skin, some headache and increase of the pulse to 100. Next day two stools were again reported,
liut the skin had recovered its moisture and the tongue was natural. On the 24tli there was slight deafness but no
congh nor pain ; the tongue and skin were in natural condition and the appetite good. Again on the evening of the
26th, with an acceleration of the pulse and dryness of skin, there was abdominal pain with liorborygmus, followed
by free jierspiration during the night. From this date to October 1, when he was transferred to Annapolis, Md., the
patient slept well, had a good appetite, moist and clean or yellow-patched tongue and natural skin; but there was
more or less abdominal pain with from two to four stools daily.
Case 65. — Date of onset ohscured hi/ sequela; of measles; deafness and tinnitus auriiim; diarrhuu and rose-eohred
sjwts; convalescence. — Private C. Mills, Co. E, 6th Wis.; age 22; had measles in August, 1861, and about September 1
was taken with chills, fever, diarrho?a, cough ar,d headache, for which calomel and opium had been administered.
He was admitted October 1. Diagnosis — typhoid fever. Turpentine emulsion and astringents were ordered. He
slept but little, and next day was looking dull and had slight headache and congestion of the face ; pulse 90, (juick ;
skin natnral; tongue moist, heavily coated brown; appetite moderate; he had a bad cough with slight expectora-
tion ; three stools were passed and micturition was difficult. Cough mixture was given with small doses of 'ilue-pill
and opium every two hours. On the 3d the skin was nuiist and covered on the left side of the chest and abdomen
with a profusion of rose-colored spots. Next day deafness and tinnitus auriuni were noted. On the 5tli the pulse was
85, full, the skin cool and moist, the tongue moist and having a yellowish patch in the centre, the appetite poor;
one stool was passed, and there was some tenderness in the left iliac region; respiration was natural although there
was much cough and free expectoration. Four stools were passed on the 6th, six on the following day, and three
daily after this until the 11th, when there was but one; during this time the expression was dnll, the face somewhat
congested, the tongue moist, white and flabby, and the appetite poor. On the 11th the tongue became clean and the
apjietite good. Tinctnre of iron was ordered. He slept well during the night, and next day his eyes were bright,
cheeks not flushed, pnlse 90, regular, skin natural, tongne moist, slightly coated white, appetite good. (.)u the 14th
he was transferred to Baltinujre, Md.
C.\.SE 66. — Cliill and remUtiny ferer ; rose-spots on 12/A day; dronminess ; sordes; couijh ; diarrhwa and iliac tenderness ;
record unfinished. — Private J. M. Foster, Co. A, 6th Wis. Vols.; age 21 ; was admitted Nov. 1, 1861, as a case of typhoid
fever. Late in September he had measles, and on October 24 was taken with a chill followed by fever, weakness,
anorexia, pain in the back and bones, nausea, vomiting and diarrhiea, which continued up to the date of his admis-
sion. He said he felt better about noontime daily. On November 2 he was dull, his eyes slightly suffused, pulse 112,
(juick and of fair strength, skin soft and moist, tongue soft, coated in the centre and at the tip, teeth covered with
sordes; he had anorexia, much thirst and a diarrlio-a of four stools daily, with some abdominal tenderness and
some cough. Quinine in live-grain doses was given three times daily. Next day his condition was unchanged but
on the 4th the pnlse bccaflie reduced to 100 and lost its ([uickness and strength, the skin was hot and covered witii
minute rose-colored spots, the tongne moist and brown, eyes injected and the respiration labored. The patient
continued dull and drowsy on the (Jth, -and the diarrhtea persiste<l, with some tenderness in both iliac regions;
but the tongue appeared cleaner at the edges and the respiration was n.atural. On the 7th the pulse was 108 and
weak, the skin dry, hu.sky and covered with rose-colored spots, the tongue dry and brown, the gums and teeth
blackened, the bowels loose, tympanitic, tender and gurgling on pressure. The record leaves the ]iatient in this con-
dition on the 8th, and closes with the remark that he was transferred to Philadelphia, Pa., Feb. 15, 1862.
Case 67. — Headache; epistaxis; hehetude; ahdominal symptoms not marked; rose-spots on the 9th day, with jterspi-
rations and sudamina about the lieijinning of the 3d week, accompanijinii deferrescence. — Sergeant John Evans, Co. H, 12tli
Pa., had a chill on the morning of Aug. 30, 1801, followed next day by fever which increased towards evening, and
was associated with headache and pains in the bones and small of the back. To these symptoms, on September 2,
epistaxis, lassitude and a tendency to stupor were added; but the bowels remained regular and urination free. On
(he 4tli he was admitted to hospital as a case of typhoid fever : pul.se 78, skin hot and dry, tongue coated white, bowels
constipated and tender on pressure. Two grains each of compound cathartic mass and blue-pill weie given at
once, with sulphate of (|uinia, by which the bowels were moved three times. He rested well during the night, and
on the morning of the 5th his pulse was 80, skin warm and moist, but his tongne was dry, red, coated and flabby,
and he complained of pain in the limbs. During the day he had three small thin stools, and in the evening the
pulse was 72, the tongne red, flabby and coated white, the skin dry and warm; there was also some dizziness. A ten-
grain dose of Dover's powder was given. During the progress of the disease there was but little variation in the
pulse; it did not go over 80, and on the 11th fell to 64, coincident with a warm moist skin and the development of
an abundant crop of sudamina on the abdomen and shoulders. The skin was warm and generally dry, but sometimes
it felt moist; it was covered with perspiration on the 11th and 14th, after which latter date it was generally either
cool or natural. The tongue became brown-coated and dry on the 7th coincident with the occurrence of anorexia
and some obtuseness of the intelligence followed by drowsiness: it became nmist again, but very red and coated on
the next day, when also the appetite showed signs of return, and a few rose-spots were noted on the abdomen, with
slight tenderness and borborygmus in the right iliac fo.ssa, but it was not until after the apjiearance of the sudamina
on the 15th and 16th that the mental hebetude was removed. The bowels were not notably loose at any time save
THE CONTINUED FEVERS. 233
immediately after admission, as already related ; Imt there was a tendency to laxness, as t \vi> drachms of castor oil
ou the i'tli produced two thin stools: — on the other hand, ten grains each of cahmiel and jalap on the 14th, after
yielding three thin stools, created no further disturbance of the intestinal tract. Durin}; the nifjht of the Gth he had
a colic, which was relieved liy the application of nnistard. (In the Ititli, as a slifjhtly jaiindici'il hin> of the face was
apparent, small doses, two arains each, of Iilue-pill and iniinia were j^iveii with port wine three times daily. After
the 20th the patient did some lifjht duly about the waril, and was returned to his command October .">.
Case 68. — Mtiilal diilncs; norihs; rihinx; right Uiac and hepuliv liniJiTiicim, hut iio iliiinhiia nor rDxi-mJored si)ots;
impro,remint about Ihr end of the 3d iretk. — Private W. I'atcheii, Co. V, 74th N. Y. Vols.; age 18; was admitted Nov. 2,
18(>1, having been taken sick two weeks before with chills, anorexia and pain in the back. The case on admission
was diagnosed typhoid fever. On the 3d the patient was dull and 8tii|)id, his eyes siili'used, cheeks congested, pulse
100, skin hot and dry, tongue dry and clean, lips and teeth covered with sordes, ai)i)Htite lost; there was some
tenderness and gurgling in the right iliac region: twelve grains of (luinine were given at once, followed aftera time
by a half-ounce dose of castor oil and b.v turpentine emulsion every three hours. Next day one stool was passed; the
patient had some cough and hepatic tenderness, and vibices a|)]ieared on the (Oiest. On the titli he had tinnitus
anrium. On the 8th he seemed better; his tongue was red at the tip and edges and coated white in the centre; his
bowels had been niove<l but once since the day following his aihiiissioii. He inipnivcil gradually after this, and was
transferred to Baltinioie, Md., Decenilier 3.
C.VSK t>9. — I'lahbij loHijne: ijastric irrituhililii ; ricurriny rpixtaxis ; dlarrhaa and ijeniral alidominal li udfruess; head-
avhe : delirium : sordefi : prostrutitin ^ inftuniwatiou of parotid ; ro••^e'spot!t and r ibices ; dischtirtjed on atrount of ti/plioid fever, —
Private Patrick Devine, Co. K, 3d Vt.; age 18; was admitted Oct. 1, 18(!1, with typhoid fever. He had been taken,
September 26, with headache, chills, fever, diarrhani and epistaxis (which last had been of frequent occurrence during
the previous montlO, and on the 28th with retention of urine. On October 2 the patient's face was congested ; his
eyes dull and heavy; ])nlse 112, quick andstrong; skin hot and dry; tongue moist and coated brown; teeth covered
with sordes; stmnacli irritable and unable to retain food or medicine; he had headache ami ]iain in the back, with
tenderness *tver the whole of the abdomen ami slight borborygnuis. Kepeateil tloses t>f calomel and opium, with
turpentine emulsion, were given. Quinine, extract of bnchn and sweet spirit of nitre were administered on the 4th,
and beef-essence. milk-pMiich ;iiid astringents on I he tith, :is diarrlnea began to be a prominent symptom. On the 7tli
the pulse Avas !K) and strong, the skin natural, th<' tongue slightly moist, red at the tip and edges, heavily coated
brown and fi.ssured in the center and jit theb:ise; eight stools were pas.sed, and micturition was ditiicult. Rose-colored
spots ajqieared on the following day; there was some mental dulncss with headache and oc(^:isional ilclirium; cough
was tronblesiune, and the diarrlnea was accompanied with general abdominal tenderness which was especially acute
in the right iliac region. Epistaxis occurred on the lllh and next day the bowels were quiet. With the moderation
of the diarrho'a the tongue became llabby and reni;iined dry and brown-coated in the centre, although the appetite
improved. Epistaxis recurred on the 14th with .some headache and delirium : the tip and edges of the tongue became
red, the lips covered with sordes and the bowels relaxed to five stools daily. Next day the imse bled again, some
rose-coloreil spots apjiearcd, and the patient was unable to protrude his tongue on account of swelling of the
parotid gland. Epistaxis, |)rofuse perspiration and vibices on the neck and'chest, with headache and increased
swelling of the parotid, but no delirium, were noted on the 17th; the diarrhoea continued with geneial tenderness and
some meteorism, especially marked in the right iliac region. Vibices were numerotis on the abdomen on the 18th, and
fresh rose-spots appeari'il on the 20th, 22d, 23d, 2.")th and 28th: during these days the diarrlnea moderated, but the
tenderness continued, being sometimes general and at others specially marked in the umbilical and right or left iliac
regions; some heailache and cough were noted but no delirium ; the appetite was good, the skin generally moist, .and
the tongue moist and but slightly coated; the i>atient continued uiiabli' to ],rotrude his tongue. Epistaxis recurred
on the 28th and on November 2il, 4tli, (ith and 8tli, during which days there was s<uue heat ami dryness of skin, n itii
heaihiche and tinnitus, relaxation of the bowels, abilominal teiulerness and coated tongue, the appetite continuing
gooil and the eoi\gh subsiding; pnlsi^ 80 to 100. No change took place in his condition iij) to the bstb, wlicii lie was
transferred to .\nnapolis, Md. [whence he was discharged on the 2ilth on account of typhoid fever].
Cask 70. — Strcre diarrhira and abdominal j)ain ; free perspirations ; mental dulness; row-spots from l.^^/i to 'Mtth daij:
tongue tiabbii and !iellon--toated: improrrment in 'itli week. — Private Byron Steinback, Co. A, Ist Pa. Art.; age 21 ; became
alieeted on .Sept. 2.">, 181)1, with headache, pain in the back and limbs and diarrhcea, ou October 2 with chills and
fever, and on the Gth w ith epistaxis and some retention of urine. He was admitted on the itth, on the evening of
which day he was found to be weak, having had ten stools, with geiu'ra! :ibdominal tenderness an<l some retention of
urine; a few rose-spots were scattered on the che.st anil abdomen ; the faci' was slightly Unshed, the eyes injected ami
sntt'used and their lids closed, the skin of natural temperature, pulse 80, tongue moist, red at the ti|( and edges,
coated yellow on the ilorsum, appetite delicient; he had some cough and pain in the limbs. On the Idtli there was
nincli thirst ; the skin w as hot and dry ; four new rose-spots had appeareil ; the tongue w as moist and llabby, red at
the tip and edges ami heavily coated yellow in the centre; six stools were passed. Tincture of iron was given three
times daily. Ou the 11th the skin was covered with persi)iration, the rose-spots had increased in number, the bowels
were moved twice and there was tenderness at the umbllicns and in the iliac regions, markedly on the right side,
with some tympanites and borborygmns. Turpentine emulsion was given every three hours. On the 12th the patient
was reported as having slept well; he was dull and stupid; his eyes dull and injected : cheeks somewhat Hushed;
pulse"."), regular; skin hot, dry and profusely covered with rose-colored spots; tongue slightly moist, red at the tip
and edges, coated yellow in the centre; lips and teeth covered with sordes; appetite i)oor; his bowels were moved
five times, and there was much abdominal tenderness, notably about the umbilicus. Astringents were given, but the
diarrlnea continued. Ou the l.'ith, lUtli and 17th profusi' perspirations were noted, and rose-spots, perceptible to the
Mei>. Hist., Pt. 111—30
234 CLINICAL RECORDS OF
touch, coiitiiuied to erupt. A few of these spots appeared on the forehead on the 22d and a few more on the chest
two days later. On the 22d the diarrha-a was controlled: one stool only was passed instead of three, four or more,
as on previous days; hut the general abdominal and extreme umliilical tenderness was not relieved until some days
later. Meanwhile the tongue became clean, the skin natural and the appetite good. The cough, which had attected
the patient more or less from his admission, now assumed prominence as a 8ym))tom, and was accompanied with
mucous expectoration. He was transferred November 1 to Annapolis, Md. [whence he was discharged from the
service on the 2!Hli because of debility].
Case 71. — Hiadndu: ; ilciifness ; iViurrhiin ; coiiijh; rose-colored spots foJhiirUitiiyarorijsmdl fever. — Private F. t^anu-rou,
Co. F, 74th N. Y.; age 2,S; was admitted Nov. 2, 1861, as a case of typhoid fever. lie became sick about Octolier 1
with chills, fever and sweating, epistaxis, headache, anorexia, thirst, diarrhiea and irritability of stomach. When
admitted his eyes were dull and somewhat injected, cheeks slightly flushed, pulse 75, regular but weak; a few rose-
spots on the chest; tongue red, dry and fissured in the centre; lips and teeth covered with sordes ; appetite poor;
he was a little deaf and liad buzzing in his ears; one stool was passed with much right iliac and umbilical tenderness
and tympanites; he had also a slight coiigh with some whitish expectoration. He slept none during the night and
had but one stool on the 3d; the tenderness lessened and the congh ceased. Beef-essence, punch and turpentine
emulsion were given. After this the bowels continued (|uiet, and on the 7tb the tongue began to clean aod the
appetite to return. He was tran.sferred to Annapolis on the 8th [whence he was discharged for disability on the 2Htb].
Cask 72. — Cerebral maiiifrsiutions sliyltt : rose-spots on the Sth dai/ with successive crops to 22d duij ; diarrlneu ceasing
on occurrence of free nocturnal perspirations on 17th dai/. — Private Peter Martin, Co. B, 3d Vt. Vols.; age 18; was seized
Sept. 28, 18G1, with chills, fever and pain in the head, back and limbs, for which he was admitted OctoVier 3. His
pulse was 8."), full and strong; skin natural; tongue moist and furred yellowish. He was somewhat dull and had
pain in the head, anorexia and relaxed meteorized bowels. Blue-pill was given with opium every two hours. Rose-
colored spots api)eared on the chest and abdomen on the 5th, and on the 7th were very profuse. The tongue, from
being covered with a thick yellow fur, became red at the tip and margins, remaining coated on the dorsum. The
diarrhiea caused three or four stools daily, and was accompanied by tympanites and right iliac, umbilical and, indeed,
general alidominal tenderness. Sixteen grains of quinine were given on the forenoon of the 7th. The headache,
anorexia and other symptoms as stated continued until the 14th, when, after a free perspiration during the night,
the pulse fell to fit!, the Iiowels became (|uiet and the appetite returned ; the tongue, however, remained coated heavily
with a moist yellow fur at the l)ase and centre. A small dose of blue-pill was given on the Ifith, but tlie fur was
not removed until the 2od. Rose-spots appeared on the Ifith and again on the 19th. Nocturnal perspirations were
recorded on the 17tli and 19tli. Some cough occurred during the progress of the case. The patient was returned to
duty on the 28tli.
Ca.se 73. — I>i::iuess and slitjht headache; diarrhical teudencji not marked; rose-colored spots on the VHh, \9lh and 30M
dai/s, and rihices on liHh. — Corporal .J. 1!. Morgan, Co. E, 1st Pa. Rifles; age 24; was healthy until about Oct. 1, 181)1,
when he had chills, fever and profuse sweating, with paiji in the head, dizziness, epistaxis, pain in back, limbs,
shovilder and chest, some cough, diarrhoja and retention of urine. He was admitted October 10 as a case of typhoid
fever. The jiulse on admission was*90 and quick; the skin hot and dry, exhibiting a profuse eruption ; the tongue
was slightly nu>ist, red and clean ; the appetite jioor; the bowels unnmved but somewhat tender and tvnii)auitic ; the
patient luid slight headache, cough and pain in micturition. Wine and cinchona bark were ordered. The eruption
faded, but no other change took place until the 13th, when the tongue became dry. One ounce of Ei)som salt was
given. Three stools were passed on e.ach of the two following days, and the tenderness became more marked in the
right iliac region ; otherwise there was no change. The Epsom salt was re]>eated on the IGth. Three stools were
passed on the 17tli and one on the 18th. Vibices ai)peared on the chest and rose-spots on the abdomen on the 19tli.
A few more rose-spots were detected on the 30th, During this period the skin wiis generally of the natural teni-
per.ature, the tongue moist, red and clean and the apiietite good. On November 1 the patient was transferred to
Annapolis, Md,, where his case was entered as one of debility, and whence he was returned to duty on December 2,
Case 74, — Dulness and drowsiness for a day or two; diarrhaa and dry skin pei-sisting ; rose-colored spots and vibices;
tongue flabby and coated yellow; moist skin, and convalescence on 3Sth day. — Private William Morrison, Co, E, 1st Pa.
Rifles; age 38; had a chill about Oct. 1, 1861, followed by fever and perspiration, slight headache, anorexia aud
some cough. He was admitted on the 10th as a case of typhoid fever. Next day he was dull and drowsy, but
without any sign of congestion about the face; his pulse was 80 and feelile, skin hot and dry, tongue sliglitly moist,
red at the tip and edges and lieavily coated with yellowish fur in the centre; he had inten.se abdominal tenderness,
but only one stool during the previous twenty-four hours. Enuilsion of turpentine and tincture of iron were ordered
in repeated doses. On the 12th the eruption appeared; the skin was of natural temperature, tlie tongue slightly
moist but coated with yellowish fur, and the appetite good; two stools were passed, and the patient had some
abdominal tenderness and cough. He slept well and next day was brighter mentally. From this time till the
end of the month his general condition remained unchanged. The tongue was flabby and always more or less
yellow-furred; the appetite usually good; the bowels moved from one to seven times daily, with general aud occa-
sionally umbilical and left iliac tenderness, and with slight tympanites on the 10th and 29th ; the skin, usually hot
and dry, showed some vibices on the 19th and 20th; on the 22d rose-colored spots appeared on the face and did not
fade until the 29th, when some epistaxis occurred; there was more or less cough with some mucous expectoration;
the pulse beat generally about 75 per minute. On the 30th quinine was ordered in three-grain do.ses every tvvo
hours. Next day the i)ul.se was lowered from 80 to 60, and the diarrluea increased from one to seven stO(ds; other-
wise the jiatient's condition ajipeared unaltered. Astringents were given, and in the course of four or five days the
diarrhiea became lessened to one or two stools daily. On November 4 a boil appeared on the patient's forehead. Ou
THE CONTINUED FKYERS. 235
t lie "111 the skin is rcoordeil fur the liist time as liciiif; moist; pulse 75; tonguo cleaning; appetite t;oo'l> bowels
tender and moved twice. Cod-liver oil and wiuo were ordoied on the lOlh. The daily record of symptoms ceases on
the nth. The patient was transferred to Alexandria, Va., December 20.
Case 75. — Siicciniiir crops of rose-colond kjhiIs from Wlh to 'iGth day; perspirations; diarrhnal InuUitrii xlitjlil :
(jastriv inilahilitii; coiiviiliscciicf on 'A><lli dai/. — I'rivate S. I!. Freneh, Co. li, (ith Wis.; agi* 25; is said lo have had typhoid
fever in 1S.".!1. On Sept. 21, 18(>1, he was taken with chills and fever, headache, pains in the back and limbs and
diarrluva, for which (|ninine was fjiven. He was admitted October 1. Next day his face was somewhat conjiested.
eyes lirifrhl, pulse UHt, <|uick and stron';, skin hot and uu)ist, edf^es of the ton-jue dry and its centre covered with a
brown crust, appi'tite small; three stools were pa.ssed, and there was some cou};h with visciil mucous expectoration.
Turpentine eiMul,si(ui ami astriniieuts were given. Kose-colored s]iols ajipeared on the 3d and continued to erupt at
Intervals until the 2!l|li. The skin was generally nu)ist ; but on the Gth and 7th free perspiration occurred accom-
panied with sudaniina; tinnitus aurinin also was noted at this time, and the pulse fell to 75. The bowels were moved
once or twice daily, and there was niore or less tenderness, chieliy umbilical aiul left iliac. Five stools were passed
on the lOlh and again on the 15th, but the tendency to diarrhn-a was not marked, for three grains of l)lue-pill repeated
twice on the latter day, and six grains of compound cathartic i)ill repeated twice on each of the two following days,
did not aggravate it; the bowels were generally moved twice, but sometimes only once daily to the end of the
record. Profu.se nocturnal |>erspiration occurred on the 15tli and following days. The tongue on the 8th became
red at the tip and edges and brown or yellowiNh-brown in lln^ centre; on the lOtli it became slightly dry in the
middle; on the 17th ri'd, moist. Ilabhy and with ])roniiiicnl papilhe, and after this more or less coated to the end.
'I'he appetite continued good from the second day after admission, but on the 26th and 27tli there was some irritabil-
ity of stomach. (,|uinine was given at this period in three-grain doses every two hours. On the 2!)lh the patient
sleiit well; his eyes wiMe bright ; cheeks not tlushiMl; pulse IX, regular; skin hoi and moist, a few rose-spots appear-
ing on the brea.st and abdomen; tongue red at the tip and edges, yellowish coaled and fissured in the eentri'; ap])etite
gini<l; one stool was passed; the stomach continued irritable, and there was sonus cough with yellow expectoration.
On the ;ilst he was silting uji; the gastric irritability and the cough had ceased. On November 1 he was transferred
to Annapolis, Md. [whence he was discharged on account of atrophy of the leg, March 28, 1862J.
C.\SE 76. — Itviiird impirfict during first four wnks; dcHrii(ni: diarrlioa; rose-spots from 2il//i lu 'iWth duij; coiiva-
leiernci on iOtIt rfii.i/.— Private Peter Conrtwright, Co. B, 1st Pa. Rilles; age 27. This man stated that he had suliered
from sonui kidney trouble at the age of 20, and aflerwards from both liver and kidney <lisease. About Se]>t. 12,
IXIil.lie had chills followed by fever and sweating, with e]>isl.ixis, jiain in the back and limlis and anorexia. He was
admitted October 10. when he seemt^d stupid ; his eyes were dull ; cheeks tlnshed : jiulse 90 ami (|nick ; skin hot and
dry; tongue nu)isf, reil at the tip and edges, coated whitish in ci'iitre; appetite poor; the bowels ([uiel, but with
some gurgling and slight tenderness in the left iliac and nnibilii'al regions; a few rose-spots were noted. Dover's
powder was given. On the 11th and I2th the general condition remained unaltered; the skin lost its heat but con-
tinueil dry. Tineturi' of iron was ordered to lie taken three times a day. On the llith the eyes were dull, injected
and sutlnsed and the cheeks slightly liushed; the pulse had fallen to CO; a few rose-spots appeared on the chest and
abdomen ; three stools were pas.sed, and there wa.s pain on nrinatiug. Profuse perspiration occurred during the night,
and in the ni€>rning the patient looked bright but there wa,s some mental derangement; the pulse was 4G, full and
firm ; si.\ stools were passed. Astringents were ordered. The condition on the 15th is not recorded, but on the fol-
lowing day there were more rose-spots, delirium, tinnitus anrium, six stools and umbilical tenderness; pulse 68.
Tenderness and tympanites over the tranverse colon accompanied six stools recorded on the 17th. There was less
delirium on the 18lh; the face had become pale and the eyes sunken; one stool was passed. Three stools were
reported on the 19th and six on the 20th, on which day also some rose-si>ots appeared. On the 21st, after sleeping
well, the patient's tongue, which had heretofore been red at the tip and edges and nu)re or less coated in the centre,
W.1S found to be clean and natural, his skin of normal ti'iiiperatnre, ])ulse 70 and ajjpetite good; two stools were
passed. After this he imju-oved, but a diarrluea, causing about three stools daily, ])ersistiMl until November 4, when
the bowels were re)iorted regular. He was able to be uji and to walk about October ;!Oth, and was returned to duty
November 10.
Case 77. — DiliriHm,diarrliaa and involuntarij stools; eruption of rose- and dark-colored spots : improvement about end
of 4(A ireci-, hut debilitii with flahlnj tongue continuing after defervescence. — Private B, T. Conglin, Co. (i, 5th Wis, Vols.;
age 22; was taken about Sept. 16, 1861, with epistaxis. headache, pain in the limbs and back and diarrhcea, and was
admitted October 1 as a case of typhoid fever. On the 2d his face was congested and he looked dull: his pulse i)0,
quick and strong, skin normal and tongue moist, brown and with prominent papilhe; he had some pain in the back
and anorexia, but no movement from the bowels; the alidomen was covered with dark spots (vibices?) and showeil a
few rose-spots, which latter disappeared on pressure ; he was delirious. Emulsion of turpentine was given every two
hours, tincture of iron three times daily and beef-essence as required. Five involuntary stools were pa.s.sed on the
M, and astringents were administered. The passages were frequent but passed voluntarily on theltli: the abdo-
men and chest were covered with dark-colored spots imperceptible to the touch and disap])earing on pressure; the
tongue was dry and brown and there was some hoarseness. The stools became again involuntary on the 5th, and
the teeth and lips covered with sordes. The patient's face was congested, eyes dull, skin hot and showing the
remains of the dark-red spots. He had anorexia, slight tympanites and iliac tenderness; pulse 100. Beef-essence
and punch were ordered, with Dover's powder in the evening. Involuntary micturition and defecation, with much
tenderness, were noted on the Gth : pulse 112. The vongue was clean, red and dry on the 7th ; the appetite improved
and there was but one stool. During the three or four days which followed the tongue becanu) moist and tlabby,
with prominent itapilhe; the appetite continued to improve: the bowels were quiet, but there was much umbilical
236 CLINICAL RECORDS OF
and some iliac tenderness. On the 12th the pulse fell from HO to 80, the eyes liecauie bright and the delirium ceased.
Next day the tongue was moist and clean and the appetite good; luit until the end of the month Habbiness and
prominent papillie were reported. The patient was free from diarrhoea, but the abdomen was occasionally tender;
at times he had headache. He was transferred to Annapolis, Md., November 1, as a case of debility [and was
returned to duty Feb. 3, 1862].
Case 78. — Becord imperfect at heginnhuj iiml end of ciise; lieadtiehe : diarrhita ; ahdominal tenderness; rose-colored
spots. — Private Gottfried Scrieber, Co. I, 6th Wis.; age 30; had some lung trouble in July, 1861, from which he had
not entirely recovered, wheu about October 15 he was taken with chills followed by fever and sweating, with head-
ache, tinnitus aurium, pain in the back, chest and limbs, lassitude, anorexia, thirst, diarrhoea, retention of uiine and
some cough. He was admitted November 7. Diagnosis — debility. On the 8tli rose-colored spots ap])eared on the
chest and abdomen, and there was much tenderness in the umbilical and left iliac regions with a burning feeling in
the epigastric region. Bine-pill with opium, followed by castor oil, was prescribed. The skin on the 9th was covered
with iierspiration; the bowels were moved twice. On the 10th there were some rose-spots, a burning feeling in the
stomach, tenderness in the umbilical and left iliac regions, but no passage from the bowels; the tongue was very red
at the tip and edges. Eight grains of quinine were given with turpentine and tincture of iron. This patient was
transferred on the 18th to Annapolis, Md. [Diagnosis — typhoid fever. Returned to duty Feb. 3, 1862.]
Case 79. — Cerebral symptoms not marlced; constipation; hilious vomiting; rose-spots on lith and ISth days. — Private
Thomas Connell, Co. K, 3d Vt.; age 22; caught cold Sept. 27, 1861, and had headache, pain in the loins and limbs
and anorexia. He was admitted October 3d as a case of gastritis. His eyes were sutfn.sed; pulse 9.5, full and strong;
skin moist but somewhat hot; tongue dry, red and glossy; constipation, anorexia and great irritability of the stomach
were jiresent. iSulphate of nuignesia and antimony were given, and ten grains of calomel in the evening. The
Epsom salt was repeated on the 5th. Next day tw o grains of quinine were given every two hours, and tincture of
iron on the 7th. One stool was obtained on this day; the gastric irritation had somewhat lessened; pulse 70. On
the 9th the pulse fell to 45, the skin was of natural temperature, the tongue red, clean and moist but rather flabl)y,
the appetite moderate and the bowels unmoved. Rose-colored spots appeared on the 10th; the appetite was poor;
the bowels unmoved and tender. Two compound cathartic pills were given, with turjientine emulsion, every
three Lours, and two grains of quinine every hour. Next day one stool was obtained, and there was marked ten-
derness with gurgling in the right iliac and umbilical regions. Some irritability of stomach, cough, pain in chest,
suftiision of eyes and congestion efface were noted on this day; pulse 50; skin natural ; tongue moist, red and clean.
On the 13th. the liowels having continued numoved and tender in the iuterval, a cathartic enenui was given; this
was foUoweil on the 16th by an ounce and a half of castor oil. Three stools vvere passed on the 17th, three on the
18th, and seveu, twelve and fifteen on the following days, after which two stools were recorded daily for several days,
with some abdominal tenderness. Rose-s])ots were noted on the 14th. The patient was sent to Annapolis, Md.,
November 1 [whence he was returned to duty December 2].
Ca.se ho.— Dale of origin nulnown; nnconsciousness; rose-colored spots: moist tongue: diarrhita: rapid concalescence. —
Private George Robinson, Co. B, 14th N. Y.; age 19; admitted Sept. 27, 1861, having been atl'ected with diarrhcea for
two months. Diagnosis — typhoid fever. He was partly comatose and difficult to arouse; pulse 80, firm, strong;
face congested ; eyes suffused ; skin hot and soft ; tongue moist, gray; abdomen tender and bowels moved twice.
Calomel with kino was given. Next day the abdomen and chest were covered with rose-colored s])ots; the tongue
was moist and coated, except at the tip and edges, with a rough brown fur; three stools were pas.sed, and the abdo-
men was tym])anitic and tender especially in the umbilical region; there was some ])nrulent expectoration streaked
with blood, but not much cough. No cliange took place until October 1, when sudainina appeared on the chest;
the stomach became irritable the bowels remaining undisturlied. Next day the patient looked better and had some
appetite; his tongue was white at the tip aud edges and brown at the base and centre. Turpentine emulsion was
prescribed on the 4th. Profuse pers])iration occurred on the 5tli with sudamina, and on the 9tli rose-colored spots
ajipeared in fresh crops, which by the lltli were very profuse; headache, tinnitus aurium and deafness aft'ecting the
left ear accompanied the erujitiou, and the tongue, which had before beeu flabby and more or less patched with
yellow, became red at the tip and edges and yellow-coated in the centre; he slept well, however, his ai>iietite
renuiining good aud his bowels undisturbed. On the 14th he was considei-ed convalescent, and on the 21st was
returned to duty.
Case 81. — Unconscionsness : ninscnlur ticitchings; inroinntarg passages; sordes; diurrhwa during conraJescence. —
Private Luther Howard, Co. B, 72d N. Y., was admitted Sept. 29, 1861, having been sick for two weeks. Diagnosis —
typhoid fever. He was partly unconscious and unable to speak except occasionally; the face was congested, the
eyes slightly injected, the facial muscles disturbed aud those of the extremities twitching involuutarily in almost
choreic movements: he had headache and some laryngeal trouble; the skiu was soft and moist; the pul.se 88, firui;
the abdouum teniler. Camphor and oi)ium were given. Next day he was partly comatose, his face congested,
pulse 100, full and strong, skin hot and soft; no stool was passed, but thj abdomen was tympanitic and tender;
no uriue was voided for sixteen hours; the muscular twitehings continued, and the patient was unable to open
his mouth or speak. Emulsion of turjjentine, sweet spirit of nitre, valerian and Dover's powder were ordered. On
October 1 sordes appeared on the teeth, the tongue was coated dark brown and the mouth filled with dark tena-
cious mucus; the patient was iuiliH'erent, but ate food when ottered to him; the bowels were unmoved. Five grains
each of calomel and jalap, with twelve of quinine, were given him. One snuill stool was obtained next day, and the
patient was less stupid; he was very deaf, but answered questions correctly wheu put to him iti a loud voice. On
the 3d he protruded his tongue with less ditheulty and the choreic movements were lessened, but there was some
dysphagia and the stools were passed involuntarily. On the 4th he was rational; the tongue slightly moist; bowels
THE CONTINUED FEVERS. 237
tpnder and moved onoe, Imt not tympanitic. Turpentine eniiilsion, liiandv. Fowler's solution and Epsom salt were
};iven. Two involuntary stools were passed on the Ulli, lint the dysplia^jia was lessened, the twilehinss had eeascd
anil the patient was aide to artieulate well and niastieale his food. Heef-esseuec and aslrinjjents were onlered.
Some In-adaulie and diliriuni were present on IlieXtb; the toufjue was dry and trenmlons, showinf!; yellow palehi's
and prominent pa|iilla', and the bowels were loose. After this the skin was usually hot and dry or of thi' natural
temperature, altlioMf;li on the l>>tli there was souu> perspiration at ni-jlil. The touf^ue was moist, clean or ]iat<hcd
with white or yellow, and usually llahhy and with prominent papilla-; hut on the ISlli it was red at the tip ami
ed;;es ami coated yellow in the centre. The appetite was fjood, and for several days was recorded as exce.ssiv<\
Tiie howels wore loose, yielding two or three passaf^cs daily, with occasional tympanites and tenderness mostly in
the right iliae region, lie slept well, but was occasionally troubled with a little cough. Epista.\is occurred on the
3(ttli, and on November I, Sand (5 there was 8omo headache with dizziness and twitchings of the eyeballs, lie was
transferred to .\nnapolis, Md., on the IHtli [as a case of typhoid fever, and was returned to duty December 27J.
t'.vsE H'2. — .tijiii-; ijtmtric irriliitioii; rose-colored spots; cerebral si/mploms slirihllii markefl; 2>erspirnlion and periodic
Utixtaiia. — Private Kreil. Shaflcr, Co. U, 72d N. Y.; age 2H; became affected in July, WA, with ague which lasted
for six weeks, after which he was confined to bed with abdominal pains. He was admitted September 2!t as a
ca.*e id' typhoiil fever. For sonu- days after admission he restiMl well at night, but had from two to six stools daily
with, but sometimes without, tympaniti's and abdominal tenderness, ehietly marked in the' umbilical and left iliac
regions; he had some congestion of the face and headache, an<l the jiulse ranged from ><"> to 1011, being usually some-
wlial more rapid at the evening visit; his skin, which was natural or slightly moist with the lower pulse and usually
hot and dry with the higher, presented a few rose-spots and a profuse eruption: he was troubled with ain)rexia and
great irritability of t he stomach : his tongue was moist and white or yellow-coated, or dry and brown ; he had some
dirticully in micturition and afterwards retention of urine. He was treated with turpentine emulsion, Dover's pow-
iler. astringents and small doses of calomel and opium. On October 5 he was restless at night; his face was con-
gested, eyes dull, ])ulse 'X< and weak, but his skin was cool and covered with perspiration. Next night he slept well
and in the nu>rning looked better; pulse XO, regular; skin natural; tongue nu>ist, clean; appetite good; but the stomach
continueil irritabh' and much green matter was vomited; four stools were i)assed. Tincture of iron and astringents
were given. From this time forward the record shows the presence of occasional headache with dizziness and tin-
nitus aurium. The stomach continued irritable, lint after the occurrence of epistaxis on the KMh and free perspira-
tion on the lltli, this symptom became less prominent and disappeared. The epistaxis recurred on the llrth, loth,
17th and L'lst. The tongue was always moist and generally clean, but flabby and with prominent jiapilhe. The
bowels were loose, giving two or three jiassages daily, with decreasing tympanites, gurgling and general abdominal
tenderness, sonu^times particularly marked in the umbilical and right iliac regions; towards the end of Ihenumth
the stools became reduced to one daily. On the '25th quinine in two-grain doses was given three times daily. The
patient was transferred to Annapolis, Md., November 1 [as atfected with typhoid fever, on account of which be
was discharged from the service ou the 25th].
f'.vsK 8^1. — Chills; diarrhua; umhilical paiu; free jxrspirations; nonolahle cirehral siiniplaiiis. — James Tobin, attend-
ant; age l!9: was admitted Sept. 11, 18til. having been taken sick ten days before with headache, constipation, pains
in the bones and a chill and fever, for which i|uinine was administered. On the day after admission he was restless and
had an anxious exiiression; be perspired during sleep, but when awake his skin was hot and dry: pulse 74; tongue
pale but red at the ti|> and edges; four thin stools bad lieen passed during the twenty-four hours, and there was slight
pain, ehietly umbilical and during micturition; be had also a stitch in the side and some i)aiu in the breast. (Quinine
was given. In the evening the pulse was 78. the skin hot but sweating and the tongue pale, Habby and somewhat
brown: four stools were passed during the day. Acetate of lead and opium were jirescribed. Next morning the
pulse had fallen to 5(> and the patient was sweating profusely. In the evening there was a slight accession of fever;
only one stool was passed during the twenty-four hours. For some days after this the perspiration continued pio-
ftise, especially at night, although aromatic sulphuric acid was administered; the bowels remained quiet and the
tongue Habby and coated gray or brown at the base. Blue-pill was given three times on the 15th, and in the evening
of the Kith ten grains of calomel, which produced three painful stools, but the bowels thereafter became again quiet
although tender esjiecially in the right iliac region. The perspirations continued. Morphia was given at night and
the patient was sponged with alcohol. On the 18tb some pustules appeared on the abdomen. Next day he is
reported as looking stout and healthy, with bright eyes and clear mind, although there was some headache and jiain
in the back and breast, with a slight gray coating on the tongue. Three grains of calouud and a half grain of opium
were given three times. The record concludes on the 21st. the patient still perspiring at night and ha\irigtlie
uinbllical region tender.
C.\SE Ki.—llealh, prohahly from perforation of the intestine, on the 'JSth daif. — Sergeant David Puckett, Co. E, 5th
C S, Cav.; age '27; was admitted Oct, 18, 1861, having been sick since the beginning of the month with headache
and pain in the liud)8, hack and ei)igastrium. A cathartic, to be followed by quinine, was prescribed. On the day
after admission the patient was wakeful, his eyes dull and yellow-tinged, cheeks flushed, pulse 110, full and strong,
skin hot, tongue slightly moist, red at the tip and edges but heavily coated yellowish-white in the centre; be had
anorexia, thirst, three pas.sages from the bowels during the twenty-four hours, much umbilical tenderness and tympa-
nites, a slight cough a lid dithcult micturition. Sinapisms were applied to the abdomen and emulsion of turpentine given
every three hours, with extract of buchu as required. On the 20th the pulse fell to !I0, but the condition of the
patient w.->s otherwise unchanged. A powder containing three grains of calomel, one grain of ojiium and one-eighth
of a grain of tartar emetic was given every three hours. Next day the tongue became dry ;_seven stools were passed
, and the hypogastric and iliac regions were highly tympanitic and tender. On the 22d the diarrbcea continued, eight
238 ■ CLINICAL RECORDS OF
stools having been passed; cerelmil symptoms were manifested, as headache, hebetude, dizziness and tinnitus ; the
stomach became irritable and the tongue diy, red at the tip and edges and brown in the centre. On the 23d no
change was recorded except the passage of urine without pain for the first time in several days. Lead, opium and
tannin with tincture of irou were prescribed. On the 24th the patient was dull, lying with his eyes half closed in a
semi-delirious condition; no stool %yas passed, but there was much vomiting. Two grains of calomel and a half
grain of opium were ordered for administration every hour. On the 26th, having slept well at night, the patient
was brighter, his mind less obtuse, and there was less abdominal tenderness; but the tongue was heavily coated
yellow and the anorexia, thirst and vomiting persisted. Next day five grains of calomel and a quarter of a grain of
sulphate of morphia were given, but no marked change was apparent until the 27th, when the patient was partly
unconscious and delirious, lying with his eyes rolled up and mouth open, his breathing hurried, pulse 125, tongue
dry and coated brown and stomach rejecting everything; there was extreme tenderness t)f the abdomen and much
meteorism. Stimulants were administered by enemata. Death took place on the morning of the 28th.
Case 85. — Remittent fever; sijmptoms of tjiphoid fever not distiiictUi manifested; fatal hij peritonitis on the25th day. —
Private Mason Hitchcock, Co. A, 19th Ind. Vols.; age 33; had a chill Aug. 28, 1861, with pain in the bones, back and
calves of the legs, rela.xation and tenderness of the bowels, and fe\er which was worse in the evening. He was
admitted on the morning of September 5, when his pulse was 80, skin warm and moist, tongue pale and coated
and colon tender on pressure. Quinine was given. He had a chill at 2 p. M., and in the evening the skin was hot
and dry and the tongue very red, flabby and coated. On the 6th, 7th and 8th he had no fever at the morning visit;
but in the evening the skin was hot and dry and the bowels .somewhat relaxed and tender; his complexion was
sallow and his mind rather dull. He was treated with Dover's powder and small doses of blue-pill. After the 9th
there was slight fever at the morning visit, but the patient was able to be up and walk around a little until the 12th;
the tongue was dry, Crown, yellow and white by turns, but usually red at the tip; the pulse was weak, 80 when
lying, 100 when standing; the bowels were moved from one to three times daily, and there was always some tender-
ness along the track of the colon. On the 15th two bloody stools were passed and the patient was much depressed,
the colon teuder. the tongue thickly coated jellow, the skin hot and sweating, pulse 86. A blister was applied over
the colon and opium and tannin iirescribed. The bowels remained (juiet until the 17th, when an enema of soap was
administered. At this time there was some tenderness in the right iliac region. On the 18th the stomach was irrita-
ble and the pulse ran up to 120. Vomiting continued next day and was accompanied with acute tenderness in the
epigastrium; the iiatient lay on his back with his legs drawn ui). On the 21st the pulse was 1411, tongue nearly
clean but very dry, skin hot, abdomen tender. In the evening the body became covered ^^•ith a iirofuse sweat, the
extremities cold, the features pinched, the ]uilse imperceptible, the heart's action irregular, speedily ending in stupor
and death. No rose-colored spots were discovered in this case although specially looked for.
Case 86. — Defervescence on the 22d day checked by chest complications; return to duty delayed to SOth day by diarrhmal
a('7«f/<j'. — Bugler Henry L. Case, Co. H, 4th Mich.; age 22; was adnntted Sept. 6, 1861. Diagnosis — typhoid fever.
This ])aticnt had good health up to August 26, when he was taken with pain in the head and bones, chills and fever,
somnolence, great thirst and epistaxis. His case was not taken up in detail until the 13th, when the morning record
shows him to have rested well during the preceding night; he was very weak but had some apjietite, regular liowels,
a thickly coated brown tongue, a pulse beating 98 per minute and a slight cough: the evening record shows a
w hite tongue, bad taste in the mouth, some fever, bowels regular, abdomen tender and slightly tympauitic, cough,
tinnitus aurium and musca' volitantes. On the 14th anorexia was added to the symptoms already stated. Next day
he became dull, complained of heaviness over tlie eyes, and in the evening seemed drowsy. On the evening of the
16th the tongue became moist and white, but this was not followed by any general improvement; on the contrary, on
the evening of the 17th the fever increased with slight nausea, the pulse running up to 106, while next day a pain
on deep inspiration was developed. But on the 19th the pulse again fell to 92 and the skin became moist and sweat-
ing. There was some tenderness in the epigastrium on the 20th, in the hypochondrium on the 22d and in the right
iliac region on the 23d, in addition to the abdominal tenderness which had existed from the time of admission. On
the 21st the patient became somewhat deaf in the left ear, and next day his eyes became dull. The abdominal ten-
derness was relieved on the 24th, when, also, the tongue began to clean in patches, but thirst continued until the
27th. The patient slept badly on the night of the 24th, the only night which furnished such a record, for usually he
rested w ell, and next morning his pulse was 96 and he had a soreness iu the chest. On the 26th the tongue was moist
and only slightly coated, which improvement was followed next day by a brightening of the eyes, abatement of the
thirst and a return of the appetite. The bowels, which to this time had remained (|uiet rather than lax, now
became loose, giving two, three or four stools daily, with iliac tenderness and a yellow fur upon the tongue; but in
progress of time this diarrhiea abated and on Novemljer 1 the patient was transferred to Annapolis, Md., whence he
was returned to duty on the 13th. He was treated at first with Dover's j)Owiler and sweet spirit of nitre, and after-
wards, on the 23d, with turpentine enurlsiou and iron, opium, acetate of lead and tannin.
Case 87. — Headache, dizziness, deafness, delirium and muscular twitchings; relaxation, tenderness and tympanites of
the bowels; 2>"eumonia; no rose-colored spots. — Private Sidney D. Way, Co. I, 2d Vt.; age 18; was admitted Sept. 27,
1861, having been taken three weeks before with intermittent fever, cough and jiain in the breast. The case was
diagnosed typhoid fever. The patient was weak, his cheeks flushed, countenance anxious, pulse quick, 120, skin
hot and dry; he had some pain in the head and chest, with deafness and muscular twitchings; there was anorexia
with a moist white tongue, and relaxed bowels with much tympanites and general abdominal tenderness. Small
doses of blue-pill and opium were given on the 28th and turpentine emulsion on the 29th. During the next four
days his condition was but little altered; the deafness increased, and delirium, dizziness and aphonia were mani-
fested ; three or four passages from the bowels were recorded every twelve hours ; the cough occasionally became
THIS rONTINUEO FF.VKRS. 239
troiiWeMiiiif, ami was aoc()iu|iaiii<'il with a iiiiicoiis oxiierloiiitioii ; tlin ri'spiialiiPiiN wciti at oiio time as liigli aw 3t) por
miiiutv. On (lie iiiiiriiiiif; of Ortolier 2 tlu' ]iatii'nt, having Kh'pt well dniing th<' ))!i<vii)ns iiifjht, was f'onnil with (ho
skiu of natural t('ni]ioiatiiii< and liatho<l in ]>i'i'spiralii>n, sndaniina on the lijjlit sidii and ovci' llio ahdoinen, the
tongue moist and sliglilly Ooated vollow, and the pulse ST) hut strong and ijuiek ; two stools had heen passi'd during
tlie night and a littli- blood expeetorated, after which the eougli lieeanie less trouhlesiune; respiration 28, witli
niuili erepitation anteriorly on the left side and a little on llie right side. Next day, however, th(( ))nlse was again
aeeelerated, 1 lli, and tlu' skin hot and more or less dry, the oilier synijitoms eonlinuing as already described until
the tith, win II w ith a freely perspiring skin the pnlse fell to !t(l, and the patient had less cough and some iiuprovo-
niont in the voice. After this the pulse again rose to 105, the skin becoming hot and dry, but the tongue remain-
ing moist and yellow-eoaied ; the cough and expectoration of mucus and blood continued, with dulness over the
lower lobe of the right lung posteriorly and nincous and subniufcous rales above, ami with crepitation over th(i
left lung posteriorly; the diarrluea and abdominal tenderness continued as already re]iorted. By the lltli the pulse
had risen to II.S, and the patient was quite deaf and coin)ilaim(l of headache. On the 12th the tongue, si ill con-
tinuing moist and yellow-coated, became red at the tip and edges; some sordes formed upon thc^ lijis, and tormina
accouipaniid I he diarrlneal passages. From this time to the end of the month the condilion varieil little from day
to day, bill a gradual alleviation of the symptoms of the lung anil bowel coiiiplaints was observed. A free ])erspi-
ration which oecnrnd on thi^ 20th was followed by a reduction of the pnl.se on the 21st and the manifestation of
some appetite. The alxlomin.il tenderness bceaini' li'ssened and the passages less frei|iienl until the .'Jlst, when, for
the lirst time, tlui daily record shows that no stool was |)a.sscd iliiriiig the previous twenty-four hours. On Novem-
ber 1 the ]>nlse was SO and feeble, the skin natural, the timgue pale, the ajipelite good ; the cough was less trouble
some and there had been hut one stool. His coiidiliiui had not chaiige<l m;it(uially on the 9th, vvlieu he was
di.scluugeil from the service on account of debility; the cough persisted with occasional rehi.xal ion ol Ihi'liowels
anil abdominal tenderness, but with a good appetite and natural skin.
Case 8S. — Diarrhoea; bilious rumiting; pcrxpirationn; no rose-colored sjioh : di;;inrnH; piibiuninrii iiimjiliiiiliniiK nii
Ihi V'lli iliiii: improraiKiil on '2Slh. — Private Dwight Tousely, Co. E, 3d Mich. Vols.; age 30; was admitted Oct. 10,
18til. Diagnoses — tyjihoid fever. Ou the 12tli, after undergoing much fatigue, ho was taken with hi'adaelie, weak-
ness and slight diarrluea. He slejit well after ailmission, and on the morning of the 20th his <u)unt(Uiaii<:o was na.t-
ural, pul.se f<.S and strong, skin perspiring, tongue moist, pale-re<l at the ti]) and edges and brownish in the centre;
he had some appetili', slight thirst, two thin watery stools, some right iliac tenderness, borborygmusaiid slight tym-
panites. (Quinine administiucd in a full dose at noon was vomited along with much plilegin and giccnish-natery
li(|uid. On the evi'uiiig of the 21st he again vomil<<l a greenish mass mixed with Hio rejected ingesta; lll^ had diz-
ziness and tinnitus auriuin. The tongue on the 23d was covered with white scales; on the following day it was
raw, red in the centre, pale and slightly coated at the sides; it became scaly again on the 25tli, and the pulse
lose tu 01. On the2tith the pulse was 120 and feeble, the patient delirious, his countenance liaggaid and anxious,
skin warm, iiioisl and at times sweating profusely, tongue moist and cleaning from the tij) and edges; he had no
pain, but there w.is much tympanites, which was relieved by an enema; rales and creaking sounds were heard in the
upper part of the chest, and the respirations were increased to 25. The pulse fell to 96 on the 27tli, and on the 28th
the patient appeared somewhat better; his mouth and fauces were covered with aphtlue. He had a idiill ou the
afternoon of the 20th, and on the 30th was very nervous, although the tongue was cleaning, aiipetile good, bowels
quiet and rcsiiiration normal. His condition did not im]irove materially until November 8, tin', tongue being
occasionally dry and brown or moist and cleaning, the skin husky and the jiulse acirelerated. .MtiM- that date,
however, he slept well, had a good apiietite, no thirst, soft skin and (luiet bowels; some temhnness remaiiie<l in
the right iliac li'gion ; he had sore throat, but no cough, and his respiraticu was normal. He was" transferred to
Annapolis. Md., on the 18th.
C.xSE 89. — Dale of onuct nol defined; persinliny diarrhira and roniiling of bilious mailer; rose-colored spots: sordes;
mutliring delirium; inroluntarg passages; cold perspiralions; death on UMIi dag after admission. -Vvivdte Charles
Green, Co. C, 1st Long Island; age 18; was admitted .S(^pt. II, 18til, having been suliering for some time fron
weakness, pain in the bones, heat of skin, thirst and diarrho'a. (Ju admission his stomach was irritable. He
rested well during the night, and next day, although he had a brown and thickly coated tongue and a liad taste in
his mouth, his ap|M-tite was good, pnl.se 92 and skin hot and moist. Hover's jiowiler was given. The tongue
l>eeanie dry and red at the tip on the 10th; the bowels were moved six times and were teiulcr; (he jmlse rose to
108 an<l there was some deatne.ss. He muttered continually during sleep on the ITIh; the diarrho-i and irrit;i-
bility of stomach continued. In the evening rose-colored spots ap]ioared on the chest and abdonicn ami sordes
on the teeth; the lips were livid, and a pe(^iiliar odor emanated from the body. The multering during sleep
Increased, and on the evening of the 18th the patient was delirious on awaking; nausiia returned and he vomited
twice. During the night he vmnited live times a thin greenish-yellow matter of a highly otlensive odor. Mild
delirium continued during the 10th, and the nrine was passed involuntarily; the matter vomited became of a lighter
color; the diarrlm^a persisted notwithstanding the administration of astringents, and there was intestinal gurgling
with umbilical tenderness. Calomel in one-grain doses was given. Next day the gastric irritability was <inieted
and the diarrhiea lessened. In the evening he was restless and wakeful, his skin hot and dry, but his face covered
with a cold perspiration, pulse 120, weak and tremulous; ho had subsultus tendinum and jiassed one stool invol-
untarily. A similar stool was passed ou the 21st, during which the prostration increased. Thc! right ilie.c region is
noted as having been tender on this day. He died on the 22d.
Cask 00. — IHarrhmi : delirium : sordes; j'neumonie complicalion ; eruption : slightlji marked improremcrl on Vttli dag,
after \ihich free pi rspirations alternated with diarrliaa; rihices; epistaxii ; peritonitis ; death on the 'A\sl rf«//. —Teamster
240 CLINICAL EECORDS OF
Jas. H. Perkins, quarteimaster's department; age 23; a Virginian ; was admitted Sept. .SO, 1861. Diagnosis — typhoid
fever. He had been taken with diarrha-a on the 25th and with head-pain and rhenmatism on the 27th. On admis'-
sion his face was flushed, eyes bright, pulse 96, quick and strong, tongue moist and slightly coated white; his
bowels had been opened three times during the previous twenty-four hours, and the iliac regions were tender and
tympanitic; he had also some eougli. Calomel, opium and tartar emetic were prescribed. On October 1 the bowels
were ijuiet, but there was some pain in the chest when coughing, with dulness over the lower lol)es of the luugs.
Small doses of calomel and quinine wore given. He had three stools on the 2d. Next day the pulse ran up to 112,
and comidaiut was made of headache and backache. Tincture of iron and camphor with opium were prescribed.
He viuuited twice on the Ith. His skin became moist on the 5th, and on the following day was covered with a
profuse perspiration; but there was some delirium and much twitching of the tendons. On the 6tli emulsion of
turpentine was administered. On the 7tli the jiulse was 10."), quick and strong, the skin natural, the tongue moist
and heavily coated yellow; four stools were passed; the transverse and descending portions of the colon were
tympanitic and the uniViilical region tender; he had some cough, with slight pain in the right side below the nipple,
and there was dulness on jiercussion over the lower lobes of both lungs, especially marked on the right side. On
the 8th the skin was hot and dry and the bowels loose. On the 9th the patient was wakeful at night and dull and
stupid during the day; the pulse 120, quick and strong ; the skin hot and dry, showing some eruption (the character
of which is not stated); the tongue red, tissured at the edges and coated dark-brown in the centre; the teeth and lips
covered with sordes ; he had, moreover, deafness, delirium, anorexia and diarrh(ea. He continued in this condition
until the 15th, when the tongue became moist, yellowish at the centre and red at the tip and edges, and the delirium
and deafness were somewhat less marked; the juilse had fallen to 100. The skin was bathed in perspiration on the
16th and ITlh, and this condition recurred on the 19th, 21st, 23d and 25th. Three or four stools were passed on the
alternate days when .the skin was hot and dry, but on the days when the skin was moist the bowels remained
quiet except on the 21st, when they were moved six times. On the 19th vibices appeared on the skin and on the
23d liecame very numerous. Ou the 21st the pulse rose again to 120, and there was epistaxis w ith low delirium
and increased deafness. The epistaxis recurred on the 22d. The patient became almost pulseless on the 25th ; his
skin was bathed in perspiration, and there was acute pain in the abdomen. He died on this day.
Cask 91. — I\ela2»ic of tiiphoid; ferer, pcrsjnnilion, dcUiium, (Uarrhaa and tenderness ; rose-rush; death three days
after the occurrence of what was regarded as a eongestire chill. — See case of Private James Beckwith, Co. F, 2d Me.,
No. 16 of the post mortem records.
Ca.se 92. — Chills, diarrhwa and tenderness ; nausea anil rnmitimj: epista.ris and hemorrhagic stools; deafness: tempo-
rary improrrnicnt; death from parotid inflannnation and gangrenous erysipelas, — See case of Private .Tames M. Forman,
Co. H, 33d Pa., No. 103 of the post-mortem records.
Case 93. — Chill and perspiration ; diarrhaa, tenderness, rose-rash and mental confusion; temporary improvement
followed by inflammation of the larynx and lungs, hemorrhagic stools and death. — See case of Private D. F. McLachlan,
Co. G, 14th N. Y., No. 110 of the post-mortem records.
Eleven Tvriioii> Fever Ca.ses in which Aguish Pai!Oxysms preceded the development of the Continued
FEVElt.
Case 94. — Intermittent fever; relaxation of the howels and abdominal tenderness; no cerebral nor special typhoid
symptoms, but no particulars arc given of the patient's condition for some days preceding death. — Private Andrew Landon,
Co. C, 74th N. Y. Vols.; age 18; was admitted Nov. 2, 1861. Diagnosis — typhoid fever. His health had been good
until about a month before admission, when he contracted intermittent fever. Ou the 3d his eyes were bright,
cheeks flushed, pulse 100, quick and small, skin hot and dry, tongue faintly yellow; he had some a]>petite, some
thirst, two stools and slight epigastric tenderness. On the 5th a blister wiis applied on account of increasing
tenderness with some tympanites in the umbilical and iliac regions. At this time he was taking twelve grains of
quinine daily with tincture of iron. On the 8th he was wakeful, the pulse rose to 120, the skin continued hot and
the tongue coated; the tenderness had decreased, but the bowels were slightly relaxed and there was some cough.
Emulsion of turpentine and beef-essence were prescribed. On the 10th there was much tympanites and three stools
were passed. Whiskey -punch and astringents were ordered. On the 11th the eyes were bright, face pale, pulse 120
and quick, skin hot and dry, tongue dry and red but slightly yellow in the centre, appetite good. Acetate of lead
and tannin were prescribed, but death took place on the 17th.
Case 95. — Chills, fever and perspirations; eruption on ISIh day: relaxation of bowels; iliac and epigastric tenderness;
delirium; death on 3oth rfay.— Private .John Dietrich, Co. B, 35th Pa. Vols.; age 19; was admitted Nov. 5, 1861. Diag-
nosis— typhoid fever. He had been healthy till Oct. 20, when he was taken with chills, fever, perspirations, pain
in the head, back and limbs, lassitude, anorexia, thirst, vomiting, diarrhoea and cough with expectoration. On the
fith he was wakeful, eyes suffused, cheeks flushed, pulse 120, quick and bounding, skin hot, perspiring and covered
with eruption and sndamina on the chest and abdomen, tongue moist and white-coated, bowels slightly relaxed,
tympanitic and tender in the iliac and epigastric regions; ho had some appetite, ranch thirst, slight cough and
somewhat accelerated respiration. Quinine and tincture of iron were prescribed, with sinapisms to the abdomen.
On the 7th the tenderness and tympanites were lessened. The mustard was repeated and Dover's powder given
at night. He had some headache on the 8th and became delirious on the 10th. Here the record closes abruptly with
the announcement of death on the 23d. Turpentine emulsion was administered on the 8th.
Case 96. — Cerebral symptoms strongly marked: intestinal and jyulmonary sym2>toms obscured; death on 19th day. —
Corporal S. H. Forsyth, Co. A, 3d Pa. Cav.; age 33; was taken sick Sept. 7, 1861, with chills, nausea and vomiting,
THE CONTINUED FEVKRS. 241
wliieh recurrtnl for three days. He was admitted on the lltli. Diaguosis — typhoid fever. He had pain in the head
and liones, increased heat of skin, tinnitus aurinni, dniness of intellect and ooeasiunal epistaxis. A bath was
ordered for him and Dover's powder at night. He rested well, his bowels remaining qniet although somewhat
swollen and tender; the tongue was brown and dry. Turpentine emulsion was given every two hours. On the 16th
the pulse was 106 and strong, tongue brown, bowels regular but tympanitic, skin hot and dry, showing some rose-
coloii'd spots; there Avas anorexia and occasional epistaxis. He was restless during the night, and on the 17th
became somewhat delirious, dull and drowsy: the pulse was 106 but weaker: the bowels regular but distended.
A few rose-colored spots appeared on the ISth, and one dark-colored stool was pa.s.sed. The tongue was tremulous
and protruded with difficulty on the ISIth, and the teeth were black with sordes. In the evening (he tongue was
<liy. red at the ti|> and edges and black in the centre and at the base, lieef-essence and whiskey-punch were pre-
Bcriliod. On the 120th the eyes were suft'iised, pu]>ils contracted, ]>ulse 116, skin hot and dry but soft, teeth and
lip" covered with sordes, breathing labored, bowels <juiel but tympanitic and gurgling on pressure. In the even-
ing the pulse had risen to 126: a slight perspiration bedewed the forehead and arms and a few rose-colored spots
appeared on the chest and abdomen: the delirium was accompanied by some deafness and muscular twitchings, but
the respiration hud become quiet and natural. Two days were pas.sed without material change, but on the 2l5il the
respiration became increased to ;i5: the skin was moist and hot, hands cold and clammy, pulse 136, small aud trem-
ulous, bowels (piiet but largely nieteorized, urine passed involuntarily. Tincture of capsicum was given and a
blister and bandage applied to the abdomen. On the 24th the pulse reached 11-1 and was very feeble ; the face was
covered with sweat, the hands cold and damp, the feet warm: the patient was somewhat conscious but very deaf,
and he hail some ditlicnlty in swallowing. A tube was passed to relieve the tympanites. On the 2.5th he wiis uncon-
scions, muttering in his delirium, pulse 148, features pinched, forehead fhished, nose and lips blanched, eyes sunken
and injected, cornea dull and partly glazed, extremities pulseless, heart's action feeble, skin of body warm and
bedewed w ith perspiration, hands shrunken, damp and cold, tongue dry, lirown and badly li.ssured, lips and teeth
covered with dark-brown sordes : he was very deaf, had violent subsultns, dysphagia, involuntary urination and
excejisive tympanites, but no movement of the bowels: respiration was slow and labored. He died on this day.
t'ASE y7. — I'nifded hi/ {jiioliiluni cliilh; dute of onset iindcjincd; dinrrliaal affection mrcre ; dtliriiim ; prostration ;
death. — Private Jacob Benson, Co. H, 1st Pa. Cav.; age 23: suftered with quotidian chills during August, 1861, and
on September 7 was admitted. Diagnosis — typhoid fever. The patient was weak, dull and stupid : pulse 104, skin
hot and dry, tongue dry. brown and heavily coated, bowels relaxed aud painful. Whiskey and beef-essence were
administered. Six thin stools were passed during the next twenty-four hours; the right iliac region was tender.
rur]>entine emulsion, Hoffmann's anodyne and morphine were prescribed. On the 9tli delirium, epistaxis, rose-
colored spots and three thin dark stools were noted, aud on the 10th sordes, subsultns, difficulty in protruding the
tongue and aggravation of the diarrhiea. Enemata of starch and laudanum were used, but the diarrhtea persisted,
giving live or six stools daily until the end. A profnse eru]>tion of rose-colored spots and siidamina appeared on
the 14th. The stools were passed involuntarily on the 16th, and afterwards the abdomen was tympanitic and
tender in the right iliac region. Carbonate of ammonia was prescribed on the 17th. Xc.xt day the stounich was
irritable, the respiration labored, skin congested, eyes dull, half oi)ened and with contracted jiupils. On the UUh
a few rose-colored spots appeared: the pulse was 120, soft and compressible, and the features shrunken. Death
took place on the 2Uth.
C.\SE 98. — Chills and firer uilh, subsequently, the gradual accession of symptoms of enteric fercr; diarrhceal attack
an 17(A day: rose-spots and delirium on IXth : intlamniation of parotid on 2ith ; atjgruration of diarrhwa on 2Sth and death
OH 30/A day. — Private James Roe, Co. F, 1st Mich.; age 22; was admitted Sept. 28, 1861, having been taken sick
about a week before with chills and fever, for which quinine and alteratives had been administered. On admission
he was weak, had anorexia and headache, but his skin was natural, tongue moist and slightly coated, pulse 72 and
bowels i|uiet. I'p to October 5 there was no marked change in the patient's condition ; the coating of the tongue
liecame somewhat thickened: the skin was dry, hot on the 3d, perspiring on the 4th: the l)owels were quiet or
moved once daily, and there was .some tenderness in the right iliac region: the headache continued and there was
slight cough. On the 6th the patient vomited .some dark-colored matters. On the 7th he was restless for the lirst
time since admission : the bowels were moved four times and the tongue was moist, red at the tip and edges aud dark-
brown at the centre and base. On the 8th he was delirious ; pulse 90 and quick ; skin hot and dry, showing a few
rose-spots, disappearing on pressure, and mingled with profu.se eruption (character not stated); tongue dry, flabby,
red at the tip and edges, coated brown in the centre ; appetite very good ; he had one stool, some tympanites and slight
gurgling in the right iliac region. No change was manifested save increasing duluess of mind and prostration until
the 13th, when the tongue became slightly moist and the delirium lessened. During this period the teeth were
covered with sordes and the mouth filled with tenacious nuicus. On the 14th the parotids became swollen. Next
day the pulse was 120 and feeble and the bowels quiet but tender and distended: the patient, nevertheless, when
aroused from his low delirium, expressed himself as feeling quite well. The tongue became moist and its coating
yellowish-white on the 16th, and on the following day the patient was more rational : the eruption was present up
to this date. A sharp diarrho-a of seven stools occurred on the 18th and the pulse reached 140. A blister was
applied to the abdomen. On the 19th vibices appeared ; the tongue could not be protruded on account of the
parotid swelling: the bowels were moved once only, but they were generally tender aud much meteorized.
Death took place on the 20th.
Case 99. — Typhoid fei-erfolloteing intermittent; intestinal symptoms not marked; death from pneumonic complications. —
Private A. W. Armagust, Co. I, 33d Pa. Vols., was admitted Oct. 2, 1861, Diagnosis— typhoid fever. About Sep-
tember 28 he had been taken with headache and chills, which recurred every night. He felt well on the mom-
Med. Hist., Pt. 111—31
242 CLINICAL RECORDS OF
ing after admission, but in the ereiiing tlie pulse liecame accelerated and strong, the skin hot and dry and the
tongue red, clean at the tip hut coated at the liase ; he had three stools during the day, with some soreness of the
abdomen, but no tympanites nor gurgling. Quinine was given. He is reported as having slept well on the 4th
and as having had no chill on the 5th; on the 6th his condition is not stated. On the 7th he had headache and was
restless; countenance natural; pulse 86, steady; skin hot and dry but soft; tongue moist, red and quite clean; he
had pain in the bones, two stools and abdominal tenderness, l)ut no tympanites. He had one stool on the 8th.
Small doses of calomel, quinine and opium were given. The headache was worse on the 9th ; there was a feeling of
pressure on the brain with b-azzing in the ears and deafness ; four stools were passed; the tongue was dry, red at the
tip, furred in the centre and coated gray at the base. Sweet spirit of nitre was prescribed. On the 10th the bowels
were quiet and continued so to the end with but little complaint of abdominal tenderness or tympanites. Enmlsion
of turpentine and Mindererus' spirit were administered. On the 11th the skin was hot but moist; the tongue
continued dry and the appetite did not return, although there was marked improvement in the cerebral and abdom-
inal symptoms. On the 15th the patient was restless, and there was some cough for the iirst time in the progress of
the case; the cough grew worse, and on the 17th brown mixture was prescribed. Next day there was anxiety of
countenance and much cough, but neither accelerated respiration nor pain. On the 20th the patient was slightly
delirious. Whiskey -punch and citrate of iron and ([uinine were given. On the 22d his face was pale, countenance
dull, pulse 82, steady, surface circulation good, skiu dry and husky but not hot, tongue slightly brown and dry in
the centre, whitish and moist along the sides, red at the tip and edges, teeth and gums clean ; he liad some appetite,
no thirst, and a cough with slight wheezing and gurgling sounds in the lower parts of the lungs: at times also he
had some dizziness and tinnitus. On the 23d the respiration became increased to 26; the pulse to 102; the abdomen
was soft and natural. He died on the 29th. No eruption was noticed in this case.
Case 100. — Chills; pale, coated toni/ue and offrnsive breath; jaundice and epigastric pain ; hoivcls quiet; cerebral
symptoms not marked; record unfinished. — Private George H. Peters, Co. F, 4th Mich. Vols.; age 21; of weakly consti-
tution, was admitted Nov. 1, 1861, as a case of typhoid fever. On October 23 he was taken with headache and chills
which lasted for three days, and with anorexia, weakness, diarrhoea, cold feet, tinnitus aurium and fever, for
which Epsom salt and quinine had been administered. On admission he was dull and unable to collect his
thoughts on account of a fulness in the head and ringing in the ears; his pulse was 98 and strong, skin warm and
soft, left cheek ilushed darkly, tongue dry and moist by turns, pale, clean at the tip and thickly coated whitish-
gra)' at the base; he had no appetite but much thirst, acute epigastric and right iliac tenderness, tympanites, hut
nodiarrhiea; respiration was normal, but the breath was very ofi'ensive ; there was also some pain in urinating.
Brandy-punch and beef-essence were given with quinine, calomel and opium three times daily. A few rose-colored
spots appeared next day. On the 4th the skin was dry, warm and somewhat jaundiced; the tongue red at the tip
and edges, pale and coated white in the centre and at the base, the bowels meanwhile remaining tympanitic and
tender but unmoved. He slept well during the night, and on the 5th his mind was clear and eyes intelligent, skin
dry, tongue moist, pale and slightly coated in the centre, breath free from all oft'ensive odor. On the 6th a few more
rose-colored spots appeared, but the bowels remained quiet, and the slight tenderness present was in the epigastric
region; the abdomen was soft. He had two stools on the 7th. Turpentine was administered. On the 8th the skin
was warm and soft and presented a few dark-red spots which were imperceptible to the touch and disappeared on
pressure; pulse 56, small and compressible; tongue moist and thickly coated in the centre. At this time he did not
sleep well and his appetite continued poor. Here the record leaves him, concluding with a statement of his transfer
to Annapolis, Md., on the 18th.
Case 101. — Eecurring chills; cerebral sjimptoms slightli/ marked; gastric ii-ritubility; diarrhna and abdominal tendtr-
ness. — Private Frederick Doser, Co. B, 24th N. Y. Vols.; age 24 ; had been troubled with liver complaint since 1856,
and about Sept. 16, 1861, was taken with intermittent fever, which persisted notwithstanding the use of quinine
and opium. He was admitted on the 30th as a case of typhoid fever. His eyes were dull, pulse 96, skin natural,
tongue moist but furred white; he had pain in the bones and anorexia, cough and pain in the chest, three stools
daily with tympanites, iliac tenderness and some gurgling. Opium, antimony and blue-mass in small doses were
given every three hours. Next day the pulse was 112, skin somewhat hot, eyes injected and suft'used, tongue moist,
furred in the centre and red at the edges, bowels much meteorized and tender at the umbilicus. Quinine was given
with turpentine enmlsion in place of the mercurial. The quinine was continued on the 2d and tincture of iron
ordered on the 3d, the pulse having meanwhile fallen to 85, the tongue become cleaner and the appetite improved.
A diarrhoea of four stools daily set in on the 4th, followed on the 5th by epigastric pain, intestinal gurgling, tender-
ness in the right iliac region and in the course of the transverse colon, and on the 6th by loss of appetite and
irritability of the stomach. Seven stools were passed on the 9th and three on the 10th, after which the attack grad-
ually declined; during this time there was some head-pain with dizziness and tinnitus aurium, and the tongue
remaining red at the tip and edges became covered elsewhere with yellowish patches. Conjunctivitis, which appeared
on the 11th, was treated with a zinc wash. On the 14th the pulse was 56 and regular, the skin natural, the tongue
moist and clean and the appetite good. The patient was transferred to Annapolis, Md., November 1.
Case 102. — Uccurrini/ chills and diarrhira ; perspirations; nothing hut rose-spots on the 13th day as specially ehur-
aeterisiic of typhoid fever. — Private A. Stoughton, Co. C, 5th Vt. Vols.; age 18; was admitted Nov. 1, 1861, as a case
of typhoid fever. On October 23 the patient had chills which recurred for several days, fever, general pains, weak-
ness, anorexia and diarrhiva. On November 2 his eyes were bright, countenance calm, pulse 88 and of fair strength,
skin warm and j)erspiring, tongue clean at tip, moist and slightly coated at the base and in the centre, lips and
teeth clean, appetite fair, abdomen soft and respiration normal ; one stool was passed in the twenty-four hours. A
full dose of quinine was given three times daily. On the 3d he was reported as having slept well; pulse 84, appetite
TlIK COXTTNUKl) KKVKRS.
243
good, skin iiatuial, tongue deauiuj;; two stools wru- iiassod. On tlio following <lay, without any otlitn- oliange in
tbe syinptonis, rose-colored spots appeared on the chest and abdomen: he had one stool on this day, and after this
his bowels were reported as regular. He was returned to duty on the 11th.
Case 103. — AVc«rri«</ cliillx: (liuirhoal teiKlinfi/: nifiitiil (liilnisn; roiic-HpolK on Hlh (Im/, iniiiirilinlihi folloivid hi/
(•()iirii?(s<riu(.— Private Samuel liisslnette, Co. A, Ith Mich.: age 22: was seized about Sept. 9, 18()1, with daily chills
accompanied by headache, pain in the back and legs, anorexia an<l cosiiveness. He was admitted on the IGth.
Diagnosis — typhoid lever. In the evening the (latient was weak and had no a))petite; the pulse was HO; skin hot
anil moist; tongue coated white, but red at the tip and edges; one stool was passe<l ; the right iliac region was ten-
der, and complaint was made of pain in the back and legs. Ten grains of calomel and jalap were given. Eight
dejections occurred during the night, and next morning the skin and eyes were jaundiced. Quinine was given. In
the evening the pulse was 74, the skin warm and moist, the tongue coated gray but red at the tip, the bowels quiet;
there was acute right iliac tenderness and mental dulness with tinnitus auriuui. Next day the bowels remained
(|iiiet and the tenderness cea.sed: but pain in the head and in the back was noted. The abdominal tenderness
returned on the ll'th, when, also, the tongue was nearly clean hut dry, the cheeks flushed ami the )iain in the back
so acute as to require sinapisms. The bowels were <iniet on the 20th and without pain or rymiianiles; the tongue
coated gray: the skin moist. Two stools were passed oil the 2l8t; the tongue was white, the skin hot and dry, and
there was some thirst and cough, but the appetite was good. A few ro.se-spots ap|)eared on the 22d, the tougue
being pale and moist, the pulse 80. In the evening of this day he was dull: pulse G-1. He persjiired during the
night, and next day the skin was warm and moist, the tongue pale and clean and there was no tenderness, tympa-
nites nor eruption. A few ilark sjiots were found next day on the abdomen and chest. After this improvcnu ut was
steady. The patient was w:ilking about on the 2!ttli, and was transferred to Annapolis, Md., October 1.
Cask 104. — lienirrinti chilh and fevtr; diarrhwa ; sliglil ddiriiim ; gnat prnstration; vibian am! ijaniirnuof liVm-
terrd mirfaces; dtath.—See ease of Private Daniel Pluninier, Co. H, 33d Pa., No. 93 of the poHl-mortim records.
Eight TYriioin Keveh Cases niECEDEi) ou AccoMrANiEr> by REMiriEXT Fevek.
Case 10.5. — Record givni in fall. The eTisiing malarial attack appears to liare ended on October 7, when the pid.se hail
fullen to 80 and the akin and tongue irere in natural condition, leaving the patient, however, with a diavrhua, xuggenting a congested
anil perhaps ulcerated condition of the bowels, and some puhnoniiry engorgement. The tgphoid fever is unmarked bg prominent
sgmptoms: its injiiunce, other than in the appearance of the rose-colored spots, seems onlg to hare prolonged the period needful to
a return to health. It is noticeable that on (Ictobcr 16, while the rose-spots teere get fading, the patient was permitted to be out
DM j>a*,'>.— Corporal Christoi)her Heningor, Co. D, 3d Mich.; age 26; had been liable to attacks of intermittent fever
since 1858. He was admitted Sept. 28, 1861, as a case of typhoid fever. He had been taken sick three days before
with chills, fever and pain in the back, and had taken quinia; facetinshed, eyes dull, lids dropped; pulse 104,suuill,
easily compressed; skin moist, slightly above natural temperature; tongue moist, slightly coated white; anorexia
and irritability of stomach numifested by unsuccessful efforts at vomiting; tenderness over entire abdonuin. slight
tympanites in right iliac region, no stool; dull, heavy head-pain; nervous twitchinf.s of muscles; no cough but
respiration hurried, 30 per minute. During the examination a violent chill came on: the extremities became cold,
the pulse small and at times imi)erce])tib!e at the wrist, the cheeks cold, the breathing hurried and interrupted, the
eyes turned upward; some stupor was also noted. Quinia, opium and calomel were ordered to be given every four
hours. 2ttth, morning: Slejit .some; face congested; eyes suffused; pulse 120, quick, feeble; some pain in head and
limbs: some deafness and stu)ior; skin of natural temperature; t(uiguo dry, brown, moist at edges; anorexia:
epigastric and general alidouiin;il tenderness; tympanites; derangement of liver; no cough. Milk-punch, beef-essence
and blue-ma.ss and opium were ordered. Evening: Feeling better; face flushed; eyes suffused ; head dull and heavy;
pulse 120, fnll and strong; skin moist; tongue moist at edges, brown and dry in centre; anorexia; slight tenderness
in abdomen, particularly in right iliac region; some tympanites and borborygmus; no stool; no cough. Dover's
powder was given. 30th, morning: Slept well ; cheeks congested ; eyes dull ; head-pain ; pulse 112, quick, small ; skin
hot and moist; tongue moist at edges, dry iu the centre; anorexia; tympanites; slight tenderness in right iliac
region, marked iu left; much soreness in right hypochondriac region; two stools. Ordered three grains of calomel,
one of opium and one-sixth of a grain of antimony every three hours. Evening: Drowsy; face congested: eyes dull:
bead-pain: pulse 112, strong; skin above the natural temperature, covered with perspiration; tongue slightly moist
at tip and edges, dry and brownish in cenire: four stools; slight tyuijiauites; tenderness iu left iliac region. Ordered
astringents. October 1, morning: Head-pain; pulse 112, quick, strong; skin moist, slightly above the natural tem-
perature; tongue moist at edges, dry and white iu centre ; appetite small; several stools; some cough; pain in right
lung; respiration 30. Ordered beef-essence and astringents. Evening: Ordered one grain of (|uinia and two grains
of Dover's powder every three hours. 2d: Slept some: face congested; eyes dull; slight head-pain; pulse 10r),quick
and strong; skin hot and moist: tongue moist, coated white in patches iu centre; some appetite; slight tenderness;
no tympanites: paroxysms of coughing; mucous expectoration streaked with Idood; respiratory murmur in lower
lobes of right lung entirely lost. Veratrum viridc and sweet spirit of nitre were ordered to be taken every hour.
'AA: Slept some; head-pain and slight delirium; pulse 112, quick, strong; skin somewhat hot; tongue moist, clean
but for a few yellowish patches in centre; some appetite; two stools; much cough; viscid mucous expectoration
streaked with blood: respiration :« : respiratory murmur absent over lower part of right side; some dulness on per-
cnssion on both sides. 4th: Slept but little; some head-iiain; imLse 108, strong; skiuhot; tongue moist, covered with
yellowish patches iu centre; vomiting; anorexia; three stools; some cough; mucous expectoration streaked with
blood; re.s]iiration 30 but deeper ; dulness decreased in left lung, increa.sed in right. Fifteen drops of veratrum viride
weregiven during the day. 5th: Slept well; pulse 8.5, full; skin soft but rather warm : tongue moist, slightly coated iu
244 CLINICAL RF,CORDS OF
centre with yellowish patches; some appetite ; three stools; hut little expectoration; respiration 26. Milk-punch
and Dover's powder were given. 6th: Slept well; head-pain; pulse 90, full; skin of natural temperature, covered
slightly with perspiration; tongue moist, coated white in centre; appetite good; some tympanites; right iliac ten-
derness; two stools; slight cough and expectoration; respiration 2.5. 7th: Slept well; looking better; pulse 80,
natural; skin and tongue natural; two stools; slight cough ; respiration 2.">; respiratory murmur absent on left side
below third rib. 8th: Not so well; countenance and skin natural; pulse 85, (|Uick; tongue moist and clean; appetite
good; three stools; some cough; slight expectoration of mucus slightly tinged with blood; respiration 35; some
crepitation and absence of respiratory murmur on left side, lower portion ; mucous rules in middle lobe of right lung,
vesicular murmur in upper portion. 9th: Slejit widl : pulse 80, weak ; skin natural; appetite improving; two stools;
respiration 26. 10th: Restless; eyes more natural, cheeks less congested; pulse 80, ([uick; skin natural; tongue
moist, clean; appetite moderate; cough slight; two stools. Tincture of iron ordered three times daily. 11th:
Stronger; slept some; eyes bright; face slightly Hushed; pulse 85, quick; skin natural ; tonguenioist, clean; appetite
good; three stools; cough slight. 12th: Slept well; looking better; cheeks congested ; pulse 90, strong, wiry ; skin
of natural tem])erature, an occasional rose-spot appearing; tongue moist, clean; slight tenderness in right iliac
region; two stools; no cough. 13th: Slept well; looking bright; pulse 90, quick; skin a little above the natural
temperature; slight i)ain in right lung; tongue moist and clean ; appetite good; six stools; no cough. 14th: Slept
well; looking bright; pulse 110, quick, corded; skin of natural temperature, an occasional rose-spot appearing;
tongue slightly coated yellowish in centre; appetite moderate; three stools; moderate tenderness in right umbilical
and left iliac regions, loth: Slept some; pulse 80, regular, corded; skin of natural temperature, showing a few rose--
sjiots, disapjii^aring on j)ressure; tongue moist, coated yellowish-white in centre; appetite good; three stools; some
umbilical tenderness; some pain in middle of right side on deep inspiration. 16th: Out on pass. 17th: Slept well;
pulse 85, (|uick; skin of natural temperature; tongue moist, coated slightly white in centre ; appetite moderate; two
stools. 18th: Wakeful; pulse 8f), somewhat irregular; skin covered with perspiration; slight headache; tongue
moist, clean; a])|ietite poor ; two stools; some epigastric pain and tenderness. 19th: Slept well; pulse 62, regular;
skin natural; tongTie moist, clean; appetite moderate; three stools; pain on deep inspiration. 20tli: Slept well;
pulse 86, regular; skin and tongue natural ; appetite good; two stools. 21st: Slept well; pulse 90, quick; skin and
tongue natural; buzzing in ears; appetite good; two stools. 22d: Slept well; bright; pulse 90, somewhat quick;
tongue clean; appetite good; two stools; some abdominal tenderness. 23d: Slept well; pulse 90, natural ; stillsonie
pain in right side of chest. 24th: Wakeful; pulse 90, quick; skin moist; tongue white; appetite moderate; two
stools; less tenderness. 25tli: Slept well; pulse 90, quick; skin natural; tongue clean ; appetite good; two stools;
some general tenderness. 26th: Returned to dut}'.
Case 106. — llomUlent fever not amenable to Ireiitment lii/ quinine; reeord deficient, hut typhoid ferer suggested by
diarrhau, tenderness in the riijht itiaa region, hrown tongue and sntiseijuent disehurge for dehililg. — Private James Ellison,
Co. F, 19th Ind.; age 24. This man contracted tertian ague about Aug. 20, 1861. The chills were broken up by
quinia. He was admitted September 4 as a case of typhoid fever. On the morning of the 5th the fever was slight, the
pulse 72, skin natural, tongue tlabby and coated yellowish-brown, appetite good, bowels somewhat relaxed and
tender on iiressure. Quinia was ordered. In the evening there was a moderate fever with tlushed face, hurried
respiration, hot and dry skin and a burning in the mouth and throat; the bowels were moved twice during the day.
Dover's jwjwder was given. lie rested well during the night, and next morning was sweating and without fever;
but in the evening the skin became hot and dry, the tongue pale, dry and slightly coated, and seven loose stools
had been passed accompanied with umbilical pain. A similar remission and exacerbation occurred on the 7th, the
dejections on this day being thin, small and lumpy. The remission on the morning of the 8th was not so well marked,
although the bowels had not been disturbed during the night; the mind was clear. On the 9th, in the morning, the
face was tiushed, the pulse 68, the tongue pale, flabby and coated in the centre and at the back,- the skin warm and
dry; one thin stool bad been passed without pain but with borborygmi. In the evening the pulse was 86, the skin
warm and dry, the tongue ]):ile and coated brown in the middle; there were no rose-spots; three thin small stools had
been i)as.sed without pain; the appetite was improving. Dover's powder with small doses of blue-jiill and citrate
of iron and <|Hinine were ordered. The 10th gave a similar record, but in the evening the tongue was dry and coated
brownish, and in connection with four thin small stools passed during the day, it is stated that there was some right
iliac tenderness. The blue-pill and iron were omitted and the Dover's powder and (|uinine continued. On the
11th an acetate of lead and opium pill was given three times, liut the diarrhu'a continued with slight fever in the
evening, and a moist tongue, coated brown in the centre, up to the 13th, when he was transferred to hospital at
Baltimore, Md. [He was discharged October 15 on account of general debility.]
Case 107. — liccurring chills; diarrha-a; rose-colored spots; gastric irritahility; improvement about end of ith week. —
Private R. M. Robinson, Co. C, 9th Pa. Vols.; age 19; was admitted Sept. 19, 1861, with typhoid fever. About three
weeks before his admission ho had been taken with chills and pain in the head and bones; the former recurred at
intervals of several days with fever at night and continued diarrhu'a. On the evening of the 19th the j>atieut was
weak but looked well; pulse 78, eyes bright and clear, skin warm but dry and covered on the abdomen and chest
with characteristic rose-spots, tongue dry, smooth, glossy and nearly clean; but he had ])ains in the head, back and
limbs and in the hypogastric and right iliac regions, with distended bladder and dysuria. Castor oil, acetate of
potash and sweet spirit of nitre were given. He slept badly and had epistaxis at night. Next day the pain in the
back and limbs was severe; the skin was dry and warm, the tongue dry, cracked and yellowish-brown in color, the
stomach slightly irritable, the bowels tender; one stool was passed. On the 23d a second crop of rose-colored spots
appeared on the surface; the bowels were quiet and the tenderness much relieved. The tongue became clean on
the 25th. On the 30th the patient was considered convalescent. He was transferred to Annapolis, Md., November 1
[and was returned to duty December 12].
THE TONTINUKD FKVKRt!. 245
Cask 108. — Mild liipho'id (jrnfled on nmilltiil J'lvir. — Private R. 1\. Lassoy, Ck. A, llli MUh.; :ij;i' I'S; was scizcil
with lieadaobe, weakness and nausea aliout Sept. ti. ISlil, and on the Kith was admitted as a ease of typhoid lever.
In the evening the patient's faee was Hushed and lie had nausea and h)ss of appetite, pul.se !I2, skin warm and
moist, tongue moist, yellowish and lieavily coated, bowels (juiet. Ten grains each of calomel and jnla|i were given;
two dejections followed, and next morning the tongue was eleaner at the tip and edges. Quinine was ordered.
In the evening there was no fever, the skin was cool, nioLst andperspiring : one stool was passed during the day,
and there was tenderness in the right iliac region. On the morning of the 18tli there was no fever, the skin heing
cool and moist, and the ahdominal tenderness relieved; but in the evening the patient had one thin, largo stool,
and the right iliac regioTi became acutely tender. Dover's powder was prescribed. On the 19th there was tympa-
nites and the iliac region continued tender, but the skin remained cool and moist and the bowels quiet. The con-
dition of the patient was changed on the :?Oth only by the diminution of the tympanites; one stool was passed
during the day. On the Jlst there was deafness with au.\iety of expression ; there was also some thirst, but the
appetite was good and skin natural. The tongue was clean on the 2"id, the puLse ti8, small and soft, the skin natural,
the bowels ijuiet and neither tender iu)r tympanitic, but the face was somewhat liushed. In the evening rose-spots
made their appearance, and a .second crop on the L'llh. Wine and bark were ordered. He was reported as walking
about on the 30th, and was transferred to Annapolis, Xld., October 1.
C.\SE 109. — ^fiM liiphoid (/rafted on rnnitlrnl ferer. — Private Kli Sulgrave, Co. D, 19th Ind.; ago 18; had a
chill about Aug. 25, 1861, and was admitted September 4. Diagnoses — typhoid fever. Ho had headache, pain in
the liones and back, and slight diarrluca with fever, which was aggravated daily about noon. On the nmrning of
the 5th there was tinnitus aurium but no fever; the pulse was 78, skin cold and nujist, tongue coated, pale and
Habby, appetite good, bowels regular. (Quinine was ordered. In the evening the pulse was 72 and strong, tongue
pale. Ibibby, red at the edges and white at the base and centre. During the da,y ho had one thin stool and was
weak and giddy. Dover's powder was given at night. I'ntil the 11th the patient continued without change, a
slight febrile action occurring every evening, manifesting itself in flushing of the face, but the pulse in no instance
rose higher than 80: there was one stool daily, with, on one occasion, pain in the left iliac fossa. He usually
rested well and had a fair ajipetite, although his tongue eontiuued pale, flabby and coated. On the Utli a few
rose-spots appeared, which faded next day, but were rcphuM'd by others and an eruption of sudaniina; the ]uilso was
H8, the skin cool, bowels ipiiet anil not tender, tongue coated brownish liut red at the tip. On the IDth ho was
sent to hospital at Baltimore, Md. file was afterward transferred to the 20th Ind. and served until the close of
the war.]
C.\SE 110. — Mild tjiphoid iiniflid on rvmitlmt fevir. — Private E. S. Elmer, Co. K, lltli N. Y.; age 22; was admitted
Sept. 24, 18(51. having been taken sick three weeks before with diarrha>a followed by bilious remittent fever. On
admission he had severe headache with flushed face, injected eyes and accelerated pnlse. He slept little during the
following night; in the morning he was covered with sweat, pnlse 108, full but weak, tongue slightly yellow, bowels
moved once, respiration natural; his appetite was good, but he had much thirst and was sonunvhat dizzy. Two
grains of blue-mass and a lialf grain of i|uinine were ordered to be given every two hours. On the 2()tli he was
not so well: his face was flushed, c.ves nuicli sutt'used and countenance auxious; the dizziness was. increased
and there was delirium; the tongue was heavily coated yellow and the appetite lost; there was also retention of
urine, but the skin was moist ami profusely covered with sudaniina: there had been but one stool, and the patient
had no pain nor tenderness. Castor oil and extract of buchu were ordered. In the evening the skin was hot but
bathed in perspiration, the pulse 96, strong, the tongue coated and moist, the bowels tender and slightly tympa-
nitic. On the 27th the face was not flushed; the skin was soft and natural, the respiration normal, the tongue
moist, yellow in the centre, and the appetite good ; two stools were passed aud there was some right iliac tenderness ;
a few rose-colored spots appeared on the abdomen. One draidim of turpentine emulsion was given every three
hours, with twelve grains of (jiiinine in the forenoon. In the evening the cheeks were flushed, the eyes suffused,
the pulse 96, the skin dry and hot, the tongue moist and heavily coated gray, the appetite good; two stools w'ero
passed and tympanites, borborygmus and tenderness were present. Sweet spirit of nitre and Dover's powder were
given. Xo stool was passed on the 28lli; the skin was natural, jiulse 92, strong, the tongue moist and yellow, the
appetite moderate; there was some difficulty in micturition bnt no abdominal pain nor tcuderne.ss. In the evening
four or five ro.se-colored spots ai>peared on the abdomen and chest. Next day the skin was soft but rather above
the natural temperature, the tongue moist and yellow-coated but red at the tip and edges; there were twelve dull
red sjiots on the abdomen, which was slightly tymjianitic but not tender. He vomited during the following uiglit
and had three stools with some tympanites and left iliac tenderness. Lead, opium and t.annin were given. Slight
relaxation of the bowels continued np to October 10, when the patient w-as sent to hospital at Annapolis, Md.
Case 111. — Chill; mnitting fever: slight dinrrhn a : moiKt /ikin ; Jtahhy tongue; rose-KjMts on I5th da)i ; drowsiness;
pfrspirations ; sordes: record ini]>erfect; death. — Private Henry Martindale, Co. F, 19th Ind. Vols.; age 24; was taken
Aug. 2H. 1861, with headache, pains in the bones, languor and chill. He took quinia and had no recurrence of the
chill ; but the fever which followed was generally worse in the morning. He was admitted September 4. Diagnosis —
typhoid fever. Onthe5tli: Pul.se 76; skin warm and moist ; tongue heavily coated, pale aud flabby; slight diarrhipa;
pain in the back. (Quinine was given. Erening: Skin warm, dry; tongue flabiiy and coated white; four thin small
stools, but no pain or tenderness in the V>owels; appetite fair. Dover's powder at night. On the 6tli and 7th the
symptoms were unchanged. On the 8th the mind was somewhat dull: the patient continued to be up and to walk
almnt occasionally. Sugar of lead and opium were given. No material cliange took place until the 11th, when
the warm and moist skin showed sudaniina and some rose-colored spots on the abdomen, the tongue at this time
being pale, flabby and coated gray, the bowels but slightly relaxed and the appetite good. Whiskey-punch was
246 CLINICAL RECORDS OF
prescribed. The patient was drowsy on the 12th, and on the foUowiufi; day the tongue became brown and cracked
but remained pale at the tip, tlie skin hot and dry, the breathing hurried, and the bowels moved eight times lint
free from pain and distention. On the 14th the tongue was dry and the countenance liaggard. Two grains of
quinine and one of calomel were jirescribed for administration three times daily. Profuse perspirations occurred ou
the 15th, but the diarrho-a continued and sordes appeared on the teeth. Turpentine emulsion was given. On tlie
evening of the 16th there was some tenderness of the abdomen and the patient kept tossing his head from side to
side. On the 18th the pulse was 80, weak and small, tongue heavily coated, brown in the middle and red at tip and
edges, skin hot and moist, bowels not tender but quite loose, especially at night. On the 19th there was bolmb
tenderness in the right iliac region. Ten stools were passed on the 22d, and on the following day the abdomen was
tympanitic. The record closes abruptly with the announcement of death on the 28th.
C.\8E 112. — Coincidnwe of remittent fever and ti/phuid. — Arininius Tyler, attendant; age 21; was admitted Sept.
9, 1861, having been sick since the 1st with headache, pain in the back and fever, .aggravated at night, but not pre-
ceded by a chill. On admission his face was flushed, pulse 79, tongue white and coated, skin warm and sweating;
he had epistaxis and a few rose-colored spots on the abdomen. Next day the tongue was moist, brown-coated in
the centre and red at the tip and edges ; the bowels were quiet but tender on pressure. Quinine was taken during
the day and Dover's powder at night. On the 11th the patient was dull and prostrated, pulse 68 and feeble; but in
the evening there was much restlessness with high fever, pulse 90 and strong. Next morning a remission occurred,
followed by an exacerbation in the evening; the tongue was pale, flabby and coated brown, and the bowels con-
tinned c|uiet. On the 13th the evening exacerbation was not so marked, but the tongue was heavily coated gray
and the skin and coujunctivie were jaundiced. Blue-mass was given in addition to the quinine. On the loth two
large stools were passed, and in the evening three free, thin and painless stools. Aromatic sulphuric acid was
prescribed. On the 16th the pulse was 62, the tongue pale and heavily coated gray, the bowels (juiet, the jauu-
dice disappearing; there were rose-colored spots and a profusion of sudamiua ou the skin, which jierspired freely.
Kose-colored spots appeared again on the 18th; the bowels continued quiet and the evening accession became less
manifest; night-sweats were profuse. On October 1 the patient had so far recovered as to be placed on light duty.
Eight Remittent Fever Cases with more or less evidence of the co-existenck of Typhoih Fever.
Case 113. — Diiii/nosis — remittent. Velirinm, stupor, deafness ; diarrhoea; rose-colored spots and lied-sores. — Private
Bennett Pepper, Co. H, 62d N. Y.; age 19; was taken sick early in February, 1862, with headache, nausea, vomit-
ing and pains in the back and limbs, and was admitted on the 27th as a case of remittent fever. On March 5 he
was delirious, drowsy and inclined to stuiior; he had tinnitus aurium and twitching of the mouth, putty eyelids,
flushed cheeks, rapid and weak pulse, hot and dry skin, moist but much coated tongue, sordes on the teeth, some
apjietite, much thirst, a diarrhcca of four watery stools daily, which were sometimes passed involuntarily; respira-
tion was hurried and there was some cough. Beef-essence, turpentine emulsion and tincture of opium were pre-
scribed. On the 6th there was profu.se perspiration with sudamina. Next day the delirium abated and the patient
replied ration.ally but with difficulty; the tongue was coated but moist, and was permitted to remain [irotruded
iudeflnitely; the bowels were regular but meteorized and tender and the abdomen showed some rose-colored spots;
tlie breath was very ort'eusive from oza'ua. There was much tendency to stupor on the 9th, with occasional delirium.
P'ree perspiration with sudamiua occurred again on the lOlh, and the urine was excessive in quantity; cough per-
sisted and there was some dulness on percussion a little below the clavicle on the right side. The skin Ijecame
liot and di'y on the 12+h and the watery stools returned ; respiration was hurried and the breath very ott'ensive.
The mind became clear on the 14th, and on the following day the skin was natural, the tongue clean, the pulse
good, but the bowels continued loose. The diarrha'a, however, subsided on the 16th, on the occurrence of copious
sweating with sudamina, and the congh was much relieved; earache, developed ou this day, was noted also on the
17th, when the skin again became hot and dry and the tongue somewhat coated. Some sore spots on the back
and hips were observed on the 18th, and next day the patient was placed on a water-bed. He l>ecame deaf at this
time, but his general condition improved, and on the 28th he was able to walk about. He was discharged April 26
because of general debility.
Case 114. — Diaiinosis — remittent ferer. DiarrJura and ahdoininal pain : deafness, deliriioii and prostration ; record
incdmphte. — Private Edwin White, Co. H, 86th N. Y. Vols.; age 18; was admitted March 2, 1862, with remitting
fever, headache, giddiness, nausea and constipation. The record is silent as to his condition until the 13th, when
he was dull and dejected and talked much in his sleep, having a Uot and dry skin, a dry tongue, rough and coated
but clean and moist at the edges, some pain in swallowing, diarrha'a, abd<?ininal pain and slight iliac tenderness,
with headache and flushed cheeks, rapid pulse and occasional epistaxis. The fever increased towards evening and
was followed by a chill. From the 14tb to the 18th he had delirium at night but was rational during the day; his
bowels were slightly relaxed, the stools thin and watery, and there was much abdominal tenderness. Quinine was
ordered on the 14th, tincture of iron and turpentine eunilsion on the 15th; epistaxis was noted on the 16th and
deafness on the 17th. On the 18th delirium gave place to dnlness and stupidity, which increased until ou the 21st
the patient was unable to protrude his tongue well and swallowed with difticnlty; there was epistaxis; cough
became troublesome and the expectoration was tinged with blood, which was conceived to be owing to the epis-
taxis. From this time to the 30th, when the daily record ends, there was little change in the symptoms. The
patient was discharged for debility May 10.
Case 115. — Symptoms of typhoid in a case entered as remittent; discharged on account of rheumatism. — Private L.
Pettit, Co. D, 3d Mich. Vols.; age 22; of delicate constitution and liable to pulmonary troubles, was admitted
Oct. 19, 1861, as a case of remittent fever. Next day his eyes were bright, cheeks slightly flushed, pulse 74 and
THE CONTINUED FEVERS. 2J7
rc'ular, skiu soiiiewliiit abovt' tlu' natural U'liipoiatiuc, toii^uc moist, fissured anil faintly coateil yollow, ap|«lili'
"ooil; he had a slight oou^h, pain in tho back and limbs, rclaxi'd bowels, tympanites and general abdominal tender-
ness, marked in the right iliac region. Two rose-colored spots were discovered on tho 21st, tlie symptoms otherwise
remaining as stated. Twelve grains of quinine and two of opium were given daily in divided doses, with Dover's
powder at night. On the 24th the skin became moist. Next day he was wakeful, his eyes dull and cheeks congested.
Two drachms of sulphate of nnignesia with one-twelfth of a grain of tartar emetic were given in the morning and
t wo compound cathartic pills at night. After this ho seemed to improve, his pulse, tongue and skin becoming natural
and appetite good, lie slept well, and on the 2i)th was out of bed and dressed; but on this day his eyes wore
bright, cheeks somewhat llushed, ]>ulse 80, and he had pain in the hip, knee and ankle-joints, which continued until
his transfer, November I, to Annapolis, Md. [Diagnosis — rheumatism ; patient discharged from service on the 2!tth.]
Case lit!. — lHuiiiiosis — n-mittini. Ditinliiiu tuiti nm-volurid xpoh; no cirdiral xi/mjitoms. — Private Oscar II. Kield,
Co. C, 24th N. Y. Vols.; age 30: was taken f^ept. 23, 18G1, with intermittent fever, aud admitted on the 30th as a
case of remittent fever, presenting a (luick strong pulse, 100, continuous headache, a red and slightly coated tongue
and capricious appetite. Dover's powder was given. Tho patient vomited during the night; next day the tongue
was dry, red at the edges and brown in tlie centre, and the tooth covered with sordes. Turpentine emulsion was
given every two hours, with small doses of opium, ipecactianha and nitre. On October 2 wine and cinchona were
ordered in repeated doses; at night tho patient perspired a little. On the 3d the skin was of natural temperature
and presented some rose-colored spots, which were perceptible to the touch and disappeared on pressure; tho bowels,
which had been ([uiet since admission, were on this day moved fonr times. He rested well at night, and on tho 4th
had a natural skin, moist aiul slightly brown tongue and feeble pulse, 90 i)er minute; three stools were passed.
During the following week the patii'iit continued without much change. On tho ."itli there was some ringing in the
left ear, with slight headache on the Ibllowing day; on the 10th marked deafness with tinnitus aurium. Tho bowels
were somewhat relaxed at this time, the jiul.se from 80 to 100, the skin natural and the tongue brownish and inclined
to be dry or, occasionally, moist and yellow-coated except at the edges, which were red. On tho 11th fifteen grains of
(|uinine, with six of blue-pill and two of opium, were given in two doses at an interval of two hours, with four
grains of quinine every two hours thereafter. During the night profuse sweating occurred, and next day there
was no stool. On the 14th the patient was transferred to HaUimore, ild.
Case 117. — Diagnosis — remittent. Bowels loose and tympanitic; no charactefistic s!imj>toms of typhoid. — Private O.
(iunderson. Co. B. 6th Wis. Vols.; age 19; was admitted Nov. 8, 1861, having been attacked about the 1st with
chills and fever, headache, pain in the back and limbs and anorexia. On admission he was wakeful and suftering
from Iieadache, his countenance anxious, eyes dull, cheeks (lushed, pulse 100 and thread-like, skin about tho natural
temperature, tongue red and moist at the tip aud edges, dry and coated yellow in the centre, appetite lost and
bowels loose and tympanitic: he had some cough with whitish expectoration. One drachm of sweet spirit of nitre
w,is given every hour. Small doses of blue-pill and opium were prescribed on the 9th and repeated on the 10th an<l
lull, with twelve grains of (luiuine each day, aud with eight grains on tho 12th, on which day bcof-ossence and
emulsion of turpentine wore also administered. Tho tongue, however, remained coated yellowisli-whito and the
appetite poor up to the 19th, when the last notes were entered on the record. The patient was transferred to Balti-
more, Md., December 3.
Case 118. — Remittent fever follotoed by typhoid. — Private A. Whipple, Co. A, 4th Mich. Vols.; age 19; was
admitted Oct. 30, 1861, as a case of remittent fever. On October 8 ho had chills and fever which continued a week,
with weakness, anorexia, nausea and vomiting, and during this period he felt bettor in the morning than in tho
evening. He was treated with quinine, rhubarb and capsicum. On admission his cheeks wore slightly tlushed,
countenance calm, eyes bright, conjunctiva' yellow, pulse 99, full and strong, skin yellow, warm, dry, soft and without
eruption or sudamina, tongue moist, red at the tip and coated grayish in the centre, appetite deficient; the bowels
were moved five times, and there was abdominal tenderness with slight gurgling but no meteoristu. Calomel and
full doses of quinine were prescribed. During the night the patient was delirious at times, and on the following
day he had some deafness and tinnitus aurium. The <iuinine was continued and the calomel omitti^d. On Novomlier
1 the tongue was moist, pale and coated somewhat in the centre and at the base. Next day two roso-colored spots
were nuticed and sordes appeared on the teeth. Milk-punch, beef-essence and turpentine emulsion were proscribed.
On the 4th the patient's condition was unchanged; he was very delirious, his face much flushed, pulse 98 and
strong, skin very hot and showing some rose-colored spots, tongue dry in the centre but moist at the edges; he had
no cough, but mucous and sibilant rales were heard in some parts of the chest; the bowels were moved by an
enema of castor oil and turpentine and the tympanites which had been present was thereby reduced. He was dull
and stupid on the .^th and had subsultus tendinum. Next day some petechial spots appeared. No further details
are given. The^iatient was transferred to .\nnapolis, Md., on the 18th.
C.\SE 119. — Typhoid ferer followimj remiltint fercr: prognosis farorahit- nnlil the advent of 2)evitonilis. — Private
Abraham Haner, Co. D, 14th N. Y. Vols.; age 21; was admitted Sept. 23, 1861, as a case of remittent fever. lie had
lu-en epileptic from infancy to tho age of lil, when the tits ceased. He was taken two weeks before admission with
a convulsion. Quinine was given but the convulsions recurred. On admission his face was flushed, eyes in.jected,
bowels loose and abdomen painful. A slight fever was present on the 25th; appetite deficient, thirst considerable,
pulse 88, full and strong, skin warm and moist (ho had perspired profusely at night), tongue light-brown and
fissured: he had a little headache and dizziness. Acetate of ammonia was proscribed with live drops of Fowler's
solution four times daily. He did not sleep well at night, and on the 2Gth was restless, his cheeks flushed, eyes
6uftused. pulse 96, skin hot and moist, tongue brown and dry in the centre, fis.sured and moist at tho edges; he had
headache aud slight delirium, pain in tho stomach, pain and great tenderness in tho iliac region, some cough and
248 CLINICAI- RECORDS OF
difficulty in letaiuing urine. Tlie acetate of ammonia was continued and turpentine emulsion was ordered for
administration every two hours. In the evening the skin was moist, the pulse 102, the tongue yellowish. Hoff-
mann's anodyne was prescribed in drachm doses every four hours. He slept hut little during the night, and on
the 27th the pulse was 96, skin hot and dry, tongue dry in the centre, moist at the edges ; he had headache, anorexia,
tympanites on the right side, tenderness in the right iliac region and his bowels had been moved six times. Tur-
pentine emulsion and Fowler's solution were renewed and pills of opium, lead and tannin prescribed. In the evening
the pulse was 104, the skin hot and moist but with no eruption nor sudamina, the tongue rather yellow in the centre
hut less fissured ; the headache was lessened and the diarrha-a reduced to one stool, but the tenderness and tympanites
continued. Sweet spirit of nitre and wine of antimony were administered during the night. He slept well and
perspired early in the morning; no stool was passed. On the 28th the skin was hot and moist, tongue brown, dry
and fissured in the centre, its edges moist and white; the anorexia, headache and cough persisted, and there was
partial retention of urine, with pain in the hypogastrium. Extract of buchu was given. In the evening the face
was flushed, eyes bright, pulse strong and regular, skin soft but somewhat hot, tongue moist, white and fissured;
"bowels moved once, tender and tympanitic ; the cough had subsided and the appetite was returning. Dover's powder
was ordered. He slej)t well during the night, and on the 29th the face was somewhat flushed, eyes injected, pulse 88
and strong, skin hot and moist, tongue brown and dry in the centre, moist at the edges, the bowels quiet but a little
tender and tympanitic. In the evening there was slight headache; the bowels were moved once, but the tenderness
and distention continued ; the appetite was good. Tincture of opium and essence of peppermint were administered.
Ou the 30th the skin was soft and its temperature decreased; the tongue moist at the edges, brown and dry in the
centre, the appetite moderate; three stools were passed and there was much tympanites with marked tenderness in
the right iliac region and some in the left side. On October 1 the skin was natural, the tongue slightly coated in the
centre and fissured, the appetite good and the bowels quiet. He improved after this, so that from the 3d to the 6th
no note of his condition was recorded. On the 7th the pulse was 85, skin natural, tongue moist but red at the tip
and edgce, yellow and fissured in the centre; bowels moved three times. No marked change occurred until the lOtb,
when the skin became hot and dry, followed ou the 11th by a profuse eruption of rose-colored spots; on this day the
tongue was slightly moist, yellow in the centre, the appetite good and the bowels quiet, but the abdomen was tender
and tympanitic, especially in the umbilical and right iliac regions. Tincture of iron was prescribed. Fresh crops of
rose-colored spots appeared at intervals until the 28th, when they faded. The heat of skin gradually lessened until
on the 16th it became normal; two days later the skin was moist. The bowels were moved once or seldom twice
daily, but a good deal of tenderness and distention was noted in the umbilical and right iliac regions. Ou the 20th
extract of senna was administered and two passages followed its exhibition. The patient usually slept well and his
appetite was good; the tongue was moist and clean, faintly furred or yellow-coated in the centre. He appeared to
be doing well when, on the 29th, he was seized with extreme tenderness of the abdomen. After a wakeful night his
eyes on the 30tli were dull, cheeks flushed, pulse 100, skin hot, tongue moist, brown and fissnred, lips and teeth
covered with sordes; he had some deafness and mental dnluess, anorexia and thirst; there was no diarrhica, but
much general abdominal tenderness and souie tympanites. A blister was applied to the abdomen and calomel and
opium prescribed for administration every three hours. On the 31st the pulse was 140 and irregular and the skiu
bathed in perspiration, but the abdomen was lesoi tender. Death took place on this day.
Case 120. — Eemiltetit fever and a recurrence of remittent oeerlapping the typhoid co^e.— Private E. J. Tice, Co. ti,
14th N. Y. Vols.; age 23; had chUls, perspirations, pain in the head and umbilical tenderness on .Sept. 28, 1861, and
was admitted October 2 as a case of remittent fever. Oc the evening of admission the patient's pulse was not accel-
erated, but his face was flushed, eyes injected and skin hot; his tongue was moist and coated white, appetite
deficient, bowels tender and moved once during the day. Blue-pill and opium were given. Next morning the
tongue was coated yellow and bowels moved; pulse 80, strong- skin perspiring. Quinine was ordered to be taken
at the rate of sixteen grains a day, with Dover's powder in the evening. This condition of slight fever with yellow-
coated tongue, anorexia and some headache continued for several days- but iu the meantime the bowels became quite
loose, mcteorized and tender, especially in the right iliac region. On the 8th the tongue was red at the tip and
edges and yellowish-white in the centre, the appetite improved and the pulse lowered to 60. Tincture of iron was
ordered. During the following week the bowels were less aftected, only one or two stools being passed daily; the
skin was of the natural temperature and sometimes perspiring, the appetite good, but a slight headache persisted. A
chill occurred suddenly on the 16th, and next day the pulse was 100, full and strong, the skiu hot and dry, the
tongue slightly moist, white at the sides, yellow in the centre, the appetite poor, the bowels moved once, the abdomen
tender, especially in the right iliac region. Blue-pill and opium were given in repeated doses. Ou the 18th the pulse
fell to 70 and several rose-colored spots appeared on the skin; but the tongue continued coated until the 28tli,
Fowler's solution having been given in the meantime, and the headache, relaxed bowels and abdopiinal tenderness
lasted for ten days longer. The patient was transferred, November 18, to Annapolis, Md. [as a case of typhoid fever;
he was returned to duty with his regiment December 2].
Two Cases entered as Typhoid, but in which only the Malarial Element was prominent.
Case 121. — Malarial symptoms prominent; the presence of enteric fever not clearly established. — Private Matthew
Baird, Co. C, 3d Mich. Vols.; age 23; was admitted Oct. 19, 1861, as a case of typhoid fever. About October 5 he
had been seized with pain in the head and bones, fever and chills; he had some nausea and vomiting at first, and a
diarrhcea which continued for two days; the headache lasted four days; during the second week his urine had to be
removed by catheter. On admission his pulse was 62 and of fair strength, skin soft and warm, tongue pale, moist and
slightly coated brownish in the centre, appetite good; he had tinuitus aurium and giddiness, but no pain, eruption
THK CONTINUED FEVERS. 249
nor sudamina: one thin watery stool was passed, but tlifire was uo tenderness, borlioiygnius nor tympanites, and the
abdomen was soft; there was no cough and the urine was normal. Quinine was prescril>ed in full doses three times
daily. Next day the face was calm and natural, the pulse lil, steady and of fair strenf;tli, the skin soft and warm,
the tonitue slijjhtly pale and llabliy but moist and clean, the appetite good; one thin fetid stool was ))assed. On
the 22d the i|uiiiine was reduced to two grains three times daily, and during the night the ]>atient had a chill, but
next day its etierts disa|)pearcd. On the 2>'th he resteil badly and had some iliarrlKca, but there was no tenderness"
nor tympanites : the tongue was pale and moist and the appetite fair. The skin and conjunct iv:e beeauu' jaundiced
on the 31st. Small doses of calomel and opium were given. November 1 he slept well ; his mind was clear, counte-
nance calm, bowels regular and appetite good. He was transferred to Annapolis, Md., on tho l«th.
C.^SE 122. — Ihulh in ciijlil daijs. Diaijnosis — li/phind, hut si/mptoms and Iraitment llione of rcniillint fiver. — Private
Edwin Graves, Co. D, 86th N. Y. Vols.; ago 20; was admitted March 17, 1862. lie was taken sick about the 12th
with pain in the chest, headache, nausea, a feeling of general swelling and much debility, succeeded by a chill,
fever and profuse perspiration, which symptoms recurred daily about 11 A. .m.; he had also much annoyance from a
numli feeling in his fingers. On admission the pulse was rapid and weak, the skin hot and moist, the tongue moist,
red and slightly coated; the patient's appetite was poor and he had some diarrhcea and pyrosis; he stated that the
chill and fever occurred at the sauu> time in rapid alternations in ditl'erent parts of the body, the ])aroxysm8 lasting
two or three hours. 'IWcnty-four grains of (luinine were directed to be taken during the day. He was delirious
during the 18th; his pulse rapid and weak, skin natural, tongue moist jjud coated white, runcli and beof-esseuco
were given every two hours, lie died delirious on the morning of the Ulth.
The last case of this series appears to liave been one of mistaken diagnosis:
l'.\SE 123.— Private Wni. IT. Courtney, Co. H, 21th N. Y. Vols.; age 21; was taken Sept. I, 1801, witli jiain in
the shoulders :ind left side and also on breathing; he had chills and fever and had been blistered, lie was admitted
on the 18th. Diagnosis — typhoid fever. The pulse was l(i, skin cool and moist, left side tender and dull, respira-
tion short, decubitus on tho sound side, tongue syiooth, lu^arly dry, bowels constipated and tender in both iliac
regions. Two grains of calomel and one-fourth grain of hmrphia were prescribed. Next, day the pain was less
sharp, the pra-cordia seemed elevated and the sounds of the heart were obscured. In the evening the patient was
drowsy, pulse ,50 and irregular, skin natural, tongue slightly coated gray posteriorly, red at the tip. Calomel in
two-grain doses with oi)ium was given every two hours. On the 20th there wiis acute tenderness in both iliac
regions but the bowels continued ctuistipated. On the 21st the breath became fetid, and on the following day the
gums were swollen and tender. The mercurial was omitted. On the 2itli chlorate of potash was given on account
of the salivation. The patient was walking about anil had a good appetite on the 30th, and was doing light duty in
the ward on October 3. He was retuiiied to duty on the 17th.
Fever cases from regi.mkntal records. — The symptoms of typlioid fever assumed
a prominence in the typlio-mahirial cases of the Seminary Hospital, and no doubt in those
of other general hospitals, which was not shown in the cases occurring at the same time in
the field. This difference in character was a consequence of the greater prevalence of
remittent fevers at the front. Remittents seldom reached the general hospitals, as they
proved fatal if pernicious, or recovered if of a mild type, under the influence of quinine,
at the regimental or field division hospitals. Similarly, if the remittent fever masked
an existing typhoid, the notable symptoms in a rapidly fatal case were those of the perni-
cious fever, while in a mild attack the treatment prior to the transfer to the general
hospit;il had its effect on the malarial symptoms and left the case for the records of the
hospital as one of comparatively unmodified typhoid. But even in the febrile cases treated
in the field the symptoms of typhoid fever were sometimes so strongly developed as to leave
no doubt concerning the nature of the disease. Not only was this the case in local epi-
demics occurring in non-malarious districts, but in commands which at the same time
reported numerous cases of malarial fever, the presence of which led to a routine adminis-
tration of quinine in all febrile cases. This may be illustrated by a series of cases from
the records of the 27th Connecticut Volunteers. Fevers had prevailed in this regiment
from the establishment of winter quarters at Falmouth, Va., after the battle of Fredericks-
burg. Thus, in January, 1863, there were reported on the monthly report of sick and
wounded six cases of typhoid, seven of typho-malarial, three of intermittent and sixteen of
remittent fever; but the details of none of these cases are preserved. In February and
March, the months during which the recorded cases were treated in the regimental hospital,
Med. Hist., Ft. Ill— 32
250 CLINICAL RECORDS OF
no typlio-malarial cases were reported, the fevers being entered either as remittent or as
typhoid. The histories of thirteen cases of typhoid are recorded; one of these, in which
the body was examined after death, is presented as case 330 of the post-mortem records of
the continued fevers;* the others are given below in the order of their admission for treat-
ment. Appended to the record of tlie first case is a remark by the regimental surgeon,
Wm. 0. McDonald, as follows:
I regard this as a jiurer case of typhoid fever than that of Dolph, for this was uucomplicated. The rose-spots
appeared on the seventh day of his stay in hospital, the disease having probably made some progress before any
record was kept of the case.
Case 1. — Delirium ; involuntary stools; aMominal tenderness ; rose-colored spots; improvement from the end of the
second week. — Private H. E. Kurnham, Co. H, 27th Conn. Vols., having been complaining for two or three days, was
admitted Feb. 2, 1863. The pulse was 132, small and weak, and the muscles of the body were sore to the touch. On
the 5th the tongue was dark-colored and there was some delirium. Sixty grains of quinine were administered
in three doses during the day. On the 7th the bowels were moved twice and there was tenderness over the ca>cum
and ascending colon. Next day the pulse was 132, tongue dry, red and cracked, lips black; the patient was very
delirious and had several involuntary passages from the bowels. Stimulants were given. On the 9th the pulse was
132, tongue a little more moist, bowels quiet and delirium lessened; six rose-colored spots were found on the abdo-
men. The patient was not so well next day; the tongue was dryer and darker; the abdomen was distended and gur-
gled on ])ressure in the right iliac fossa, and there were several ineft'ectnal attempts at stool. On the 11th the tongue
was dry as ever and the lips as black, but the patieut w'as able to talk sensibly. After this the pulse gradually
fell to 80, the tongue became clean and moist, the abdominal tenderness ceased and the appetite improved; but the
return to health was slowly effected.
Case 2. — Low fever and hehetude; diarrhuu and ahdominal tenderness ; nighl-sweais and udema of legs ; recoverii. —
Private William A. Morse, Co. H, 27th Conn. Vols., was admitted Feb. 2, 1863, after exposure on picket duty to cold,
wet and stormy weather. Diagnosis — typhoid fever. Stupor; pulse 96; tongue dry and red; twelve stools; ten-
derness in the right iliac and hypogastric regions. 3d: Dull and stupid; pulse 88, full, soft ; skin moist; tongue
dry and red; one stool; tenderness; pains in the back and limbs. 4th: Looking better; pulse 84; tongue dry;
much thirst; two stools. 5th: Pulse 72; tongue red, clean, moist; tenderness below umbilicus; one thiu watery
stool. 6th: Pulse 84; tongue red, bare, moist; one stool; less tenderness. The patient took ten grains of quinine
five times a day during the first four days of his stay in hospital. 7th: Pulse 72, dicrotic; tongue red, dry, glazed;
odor feverish ; eyelids dusky; iliac and hypogastric tenderness. 8th: Tongue dry, glazed; face dxisky; three stools.
Whiskey was prescribed. 9th: Pulse 78; tongue nioister; one stool. 10th: Two stools. 13th: Pulse 84; tongue
glazed, bare; one stool. For some days anterior to this date the patient had been taking solid food. On the 27th
aromatic sulphuric acid and quinine were given on account of night-sweats. These recurred on March 12, but
were immediately controlled by renewing the acid medicine. He was very pale and anannic; iron was prescribed.
After this his legs became oedematous. He was not returned to duty until May 24.
Case 3. — Felirile attack duriny convalescence from jaundice ;\ diarrhaa and rigl/t iliac tenderness; mental dulness;
moaning respiration ; dusky skin; great 2>rostration aijd tremulousness; death on IZth day. — Private Joseph Hull, Co. I,
27th Conn. Vols.; intemperate; sutfered in January, 1863, from an attack of jaundice from which lie convalesced
slowly. On February 18 he was taken into hosjiital. Fifty grains of quinine were prescribed for admiuistration
during the day. Ou the 19th the pul.se, which had been very slow for some days, rose to 60, the lijis were black,
tongue red and dry, bowels quiet and free from pain. The quinine was omitted on the 20th. On the 21st the patient
was drowsy, mind dull, speech thick, bowels moved twice and abdomen tender; deafness, which was probably in
part induced by the quinine, became somewhat lessened. Beef-tea and stimulants were ordered. Little change
took place until the 26th, when the bowels became more relaxed; on this day four watery stools were passed, the
tongue was dry as a board, pulse 84, respiration moaning, hands tremulous. Next day the tongue became somewhat
moist, the hearing improved and there was less dulness and wandering of the mind; the bowels were moved three
times and the right iliac region was tender. On the 28th the i)ulse rose to 120, the respiration to 27; the tongue was
dry and cra<-ked but not very dark, the skin dusky or purplish; the jiatient slept with his mouth opt-n and moaned
with each breath; he was emaciated and extremely prostrated. Death took place March 2.
Case 4. — Bronchitis; slight diarrhaa and delirium ; sordes; rose-colored sj)0ts about the litth day : faroralde signs at
end of second week; distention and cvchymoscs of the aidomcn; bed-sores; pneumonic symptoms and death at the end of the
fourth week. — Private Charles L. Ailing, Co. H, 27th Conn. Vols.; age 18; a slender boy, was first seen Feb. 18, 1863,
suffering from a cold contracted while on picket duty. Veratrum viride was given daily until the 21st, when it was
omitted and quinine substituted, sixty grains in divided doses during the day. He was admitted to hospital on the
* Infra, page 408, case of Trivato E. B. Doljili.
t Surg. J. T. Webb, 23d Ohio Vols., in a letter dated Feb. 10, 1802, at Fayctteville, Va., and published iu the Cinciunali Lancet and obxrcer. Vol.
V, p. 171, makes the fallowing statement : "At the close of this month jaundiee m.ade its aj)pearauce, and what is most remarkable, its advent among us
appears to have eradicated all the different forms of fever, and since the 10th of January, just one month this day, not a single case of fever of any
description has made its appearance. * * * For the first time since we have been in "Western Virginia, a little more than seven months, one whole
month has passed without a case of camp-fever occurring in our midst." Jaundice prevailed in the ramp of the 27th Conn. Vols, at Falmouth, Va..
during January, 1863, but its prevalence wa*i not associated with that disappearance of fever which occurred in the e.\perience of .Surgeon Webb. See
infra, p. 875.
THE CONTINUKi) FEVERS. 251
22(1 as a case of typhoid (r\vr witli hioncbial complication. Small doses of ipecacuanha, opium and camphor wore
administered. On the 2.Sd the jinlse was !U> and the bowels tender hut unlet. Three ten-frrain doses of i|uiiiine wore
I'iven dnrin;; tlio day. On the 2r>th the tongue was dark at the base, red at the tip, tlie lips and teeth black, the
bowels moved twice, the mind wauderin;;. lie had been takinj; beef-tea and (luinine up to this time; wliiskey was
now added. A few imlistiuct rose-colored spots apjieared on the 27th: 8i)eech was dilhcnlt and inc(dierent. Tliore
was some dysuria on the 28th, relieved by hot fomentations to tlui ab<li)inen; the tonf;ue was dry, dark and cracked;
pnlse WX. The patient liad coufihed more or less since his admission, but at this time the chest symptoms became
more prominent. On March 2 tlie pulse was 120 and dicrotic, the abdomen tender, the bowels moved tliree times,
the stools thin and watery; the hands and cheeks were purplish in color; speech somewhat less incoherent. On
the 4th the pulse was 120, tonsiie sli};htly moist and softer than heretofore, face pale; the patient took some
interest in his condition and sutl'ered much from abdominal distention. Turpentine was i)rescril>ed. Ou ibefjth
the imlse was 108 durinj; sleep, 132 while awake, respiration 23, tonf;uc dry, abdomen distended and ecchymosed,
skin over sacrum congested. Ou the (ith the pulse was 144, respiration 36, tongue dry, cracked, dark and bloody.
No material change took place until the 8th, when the integuments over the sacrum formed a sloughing bed-sore.
On the 10th niucli flatus was passed from the bowels with great relief to the patient; dysphagia was noted at this
time. On the 14th the pulse was 128 to 132, respiration 3G to 40, pulse dicrotic, clieoks (lushed, li])s and nose white,
tongue dry, brown and cracked; the distention of the abdomen was again a cause of much suH'ering and prevented
the patient from taking his allowance of beef-tea and whiskey; the liowels were moved twice. On the IGtli the
dierotism of tlie pulse ceased, the tongue became more generally uu)ist, and the jiatient smiled in answer to a (jues-
lion. But delirium returned on the IStth, respiration became reduced to 2l> ami the lower Jaw moved with each
breath; the expectoration was rusty. Ueatli took jdace on the 21st.
Case 5. — Ilronchiliii; tcndt-rncss otwr colon, but a large cathartic dose jtrod need no injiirioKi effect; pink spots on chest
about 9lh day; no cerebral siimptoms until late in the attack, when the delirium noted was probablji dtte to continued pain
in the feet and morphia niren J'or its alleriation ; gangrene of the feet; death. — Private Wm. F. llernhardt, Co. K, 27th
Conn. A'ols., was admitted March 17, 1863. Diagnosis — bronchitis and probable fever. He had taken veratrum
viride for two days. Ou tlio 18th the pulse was 96, respiration 20, tongue dry in the centre; there was some cough
with expectoration and substiunal soreness, and the right iliac and umbilical regions were tender. During the five
folhiwing days two hundred and forty grains of (luinine were taken in ten-grain doses, the tongue meanwhile
becoming red at the tip an<l eilges and somewhat moist and tins cough and scanty mucous exi)(Mtoration continuing.
There was tenderness along the track of the colon but no movement of the Iiowels. Five couii>ound catluirtic jiills
were administered on tlie 21st, and two stools were i>assed on the following day. 8ome pink spots ap[)eared on the
chest on the 23d. On the 2."ilh tlie tongue was moist and cleaning, the abdomen covercid witli siidauiina, but the
riglit foot was very painful and numb. For some days tliere was little change in tlie condition of the jiatient:
I'ulse 108; respiration 20, with sliglit cough and expectoration and rales posteriorly: tongue clean and moist : api)etito
good; face natural; bowels quiet and free from jiain; feet very painful especially at night, rci|uiring the admin-
istration of large doses of mor]ihia to give rest and relief. Aconite and turpentine liniments were used but without
benefit. On the 29th the dorsum of the right foot became purple and cold and the leg immediately above the ankle
pufty; two days later the left foot became similarly afl'ected. Small doses of tincture of iron, <iuiniue and sweet
spirit of nitre were prescril)ed and great attention was paid to tlie diet of the patient; hot bricks and flannel wrap-
pings were api)lied to the feet. On April 7, in addition to the ecchymosis on the dorsum of the right metatarsus, a
slough extended over most of the toes; tlu* patient was delirious during the night. One grain of sulphate of
morphia was presi-ribed lor administraticui at bed-time, tlu^ dose to be rep<ated in an hour if required. The black
line forming the margin of the (■cchymosed and piitf'v patches spread gradually towards the ankles and toes; buihe
formed on their surface. On the Hitli the end of the great toe and upper surface of the toes of the right foot were
hard, horny, shruuken, dry and black, while the dark patches were slowly extending over both feet. Tlie ]>atient
was transferred to Stanton liospital. Wasliington, 1). ('., on the lIMli, wlieie lie died .luue 15 of "tyiilioid fever and
gangrene of the feet."
Case 6. — Date oj onset undefined; rose-spots; iliac and umbilical tenderness ; pneumonia; numerous spots like small
blood-blisters on the limbs and trunk; duskg skin, low delirium, tremulousncss and subsullus; vomiting: epistaxis: bed-sores;
rrcorerg of intrlligence for a week before death. — Private S. H. Plumb, Co. C, 27th Conn. Vols.; age 22 ; had been treated
in quarters for (|uite a long time before his admission into hospital, March 23, 1863, as a case of typhoid fever. The
pulse was 88: respiration 16; tongue shrunken, furred and dry, the tip and edges red; eyes somewhat yellow; hear-
ing dull; chest and abdomen covered with sudamina and a large crop of red and jiink sjiots, disappearing on
pressure; bowels moved once daily, and tender in the iliac and umbilical regions. There was free [leispiration
during the night of the 24th, and next morning some of the sudamina had coalesced into buIhe (containing turbid
yellowish-white lii|uid: (uie loos(! watery stool was jiassed. Twenty-live grains of sulphate of (luinine were given
three times daily with aromatic sulphuric acid. Next day there was no sweating, but the condition was otherwise
not nuuh changed; pulse 108; bowels moved twice; no abdominal tenderness; red spots disappearing; sonorous
rales posteriorly on both sides of the chest. On the 27tli the quinine was continued in ten-grain doses three times
daily, but the acid was omitted; the expectoration was white, slimy and adhesive, with intermixture of scarlet blood;
there was soreness over the ascending and transverse portions of the colon. On the 28th the patient was reported as
having had some delirium in the early part of the night; the skin of the abdomen was des(|uamating. Small doses
of ipecacuanha and opium were giveu. The quinine was omitted on the 29th; the chest was not tender on jiercus-
sion, but the sputa contained bright blood. Ou the 30tli the )iulse was 96; respiration 16; tongue cleaner and less
dry; bowels moved once; abdomen somewhat sore all over; sputa thick and adhesive, containing bloody masses;
252 CLINICAL RECOEDS OF
email crepitation was heard iu the left liuif; under the fourth rib. Carbonate of ammonia was prescribed. On the
31st he was again reported as having been delirious during the night. Some nearly pure blood was expectorated on
April 1: the tongue was brown at the tip and centre, the lips dry, cracked and bleeding, the teeth covered with
dark patches, the bowels moved once; the patient was again delirious during the early part of the night. Quinine
in three-grain doses was given three times daily, with snuill doses of carbonate of ammonia and ipecacuanha and
a full dose of morphia at bed-time. He perspired profusely on the 2d; his cheeks were somewhat flushed:
many spots like snuiU blood-blisters appeared on the limbs and shoulders and a few were present on the trunk; he
was delirous and wanted to get out of bed. Beef-tea and whiskey were given at intervals during the day. The
pers]>irations continued on the 3d; on this day some nausea was developed and the appetite, which had been very
good hitherto, became affected; the expectoration was scanty, rust-colored and contained bloody masses; all kinds
of murmuring, bubbling anil rattling were heard in the chest; pulse 100; respiration 26 and irregular. On the 4tli
there was some vomiting, no stool, but some tenderness in the right iliac and umbilical regions; the small purplish
ecchymosed spots were fading from the arms, bnt those on the abdomen were very numerous and presented a pur-
I)ura-like appearance. On the 6th the pulse was 120, respiration 30 and irregular, tongue dry, brown, hard and
fissured, lips dry and cracked, cheeks slightly flushed of a dusky-violet color; the stomach rejected solid food; one
natural stool was passed; the purpuric eruption appeared on the back and hips. On the 7th the ecchymosed spots
increased on the abdomen ; there was frequent but scanty vomiting and an incoherent muttering, with tremulousnc.ss
of the hands and incessant subsultus. Bed-sores on the hips and sacrum and continued vomiting were recorded on
the 8th. Next day the erujition had nearly faded; the pulse was 96 and respiration 28, the lower jaw participating
in the respiratory nu>vement: a copious epistaxis occurred; the stomach was less irritable. On the 10th the face was
pale and sunken, the hands and jaw twitched and there was occasional moaning on inspiration, but the lower jaw
did not move as ou the previous day. Next day he seemed to recognize the attending physician. On the 12th the
tongue was somewhat moist and the patient brighter; he talked a little. From this time until death on the 18th
he retained his intelligence, s.ometimes expressing his wants. The vomiting ceased and he swallowed the beef-tea,
whiskey, etc., oftered him without objection. As the left hip and back were raw and granulating, he lay usually ou
the right side. For two or three days the bowels were slightly relaxed. A peculiar odor, like that of spoiled meat,
was noticed about his person. Cough was troublesome but useless, as it brought np nothing from the lungs. On
the day before death the respiration suddenly rose to 44, the pulse being 120; on the day of death the pulse fell to
60, respiration lieing 48.
Case 7. — Deaf mas; ilcliriaiii; petspirtilionx; rosf-colored spots: iliarrhira: rccofcri/. — Private Daniel Doolittle, Co.
A, 27th Conn. Vols., was admitted on the evening of March 23, 1863. Next day the ijulse was 84 and dicrotic, tongue
clean and moist, skin moist, conjunctiva of right eye inflamed, throat sore; one thin dark-colored stool was passed
and the abdomen, which was full and soft, was somewhat tender over the track of the colon ; the patient was deaf
and talked thickly in a dull delirium. Qninine in ten-grain doses was prescrilied for administration five times a day
and thirty grains of blue-pill were given at night. On the 25th there was free perspiration but no sudamina; one
faint rose-spot was found on the chest ; the lower eyelids were so dark as to seem ecchymosed ; the bowels were moved
twice; the patient was sullen and ate nothiug; during the night he had been violently delirious. No medicine was
given. On the 26tli the pulse rose to 108, the tongue became somewhat dry and the delirium of a jocose character.
Quinine in ten-grain doses was given three times a day with morphia at uight. On the 27th the pulse was 120; the
patient rested better at night, and although dull and stupid gave rational replies to questions; one thin stool was
passed. On the 28th the tongue was furred at the base, clean at the tip and edges, pulse 96; delii'ium had returned
dnring the night ; two stools were passed and the ai)domen was tender over the ciecum and the ascending and trans-
verse portions of the colon. The prescriptions of the 26th were repeated. Ou the 29th the pulse was 72; a few
elevated pink spots appeared on the abdomen and the upper eyelids seemed ecchymosed. The tongue was clean and
moist on the 30th; three stools were passed and the bowels were tender. On the 31st the patient was rational and
the spots fading, but the bowels continued loose and tender. On April 1 there was vomiting, the condition of the
bowels remaining unchanged. Quinine in three-grain doses with whiskey, and at night morphia, were prescribed for
administration. On the 2d a few spots appeared on the chest and abdomen; five stools were passed. On the 3d
three stools, resembling pea-soup, were passed, and the patient was very thirsty; but after this the diarrhoea ceased,
so that on the 9th a compound cathartic pill was given, which was not followed by any alviiie movement until the
11th. Meanwhile the patient's appetite had returned; on the 7th he had been permitted steak for breakfast. He
Tvas transferred to division hospital ou the 21st.
Case 8. — Diliriiim, jx^rsjiirafions, jnnl-colorrd spots; constipation until after the free administrnlion of punjntive
■medicines; recovery. — Private Amos N. Benton, Co. C, 27th Conn. Vols.; age 36. This patient had suffered from jaun-
dice, for which mercury and ipecacuanha had been taken. He fainted on the night of March 23, 1863, and was
admitted next day. He became very delirious in the afternoon, expecting to die, and thinking that the attending
physician had killed him. On the 25th the pulse was 96, respiration 24, tongue moist and brownish, skin sweating
constantly and freely; he had a slight cough which had troubled him for two weeks before his admission. The .
delirium continued during the night but abated and ultimately ceased towards morning, the patient becoming
rational. The skin was bathed in perspiration on the 26th, but was free from sudamina; the abdomen was swollen
and there was some gurgling in the right iliac fossa. Quinine was given in ten-grain doses three times, and morphia
ordered for use at bed-time. On the 27th some faint pinkish-colored spots were found on the abdomen. As the
bowels had not been moved since admission, four compound cathartic pills were given. Next day the tongue was a
little dry at the tip, the bowels were moved twice without pain, the perspirations continued and the patient was
iu a constant delirium. Two stools followed ou the 29tli, none on the 30th, but the perspirations and delirium
THK CONTINUKD FEVERS. 253
remained iinahated. The face was pale on the 31st and the patient sullen although not parf iculaily delirious; the
persjiiiations had ceased. Ne.\t day the sweatin-; was renewed and eontinui'd until the bowels lieeauie disturbed.
lie was rational on the 3d and his appetite returned on the -Ith; he eouiplained at this time of his hips being
sore; eight or ten spots or jiiniiiles appeared on the abdomen, lading on the following day, exc«])t one wliieli
developed into a jjustifle. As the l)0wel8 on the oth had not been moved for six or seven days, three eom])ound
cathartic i)ills were given. Next day two stools were passed, and ou the 7th six, which were snnill, bloody and
accompanied w ith tenderness in the right iliac and epigastric regions. An ounce and a half of suliihate of magnesia
was given, producing six copious watery stools on the 8th. During the three following days the bowels were moved
twice daily. On the 11th and 12tb the persjurations recurred, and (|uiniue in three-grain doses, with aronuitic sul-
phuric acid, was administered. On the llith eight stools were passed and the patient perspired but little. An ounce
and a half of sulphate of magnesia was given, and morphine prescribed for use at night to produce rest and (juiet the
bowels. Four stools were pasSed on the 11th but none on the I'ltli. Again on the 16th the bowels were moved four
times. Meat and vegetables were omitted from the diet, the patient being placed on tea, toast and rice; one ounce
of castor oil was given. On the 17th thrive stools were passed, and there was tympanites with gurgling and some
tenderness of the abdomen. After this the bowels were moved twice daily until the close of the record. On the l«th
tincture of iron was j>rescribed, and beefsteak and potatoes allowed. On the liOth the patient complaini'd nnich of
pain in his foot. On the 21st he was transferred to division hospital. During the continuance of this cas<> there was
some cough with frothy mucous expectoration, and at tinu'S some acceleration of the respiration.
Case !1. — Hiarrha-a and umbilical te)idmic«»; piiciimoiiiii; rout-colored xpotn; delirium; epistaxiif; rceorcry.— Private
Patrick tilinn, Co. U, 27th Conn. Vols.; age 24 ; w as admitted from quarters March 28, 1803. Next day the pulse was
96, respiration panting, tongue yellow, furred in the centre and moist, bowels tender, especially in the umbilical
region, and moved six times: the patient had eaten nothing for four days. A full dose of castor oil was given. On
the 30th the pulse was 104 and dicrotic, the res])iration 28, the tongue furred white or yellowish-white but red and
somewhat dry at the tip; the bowels were moved live times and contiuued tender. Quinine in ten-grain doses was
given w ith opium three times a day. The diarrhoea persisted, giving daily three to five stools resembling p<M-soup,
until .\]iril 8, when it ceased; it was accompanied by tenderness in the epigastric region, tenderness and gurgling
in the umbilical and right iliac regions. The resiiiration contiuued somewhat accelerated, about 24, and on the
1st the sputa became rusty, changing in a few days to yellow matter mixed occasionally with bloody lumps, and
retaining this character until the loih, after which the pulmonary symptoms lost their prominence. Some indistinct
rose-colored spots ai)i)eareil on March 31 ; eight were noted on the abdomen on April 1, and alxuit fifty on the follow-
ing day. On the 1st the <ininine was diminished to three grains three times daily, with whiskey and morphine.
beef-tea, toast and rice: carbonate of ammonia was ])rescribed on the oth, but as it seemed to catise vomiting its
administration was suspended. No delirium or other head-symptoms had been noted uj) to this time, but on the 7th
there was deafness, and although the pulmonary symjjtoms were improving, the respirations being but 18 per minutei
the face was of a dusky -purj)lish color. On the 8th the face was less dusky and the appetite returning. On the 9th
there wa« epistaxis and the integuments over the sacrum were reddened. Sudaniiua appeared on the 11th, many of
them occurring ou the site of rose-colored spots which were yet present. At this date free perspiration began to
oocur at night and continued to the end of the period covered by the record. The eyes were jaundiced on the 12th,
and two <Iays later delirium occurred for the first time in the progress of the case. Quinine, in small doses, with
aromatic sulphuric acid, was given on the 16th. On the 18th the ])ulse was 72, the tongue clean, apjietite good
and bowels i|uiet ; there were many ro.se-colored spots on the abdomen and the sudamina were shrinking. Steak was
permitted to be used and tincture of iron prescribed. Next day the i)atient was transferred to division hosi)ital.
Case 10. — Bronchitis; diarrhaa and abdominal lendcrnenn, chiiflij umbilical; febrile morcvirnt slight; rose-spots on Sth
and Uith days; recorery. — Private Frederick Buckley, Co. A, 27th Conn. Vols.; age 19; was taken with diarrhoja
Dec. 1, 181)2, and sent to general hospital. On his return to the regiment the disease recurred after exjjosure on
picket towards the end of March, 1863. He was admitted to hospital on the 28th, and on the following day the pulse
was 84, respiration 20 to 24, tongue furred white and its papilhe projecting; he had ten stools during the twenty-
fonr hours, and there was tenderness over the entire course of the colon, particularly over the transverse colon.
Qninine in five-grain doses was given three times a day. Ou April 1 the bowels were (juiet, the tongue red at the
tip and edges and less moist ; there was cough with thick white expectoration ; the abdomen was full, tender in the
epigastric and umbilical regions and tender and gurgling on ])ressure in the right iliac region. Ou the 4th two
])ink-colored and slightly raised papules were observed ou the abdomen. After this the patient improved; his bowels
were but slightly relaxed and the tenderness diminished daily: the cough lessened and the respirations became of
normal frenueucy. though continuing somewhat labored; his appetite returned and he was allowed meat twice
daily. No cerebral 8ynij>toms are mentioned as having been present. Perspirations and sudamina were noted on the
12tb, as also a few rose-colored spots on the abdomen, but the bowels continued quiet and free from tenderness except
in the umbilical region : a cathartic pill ou the 16th caused but one movement. The case was transferred to division
hospital ou the 19th. [This man was ultimately returned to duty from the Mower hospital, Philadelphia, July 20.]
C.VSE 11. — Xaiisea and romiling ; slight diarrhaa and tenderness in the umbilical and iliac regions; pink spots on the
abdomen and chest; rccorery.— Private \Vm. A. Beard, Co. C, 27th Conn. Vols., having been feeling sick for a week,
was admitted to hospital April 5, 1863. Next day the pulse was 96, respiration 20, tongue brown and dry in the
centre, bowels slightly relaxed and tender on pressure in the right iliac fossa; he had anorexia, thirst, nausea and
vomiting but no cough. Quinine in five-grain doses was given three times daily. The tongue becauu? dry and
rough as if baked or toasted, but the symptoms did not change much for the worse. The bowels were moved once
or twice daily, the passages thin and watery; sometimes there was no movement during twenty -four hours, but
254 CLINICAL RECORDS OF
tenderness, chiefly marked in the umbilical and iliac regions, was present. On the 10th the patient was reported as
looking brighter and laughing. On the 11th one red pimple was found on the abdomen; it faded on the 14th; mean-
while there was some vomiting on the 12th. Three pink spots appeared ou the abdomen and chest on the 15th, fading
on the 18th. Some headache was reported on the 17th. Ou the 19th, when the patient was transferred to division
hospital, the tongue was sticky and somewhat furred, the appetite fair and the bowels quiet and not tender. Roasted
apples formed a part of the dietary throughout the progress of this case.
Case 12. — Secitrring chills; abdomen concave and tender; rose-colored spots; nocturnal delirium ; record incomplete. —
Private H. E. Ishell, Co. G, 27th Conn. Vols.; age 30; was admitted April 8, 1863, having lieen sick in nuarters since
March 20 with chills daily in the afternoon or evening. On the 9th the pulse was 72, respiration 24, lips cracked,
tongue nmist and white furred, bowels quiet but tender in the umbilical and left iliac regions; the patient was very
nervous-looking and did not rest well. Quinine in four-grain doses was given tliree times daily, with diet of toast,
roasted apple, tea, rice and beef-tea. On the 10th there was continuous headache and soreness in the chest in deep
breathing. Next day about a dozen spots appeared on the abdomen. They were touched with nitrate of silver.
On the 12th they were replaced by eight fresh spots; eleven others appeared next day, all of which were touched
with nitrate of silver. The abdomen at this time was concave aud tender and there was gurgling under pressure;
sleep was disturbed by dreams. On the 14th the pulse was 88, respiration 1(5, tougne raw and glazed in the middle;
three thin and watery stools were passed; six new spots appeared on the surface; the patient talked in his sleep.
While in this condition he was transferred on the 19th to Division hospital: [he was discharged July 27.]
Case 13. — Fehrile condition associated leitli bronchitis ; stools infrequent itut loose; tenderness orer colon, Init no tym-
panites nor rose-colored spots; cerebral symptoms slight; elinical history not suygestire of the typhoid affection. — For this case
see No. 330 of the post-mortem records.
It is difficult to determine to what extent the freedom of these cases from the acute
manifestations of malarial disease was due to the lavish use of quinine in the medical serv-
ice of the regiment. We may suppose that this treatment would liave prevented chills and
febrile accessions in the subsequent progress of the cases; but mflammatory processes fol-
lowing malarial congestions of the intestinal mucous membrane would have persisted for
some time, giving rise to a more general abdominal tenderness than usually characterized
unmodified typhoid fever. The tenderness so fi'equently noted in these cases in regions
other than the right iliac may therefore be accepted, among other indications, as suggestive
of a malarial complication. It is true that only in case 12 was the attack ushered in by
recurring chills, but the concurrence of remittent fever in other members of the command,
the existence of fevers reported as typho-malarial during the preceding month, and the
method of treatment adopted by the medical officers, give sufficient countenance to the
opinion that typhoid fever in these instances occurred in those wlio had been exposed to
the malarial influence.
If the practice of keeping clinical records of fever cases had been generally, instead
of exi;eptionally, followed, there would have been ample proof that in a large class of cases
the symptoms were not such as to indicate with certainty the specific typhoid or malarial
origin of the febrile phenomena. Fortunately Surgeon J. F. Dykr, 19th Mass. Vols., has
preserved in his regimental case-book a series of sixteen cases which illustrates the diffi-
culty that was frequently experienced in making a diagnosis. Three of these cases have
already been pi^esented as Nos. 5, 13 and 41. of the malarial series; the others are given
below. Cases 1 and 2 were regarded as remittents; in fact tvphoid fever appeared to be
excluded by the absence of symptoms specially indicative of that affection. No. 3, in
which no diagnosis was entered, was of a similar character. In case 4 there was in addition
some bronchial inflammation. No. 5, although reported as remittent, presented certain,
symptoms — abdominal pains, diarrhoea, faintings and continued ill health — which become
of interest in connection with the cases accompanied by more pronounced indications of
typhoid fever. A similar remark applies to the deafness in case 6. la 7, 8 and 9 the
difficulty in discriminating between an adynamic remittent and a specific typhoid fever
sufficiently accounts for the absence of a formally recorded diagnosis. The fatal case, 10,
THE CONTINUKD KEVKR.S. 255
wlii<Ii ill point of time was the first of the series, was reported as a case of typiioid. Case
11 was entered as a remittent, althougli presenting one or two equivocal rose-colored spots.
But tlie rose-colored eruption in 12 ajipears to have suggested the presence of tiie typhoid
poison not only in it, although the' bowels were not relaxed, but in the ialal case l:!, in
which there was no rose-colored eruption.
Cask 1. — l'iiv;it(< Cliarlos C. Forlios: sliaipshooler; was iKliiiittiil (let. •-':(, imil, with t'cvcr and slifi;lit dclirimii,
vi'llow-fiincd toiifjup. ciinstiiialiMl liowcls and iili'ciisivo lireatli; he had an eczcniatons i-inplion hotween and nniler
till- i-vt's, and sliowed a morbid desiie to lie with his head covcivd li.v th(^ Ipcdtlotlics. (Quinine in lhrc<'-<;niin doses
was used three times daily, with occasional puif;ativcs such as componnd colocynth pills and tlnid extract of senna;
milk diet was ordered. On Xovemlier 11 the toiifine liecame cleaner and the api>etite improved. Tincture of iron
was prescrilied on the 1 Ith and lieel'stoak allowed on the Kith. Hut the bowels afjain became constipated, the tongue
furred and the ajppetite impaired. Compound cathartic jjills and other purgative medicines were employed. Ho
walked a little on the 18tli and seemed improving, when, on the Soth, his feet became painful and continued so up to
December i, the date of his transfer to general hospital.
C.\SF. 2. — Private William Reinnells; sharpshooter; was admitted Oct. 21, 1801, with n-mittent fever. He had
been in the hospital of the i'Otli Mass. regiuunit, but the crowded condition of that establishment necessitated his
removal. He was dull and stujiid. had headache, tinnitus aurium and pains in the limbs; his tongue was thickly
furred, appetite capricious and liowels constipated. He was treated with (|uiniue in three-grain do.ses three times
daily, with nitrate of polasli and occasionally some cough mixture; conipouud cathartic jiills and other purgatives
were also given. On the llth he had a slight purulent discharge from the ear. 'I'iueture of iron was prescribed for
daily use on thi' 12tli. liecfsteak was authorized on the 20th. Pain in the feet, complained of December 1, was not
relii'Ved on the 1th, the ilate of his transfer to general hospital.
Case 3.— Corporal John dishing, Co. H, 19th Mass. Vols., was admitted Nov. 16, 1861, having been unwell for
aliout eight days with chills and headache. On admission the pulse was 90, tongue furred and bowels painful and
tender. A half drachm of ipecacuanha was given, and fifteen grains of nitrate of potash prescribed for administra-
tion three times daily. On the 17tli the umliilical region was tender, the pulse 72, skin warm and dry, tongue thickly
furred in the centre and red at the tip and edges, api)etite deficient; the patient had headache and buzzing in the
ears but no epistaxis. His condition remained unchanged for several days. Komentatious were applied to the
abdonu'n, and castor oil ami extract of senna were given without inducing a moveiuent of the bowels. On the 21st
a half ounce of fluid extract of senna and two drachms of fluid extract of rhubarb produced one dejection, and on
the 21tli castor oil was followed l>y two movements. On the 25111 the nitrate of potash was omitted ami (piiuine
given in three-grain doses instead. The bowels continued constipated throughout thi^ jirogress of the case, but
were moved at intervals of a few days by some laxative medicine. For about a week following the 2()th the patient's
feet were so painful as to prevent him from sleeping at night; frictions and afterwards poultices were applied to
them. On the 29th the fur began to clean from the tongue and the apjietite to return. Milk diet was used up to
December 8, when beefsteak was allowed. On the 15th he was sent on furlough to jiromote convalescence.
Cask 'l.— Private F. Chandler, Co. I, 19th Mass. Vols., was admitted Nov. 10, 1861, having been ill for a week
with weakness, fever and headache. On admission his pulse was U2 and his tongue dry and streaked. An emetic
of ipecacuanha was given, and at night a Dover's posvder. During the night sleep was disturbed by pains in the liowels,
which had not been nu)ve<l since the day before admission : his tongue on the llth was dry and jiatched with whitish
fur. Three compound colocynth \tiUs were given; but these produced no ettect until the following day, when one
stool was passe<l. Squill and paregoric were ])rescribed on account of cough. On the lotli the pulse was 86, moist and
cleaning, but there was no apjietite. Nitrate of potash, which had been given since admission, was nqilaced by
three grains of <juinine twice daily. From this time until the 2:id the patient became weaker; he did not rest well
at night; cough was troublesome and was accompanied with much mucous expectoiation streaked with liloi>d ; the
bowels were constipated, requiring occa.sionaI doses of castor oil or extract of senna to relieve them. On the 2M
the tongue became very dry and cracked. On the 2.5th the nocturnal restlessness increased to delirium. After a
free pa.ssage. induced by castor oil and extract of rhubarb on the 28th, the patient slept well ; but next night he was
kept wakeful by pain in the feet. This pain continued during November 30 and December 1, causing loss of sleep
ami slight delirium. His condition was improving on the 4th, when he was sent to division hospital.
Case '). — Private F. Luut, Co. G, 19fh Mass. Vols., was admitted Oct. 2.5, 1861, with remittent fever and m ii-
ralgia of the right side of the face. He complained much of cold feet and for some days of a faintness at tlu^ ejiigas-
triuni. He was treated with three grains of quinine three times daily, but on November 9 Fowler's solution was
substituted; pnigatives were u,sed to move the bowels. On the 10th lie complained of lieada<-he, sore throat and
coryza. On the 12th he fainted on tvfo occa.sions when attempting to rise; the sounds of the heart were indistinct.
Camphor and valerian were prescribed. The headache continued, and on the 13th the scalp was rubbed with tincture
of ac(uiite diluted with alcohol. On the llth he had colicky pains and diarrhrea. The Fowler's solution was
omitted on the 15th. four grains of (luininc three times daily being substituted for it. On the 16th the patient fainted
on rising to stool. The headache became somewhat lessened next day; three greenish stools were passed with much
colicky pain. Four similar stools were recorded on the 18tli. A ten-grain dose of calomel followed by castor oil
caused fre(|nent dejections, .some being greenish in color and bloody. Opinjn was prescribed, but the colicky
pains did not cease nor the blood disapjicar from the stools for several days. On the 27th headache was again com-
256 CLINICAL RECORDS OF
plained of, and as the bowels bad become inactive, compound colocynth and blue-pills were given. A blister was
applied to the back of the neck on the 30th. On December 3 there was pain and discomfort in the stomach with
acid eructations, for which rhubarb and bicarbonate of soda were prescribed. Next day the patient was transferred
to general hospital. [He was discharged on the 13th on account of neuralgia.]
Case 6. — Corporal J. C. Cronan, Co. G, 19th. Mass. Vols., took cold about Nov. 11, 1861, and had been constipated,
without appetite and troubled with a cough since that time. He bad taken purgative pills with eft'ect. He was
admitted ou tlie 18th. Dover's powder was given. On the 19tb the cough was urgent; the patient was deaf and bad
tinnitus but no headache nor epistaxis; the bowels were ([uiet and not tender but appetite was wanting. Small
doses of tincture of opium, wine of antimony and chloioform were prescril>ed, with extract of valerian at night.
Next day the teeth were covered with sordes and the tongue with a thin black fur. Fluid extract of senna was
given. The patient had nausea on the 21st; the prescription of the 19th was omitted and quinine in three-grain
doses substituted. This was omitted on the 23d, as it appeared to increase the nausea; nitrate of potash in fifteen-
grain doses was given instead. The tongue became cleaner and the patient felt better on the 2Bth, but occasional
purgatives were required for some time after this date. On the 30th he was able to sit up and his appetite was good.
He was furloughed December 12.
C.\SE 7. — Ephraim, a colored servant, was admitted Nov. 9, 1861. He had been troubled with a cough for two
or three days, anorexia, headache and pain in the back and limbs. Ou admission the tongue was thickly white-
coated, the pulse 90 and full ; the headache luid ceased but there was much thirst and restlessness at night. Nitrate
of potash in fifteen-grain doses was given three times a day with Dover's powder at night. One loose dejection was
pas.sed on the 10th and another next day. Thirst was a prominent symptom; currant-jam with water was used
as a drink. On the evening of the 11th the skin became hot and dry and the tongue dry, white in the centre and
red on the edges. The patient was delirious during the night, and on the 12th was stupid; sordes appeared on the
teeth; the pulse was 100 and feeble. Quinine in three-grain doses was given three times a day and a half ounce of
brandy every two hours ; the nitrate of potash was omitted. During the night he escaped in his delirium fromlhe ward
and returned to quart^ers. Next day he had epistaxis, and in the evening one involuntary bloody dejection. Small
doses of carbonate of ammonia were given every two hours. Four loose and bloody stools were passed during the
night of the 13th and three on the following day; the extremities were cold and there was some muscular treml>ling.
The carbonate of ammonia was replaced by turpentine. On the 15tli the stools were frecjuent, thin and mixed with
blood-clots or consisting chielly of blood, but the delirium was somewhat lessened. On the 16th he became quite
rational towards morning; liis pulse was scarcely perceptible at the wrist, extremities cold; stools frequent, scanty
and bloody; tongue cleaner and more moist. He rallied well on the 17th, and next day his appetite was voracious;
but on the 19th he had pain in the bowels, headache and furred tongue, and there was some mental wandering,
especially at night. This condition persisted for a week, during which the bowels remained unmoved. On tlie 25th
his back was found to be excoriated, bvit on the 30th the excoriations were repoited as healing. His bowels con-
tinued confined and he did not rest well at night, but his appetite was excellent and his strength returning, when
on Decemljer 4 he was sent to division hospital on account of the removal of the regimental camp from Poolesville
to Muddy Branch, Va.
Case 8. — Private John Ross, Co. 1, 19th Mass. Vols., was taken sick about Nov. 8, 1861, with chills, pains m the
head and bowels and slight diarrh<va. On entering hospital on the 13th the patient was in a general perspiration;
his tongue was red at the tip and edges and furred in the centre ; he had no appetite, no epistaxis and no tinnitus;
he said lie usually felt better in the morning than at night. Quinine in five-grain doses was given three times a day.
He had three or four dejections during the night, with pain in the bowels, but next morning felt very well. The
diarrliiea was not restrained l>v Dover's powder or tincture of opium. On the night of the 16th involuntary watery
discharges were passed, and during the 17th the patient slept most of the day, muttering dreamily. On the 18th
his face was flushed, eyes suttused, tongue red and cracked; he groaned and talked in his sleep and was easily
awakened; he had much headache, a short cough and pain in the uml>ilical region ; the watery discharges persisted;
the pulse was 96; skin hot and without any rose-colored spots. He had some nausea after taking an opiate ou
the 19th. He continued to sleep most of the time with his eyes half closed, moaning and muttering, but always
rational when aroused. On the 23d he did not moan so much. On the 24th nausea and vomiting followed the
use of quinine, which was thereupon suspended. In the course of a few days the diarrhtea became somewhat
restrained, but the cough increased and was attended with much expectoration and some pain in the side; the tongue
continued brown and cracked, the appetite failed and thirst increased. By December 2, however, he was able to sit
up, and on the 13th he was returned to quarters.
Case 9. — Sergeant J. Q. A. Ferguson, Co. B, 19th Mass. Vols., was admitted Nov. 26, 1861. He had been
unwell for a fortnight, during which he had lost strength, and more recently had become stupid and partially deaf.
On admission his face was flushed, eyes suft'used, skin hot and dry, tongue moist and slightly coated, lips parched,
pulse 86; he had some cough and substernal pain. Small doses of opium and ipecacuanha were prescribed. On
the 27th, as the bowels had not been moved for three days, fifteen grains of compound extract of colocynth were
given; two dejections followed its use. The tongue became clean and the patient walked about a little; his appetite
was good, but he did uot rest well, his pulse was accelerated and his lips parched. On December 1 he was delirious
and deaf; on the 3d he had epistaxis. In this condition he was transferred to division hospital ou the 4th on account
of the breaking up of the regimental camp. [His name does not appear on the register of deaths.]
Case 10. — Private Elias W. Phelps, Co. G, 19th Mass. Vols., was admitted Oct. 1, 1861, having been sufl'ering
for several days from fever, lassitude, want of appetite and pains in the head and bowels. On admission the patient
was somewhat delirious, his pulse 96, tongue thickly covered with a dark fur and bowels unmoved for three days.
TTTK COiNTlMED FEVERS. 257
An ipi't-acuaiiha ciiietic was fjivoii. llo was restless (liiriiif; the nislit. talking in his sleep and incoherenl when
awake. A purgative consisting of one l)lue-pill autl one oonipound eathartie pill ])roduecd one free dejection ; but
in tlie evening the tongue was darker and the patient iuditlerent to everything when not si)eciall,v addressed. On
theM the delirium was increased, the stools involuntary, the pul.se 120 and the tongue dry au<l dark. No rose-colored
spots were discovered. Urandy was given at intervals. The diarrhiea and delirium continued: tlie teeth and lips
became coateil with sordes; the muscles twitched and the pulse increased in frequi'ncy while losing in strength until
it became imperceptible. Death occurred October 5.
Cask 11. — Private J. Fitzgerald, Co. 1, ItHh Mass. \ols., was admitted Nov. 1, 18lil, willi well marked remittent
fever, for which three grains of ([uinine were given three times daily. He comiilaiued of not sleeping well at night.
Valerian and Ilotl'maun's anodyne were prescribed for use at bedtime. On the 13th the tongue was thickly coated,
the teeth covered with sordes, pulse 96 and feeble; one stool was passed during the previous twenty-four hours; the
appetite continued fair. One stool was passed on the 13th, but there was no gurgling nor tenderness in the iliac
region; one or two equivocal rose-spots were observed; the tongue was dry; the ])aticiit slept a little during the
day and muttered in his sleep. Hrandy and tincture of iron were prescribed, lie was souu'wiiat delirious during
the lllh; his face livid, hands cold, tongno red at the ti]) and edges, respiration short and loud, pulse !)fi; on this
morning he tried to support himself and fell; one stool was ))assed. On the lath the patient was stupid, spoke
with ditiienlty and had mu.scular twitchings; the bowels were ([uiet. Next day ho was delirious; the tongue was
Vlack, dry and cracked, the pulse very feeble, and the bowels unmoved. Death took place on the 18th.
Cask 12, — Private Edward Brailey, Co, D, 19th Mass. Vols., was admitted Oct. 11, 18(51. He had been on picket
duty on the banks of the Potomac and during the last two days had felt cold and feverish. He came to camp in a
baggage wagon. His face was Hushed, pulse 90, tongue covered with a thick white fur; he was restless at night
and talked a good deal in his sleep. An emetic of ipecacuanha was given on admission and a Dover's powder at night.
Next day the pulse was 96, skin hot, face flushed, eyes suttused, tongno dry and white, teeth covered with sordes,
bowels nu)ved twice, stools thin and watery. Sweet si)irit of nitre was prescribed and ipunine in two-grain
doses three times a day. On the 18th the patient perspired a little at times and the skin of the abdomen showed
some rose-colored spots ; he had one passage and the abdomen was rather full, but there was no tenderness nor gurg-
ling. Extract of valerian was given. Delirium came on gradually and continued until the 19th, when, after a
good sleep, he awoke feeling better and more rational. During this period the bowels were rather constipated ; the
rose-colored spots were very thickly set and bright on the abdomen. He took port-wine and chicken-broth; brandy
was rejected by the stomach. On the 20th he sat up in bed with aid to read a letter. After this his condition
improved for some days, but the bowels remained unmoved and the tongue furred. An cneuui was given on the 23d,
with castor oil in the evening and extract of senna on the following day; one alvine dejection was thus procured on
the 2r)th, after eight days of torpidity. On the 26th the face was Hushed, e.yes suftused, pupils dilated, mouth
dry and tongue covered with patches of thick white fur: headache was also present. Next day the tongue was
clean but rather abnormally red in color; the patient complained of soreness from lying so long in bed. The bowels
continued constipated, stools being obtained only at intervals of three or four days by the use of extract of senna, but
about the miildle of November four to six tigs were eaten daily and under their use the bowels became more regular.
On the 9lh of this mouth complaint was made of tender feet, and this was continued until the 17th, when the ten-
derness diminished. He sat up for a short time on the 18th and during most of the day on the 19th. Beefsteak was
now allowed in the dietary instead of'the soups, broths and soda crackers to which he h;ul been restricted ii|i this
lime. He was fnrloughed December 12.
Cask 13. — Private James Kelly, Co. D, 19th Mass. Vols,, was admitted Dec. 13, 1861, having been sick for three
or four days with slight cough, anorexia and pains in the head and limbs; his tongue was dry and brown in the
centre, pulse 86, bowels constipated. Ten grains each of blue-mass and colocynth were given at night. On the
nu>rning of the 14th it was reported that the patient had groaned during most of the night; his face was flushed
and breathing short. Next day diarrh(ea, epistaxis and tinnitus auriura were recorded as present. Tannin in five-
i;rain doses was prescribed three times daily. On the 19th the passages became involuntary. On the 20th the tongue
"as dark-colored, the teeth black with sordes, diarrho-a profuse, pulse 100, rcsijiration short and mind wandering.
No rose-colored spots were found on the skin. Turpentine was substituted for the tannin. | I'lie case-book gives no
Irirther information, but on thi' register of deaths this man is reported as having died of typhoid fever Dec. 20, 1861,
at the reginieutal hospital. Muddy Hranch, Va.]
Fever cases from various records. — The following cases have been selected from
the case-books of various hospitals and from the medical descriptive lists to further illustrate
the character and consequences of the fevers which, although reported as typhoid, were
probably in many instances more or less modified by the malarial influence.
Cases 1-5 are presented as specimens of a large class of records which give an
account of the condition of the patient at some period, usually that of admission into lios-
pital, but fail to carry out in detail the daily progress of the case. It is not difficult,
however, to appreciate the course of such cases, especially when aided by a study of those
which have been recorded in full ; for, in addition to the result, there is given generally
Mkd, ni.sT.,Pr. ni— 33
258 CLINICAL RECORDS OF
some sliort statement as to progress, or, in the absence of tliis, some liint as to tlie patient's
condition is conveyed bv recorded changes in the medication or diet.
Case 1. — Sergeant Nahum L. Hayward, Co. F, 6th Conn.; age 30; was admitted from the field May 23, 18S4,
with tvplioid fever. He was unable to give a satisfactory account of himself. He had headache, restlessness and
anxiety of expression, incessant thirst and much diarrhoea; his tongue was dark, cracked and dry, pulse feeble and
rapid, abdomen tympanitic and but slightly tender. The surface of the body wa.s sponged with tepid water; cold
was applied to the head and counter-irritation to the back of the neck; turpentine emulsion was given with milk-
punch freely, beef-tea at short intervals and anodynes at night. The symptoms increased in violence; the patient
became noisily delirious and died June 1. — Hammond Sosjiital, Pnint Lool.oiit, ild.
Case 2. — Private David F.Farr, Co.E,8th Me.; age 21; was admitted Aug. 17, 1864, having been sick since
July 27 with typhoid fever. He was much prostrated, tongue furred and dry, conjunctiv;e injected. Quinine
■with brandy-punch and turpentine emulsion was given. Diarrhoea supervened on the 18th, but was checked two
day.s later. The turpentine was omitted on the 2.3d, the brandy on the 2.5th, the quinine on the 28th. The patient
was able to sit up on the 27tli. He was furloughed September 3 and returned to duty November 28.- — Sattet-lee Hos-
pital, Philadel})hia, Pa.
Case 3. — Sergeant Edwin A. French, Co. B, ITtli Pa. Cav.. was admitted July 8, 1863, with typhoid fever.
Countenance dusky; pain in back : abdomen slightly tympanitic : .sudamina and taches rouges ; gurgling on pressure
in right iliac fossa: pulse 90; tongue furred but moist; dry rales throughout chest: patient stu))id. Gave Min-
dererus' spirit, quinia, beef-essence and milk-puneh. 22d: Steadily improving, taking nine grains of quinine
daily. August 1, convalescent. November 13. returned to duty. — South strttt Eonpilal, Philadelphia, Pa.
Case 4. — Sergeant Walter A. Brooks, Co. I, 53d Mass., admitted Aug. 16, 1863; mind dull; abdomen tympa-
nitic and covered with sudamina and petechiie, gurgling in right iliac fossa; tongue dry and tissured, protruded
with difficulty; teeth covered with sordes; ftice sufi'used; subsultus tendinum; much delirium. Gave an ounce of
sherry wine every hour; beef-tea freely. Died August 20. — Ciiion Hospital, Memphis, Tenn.
Case 5. — Private Fabian Liszt, Co. C, 19th Pa. Cav.; age 22; was taken sick Aug. 10, 1863, a few weeks after
enlistment, and was admitted on the 17th much exhausted, with brown furred tongue, hot and dry skin, pulse
120 and a diarrhoea of three or four stools daily. Dover's powder, neutral mixture and sweet spirit of nitre were
prescribed. On the 20th the pulse was 100, the tongue moist and the bowels not so loose. Milk-punch was given.
Small doses of blue-pill, opium and ipecacuanha were prescribeil on the 22d, for which, on the 26th, neutral mixture
was substituted. On September 10 full diet was allowed and small doses of quinine prescribed. He was returned
to duty October 21. — Turner's Lane Hospital, Philadelphia, Pa.
In cases 6 and 7 the fever began to dechne about the end of the second week; in
case 8 it was prolonged for another week, apparently in connection with the intestinal lesion.
Case 6.— Private E. T. Ellsworth, Co. G, 16th N. Y.; .age 19; was admitted Oct. 10, 1861, having been treated
for three days before admission with astringents and nutrients. The attack commenced with a chill. On admission
he had jiain in the head, back and abdomen, a slow and feeble pulse, hot and dry skin, heavily coated white tongue
with clean tip and slightly reddened edges, thirst, slight cough, somewhat labored respiration an ' scalding during
micturition. Next day the characteristic eruption came out on the face and abdomen. His appetite was improved
on the 12th; the tongue natural and the skin perspiring on the 13th. Two days later the skin became dry and hot,
the tongue white a^t the base and red at the tip and margins, the pulse full, but there was no diarrhoea ; next day the
febrile action abated. On the 22d he was considered convalescent, and on November 1 he was returned to duty. —
Hospital, Alexandria, To.
Case 7. — Private Thomas .1. Bitzer, Co. B, 1st Pa. Res., was admitted Sept. 3, 1862, with typhoid fever. On the
4th he had diarrho-a and profuse epistaxis. On the 6th the fever ran high; the pulse 120, full but compressible, the
skin hot and dry, tongue moist and heavily coated, of a dirty brown color but red at the edges and tip; he h.ad tym-
panites, mostly over the colon, anorexia, some headache and backache. Small doses of sweet spirit of nitre and fluid
extract of ipecacuanha were given every hour and five grains of blue-pill with Dover's powder at bedtime. On the
7th the tongue was moister, the pulse full, slow and strong, the appetite better and no stool had been passed fur two
days: but on the forenoon of this day the fever returned and steadily increased; delirium, jactitation and tympa-
nites over the small intestine were noted in the afternoon. Oil of turpentine and camphor-water were given every
second hour, alternating with a diaphoretic mixture. In the evening the tongue became moist, the pulse soft,
feeble and compressible and the skin bathed in perspiration. Next day there was retention of urine. A grain of
quinine was given every hour and beef-tea and milk freely used. A few poorly defined rose-colored spots were
found on the chest and abdomen on the 9th, and the right iliac fossa was tender and gurgled on pressure; the
delirium increased in the afternoon of this day, but after a full dose of morphia and Hoft'mann's anodyne the patient
slept well, and next morning his appetite was better and there was an abundant crop of sudamina on the back and
chest. On the loth he was manifestly improving. On the 20th his appetite was excellent and the bowels had not
been moved for five days. Powdered rhubarb in small and repeated doses was prescribed. He was returned to duty
November 21. — Hos2)ital 16th and Filbert streets, Philadelphia, Pa.
Case 8. — Private David Old, Co. A, 9th Iowa Cav.; age 17; was admitted March 22, 1864, with bronchitis, and
became sick with typhoid fever on the 30th. The pulse was small, 105 to 110, the tongue furred; the patient was
restless and had headache, giddiness, chilliness, an unpleasant taste in the mouth, no appetite, scanty urine and no
diarrhoea. During the second week the pulse, was strong, 118 to 122, skin warmer, tongue dry, red at the tip and
TRK CONTINUKD FRVEKS. 2r)0
e(lf;rs: tlirre was alsii severe lieadiiclie, with si>inal and muscular pains aud syiuptoms ol' pneumonia in the lower loho
of tlie riijlit lung After the tenth day minute rose-red spots appeared on the breast and alidomen. and there was some
diarrho'a. During the third week the tongue was dry, hrown and smooth, the teeth and gums eovered with sordes,
the lips dry, the skin hot and dry, the pulse 128 to 132; ilelirium. especially at night, deafness. ))ain in the right iliac
region, tym))auites, diarrlin-a, disturbed sleeji, anorexia and great thirst were present. In the fourth and lifth weeks
tlie tongue was moister and cleaner, the pulse StO to 80, the rountenaneo brighter, the evacuations natural and the
ai)petito improving. OuMay 2 the patient was sent to Keokuk, Iowa, as a convalescent. — hiirnoii lloupilal, SI. Louis, .)K>.
Cases 9-17 illustrate the occniTence of inte,<:tinal ]i<'niorrliM<ro, of iicrforatioii of the
intestine ami of complicating or sequent erysipelas, pnemnoiiia and iliarrlioea.
Case ^.—Tntenlinal hemorrliugr.—VTivate Robert H. Howe, Co. I!, llOth I'a.: age 22: was adniitteil from Hare-
wood hospital, Washington, May B, 1802, as a convalescent from tyiihiiid fever. On the lOtli he had hemorrhage
from the bowels. Sulphate of quinine, tincture of iron and milk-punch were used in Wir treatment. Severe hemor-
rhage continui'd u]) to .Tune 11. ()n ,Tuly 18 he was much better. Meilicine was omitted on the ,Slst. The patient
was furloughod August 8 and returned to duty December U).—SiilltrUe Ho.ipilal, I'UUadilphUi. I'li.
C.\SK 10. — I'ioltiit ihinrlKia and intintiniil hemorrlKiijr. — Private David .Tacoby, Co. C, 17th I'a. Cav.; age 24; was
admitted .Inly 7. ISOli; he had been sick and under treatment in the hospital of his reginuuit since .January for rheu-
matism. On admission he had fever, injected and watery eyes, epigastric temlerness, nausea and vomiting, eight
stools in the twenty-four hours, abdominal j)ain and a thickly coated tongue, red at its edges. A poultice was applied;
mercury with chalk and Dover's powder was prescribed every four hours, and acetate of annnonia with syrup of squill
three times n day: beef-tea and wine-whey were also ordered. On the 11th the stools were occasionally bloody. A
pill of acetate of lead and opium was given three times and oil of turpentine twice daily. The pain was relieved on
the 12th and l.Sth, but returned on the 11th, with vomiting and dull headache; pulse 91. Subnitrato of bismuth was
given. On the 15th the pulse was 110 and feeble; the vomiting had cea.sed, but the headache continued with tinnitus
anrium and epistaxis. Opiate enemata were used in addition to the pills of lead and o]iium. On the 10th the stools
liecame less fre(|uent, but severe pain in the back and legs was reported. The diarrlura bertime worse again next day.
On the 2(Hh the pulse was 115 and very weak; tongue dark and thickly coated: stomach irritable and the ejected
matters bilious. On the 21st the patient was somewhat deaf and on the 22d delirious, with i)rofnse diarrhoea, cold
extremities and henuirrhage from the nose and nu>uth. The stools were involuntary and bloody on the 2:!<1, and
death occurred on the morning of the 24th. — Mower FfoKpitol, Philadelphia, Pa.
Cask 11. — Perforation of the inteiitiiif. — Private Thomas A. Watson, Co. C, 58th Pa.: ago 37; was admitted
Aug. 17. 1864. from Petersburg, Va., having been sick since ,July 29. He was very weak and much exhausted ; tongue
dry and thickly furred; subsultus tendinum. Quinia and aromatic sulphuric acid, with brandy-punches and turpen-
tine emulsion were given. Xext day he was seized with a severe pain in the abdomen, which became worse on the
19th; his pulse was thready; he picked at the bedclothes. He died on the morning of the 2l8t. — Satterlee Hospital,
Philadelphia, Pa.
Case 12. — Intercurrent eri/xipclas.^Voryt'l Daniel Austin. Co. (J. 10th N. Y.; age 25; was taken about Aug. 7, 1801,
with diarrhoea, which became worse and was accoin])anied by pain in the head, back and abdomen. He was admitted
on the 22d as a case of gastro-euteritis. Xext day his tongue was heavily coated in the centre but bright-red at the
sides, teeth black with sordes, pnlse 100, (inick, liowels tymp.anitic but not tender, yielding frei|uent watery stools.
In the evening the fever increa.sed and the p.atient was at times delirious. On the 24th the eruiition appeared on the
face and abdomen; the tongue became dry and brown; the stools continued freciuent. He was restless at night, and
next day t he tongue was fissured, abdomen prominent and mind disturbed. The eyes were fixed, the expression vacant
on the 20th and the patient raved about Mount Vernon on the 27th, but became rational again on the 28th. On Sep-
tember 1 an erysipelatous blush appeared on the nose and extended over the cheek. Tincture of iron was given every
three hours and the face painted with tincture of iodine. The swelling increased and by the 0th aftected the hairy
scalp: at this time there was .some cerebral excitement. Wine and nourishment were given and the iodine reapplied.
Ho was improved on the 13th and able to sit up on the 15th. Bed-sores were present on the right hip and on the
sarrnm. This patient was discharged May 31 because of disability from typhoid fever. — Hospital, Alexandria, Va.
Cask 13. — Intercurrent pneumonia. — Private Michael Laly, Co. K, 2d Mich., was admitted Oct. 21, 1801, as a case
of typhoid fever. This uuin had been sick with continued fever for six days prior to his admission, during which
time he was treated with diaphoretics and tonics. On the 22d his pulse was 84, tongue dry and brown, skin hot and
dry. Three five-grain doses of quinine were given with blue-mass and ipecacuanha. Xext day the pulse w,as 80, the
skin cool and the tongue moist. Four two-grain doses of ([uiuino were given with Dover's powder at bedtime.
There w.as a diarrhoea of two or three stools daily from the 24th to the 28tli, and the tongue became dry and brown
in the centre. On the 29th the pulse was 90 and quick, the tongue dry and tremulous, the skin hot : stupor, much
delirium, frequent dry congh, some uneasiness on inspiration and crepitation in the lower part of the left side of
the chest were among the symptoms recorded on this day. C:iIomel, ipecacuanha and quinine with turpentine
ennilsion and chlorate of potash were prescribed, .and a blister applied to the left side. Xext day there was cough
with bloody sputa: the patient could be roused from his muttering delirium to answer questions, but he replied
fdowly and i>rotrnded his tongue with hesitation; the diarrluca ceased during this attack. The cough became less
trcquent and the expectoration viscid and rusty on Xovember 1. Wine was ordered four times daily. During the
following night a profuse epistaxis occurred. The tongue became moist on the ,3d and next day the expectoration
was more abundant and the drowsiness lessened: pulse 76; respiration 24. A blister was api)lied to the front of the
ohest. Ou the 7th the cough was lessened, the expectoration mucous, the countenance bright, tUo bowels regular.
260 CLINICAL RECORDS OF
Milk diet was ordered with an ounce of brandy everj' fonr hours. He recovered January 10, 1862, and was returned
to duty March 7. — HospitaJ, Ahinndriii, Va.
Case U. — Srqueut j)iieumonia.—¥vi\a.te James A. Evers, Co. C, 1st DeL Art.; age 18; was admitted Aug. 20,
1863, having heen attacked with fever on hoard a transport from Alexandria to New York about the 18th. On
admission the febrile action was marked, but the mind was clear and there was no diarrhtea, although the liowels
were free : pulse 90. Profuse perspiration occurred on the 31st. No eruption was observed. On September 4 dulness
and fine crepitation were marked over the right lung, and on the 6th two-thirds of the left lung was implicated. In
the eveuing of this day the febrile action l)ecame heightened liut free perspiration broke out towards morning; the
e.xpectoration was rust-colored, the tongue clean, pulse 86. On the SHli the condition of the patient bad improved,
although physical examination revealed no apparent change. Hy the 16th the area of dulness was much diminished
and the expectoration free and without viscidity. Ten days later the patient was able to walk out, and on October
15 he was reported for duty. — Central Park Hosjntal, JV. T. City.
Case 15. — Sequent diarrliwa from injudicious diet. — Private Albert Hill, Co. I, 126th N. Y., was admitted Dec. 12,
1862, from Emory hospital, Washington, D. C, as a convalescent from typhoid fever. He was placed on full diet.
On the 14th a diarrhu-a of two to six stools daily set in and continued until the 21st. On Jan. 5, 1863, the diarrhoea
recurred after eating apples. The patient was restricted to milk diet and the intestinal trouble ceased. Full diet
was restored ou the 12th: but on the 16th there was a recurrence of the diarrhcea, necessitating treatment until
February 7. He was returned to duty March 4. — Sutterlee Hospital, Philadelphia , Pa.
Case 16.— Sequent diurrhaa and debilitii. — Private Sylvester Chesebro, Co. K, 149th Pa.; age 23; was admitted
June 18, 1863, from Stanton hospital, Wasliington, D. C, having suilered from typhoid fever since May 6. He
was much emaciated and so debilitated that he was unable to stand witliout the aid of crutches; he had pain in
the back, and his mouth and throat were slightly ulcerated. He was placed upon extra diet; a chlorate of potash
gargle was prescribed. On June 20 the diarrhoea recurred with pain in the abdomen ; but by tlie 26th this condition
was relieved and the patient was evidently gaining strength. All medication was omitted and he was allowed full
diet July 17. On the 28th he assumed light duties about the ward, and on August 18 was returned to duty with
his comma.nd. — Satterlce Hospital, Philadelphia, Pa.
Case 17. — Sequent diarrhwa and puhnonarii affection. — Private Clinton Dayton, Co. 1, 17th Conn., a convalescent
from typhoid fever, was admitted Dec. 16, 1862, with diarrhoea and shooting pains in the chest. Pills of lead and
opium were given three times daily, and ou the 21st the diarrhoea was restrained. Tincture of iron was then ordered,
but the diarrho'a returned on the 26th. Snuill doses of an emulsion of castor oil, laudanum, mucilage and turpentine
were prescribed. On the 30th the diarrhiea was controlled, but its recurrence with some abdominal pain, Jan. 12,
1863, called for opium twice a day. On the 14th ten grains of blue-pill were given; on the 18th the opium was
omitted. Meanwhile, as the cough was troublesome, an expectorant mixture was ordered on the 15th, and croton
oil applied to the chest from February 2 to the 6th. The expectorant was omitted on the 9th, but was renewed on
the 17th and continued until the 22d. On March 27 he was placed on guard duty; he was furloughed April 1, and
returned to his command June 28. — Sutterlee Hospital, Philadelphia, Pa.
Cases 18-29 show debilitv, bed-sores, deafness, oedema, anasarca ami morbid condi-
tions of the lungs, liver and kidneys consequent on fever.
Case 18. — Protracted debiliti/. — Private Samuel Watson, Co. K, 63d lud.: age 39; was admitted April 6, 1865,
debilitated from typhoid fever. [This man contracted typhoid fever in August, 1863, at Shepbardsville, Ky.; he was
admitted to hospital No. 1, Louisville, Ky., Jan. 26, 1864. with lumbago, and transferred to Madison, Ind., where
his case was entered as chronic rheumatism; on March 23 he was assigned to Co. K, 19th Veteran Reserve Corps.
He entered Judiciary Sijuare hospital, Washington, D. C, April 9, — diagnosis:. intermittent fever — and on the 26th
was furloughed. He returned to Judiciary Square hospital March 23, 1865, and on April 6, as aliove stated, was
transferred to Satterlee.] He was treated with quinine, iron, cod-liver oil and porter, and discharged from .service
May 26 on account of chronic pleurisy and protracted debility. — Satterlee Honpital, Philadelphia, Pa.
Case 19. — DeVility and })hthisis. — Private Charles McCormick, Co. D, 4th Mich.; age 20; was admitted Aug. 10,
1862, debilitated from typhoid fever. On December 9 he became affected with diarrhcea, which was checked by
chalk, opium and catechu on the 17th. A few days later bronchitis was manifested. In February, 1863, there was
dulness with sonorous rales over the apex of the left lung. He was discharged ou the 28th on account of phthisis. —
Satterlee Hospital, Philadelphia, Pa.
Case 20. — Debility, deafness and bed-sores. — Private John D. Magee, Co. D, 133d N. Y., had typhoid fever in
June, 1861, followed by an enormous bed-sore involving all the supra-sacral tissues; he had not done any duty
since the occurrence of this fever. He was admitted from Fairfax Seminary hospital, near Alexandria, Va., Bee.
16, 1862, and was placed on special diet with beef-essence and milk-punch. His appetite was impaired, bowels
irregular; he complained of pain about the joints and of a slight cough. He was treated with sinapisms and
expectorant syrups. On Feb. 9, 1863, it was noted that the patient had become partially deaf in one ear. He was
discharged March 27 because of general debility and partial deafness of the right ear following typhoid fever. —
Satterlee Hospital, Philadelphia, Pa.
Case 21. — Otorrhea. — ^Private H. Harpster, Co. K, 88th Ind.; age 21; while in hospital for an injury to his back,
caused by a fall from a wagon, was taken with typhoid fever in April, 1863, and had a long and serious illness,
during which he was much troubled with a purulent discharge from his ear. He was treated with turpentine emul-
sion, brandy and beef-tea. When transferred to Camp Morton, June 9, he was IraproTing rapidly and gaining in
flesh. — Hospital, Quincy, III.
THE CONTINUED FEVERS. Ihi
Case 22. — DchiUty, rfra/iiess and mleiuti of feet. — Private Alliert Friedlander, Co. D, l.">7tli Pa.; age 23; was
admitted Feb. 23, 1H>5, with aiiieiuia, deafness and ledeiiia of the feet, and was diseharged liy order of the A. (i. O.
dated May 3d. [This man bad a severe attack of typhoid fever in January, 1865, and passed through the Fifth
Army Corjis hospital at City Point, Va., to Patterson Park hospital, Irialtimore, Md., where he arrived February 8 and
was entered as a ease of i>nenni(>nin. On tlie 23d lie was removed to Phihidelphia.] — Snllerlce Hospital, Philadelphia, Pa.
C.VSK 23. — .'HwelliiHi of lower cxtremitii. — Private Pavid P. Cline, Co. I, 180th Ohio; age 31; was admitted
March 21, 18t>.">, his left leg being ledematous. He had an attack of typhoid fever in January, and during his con-
valescence the leg became swollen, .\rsenic and compression by Itandagcs failed to remove the tumefaction. He
was discharged from service June 5. — Tiipler Hospital, Columbus, Ohio.
C.iSK 24. — llehililij aud adrma of lower eitremilies. — Corporal Hugh MeCrossen, Co. A, 118th Pa.; age 21; was
admitted Oct. 25, 18()3, with dcliility .following typhoid fever; he had also some cough. Ou the 30th his legs
liecame (vdematous and continued in this condition until November 22, with variable ai)pctite and occasional fever-
ishness and cough. For some days, about the end of this nu)utli, he sutVered from tympanitic distention of the
alidomen. On Ueccmber t! there was much jialiiitation of the heart after exertion. On the 7th the cough continued
and the ii'dema of the legs reappeared, but <Mi the 8th there was an improvement which progressed steadily until the
patient's transfer to the Invalid Corps. In his treatment rjuinine in snuill doses, citrate of inui and (|uiiiiiu\ com-
pound tincture of cinchona, wild cherry, squill, morphine, Dover's powder, cod-liver oil, milk-punch and porter
were employed. — SattvrUe Hospital, Philadelphia, Pa.
C.\SE 25. — Sequent diarrhaa and wdema of feet. — Private John Vaus, Co. C, 82d 111.; age 35; was admitted Jvine
18, 1863, from Stanton hospital. Washington, D. C, as a convalescent from typhoid fever. Ho had been taken with
the fever in ilarch: diarrliiea followed, aud about June 1 his feet began to swell. He was placed on quinine and
tincture of iron in small doses, aud due attention was paid to his diet; but the diarrluea recurring, pills of Dover's
powder aud sulphate of iron, and afterwards turpentine in mucilage, were tried. Medication was continued to
August 1, and the i>atient was returned to duty on the 2(ilh. — Sallcrlee Hospital, Philadelphia, Pa.
C.vsE 26. — Seijurnt diarrhua aud ana.wrea. — Private Robert 11. Davis, Co. A, 78th 111.: age 27; was admitted
Sept. 16, 18t>4, having suffered from a severe attack of tyjilioid fever June 16, 1863, followed by a persisting diarrhoea.
Ou admission he had ascites and a-dematous legs. He was discharged as wholly disabled December 8, 1864. —
Hospital. (Juinvji, III.
Case 27. — Enlargement of lirer and ascites. — Private Henry C. Packard, Co. E, 6th Vt., was admitted Aug. 10,
1862. with typhoid fever. On October 3 the left lobe of the liver was enlarged and the patient at}'ect<'d with ascites.
Nitro-muriatic acid aud saline cathartics were used in the treatment. His appetite became very good, but otherwise
there was little improvement. He was discharged December 29 because of enlargement of the left lobe of the liver,
with ascites. — Satti-rlee Hospital, Philadelphia, Pa.
Case 28. — InJIammation of lirer and probable abscess discharging into colon. — Private Benjamin M. Richardson, Co. C,
93il X. Y.; age 24; was admitted Dec. 15, 1862. Diagnosis — diarrhiea. [He had contracted diarrluea at Williams-
burg. Va., in May. This lasted ten days, after which he was confined to bed for four weeks with typhoid fever;
(luring convalescence he was much troubled with pain referred to the liver and stomach. 1 Hy January 12, 18(i3, the
diarrhu'a was checked, but the .skin becauui yellowish and on the liUli Jaundice was well marked aud the liver
enlarged. Small doses of mercurials were given. Diarrhiea recurred on February 1, but was (|uieted ou the 6th by
the use of krameria and ])arcgoric. After this the stools became clay-colored, and on the !Hli pain was developed
in the right hypocliondrium, which became so acute on the 15th that the poulticing which had l>eeii employed was
discarded aud a blister apidied with relief to the patient for a day or two. On the 2l8t the pain returned and ou
the 24th a sharp diarrhiea set in, yielding from two to eleven stools daily until the 28th. After 'his he improved
under the use of quinine, carbtmate of iron and uitro-muriatic acid. He was placed on hospital guard A|)ril 10 and
was returned to his command August 27. — Satlrrlee Hospital, Philadelphia, Pa.
Case 29. — Disease of the kidney. — Private Thomas Buckley, Co. D, 6th Conn.; age 21; stated that he had never
been intemperate in the use of liquors and was perfectly healthy before enlistment. In September, 1863, he had
had typhoid fever and was sent to general hospital at Hilton Head, S. C. Two months elapsed before convalescence
was established. A week after his return to duty he was admitted to the regimental hospital with cedema of the
lower extremities. In about a month he was furloughed to his home, where he remained until his admission into
this hos|>ital, April 19, 18t>l. His face was putfy aud pallid, his feet and legs redenuitous; the urine was albuminous
and contained granular casts. He was discharged from service August 12. — Central Park Hospital, \. i'.
Cases 30-50 illustrate the occurrence of inflaramatoiy processes in various parts of
the body, but especially in the lower extremities and parotid glands.
Case 30. — Muscular pains. — Corporal Emanuel Davis, Co. K, 137th N. Y.; age 36; was admitted June 20, 1863,
convalescing from typhoid fever which had disabled him since March 10. On admission he was troubled with
subacute muscular pains aft'ectiug the left arm aud leg and sometimes the right thigh. These pains were not con-
tinuous, but came on at iutervals without premonitory symptoms or accompauying fever and la.sted about twelve
hours. Dampness aiul cold ajjpeared to act as exciting causes. The joints, large and small, were also occasionally
affected. The pains were increased by motion aud reliev(Ml by pressure; the warmth of bed aggravated them. The
patient was much debilitated, emaciated and low spirited. He was treated at first with a pill containing one-half
grain each of powdered iron and extract of nux vomica and oue-sixth of a grain each of quiiiia and calomel, given
three times a day, with a liniment of ammonia, soap and chloroform: but after a few days the pills were omitted and
a teaspuonful of a mixture consisting of one drachm of iodide of potassium, one fluid drachm of colchicum wine and
262 CLINICAL KECORBS OF
two ounces of compound tincture of gentian was prescribed instead. Two weeks after this treatment was insti-
tuted tlie patient began to improve, and on August 11 lie was returned to duty. — Act Jss't Siiry. Otto Rulirig, U.
S.A., S(it1ei-Jee Hospital, PhUadelphiu, Pa.
Case Sl.^Eheumatic jiuins. — Corporal Dudley S. Cutler, Co. F, 8.Sd Pa.; age 20; was received June IL', 1863,
from Lincoln hospital, Washington, D. C. [He had been treated for typhoid fever in regimental hospital until April
20, when he was transferred to Lincoln hospital.] On admission he complained of a dull heavy pain in the left
hip and leg and seemed to have lost a good deal of flesh. Cups, blisters and liniments were employed with turpen-
tine emulsion internally. [On August 1 he was removed to Sixteenth and Filbert streets hospital, Philadelphia,
Pa. Diagnosis — chronic rheumatism. He was transferred to the 1st Battalion, V. R. C, September 23.] — Satterlee
MospitaJ, Philadilphia, Pa.
Case 32. — Pniii and sweUiiiij uf fevt. — Private Peter Gates, Co. E, 1st MicJi.; age 2o; was admitted March 2. 1862.
This man became aft'ected with intermittent fever in November, 1861, and continued in ill health from that time.
From the daily entries on the hospital record which cover tlie period to March 29, it is found that the case was
regarded as one of typhoid fever, and that the patient was unable to wiUk, having a bed-sore on each hip and much
swelling, tenderness and pain in his feet, but his tongue was moist and clean, appetite good, bowels regular, skin
natural and pulse of fair strength. Stimulants and citrate of iron and (|uinine were given, but for some time there
was no improvement in the condition of the feet. Severe frontal headache was noted as having been present on the
10th and 11th and as having recurred on the loth, 20th and 29th. Quinine was prescribed on the ]5th. At the
time the last entry was made the bed-sores were healing and the swelling of the feet had subsided. The patient was
discharged from service May 3. — Seminary Hospital, Georgetown, D. C.
Case 33. — Pain in foot and leg .—Fiivate William Camp, Co. D, 122d Ohio; age 19; was admitted Sept. 11,
1863. Diagnosis — intermittent fever. He had been sick for five days, during which the bowels were constipated.
Three compound cathartic pills given on admission produced two copious stools at night. On the 12th the pnlse
was 90, full and strong, tongue coated, appetite deficient, skin hot and moist and urine scanty: there was pain in the
head, limlis and back. Sweet spirit of nitre was prescribed. By the loth the skin had become cooler and the head-
ache diminished: ejjistaxis occurred twice on this day. Diarrhoea set in on the 16th, the stools being liquid and
yellowish and the tongue dry and coated. Drowsiness and delirium were developed on the 18th and recurred partic-
ularly at night; the pulse ran up to 110 and the respiration to 32. Milk-punch was given and a blister applied to
the chest; squill and seueka were also prescribed. The diarrhoea meanwhile persisted, and on tlie 22d three invol-
untary stools were passed. Subnitrate of bismuth was given. The patient rested well on the 27th, and next day
was more rational; the chest symptoms also were much improved. The diarrhcea continued at the rate of three
to five stools daily, with sometimes severe pain in the bowels, until October 16, and during this period the tongue
was more or less coated and sometimes dry and the appetite poor. Wine, brandy, porter, milk-punch, wine-whey
and whiskey with quinine were used. The appetite returned on the 23d, but the diarrhoea recurred on the 26th and
again on November 17, its appearance on the latter date having been attributed to the use of apple-sauce. About
October 1 the foot (side not stated) became very painful, but no further mention is made of this until November
13, when the leg was reported as much swollen, and hop fomentations were prescribed. On the 25th the left leg
and foot were swollen and fomentations of pepper and hops were used. On the 27th chloroform, arnica and aconite
were mixed with olive oil as a liniment for the left leg and foot, but after this no more information is given
concerning their condition. The patient was furloughed Jan. 25, 1864. He returned February 21. and was sent to
his command for duty May 3. — Third Division Hospital, Ahrandria, Fa.
C'.^SE 34. — Scorbutic comjjlicalion ; pain in feet and legs; boils. — Private J. H. Penny, Co. A, 1st S. C; prisoner
of war; age 19; was admitled Nov. 1(1, 1863, as a case of continued fever. The tongue was red, streaked with white,
the gums jiale and swollen, the pulse frequent ; he was very weak and had much pain in the limbs. On the 14th the
bowels were moved five times and the tongue was dry, red and brown; nevertheless he began to imiirove from this
date, so that by the 2l8t the tongue was moist and cleaning and the bowels regular. On the 27th the patient's condi-
tion continued favorable, but he had a troublesome bed-sore. On December 20 he remained weak and emaciated and
had large unhealthy boils on various parts of the body which appeared in successive crops until January 6, 1861,
when the last lioil ceased to discharge. He also at this time suftered great pain in his feet and legs, which were
swollen and cold; this was considered due to the severity of the weather. After January 9 this pain ceased and
he steadily improved until April 27, when his exchange was ett'ected. — Act. Ass't Surg. W. A. Harreij. U. S. A.. Ham-
mond Hospital, Point Lookout, Md.
Case 35. — Superficial abscesses. — I'rivate William Dundass, Co. C, 11th N. J.; age 25; was admitted from Sum-
mit House hospital, Philadelphia, Aug. 18, 1864, as a convalescent from typhoid fever, suffering from diarrliuea and
abscesses in the right hypochondrium and over the epigastrium; his fever dated from June 10. Not until Decem-
ber 1 was the diarrlia>a cheeked, by which time the abscesses were healed and the general health much improved.
He was then placed on full diet with cod-liver oil, iron and <|uinine. On Feb. 16, 1865, he began to do guard duty,
and on May 20 was discharged by order of A. G. O., dated May 3. — Satterlee Hospital, Philadelphia, Pa.
Case 36. — Abscess and contraction of ley. — Private Aaron Chubbuck, Co. C, 2d Pa. Heavy Art.; age 18; was
admitted Aug. 12, 1864, convalescing from a tedious attack of typhoid fever [regarded as remittent during the patient's
stay at Harewood hospital, Washington. 1). C], which had left him with abscesses in the left thigh near the buttock.
The leg was partially flexed and could not be extended without much pain. Iron and quinine were administered
with full diet; pressure was applied to the leg from December 3 to January 5, 1865. On the 15th the leg was
reported as much contracted, discharging and so painful as to be unable to bear extension on splints. On Feliruary
4 another abscess was rejiorted as forming; this discharged on the 20th. On March 23 the x>atient suffered from a
THE CONTINUED FEVERS. 263
slight attack of varioloid. On June 20 he was discharged from service on account of lameness of the left leg. —
Salterlie Hospital, rhihuhlphia , Pa.
Case 37. — Vhiruliun of toes. — Private Israel J. Gromoble, Co. 1, 148th Pa.; age 18; was admitted Sept. 2;i, 1863,
from Finley hospital, Washington, D. C, as a convalescent from typhoid fever. On the 26th four of the patient's
toes were found to he ulcerated and niiicli congested. Incisions were made around the ulcers and warm- water dress-
ings prescribed, with tincture of iron internally, porter and extra diet; awash containing sugar of lead and opium
ami an alcohol and water lotion were subsequently employed. On October 18 the ulcers were granulating. All
treatment was omitted on the 25th, and on November 16 the i)atient was returned to duty. — Mower Hospital, Phil-
adelphia, Pa.
Cask 38. — I'lecratiou of hij. — Private James A. Humes, Co. H, l.")Oth Pa.; age 20; was admitted Dec. 12, 1862,
from Carver hospital, Washington, D. C, as a convalescent from typhoid fever. He was weak and emaciated and
liad slight tenderness in the right iliac region. Nnx vomica in compound tincture of gi'utian was ordered. On
Feb. 10, 1863, he had fever-sores on the leg, which were treated first with flaxseed poultice and afterwards with
oakum dressing. On the 27th the patient's hair was falling out. On March 1 the nux vomica was omitted. A lotion
of sulphate of zinc was applied on the 20th and pills of carbonate of iron and ([uinine were given three times a day,
under which treatment the ulcers healed. On April 17 all medication was omitted and the patient was ]>ut on light
duty. He was returned to his command June 28. — Salterlee Hospital, Philadelphia, Pa.
Case Zy.^.SloHijhiny of cornea. — Private William A. Chase, Co. F, 161st N. Y., was left under the care of a
nurse in regimental hospital on the departure of his command. lie had been sick for several weeks and was believed
to he dying. He was exceedingly emaciated and had delirium, diarrhoea, dry tongue, blackened with sordes, cough
and jerking respiration. Ho was admitted Dec. 1, 1862, for better attendance and treatment. He was not removed
from bed during the transfer, but was carried by relays of men, and was well protected from the cohl by blankets, hot
bottles and whiskey toddy. Ho was extreuudy weak but was restless and picked at the beilclothes; his breath was
very oflensive. The left cornea sloughed with escape of the contents of the anterior chamber, but the case progressed
without much suflering and a cicatricial staphyloma was formed. On Jan. 9, 1863, he was fairly convalescent, and
on March 16 was discharged from service on account of ilebility and loss of vision of the left eye. — K I mira Hospital, X.i'.
C.\SE 40. — Superficial iiauyrciious jmtehes. — Corji'l J. H. Kourtz, Co. C, 130th Pa.; age 19; was admitted April
20, 1863, having been sick since the 1st. He was considerably emaciated and in bad nervous condition; his pulse
90. appetite poor, tongue white-coated, dry and cracked, and bowels moved five or six times during the twenty-four
hours; he had a slight cough with thin gray sputa mixed with semi-solid masses of a dark-brown color, and
there was dulness and slight crepitus in the right infraclavicular region. Suitable nourishment was ordered with
sweet spirit of nitre and Dover's powder at bedtime. On the 21tli two small pustules with iullammatory areola;
were observed above the left knee. A two-grain dose of cjuininc in sherry was given every two hours. By the 29th
the centre of these spots had become gangrenous and evolved a very offensive odor; a similar but larger spot had
also developed on the right forearm three inches above the wrist. Chloride of zinc solution was used locally. 'I'lie
spots enlarged slowly, and on Ma}' 3 a pustule with a largo inflammatory base appeared on the mucous membrane of
the left side of the lower lip. On the 5th there was low delirium; the left side of the face was swollen and the gan-
grenous spot on the lip was as large as a penny and increasing rapidly; the diarrhcea meanwhile continued. The
jiatieut became unconscious and died on the8tli. — .let. .tss'lSur'j. 0. P. Sweet, U.S. A., Lincoln Hosiiilal, IVashinijtou. D. C.
Case il.— Gangrene of /.»«.— Private William Wollcott, Co. H, 12th \. Y.; age 53; was admitted June 23, 1863,
from Harewood hospital. Washington, D. C. [The records show that this man had typhoid fever at White Oak
Church, Va., in JIarch, and that he was received into Harewood hospital, April 21, whence he was transferred to
Satterlee hospital, Philadelphia, Pa., as stated.] On admission he was found to have a diarrha;a causing four or
five stools daily, and a gangrene, attributed to frost-bite while on picket, involving four of the smaller toes of the
right foot and two of those of the left foot ; he had also an ulceration of the left buttock which was supposed to have
resulted from riding in ambulance wagons. On the 27th the sphacelated parts of the right toes separated leaving
eleaii ulcers, and on July 4 the first joints of the second and third toes of the left foot were removed by operation.
Water dressing was applied. On the 29th the patient was fnrloughed. On September 4 he was transferred to the
Invalid Corps. — .Satterlee Hospital, Philadelphia, Pa.
C.\SE i2.— Gangrene of ?«/.— Private E. D. Ellis, Co. H, 2d Vt.; age 20; was admitted June 29, 1862, with
chronic bronchitis following typhoid fever. The patient, although lightly built and not very robust, had always
enjoyed good health until attacked by typhoid fever on the Yorktown peninsula, where he remained in hospital
until conveyed to this place. While on board the transport he noticed a pimple on the outer side of his left leg
about two and a half inches above the ankle. As it did not create annoyance at that time the attention of the
attending surgeon was not called to it until about a week after his admission. It was then painful and presented
the appearance of an ordinary boil which had broken; warm fomentations were applied. In a day or two the edges
began to slough, but under the influence of good diet and tonics, with the continuance of warm applications,
the slough separated with but little loss of tissue, leaving a healthy ulcer. Granulation proceeded kindly and
cicatrization was nearly completed when the surrounding tissues became red, swollen and painful. The general
treatment was not changed, but a bread-and-water poultice was applied to the sore with much relief to the patient.
The ulcer remained for a time quiescent, but thereafter the edges again took on violent inflammation and became
gangrenous. Nitric acid was freely applied to the whole surface, but the processes of separation and granulation
were carried on slowly. Gradually, however, the patient improved; his cough subsided; he gained flesh and became
able to take exercise in the open air. Towards the end of December the ulcer was quite small and looked well;
but at this time the patient partook freely of liquor while absent on pass, and, perhaps as a result of unnoticed
264 CLINICAL RECORDS OP
violence, the gangrene reappeared and spread more rapidly than before. Canstic potash was applied, but the
slough began to spread, involving the skin, fascia, muscles, tendons and even the bone. The general health became
much impaired; the stomach loathed food and rejected whatever was taken into it; opiates, even in large doses,
were insufficient to induce sleep, so that the patient rapidly lost flesh and became exceedingly irritable. To the
whole gangrenous surface sulphate of zinc was freely applied and carefully retained in position by dry lint and
strips of adhesive plaster; for an hour, or a little more, there was an increased aching in the jiarts, but comijaratlve
ease followed. In twelve hours a jioultice of slijipery elm was applied. Next day the slough began to soften,
free suppuration took place and the patient's appetite and sleep improved. In a week nearly all the slough had
separated and the granulations were progressing satisfactorily. The lower edge of the deeper portions of the
ulcer still looked suspicions and required a re-applicatiou of the zinc suljihate, diluted, however, on this occasion
by the addition of an equal part of powdered gum arable. The result was beneficial, and at the date of the report
the whole ulcer was filled with healthy granulations.* — Sattcrlee Hospital, PMliulvlphia, I'a.
Cases 41^-50. — Disoryanizntion of ilw parotid ylanil. — Case 43. — Private Edward J. Wilson, Co. I, 138th 111.;
age 18; was admitted Oct. 1, 1864, with typhoid fever. He had high fever, dry skin, brown and dry tongue,
sordes, anorexia, occipital pain, mental dnlness, epistaxis, yellow watery stools seven or eight times a day and tym-
jianites and tenderness of the abdomen. Dover's powder, quinine and calomel were given every four hours, and
the skin was sponged three times a day with alkaline water. On the 11th the skin and tongue had become moist,
the diarrhffia lessened and the apjjctite better, but the left parotid gland was swollen and i)ainful. On the 14th
the jtatient was delirious and refused food. On the 1.5th there was much dysphagia and the radial pulse was hardly
perceptible. He died on the 18th. — Hospital, Quinci/, HI.
Case 44. — Private B. F. Ross, Co. G, 78th 111., was admitted Sept. 19, 1862. A severe diarrhoia complicated
this febrile case. The patient had, moreover, recovered from an attack of mumps only a short time before his
admission. Two or three weeks after admission and while under treatment for the fever the parotid of the left
side, which had been most affected during the previous attack of mumps, became painful and swollen, increasing
gradually to an immense size and remaining for some time very hard and resisting. When it had softened under
continuous poulticing it was lanced in several places, and again after a few days more, without other issue than a
few drops of dark-colored blood. After this the tumor began to discharge through the ear and then through the
openings made with the lancet, the whole of the gland finally suppurating. Meanwhile a harassing cough set in
and the diarrhoea could not be controlled. The patient died October 29. — Hospital iVb. 1, Quincy, III.
Case 45. — Private James E.Taylor, Co. A, 111th N.Y.; age 18; was admitted Jan. 8, 1862, with an abscess of
the parotid gland following an attack of typhoid fever. He was much emaciated. As the abscess discharged from
the auditory meatus, an incision was made below the ear to give exit to the ]ius. Nutrients, tonics and stimulants
were employed, but the patient died on the 21st. — Third Dirision Hospital, Alexandria, Va.
Case 46. — Private John Kinnison, 48th Ind., a nurse, was placed on sick report July 13, 1863, on account of an
attack of duodenitis, with hepatic complications, supervening upon a diarrha-a of two weeks' standing. Rest in
bed, mild nourishment and Dover's powder were prescribed. During the next five days the bowels improved and
pain on pressure ceased, but after this the left parotid became painful and swollen. There was severe dysphagia
on the 19th. An abscess at the angle of the jaw was opened on the 24th and discharged freely; there was also a
copious discharge from the external auditory meatus. Iron, quinine, opium, strong wine and good diet were
employed. On August 20 he was furloughed. — Union Hospital, Memphis, Tenn.
Case 47. — Private Abram W. Pearl, Co. H, 9th N. H.; age 45; was admitted Dec. 11, 1862, from Carver hos-
pital, Washington, D. C, where he had been treated for typhoid fever since October. He had parotitis of the right
side. Simple cerate was applied. On Jan. 30, 1863, he had some diarrhcea. He was placed on guard duty Feb-
ruary 7, but three days later returned to the ward on account of severe pain in his feet. On the 13th he had some
vertigo and on the 16th a recurrence of diarrhiea, which was not checked until the 26th. The pain in the feet con-
tinued until April 10. Shortly after this he was placed on duty in the kitchen and was not returned for field service
until September 26. — -Saiterlee Hospital, I'hiladdphia, I'a.
Case 48. — Private Robert Powell, Co. D, 10th 111. Cav., was admitted Sei)t. 10, 1863, much emaciated and very
weak from fever and diarrhiea; he could scarcely speak. He had a freely suppurating parotid abscess which opened
externally and also into the external auditory canal. He died on the 21st. — Union Hospital, Mnnphis, Tenn.
C.4SE 49. — Private William Lyons, Co. B, 34th Ohio; age 17; robust and athletic; was admitted Aug. 11, 1864,
having had diarrlnea for several days, causing five or six liquid stools daily. Astringents were employed, and next
day he had but one stool, but the abdomen was tender, the skin hot and dry, the tongue moist and very glossy and
the appetite lost; there was also some faintness. Quinine, iron and whiskey were prescribed. The bowels remained
* Act. Ass't. Sm-g. Lloyd Dorsey, U. S. A., Med. and Surtj. Reporter, Pliiliidt'lphiii, Vol. X, 18{i3, p. 385, in a scries of clinical notes gives the history
of a case reported as scurvy with mortification of tlie left foot. The case had a decidedly febrile character throughout. The patient, B. W., Co. G, 33d
Mass. Vols. ; age 17 ; was admitted to ILarewood hospital Nov. 10, 1S(V2, with an urethral attection of two months' standing. Treatment entirely relieved
his ailment when, on December V, he was taken with debility, diarrhcea and febrile symptoms. On the morning of the 9th there was great delirium ; the
pulse 120, we.ak and irregular ; the skin hot and dry ; the tongue dry, rough and coated with sordes. Turpentine cnmlsion, quinrue, wine and beef-tea
were pi-escribed. During the two following days the symptoms showed little change. On the I'itli the fever was subsiding and tiie delirium lessened,
but both feet were greatly swollen, painful and covered with blisters of various sizes, while the legs wore ecchymosed and the hands purplish ; there
■was no hemorrhage from the mucous membranes and, aside from an excessive odor, nothing peculiar was noticed in the stools. After a few days the feet
became less tumid, the vesications collapsed and the eccbymoses fa4ed somewhat ; but on the 21st the left foot began to slough and this morbid action
continued to the close of the ciise. Meanwhile blotches appeared on the surface of the body, the pulse became feeble, the stools involuntary, and
delirium recurred, ending this time in stupor. Death took place Jan. 3, 1863.
THE CONTINUED FEVERS. 265
quiet, lint on the 19th two stools were obtained, castor oil and turpentine Iiavinj; liceii ^ivi^ii on the previous day.
On the 21st the pulse was llti, tongue moist ami with a slimy white coat, skin hot and dry, appetite deficient and
stomach irritable, bowels moved tive times; rose-colored spots appeared ou the abdomen; roui;h and sibilant rules
were heard in the upper lobes of the lungs. Turpentine, s<|uill and ipecacuanha were given, with warm bricks to the
feet, a blister to the chest and sinapisms to the epigastrium. On the L'3d sordes appeared on the teeth and there was
freciuent epistaxis; the abdomen was tym)>anitic and covered with dark spots; the mind so dull that iiuestions were
answered with reluctance and indistinctly; both jiarotids were iullamed and painful. The patient was very rest-
less and delirious ou the 2.">th: his pul.se was 132 and he was evidently sinking rapidly. Ho died on the morning of
tbe2tith. — Cumberhind llospitul. Mil.
Case 50. — Private Melvin Urowu, Co. U, 23d Ohio; age 18; was admitted Oct. 17, 18l)l, having been sick for
four months. He was much emaciated and unable to walk; he had no appetite; his abdomen was tympanitic and
tender, bowels loose, tongue smooth, dry and shining, lips dry and i)arched, skin dry and hot, pulse 112. tjuinine,
iron, Dover's powder, beef-essence and stimulants were ordered, and glycerine applied to the tongue and lips. On
the 22d crepitus w.is heard over the middle parts of both lungs. On the 21th epistaxis recurred about every two
boui-8 and the parotid glands began to swell. The submaxillary glands became involved on the 27th. Pus was dis-
charged from the left ear on the 2!>th. Nevertheless the patient rested well at night, had some appetite and was
hopeful. Carbonate of ammonia was given on account of the cough. Pus was discharged from the right ear on
the :>lst and the eye of that side was closed by the increasing swelling. Next d,ay there was a bed-sore on the
siicrum. The pulse became very weak and almost imperceptible. He died November .5. — Cumberland HospUiil, Md.
Injury to the nervous system is suggested on more or less definite testimony by the
eleven cases numbered 51-61.
Case 51. — (Kdema and partial paraltjuiK of riflht ley. — Private Ernest Bownuin, Co. 1>, dtli I'a. Res.; ago 20; was
taken sick at Harrison's Landing with typhoid fevQr, July 18, 1862, but when admitted, August 10, was so far
recovered as to have no fever and but little diarrluea. Shortly after admission his right leg became painful and
swollen from oedema. In two weeks the swelling disappeared, but a partial paralysis remained for a considerable
period. — Salterlec UoapUal. ['Ititadelphia, Pa.
C.\SE 52. — I'lirtial paraphilia. — Private Richard H. Martin, Co. D, 16th Maine; age 28; was admitted May 28,
1864, as a convalescent from typhoid fever. [Almnt Dec. 15, 1863, while near Culpeper, Va., he was taken with
fever and delirium and became very weak; he was treated in the field division hospital and transferred Feb. 1,
18«>4, to Stanton hospital, Washington, D. C.] On admission his health was impaired and his lower extremities
partially paralyzed; he could walk, but slowly and unsteadily. He was discharged August 15 because of this disa-
bility.— Tiinier'it Lane Hnxpital, Philadelphia, Pa.
Case 53. — Paraplegia with atropht/ nf right leg. — Private Chauncey Brown, Co. B, 97th N. Y., was admitted Sept.
3, 1862, as a convalescent from typhoid fever. He was nmch emaciated and debilitated and had a large bed-sore
over the sacrum, severe pain in the back and paralysis of the lower limbs. By November 15 he could go about a
little on crutches, for which, on December 4, he was able to substitute a cane, the bed-sore having healed, though
there still remained some tenderness and wasting of the right leg. He was returned to duty on the 26th. — South
Street Hospilul. Philadelphia, Pa.
Case .54. — Paraplegia. — Corporal .John McGinnis, Co. C, 42d N. Y., was admitted Aug. 7, 1862, as a convales-
cent from typho-raalarial fever contracted on the Peninsula. He did well under tonic treatment till September 30.
Loss of power and sensation in the lower limbs gradually increased to an almost total paralysis. During the winter
iodide of potassium and strychnia were given and the galvanic battery applied. The patient improved very much,
but as he was unable to do duty he was discharge<l Marcli 20, 1X63. — South Street Hospital, Philadelphia, Pa.
Case .55. — Partial hemijthgia with contraction of right leg. — Private William Criswell, Co. I, 12th Ky.; age 30; was
admitted Jlarch 3, 1863, with some diarrha'a, a bad cough, pain in the back and partial hemiplegia. He suffered
from typhoid fever in November, 1862, and had never fully recovered from the consequences of the attack. Cups
were applied to the back and .strychnia and capsicum administered. He improved rapidly, but continued lame in his
right leg, which was somewhat contracted at the time of his transfer to Louisville, Ky., .lune 9. — Hospital, Quincij, III.
Case .56. — Uemiplegia. — Private Nathan Smith, Co. M, 1st Wis. Cav.; age 34; was admitted Dec. 8, 1864, suf-
fering from paralysis of the left side, which, according to the statement of the patient, was the result of an attack
of ty]ihoi<l fever. He was treated with one-fifteenth of a grain of strychnia atid two-thirds of a grain of capsicum
three times a day, but there was no improvement in his condition at the time of his discharge, April 8, 1865. — Act.
Att't Surg. l>. Lewis. U. S. A., Hospital, (Juineg, Til.
Case .57. — Hemiplegia. — Private (Jilbert Leonard, Co. D, 27th X. Y., was admitted Oct. 30, 1861, having been
sick for several weeks with typhoid fever. He had some diarrlia>a and cough on admission, but the respiration was
natural. On the evening of November 4 the respiration became increased to 26, the tongue dry, the pulse accel-
erated, and crepitation was detected in the lower part of the right lung. The sputa became streaked with blood on
the 5th and rusty on the 6th. On the 9th the patient wivs very weak and swallowed with difficulty; ho was scarcely
able to expectorate; he slept with his eyes half open and was unable to speak. He was stronger on the 11th and his
bowels were qniet, but the right side of the body was paralyzed. On the 12th he was much stronger and asked for
food; his countenance was bright, tongue nearly clean and bowels regulijr. He gradually rallied from this low
condition but the paralysis continued. Strychnia was given on December 1. On Jan. 1, 1862, he was able to walk
with a cane; sensation in the arm was much improved but motion was impossible. He was discharged for disability
on February IS.— Hosj)it,tl, Aleiandria, Va.
Med. Hist., Pt. Ill— 34
266 CLINICAL EKCORDS OP
Case 58. — Paralysis of rigid arm and left Uy, with utrojihij of the hitter. — Private James Williamson, Co. G, 109th
Pa.; age 18; was admitted April 24, 186.5, as a convalescent from typhoid lever. [He was taken sick Sept. 2, 1864,
at Camp Taylor, Arlington Heights, and treated in Augnr hospital, near Alexandria, Va., for two months. He
was unconscious for two weeks, during which lie lost the power of moving his right arm and left leg. He was
afterwards transferred successively to the Lincoln, Cuyler and Turner's Lane hospitals.] On admission his general
health was good and he had recovered the use of his arm, hut he could not flex the left foot; the left calf was
atrojihied to the extent of two inches and a half and there was some atrophy of the thigh. He was transferred May
10 to McClellan hospital, Philadelphia [whence he was removed to Mower hospital on July 20 and to Harrisburg
for muster out on September 15]. — Turner's Lane Hospital, Fhilaclelphia, Pa.
Case 59. — Parali/sis ayitmis. — Private Thomas Duulap, Co. K, 68th Pa.; age 23; was perfectly healthy before
enlistment, and, so far as could he ascertained, had no hereditary predisjiosition to disease. He was admitted Dec.
12, 1862, as a convalescent from typhoid fever, much debilitated and with a constant trembling of the whole
))ody. Under treatment by quinine and iron, beef-essence, milk-imnch, oysters and eggs he increased in strength,
but the paralysis agitans continued undimiuisheil. He was discharged Feb. 11, 1863, on account of paralysis agitaus
and general debility supervening on typhoid fever. — Sutterlee Hospital, Philadelphia, Pa.
Ca.se 60. — Seejuent cerebro-.yjinal fcrer. — Private Arthur Potter, Co. M, 1st N. J. Cav.; age 19; was admitted
Aug. 20, 1864, with severe uncomplicated typhoid fever, from which he convalesced rapidly. By September 23 he
was walking about the ward; but on October 15 he was seized with headache, fever and constip.ation. Castor oil
and turpentine were given and the urine withdrawn by catheter. Ho became semi-comatose on the 17th and died
comatose next day. — Satterlee Hos^iital, Philadelphia, Pa.
Case 61. — Inflammation of spinal cord iHth parapleyia. — Private William J. Pool, Co. A, 126th N. Y.; age 23;
admitted Dec. 12, 1862, as a convalescent from typhoid fever. He was much emaciated, pale, greatly prostrated,
hut without apparent organic lesion; he had little appetite and slept badly, but under the use of quinine and com-
pound tincture of cinchona, with generous diet and porter, his general health and strength after a little while began
to improve. In about two weeks he expressed himself as feeling much better, but complained of great weakness of
the legs, which gave way irnder him when he attempted to stand. Regarding this as a local expression of general
debility, extract of nux vomica was given in quarter-grain doses three times daily; but this medicine was soon
discovered to be injurious and its use was suspended. It was found that even when in bed the patient had very
little power over his lower extremities, for when raised by the hand of an assistant they would fall by their own
weight when the support of the hand was removed. The sensibility of the skin, as tested by pressure and pinching,
was found to be remarkably deficient, but pressure in the lumbar region of the spine revealed great tenderness.
These symptoms, with the experience furnished by the u.se of the nux vomica, were believed to indicate an inflam-
matory condition of the cord or its membranes, and the case was treated in accordance with this diagnosis. Blood
to the amount of six ounces or more was immediately removed bv cupping the loins; free catharsis was induced by
compound powder of jalap, which was continued in doses of twenty grains night and morning for two or three
days; dry cupping was used; the patient was restricted to a vegetable diet, and tonics and stimulants were with-
drawn from the system of treatment. In a short time improvement was manifested by increased power in the
lower limbs and by the return of the sensibility of the surface. On Feb. 11, 1863, he was able to-raise both his legs
in bed; in a fortnight or more he endeavored to use his legs out of bed, and with assistance was able to rest a little
upon them but could not exercise any directing or controlling power. Week by week improvement was noted by
the manifestation of some power regained, but the pressure of the feet upon the iloor continued weak and uncer-
tain for a time. On March 22 the patient was allowed a pass to go to the city partly on foot and partly on the
passenger railway car. On April 25 he was transferred to the military hospital nearest his home in the State of New
York. At this time he was able to make very good use of his legs and was strong and healthy in his general con-
dition.— Satterlee Hospital, Philadelphia, Pa.
A spasmodic asthma appeared as a sequel in the foHowing case:
Case 62. — Private James Barnes, Co. G, 71st Pa.; age 17; a convalescent from typhoid fever; was admitted
Dec. 8, 1864, with deafness and spasms of the diaphragm. He was much debilitated and an*mic. The diaphrag-
matic spasm, which occurred at first nearly every night, produced constriction of the chest and seriously interfered
with the lireathing: there was also some spinal tenderness between the shoulders. He was given salines, tonics
and antispasmodics, and a blister was applied between the shoulders; but the spasms continued to recur until the
following powder was tried: Cream of tartar half an ounce, muriate of ammonia one drachm, citrate of iron and
quiuia twenty-four grains, aloes twelve grains, strychnia one grain, mixed well and divided into twelve powders;
one three times a day. This finally controlled the spasnu)dic action. He was returned to duty, still slightly deaf,
April 13, 1865.— Jc(. Ass't Surg. A. J. Dickcrhuff, U. S. A., Hospital Xo. 5, (Juincy,Ill.
Cases 63-65 are presented as instances of relapse in typhoid fever; in 65 the diagnosis
of typhoid does not appear to have been clearly established.
Case 63.— Private Edwin O. Johnson, Co. I, 8th Mass., was admitted June 17, 1863. This patient had suffered
from typhoid fever at Port Royal, but had so far recovered as to Ije aide to be removed by steamer. On admission
he was ana-mic and had diarrhcea. Two days afterward he had fever and typhoid symptoms were gradually devel-
oped; the tongue became dry, the mind dull, an eruption, disappearing under pressure, was found on the abdomen,
there was some epistaxis and the pulse became frecinent and feeble. Involuntary stools followed, but there was no
hemorrhage from the bowels until the 24th, on which day the patient died. — Ladies' Home Hospital, N. Y. City.
THE CONTINUED FEVERS. 267
Case 64.— Private Joliu Thayer, Co. I, 9th Xlieh. Cav., was admitted July 16, 1863, with typhoid fever. An
expectorant, a tonic laxative, a diaphoretic and a mouth-wash of chlorate of potash were prescribed. The patient
was delirious on the ni;;ht of the 21st and passed live copious watery yellow stools. Next day his pulse was 112 and
tongue covered with sordes; the delirium was lessened; three stot)ls were passed; there was some cough and mucous
rales were heard over the lungs. The delirium recurred on the following night; the stools were passed involun-
tarily: pulse 100 and very feeble; skin cool. He rested well on the 2:!d and was free from delirium next day, but
the diarrhoea continued until the 27th, the tongue meanwhile cleaning and the lung symptoms abating. After this
his progress was satisfactory until about August 17, when a violent diarrhoea set in. On the 20tli tlie tongue was dry
and yellowish-white iu color, the pulse had risen from SI to 110, the bowels were tender and had been moved twelve
times iu the previous twenty-four hours, the stools being large, watery and sanguinolent. Stimulants and astrin-
gents were employed, but death took place on September 5. — TftsI End Hosj)itaI. Cinciiiniili, Ohio.
Case 65. — Private Peter Dickerlioft", Co. E, ll^th Ohio; age 20: was admitted with tyjthoid fever Nov. 10,
1862. On the 3d he had been exposed to cold night-air after being overheated by marching at double-iiuick time.
A rigor followed and diarrhoea set in causing four to six stools daily. Quinine was given. On admission his face
was livid and anxious, eyes dull, skin dry and hot but without eruption, tongue somewhat furred, thirst urgent,
appetite detieient, stools watery, pulse 104 and compressible; he had severe frontal headache, pains over the whole
body and twitchings of the muscles. Neutral mixture was prescribed. On the 11th the stools became less fretiuent
and more ftecal in character but very fetid. Next day the patient's eyes were brighter, pulse 94, soft and regular,
tongue moist but much furred, skin moiist, cool and without eruption; four fascal stools were passed. Stimulants
and chicken-broth were given. Little change occurred until the 21st, when there was an increase of the fever towards
night. On the 22d there was less fever and the tongue was moist and less furred, pulse 90 and compressible. Frontal
headache and live stools were reported on the 23d, and next day the headache was characterized as periodic. Quinine
was given on the 2.5th and 26th, but brown mixture was substituted on the following day, as there was some
cough with scanty ex)ie<toration. The patient continued to improve until December 6, wlien he relapsed somewhat
in consequence of a frightful railroad accident near the building. On the 8th he was (initi" drowsy and had sub-
sultus; pulse 90, weak and compressible: skin hot and harsh: tongue furred. Sulphate of <iuiiiia in one-grain doses
was prescribed for use every two hours. On the 9tli he was less drowsy, the Ijowels were more reguhir and the sub-
sultus lessened. On the 14th there was difficulty in hearing, but after this he improved steadily and was sent to
general hospital at Camp Dennison Feb. 12, 1863. — West End Hospital, Cincinnati, Ohio.
Two cases, represented as second attacks ot" the specific fever, are also submitted :
Case 66.— Corp'l William H. Lake, Co. K, 126th N. Y., was admitted Dec. 12, 1862, on account of a sprained
ankle. A few days after a case of tyjihoid pneumonia was transferred to the ward; he complained, Jan. 13, 1863, of
some headache and nausea, and next day was in bed at the morning visit with vomiting, diarrho-a, coated tongue
and anxious countenance. Mercurials were given and a Dover's powder at night. On the 15th astringents were
ordered with iiuinine in two-grain doses four times daily. He passed a very restless night, and on the 16th the pulse
was 120, skin dry and hoi, tongue dry, face fluslicd and right iliac region tender. The ([uinine w.is continued with
tuqicntine and stimulants added. Kose-colored spots apjieared on the 20th, on which day there was also epistaxis,
Bieteorism but no diarrha-a: the pulse was still rapid, about 100, the tongue somewhat dry but moist on the edges,
the mind clear. [The i>alient stated, and his father subsequently corroborated the stateuumt, that he had at a
previotis period suffered from typhoid fever with a relapse and a prolonged convalescence.] On beef-tea, chicken
and oyster-soup, milk-punch, etc., with quinine, he progressed favorably, and was able to walk on February 12. He
was furloughed on the 19th. — Satterlee Hospital, Philadelphia, Pa.
Case 67.— Private David Lacy, Co. K, 136th Pa.; age 31; was admitted Dec. 16, 1862. He had suffered from
pain in the breast, cough and ha'tnojitysis, weakness and diarrlnea since October 3. He stated also that two years
before he had been affected with what was called typhoid fever by his physician. This attack, which had lasted
several weeks, was characterized by delirium and diarrho'a, with tympanites, pain iu the bowels and an eruption on
the abdomen, great weakness, emaciation and juolougcd convalescence. On December 22, a few days after his
admission, he had a chill which was followed next day by fever, diarrhoea, debility, headache and liebetul)e, and on
the 24th by epistaxis and great thirst but no nausea. On the 27th he had another aguish paroxysm, and three grains
of quinine were given three times daily. On the 30th he was reported as having been somewhat delirious during the
preceding night, walking undressed in the ward, trying to urinate into the stove, insisting that the doctor had sent
for him, etc. On the 31st his tongue was cleaner, his pulse nearly natural; there had been no delirium during the
previous night but six li(iuid stools had been voided. The same general condition was found on Jan. 1, 1863, but
the expression was dull and next day the tongue was rather dry. On the 3d the eyes were injected, the skin harsh^
the bowels nearly natural, jiulse 84. The patient coughed much during the previous night and brought up mucus
dotted with blood: percussion gave a dull sound and respiration was feel)ly heard over the lower third of the left
Inng, but there was no crepitus nor bronchial respiration. The quinine was suspended. Next day numerous rose-
colored spots appeared on the skin of the abdomen and chest; the skin of the face had a varnished look: tlie mind
was clear, the hearing slightly obtuse and there was slight headache. Sndaniina appeared on the 5th in the iliac
region and on the neck: the abdomen was moderately distended; one stool was passed; the matter expectorated
was thick and rusty. The hearing was improved on the 6th and the tongue more moist. The progress of the case
was steadily towards convalescence; dulness of hearing was, however, very noticeable until the 14th. The patient
was able to leave his bed on the 23d, after which he gained rapidly in flesh and strength. — Satterlee Hospital, Fhila-
delpkia, Pa.
268 CLINICAL RECORDS OF
m— TYPHUS FEVER.
Altliough 2,501 cases of typhus fever, 850 of which were fatal, were reported among
the white troops, and 123 cases with 108 deaths among the colored troops, the case-books
contain particulars of only six cases that were recorded under this heading, while the med-
ical descriptive lists of but ten cases have been placed on file. Oases 1-6 from the case-books
are submitted in full; cases 7-13 are abstracted from the descriptive lists": Three cases
treated in September and October, 1863, at the St. James Hospital, New Orleans, La., are
not presented, as the official papers, signed by J. V. 0. Smith, Act. Ass't Surg., U. S. A.,
give no information except as to names, dates and results, — death in one instance, recovery
in a second and transfer to another ward on account of an attack of erysipelas in the third.
Case 1. — ^Private Ira Martin, Co. I, Ist Mich. Sharpshooters; age 23; on his recovery from a gunshot injury of
the arm was placed on light duty in the kitchen , and while thus employed was seized, Jan. 7, 1865, with a severe chill
followed by high fever; his tongue was coated, mouth clammy, bowels constipated, and he had severe headache and
pain in the back and limbs. Blue-pill and fjuinia were given. The fever abated but recurred at noon next day with
increased violence. On the 10th the fever had become continuous; the eyes and skin were injected, and the latter
presented spots on the chest and abdomen which were neither true petechi.e nor the characteristic rose-colored spots
of typhoid fever. Next day the pulse was frequent, small and irregular, the tongue coated brown and the patient
delirious. Quinine and stimulants were prescribed; but on the 12th the stools became involuntary and the surface
livid. Death occurred on the 13th. [Acting Assistant Surgeon Wm. H. (tU.\fton, V. S. Armi/, the attending physician,
at first regarded this as a case of typhoid fever, but the injection of the surface and the subsequent collapse led him
to change the diagnosis to typhus, the more so that the patient had access to a ward in which was a well-marked
case of this fever.] — Hospital, Annapolis, ild.
Case 2. — Private William E. Tullis, Co. C, 13-tth Ohio; age 19; was admitted May 17, 1864, with measles.
He recovered and was returned to duty June 25th, but being seized with acute diarrhoea and high fever was
re-admitted on the 28th: pulse 110; face flushed; eyes suffused ; mind confused and anxious. Astringents were pre-
scribed. Next day he was restless, anxious, feverish and had several discharges from the bowels. On the 30th the
pnlse was 116, tongue red and smooth, face flushed and spotted, mind anxious, stools frequent and watery. Turpen-
tine emulsion was prescribed. On July 2d the patient lost twelve ounces of blood by epistaxis ; he was much
exhausted; the delirium and diarrhcea continued. The nostrils were plugged anteriorly with lint saturated with
persulphate of iron and tincture of iron was prescribed for internal use. On the 4th brandy was given every three
hours. The diarrhtea ceased on the 7th; the tongue became moist and the mucous and salivary secretions increased
in quantity and were of healthy appearance, but the delirium continued and the exhaustion was very great. On the
9th there were involuntary discharges from the bowels and bladder. Death occurred next day. — Cumberland Hos-
pital, M(l.
Case 3. — Private Isaac H. Starr, Co. F, 119th 111.; age 23; was admitted Oct. 25, 1862, having been sick for
about four weeks with fever. Diagnosis — typhus fever. On admission the tongue was dry and red, dark in the
centre, pulse 92, skin dry and hot, bowels not painful but moved three or four times in twenty-four hours; he
had much thirst and some cough. Turpentine emulsion and syrup of ipecacuanha were prescribed. He was rest-
less and somewhat delirious during the night but perspired slightly towards the morning of the 26th; duriug
the day he had occasional but slight epistaxis. Small doses of opium and quinine were added to the treatment.
The skin continued nu)ist, the stools became less frequent, and on the 30th the tongue lost its dryness and began to
clean, but the patient talked incoherently and was seized with a general tremor on moving. On November 1 he
seemed somewhat better; the tongue was moist, pulse 78, but the tremors of the hands continued. The dose of
turpentine was iitcreased and whiskey was added to it. There was a slight improvement up to the 6th, when the
mind again wandered and the tongue became dry, red and cracked transversely in the centre; the bowels were
neither loose nor tender, but the recti muscles were somewhat tense. Next day there was tremulousness of the
muscles of the face with subsultus; the patient was drowsy and his mind feeble; the bowels became loose on the
afternoon of this day but were controlled by tannin and morphia. On the 8th the intelligence returned. The tongue
and skin were moist on the 9th, but the former became somewhat dry next day, and in the afternoon while per-
spiring profusely a copious bloody dejection was passed from the bowels. Similar bloody stools recurred on the 11th,
after which the pulse became feeble and the general appearance of the patient unfavorable. Opium, tannin, qui-
nine and capsicum were given with whiskey, beef-soup and egg mixture; but the stools continued bloody or wine-
colored, though less frequent; the jiulse was very feeble and the features shrunken. Opiate enemata were also used.
On the 14th there was nausea and a quantity of green liquid was vomited. Death occurred on the 15t.h. — Hospital,
Quincy, III.
Case 4. — Private Isaac Howell, Co. D, 119th HI.; age 20; was admitted Nov. 1, 1862, having been sick for
eight days. Diagnosis — typhus fever. He had pain in the back and breast ; his tongue was red and rather dry,
pulse 88, skin warm and bowels open. Small doses of qiiinine and Dover's powder were prescribed. On the 2d
the patient was incoherent and somewhat deaf; the stools, thin and dark -colored, were not accompanied with pain.
Tnrpentine emulsion, sweet spirit of nitre and paregoric were ijrescribed in addition to the tji^uiniue and Dover's
THE CONTINUED FEVERS. 269
jiowder. On the 4th he was very wild (luring the night and attempted to leave nis lied. Wine was added to the
treatment. The patient slept occasionally but his sleep was interrupted by starlings; the mouth and lips became
covered with sordes, the timgue foul and the body emaciated. The skin was moist on the 7th, but delirium of a
violent character continued; his inspirations were deep and inclined to bo stertorous. On the 8th he was exceed-
ingly wild and incoherent; the pulse 90, tongue more moist but covered with sordes, skin bathed in a copious
<weat, bowels quiet. Quinine, chlorate of potjish and capsicum were prescribed with stimulants and beef-soup.
In the evening he had involuntary stools and red spots appeared on his body and face; he was much prostrated
and his features very haggard. On the 9th he seemed more natural and could jirotrude his tongue with less ditli-
iiilty. He perspired copiously on the 11th. and recognized his mother who had come to see him; his bowels were
ipiiet. On the 12tli and i;^th there was delirium with no favorable change in the general appearance; the tongue
was moist but red, raw and rough. lie died on the 14th. — Ilonpital, (Jiiincy, III.
Case 5. — Private Sanford V. I'ruitt, Co. F, 25th Ind.; age 30; was admitted Feb. 2, 18G5, with chronic
rheumatism. April 28: Pulse 101 and full; tongue red and moist; pain in back: eruption over body; thirst; auore.\ia;
>lighl headache. Diagnosis — ty]>hns fever. Gave neutral mixture, milk and beef-tea. 2ittl): Pulse 115 and full;
~kin hot and dry; tongue red and dry in centre; thirst; one stool, (iave two grains of quinine every two hours,
soth: Pulse 116, feeble and irregular; tongue moist and red; no stool. Omitted quinine. May 1: Pulse 114 and
feeble; tongue a little coated ; no stool. 2d: Pulse 110; tongue natural ; tinnitus aurium; no stool. 3d: Pulse 112;
tongue moist; skin natural; urine natural; no stool. 4th: Pulse 104 and regular; tongue dry; skin natural. Gave
oil of turpentine in emulsion. 5th: Pulse 100; tongue dry and furred; skin hot; no stool. 6th: Pulse 85 and reg-
ular: tongue moist: one stool. 7th: Pulse 78 and rather feeble; tongue moist at edges, a little furred; no stool;
free pnenmouitic expectoration. 8th: Pulse 86; tongue moist; no stool; listless and dull. 9th: Pulse 70; tongue
clean; skin moist; one stool; convalescing. lOtli: Transferred to Mower hospital, Phil;ul('lplii;i. — f'uijhr Hospital,
Philadelphia, Pa.
Case 6. — Elijah Watts, contract nurse. April 29. 1865: Tongue coated b>it moist; pulse 102; skin dry and
warm; eruption over body; three stools: thirst; restlessness; nervous tremors. Ordered neutral mixture and brandy
every two hours and a tablespoonful every three hours of a mixture of a half drachm of quinine in one ounce
each of syrup of rhubarb and water; arrow-root and milk diet. 30th: Delirium; pulse 125, feeble and irregular;
tongue dry; skin hot; one stool. May 1: Pulse as before; tongue moist; skin warm: profuse epistaxis; tinnitus
aurium. Discontinued brandy; gave a teaspoonful every two hours of one drachm of oil of turpentine in two
ounces of mucilage. 2d: Pulse 115; tongue dry and clean; skin natural. 3d: Pulse 105; tongue moist; skin nat-
ural: delirium. Gave occasionally a teaspoonful of a mixture containing one drachm of chloroform in one ounce
and a half of alcohol. 4th: Pulse 100; tongue parched; urine drawn off by catheter. 5th: Pulse 100; tongue and
mouth very dry: inability to speak or protrude tongue; dull, somewhat comatose; eyes and mouth open, fitli:
I'ulse 98; tongue and mouth dry . 7tli : PulseSO: tongue and mouth moist; could protrude tongue and speak ; rested
better. 8th: Pulse 79; tongue cleaning: skin moist; breath and passages very fetid. 9th: Pulse 90; tongue cleaning;
skin natural. The patient recovered. Contract annulled May 23. — Ciiyler noxpital, Philadvlphia, Pit.
Case 7. — Private Rudolphus (irant, Co. B, 10th N. Y.; age 23; was admitted May 27, 1863, presenting all the
diagnostic characters of typhus fever inclusive of the eruption. Treatment consisted of twenty drops of diluted
suliihuric acid every two hours, with alcoholic stimulants and nourishment. On .June 30 lie was quite well except-
ing that he complained of headache and debility. He stated that he had been insane and an inmate of the Utica
asylum for six months three years ago. He was delirious during the course of the fever and during convalescence,
but he did not show evidence of insanity. He was returned to duty July 23. — Act. Ass't Surg. Austin Flint, U. S. A.,
Lexington Avenue Hospital, X. Y.
Ca.se 8. — Private John McManus, Co. C, 25th N. Y.; age 29 ; wae wounded in the right arm at the battle of Fred-
ericksburg, and had the forefinger of the left hand carried away by a shot. He was treated in Bellevue hospital,
which he left well as regards his wounds March 28, 1863; but although without definite ailments, his general
health was not good. On April 1, while at his home in this city, be was obliged to take to bed, having at this time
chills followed by febrile movement. He soon became delirious, and in this condition was received into this hospital
on the 22d. He talked incoherently and made frequent attempts to get out of bed; the pulse was 120 per minute
and feeble: there was no diarrluva and the abdomen was not tympanitic nor tender on pressure; the body and
extremities were thickly covered with an eruption presenting the distinctive characters of the typhus eruption, dusky
in color, not elevated and the redness not disaj)pearing on ])ressure. Whiskey, half an ounce hourly, with essence
of lieef and milk, were prescribed. His condition remained unchanged on the 23d and the treatment was continued.
Next day there was less delirium; pulse 100; skin moist. The whiskey was diminished to half an ounce every two
hoars. The improvement continued on the 25th; the pul.se had fallen to 85 and the eruption had faded considerably.
The whiskey was reduced to half an ounce every three hours. On the 27th the febrile movement and delirium had
snKsided and the eruption was nearly gone. The patient desired food. Convalescence progressed without any
unfavorable symptoms, and on May 1 his case was reported as cured, but some diarrha?a delayed his return to duty
until June 29.— Jc/. Ass't Surg. Austin Flint, V. S. A., Ladies' Home Hospital, X Y. City.
Case 9.— Private Martin Walker, Co. C, 10th N. Y. Cav., was admitted Feb. U, 1864, with typhus fever. The
eruption appeared soon after admission. He was treated with diluted sulphuric acid and whiskey, and a diet of
beef-tea, eggs and milk. He was convalescent on the 26th and was reported for duty on March 1. — Act. Ass't Surg.
L. L. Tozier, V. S. A., Lexington Avenue Hospital, X Y. City.
Case 10.— Sergeant Ebenezer C. Talcott, 4th Me. Battery; age about 35; was admitted July 11, 1863, in a semi-
comatose condition ascribed doubtfully to typhus fever. A companion stated that the patient was delirious when
270 rymptomatoloctY of
put on board tlie boat at Sautly Hook, JId. The stupor gradually became more profound and death took |>lace on
the 16th. — Act. Ass't Surg. John H. Einton, U.S.A., Hospital, Lexington Areniie, N. F. CHij.
Case 11. — Private Abraham Koof, Co. M, 10th N. Y. Art.; age 23; was admitted June 10, 186S, with typhus
fever. The fever continued twenty days after his admission, and during this time there was much deafness and
delirium. The eruption was marked and disappeared under pressure. There was considerable tympanites and diar-
rhcpa l)ut no hemorrhage from the bowels. Epistaxis occurred several times during tlie early part of the attack He
suffered from bronchitis but not in a marked degree. On July 1 he was able to sit up and on tlic 9tli was arotind
the ward although suffering considerably from diarrhrea. Tonics, stimulants and opium with canijjhor were adniiii-
istered. On August 1.5 the diarrhcea continued and the patient was ana-mic; he was able, however, at this time to
walk in the yard. He was returned to duty November 29. — Ad. Ass't Surg. F. Everts, TJ. S. A., Central Park Hospital,
N. Y. Citij.
Case 12. — Recruit John Talbot, unassigued; age 20; was admitted Oct. 1, 1864, with typhus fever. He was
treated with alcoholic stimulants. On the 8th the patient became delirious; pulse 120; an eruption appeared on his
chest. Two days later pneumonia set in and death took place on the loth. — Hospital, Elmira, N. Y.
Case 13. — Private William A. Wood, Co. K, 21st Mich.; age 25; was admitted May 20, 1865, as a case of
typhus fever. On June 8 he had headache, pain in the back and pain with some soreness in the right hypochon-
drium; the tongue was slightly coated but quite red on the edges and tip: pulse 110. Soon after this delirium set
in, and on the 11th the patient was nearly pulseless, his jaw quite stiff, subsultus strongly marked and skin covered
with cold persi)iration. lirandy and Hoffmann's anodyne were given. Next day he recovered hi.s mind and seemed
stronger, but the improvement was temporary. He died on the Kith. — Act. Ass't Surg. C. A. Burnliam, TJ. S. A. , Hospital,
Fairfax Seminary, Va.
III._SYMPTOMATOLOGY OF THE CONTINUED FEVERS.
I.—COMMON CONTINUED FEVER.
Prom the abseia-e of clinical histories of cases of common continued fever it is impossi-
hle to speak from the records concerning the symptoms of the many cases which were
reported nnder this title during the first fourteen months of the war. The single case of
simple continued fever and the seven cases of continiied fever that have been presented are
insufficient to illustrate the disease.
It has already been shown that typhoid fever was recognized as the common continued
fever of the United States, and that the tendency of medical opinion at tlie outbreak of the
war was to regard all cases of continued fever which were not distinctly specific in tlieir
character as due to the poison of typhoid.* But the indefinite term common continued,
which at one time included typhoid among other possible fevers, remained on the army sick
reports, after the differentiation of typhoid, as a standing suggestion of the existence of
♦This opinion seems to have become more extenslTely diffused since that time both in this country and iu Britain : Maclacan gives expression
to this view, Edinbnrg Med. and Surg. Jmir.^ April, 1S71, where he Sii.ys, p. 875 : " Indeed, I tliinli it may bo stated generally that a febrile attack which
is too long to be febricula, which is not ague and which is not duo to local disease, must be enteric.'* Nevertheless Murchison, although regarding as
typhoid fever most of the cases called by British practitioners simple continued fever, describes the clinical histories of four non-specific varieties : TIm-
fii-st, ejihemeral /eier, is similar to a single paroxysm of ague. Chills or rigors are followed by a quick full jiulse, flushed face, dry hot skin, whittt furred
tongue, thirst, anorexia, constipation, scanty high-colored urine, severe headache, restlessness and sleeplessness or sometimes drowsiness and i)ains in
the limbs. The symptoms subside suddenly, often with perspirations, in twelve, twenty-four or thirty-six hours. In the second, corresponding to tin-
synochal grade of the inflammatory fevers of the old writers, the febrile action continues from four to ton days; the pulse is full, rapid and oftm hiird
or bounding; tho headache acute and throbbing; sometimes there is delirium. Defervescence is attended with perspirations, eiiistiixis, vomiting or
diarrhcea, and is so frequently associateil with herpes on the lips or nose that the discjvse has bscn called herpetic /crer. The ardent mutinufd fevn- of the
tropics constitutes his third variety, which is regarded as an exaggerated form of the synocha of Britain. As seen among the European troops at ('al-
cutta in 1S53 and in Burmah in 1854, the disease mostly affected young plethoric recruits recently arrived from Europe, and prevailed in the hot, dry
months, when the temperature was never below SAP Fahr. The symptoms, which in many cases commenced immediately jifter incautious exposure U>
the direct rays of the sun, were chilliness; nausea or vomiting ; accelerated, full and firm pulse; dry burning skin; flushed face; giddiness; intense
headache; ringing in the ears; intolerance of light ; muscpc volitantes : restlessness and sleeplessness ; yellow furred tongue ; parched lips; thiifit ; c<tii-
stipation; scanty high-colored urine. Acute delirium occurred about tho fourth or fifth day, followed by utu-onsciousuess, contraction of tlie i)U|)!le
and sometimes complete coma, which ended in death between the sixth and ninth days if convalescence was not meanwhile established by a copious
perspiration. He cites Moreheap and Martin in support of his assertion that tho subsidence of the fever was occasionally followed by sudden or even
fatal collapse. The fourth variety is introduced rather as a suggestion than as a clinically defined entity. It is called aHhenic ttimjtle fevn\ and is stitl tu
be characterized by loss of appetite and strength ; pulse rather feeble, ranging from 90 to 120 ; slightly furred tongue ; confined bowels ; headache ami
disturbed sleep. Tlie symptoms continue for two or three weeks without any great change except increasing prostration. It is evident that the diffi-
culty of discriminating between this variety and mild typhoid attacks would be very great, in fact, clinically the discrimination is impossible. The
distinction could only he effected by the aid of etiological considerations. — A Tredti^se on t}ie Continued Fevers of Great BrUain^ London, 1873, p. G79 e(sej.
THK CONTINUED FKVRRS. St I
otlier non-svmptoraatic febrile conditions. It seems probable, however, that the coininoii
continued fever of the monthly reports consisted in great part of anomalous cases of typhoid.
When the characteristic symptoms of typhoid were present in a given case its entry under
the specific heading was assured; but when these were absent, obscured or modified, the
term common continued fever afforded a convenient escape from a positive and specific
diacrnosis. When a febrile case did not run the [>rolonged course of typhoid; when it was
unmarked by rose-colored spots and free from relaxation of the bowels or tenderness in the
riijht iliac region; especially when in addition the cerebral symptoms did not appear to
justifv the appellation of typhoid, the indefinite terra accommodated it with an appropriate
po.'^ition on the official record.
. It is equally probable that there were reported under this lieadiiig many fel)rile cases
of short duration which were treated in quarters or in the regimental hospitals. Such cases
corresponded with the simple continued, ephemeral or irritative^ fevers of medical writers,
presenting languor, lassitude, muscular weakness, headache, inability to collect the thoughts,
wakefulness or dreamful sleep, perhaps even slight nocturnal delirium, constipation or diar-
rlnea, white-coated tongue, hot skin and feeble and rapid pulse. This condition lasted
one or more davs, was followed by perspirations or a gradual subsidence, and was seldom
characterized by the tedious convalescence of the typhoid attack.
If it be allowed that cases of this character occurred among the troops, some of them
must have assumed an adynamic form and represented with more or less fidelity the general
outlines of the clinical picture of typhoid fever; for the infiuences to which the adynamic
condition is usually attributed were in strong force in our camps and garrisons during
the war. As distinguishing between such cases and typhoid fever there would have been
the absence of rose-colored spots, a want of connection between the diarrho^al attack and
the febrile condition, perhaps also the character of the alvine evacuations and the location
of the intestinal tenderness, with the short duration of the primary fever in cases that had
been closely watched from the commencement. These would have been correctly reported
during the early months of the war as cases of common continued fever, although from the
concurrent prevalence of undoubted typhoid they were liable to be regarded as expressions
*T7nder the title Irritative Ferer, Dr. George B. Wood includes all cases of idiopathic fever resulting from non-specific cawses of irritation. An over
excitement of one or more of the functions is induced, and this being proi)agated to different parts of the sj-stem may throw all the functions into a state
of derungenicnt capable of sustaining itself after the direct cause has ceased to operate. There must be a pre-existing disposition in (ho system to the fehrilo
movement that it maybe thus independently sustained. There is occasionally slight inflammation associated with the fever, most frequently in tlu^ fauces
or in some portion of the alimentary or i)ulnionary mucous membrane, but this i.s wholly insufficient to account for the symptoms and is often wanting
entirely; liioreover, a truly symptomatic fever subsides immediately with the subsidence of the iufl.ammation. He observes that when the febrile action
is prohmgt^d to the seventh or tenth day, it is apt to become somewhat remittout, relaxing in the morning and undergoing exacerbation in the afternoon
or evening. It is usually sthenic. " IJut occasionally the general actions of the system, though excited, have the taint of feebleness. \ low fever some-
what of the typhus character is developed, though infinitely less dangerous than the genuine typhns. The previously debilitated condition of the
patient, fl depraved state 4»f his blood from bad living, or exposure for some time to depressing influences, .18 of certain epidemics, exhalations from
privies, etc., may account for this adynamic chamcter." — .4 Treatise nn the PrarMce of Medicim', Philadelphia, 1847, Vol. I, p. 224. Under the tr-rni
Ctxf-paot /crer. Dr. .\lonzo Clark describes a febrile disease which hiw been traced in almost every instance to foul water or water made foni by the
admixture of human excrement or to neglected ])rivies. It is not always ushered in by a chill, but there is always a certain amount of fever aial a
diarrhoea lasting two, three or more weeks. Tbf; illustrative case which he records had no headache, epistaxis, tenderness or pain in the abdomen or
Iliac n^gion, tym)<inites, sordes, nor rose.col(U-ed spots ; delirium was nmderate, the patient trying to get out of lied, saying he wanted to go home ; the
puLse became small and feeble, and the diarrluea continuing, death took place from exhaustion about the end of the third week. Cases of this kind
occur, according to the experience of Dr. Ci..\rk, in every region of the country; and he holds that, so far as we can judge from the symptoms, they
•re not cases of the typhoid affection.— See .lf«(. ReconI, Vol. XIII, New York, 1878, p. 303. Dr. I. A. Watsox of Sew Hampshire, in the «cj»r( oj
tkf Statr Board of HeattJi, 1884, regards as cess-pool fever certain cases which originated in a poisoned well at Little Boar's Head. They seemed to bo
instances of blood poisoning, in their last stage resembling typhoid fever. .\ wealthy Philadelphian who had spent many summers at Little Boar's Head
built a handsome residence there on an elevation about fifty feet above the sea-level and b\it a short distance from the water. The elevation consisted of
wamy ledges with only a few feet of soil covering them. Instead of building a sewer to the ocean lie constructed a cess-pool forty feet from the bouse.
Sixty feet from this cess-pool, aud apparently nn the same level, w.as dug the wa-11 which was to supply the residence with water, but before a free supply
of water was obtained it was necessary to dig ten feet into the ledge. The well and cess-pool were both constructed at the same time, and two woeka
thervafter the well-water became pol1utc>d; but the family not recognizing the source and nature of the pollution continued to use the water until it
became so tainted as to be repulsive. The owner and a lady visitor died from the febrile attack ; the owner's daughter, a servant and a guest of tho
family recovered after a severe illness.
272 SYMPTOMATOLOGY OF
of the presence of the poison of that disease modified by peculiarities of individual consti-
tution and local hj^gienic conditions. Daring the latter part of the war it may be assumed
that they were reported among other miasmatic diseases by those who regarded them as duo
to an unknown miasm, or that they were added to the typhoid or typho-malarial list, accord-
ing to the views entertained by the reporting officers of the absence or j^resence of a malarial
factor in cases essentially enteric. The following extracts from sanitary reports have a
bearing on this subject:
Surgeon Thomas C. Bakeh, 7th Mc, Camp Li/oii, Baltimore, Md., Oct. 1, 1861. — From the time the regiment
was mustered into service at Augusta till the close of the quarter ending September 30 only one death occurred.
Tliis was a case of typhoid fever. Among other diseases of this class, in the class of fevers, are eight cases, all of fever
or feverishness, some of which approached common continued fever in their general characteristics.
Surgeon W. W. Brown, 7th X. H., St. Augustine, Via., March 31, 1863. — 1 neglected to mention a variety of
fever which seems rather peculiar to this jilace, and which made its appearance in our regiment in December last
and continued to affect us somewhat during January and February, but entirely disappeared about the first of the
present month. It usually commenced with the general symptoms of fever, and in most cases assumed the common
continued type. It had no appearance of having had a miasmatic origin, but seemed to have been occasioned by the
frequent and sudden variations of temperature which we experienced during those months, and to which all places
on the Atlantic coast are subject, although the range of the thermometer may be small. About four-fifths of the
cases were mild and required little treatment other than low diet and rest after having the prima* vi;e thoroughly
evacuated. The remaining fifth tended to a typhoid condition, with diarrhi^a, and some of them assumed a very
grave character, although all recovered with one exception. The typhoid cases were treated on general principles,
but early required stimulants and nourishing diet, with occasional opiates to allay nervous irritation. There was
more or less pulmonary inflammation in the severe cases, and the diarrh(Ea was very intractable. Stimulants were
well borne, but quinine was neither required nor well adapted except during convalescence. We had in all over
one hundred cases; in the fatal case involuntary evacuations with low delirium and subsultus of the tendons came
on early, and our most active exertions proved unavailing.
Surgeon J. T. Calhoun, lith N. T., near Alexandria, Va.,Juuc 30, 1862. — But the stench from the battle-field
[Fair Oaks] was most disgusting; and in such an atmosphere, in the month of June, were our men living. Every
third day they were on iiicket, and in the interval they were frequentlj' employed in the trenches. Skirmishing was
of daily occurrence, and night alarms frequent and harassing; I seldom passed a day without having a wound to
dress. The men were ill fed, overworked, exposed to frequent alarms and living in an atmosphere largely composed
of poisonous gases exhaled from the imperfectly buried dead. A peculiar form of fever presented itself, character-
ized by an extremely weak pulse, great prostration, suftused eyes, vertigo and anorexia. Its duration was generally
from four to five days. The treatment was usually a mercurial cathartic followed by ten-grain doses of quinine three
times a day.*
Surgeon M. R. Gage, 25th Wis., Camp Randall, Wis., Dec. 31, 1862. — We have met with cases of continued fever
which might properly be termed passive in character in contradistinctiiin to those of a more absolute and active
grade. These, although manifesting but little activity, it being in fact scarcely possible to determine the exist-
ence of fever in many of the cases, are liable to indefinite protraction. The treatment most eflicacious in this class
of cases consists of a calomel cathartic and then a judicious alterative, diaphoretic and refrigerant course. Recovery
generally ensues as soon as the specific etfect of the mercurial is produced. A full dose of calomel in the incipiency
of the oases goes far towards interrupting and controlling the period of their continuance; the hepatic derangement
is overcome, the pulse reduced, and the skin having resumed its natural function, a march is stolen upon the disease
and convalescence is quickly induced. A stimvilating plan has not been required; that generally pursued has been
mildly antiphlogistic. During convalescence tonics and a more generous diet are allowed; in nuiny instances at this
jieriod remedial agents are entirely withdrawn and the patient left to the recuperative forces of his purified aiul
regenerated organism, together with the invigorating influences of a generous but carefully selected diet.
jls.'i't Surg. Henry S. Schei.l, U. S. A., Miner's Hill, T'a., S(pt. 4, 1862. — Cases of fever were of constant occur-
rence during the quarter, and under whiitever name registered, they were all of the same general asthenic character.
So far as I can determine, few if any of those which assumed a decided iieriodic form originateil prinuirily in this
locality. Miasmatic affections seemed in most instances to be the result of the seeds of disease which had remaiued
in the system from last year and were now quickened into activity by exposure to the vicissitudes of a campaign. The
prevailing form of febrile disease I regarded as an ordinary irritative fever of an adynamic type, and many of the
cases marked as remittent fever in the statistical report were of this kind: they assumed a sort of periodii^ity
which was not well defined, but which rendered it difficult to decide upon their true nature. Every case which I
have registered as common continued fever was of the same character as those which other surgeons in the division
reported remittent fever, but which on several grounds I considered independent of malarial influences. 1st: The
affection usually followed exposure to sudden changes of weather, hard duty or rapid and exhausting marching — as
for instance, the expedition to Hanover Court House. In the light batteries the fever did not follow exposure on
picket duty in the swamps of the Chickahominy because the men, once upon the ground, stretched the tarpaulins
to make shelters for themselves and went as regularly and comfortably to bed as when in camp. With the infantry
* In the Mediwl and Siirykid Uciiorter, Phila., Pa., Vol. IX, J). 399, Dr. Caluoun refers to this ftn-cr, and considers the name typho-malarial an
appropriate one for it.
TlIK CONTINTKD FEVERS. 273
pickets it was different; they, perhaps at a distance of not one hnndrcd yards from tho hatterics, stood in water to
tlip knees during the h)ng watches of the ni^ht, and returned to camp after forty-eight hours utterly exliausted, and
in a few days, it may 1)G the next day, were burning with fever. 2d: Tho cases began with languor, debility or utter
prostration, and in all instances gradually; the tongue was coated with a white fur, the bowels mostly loose, but
sometimes there was alarming diarrluea whicli clung to the patient long after the fever had disa])peared and occa-
siiinally threatent'd to destroy him; there was considerable heat of surface, pulse about 100 or 110; in a few cases
derangement of the liver was present; there was invariably a tendency to debility, which rendered the use of stim-
ulants necessary from the beginning; towards the close of the disease the kidneys were often atlectcd, and the mind
was always implii'ated if the sickness became serious. M: Most of the cases were cured, if properly treated, in
fnuu four to ten days without the administration of <iuinine, which drug usually retarded recovery, when given
in antiperiodic doses, by producing a diarrlneal aggravation of the existing debility. Uh: The treatment which
1 fnund most eti'ective was to enjoin perfect rest and keep the bowels in .as natiiral a condition as possible. Dover's
powder was administered as a dia|)horetie when there was much muscular soreness; the citrate of potassa was some-
limes given. In all cases the patient was sustained with milk-punch, eggs, beef-essence, etc. Umler this plan ho
was usually able to return to duty in a week or two after being attacked.
In estimating the causes of this disease I should enumerate tho predisposing and the exciting. Among the
former wore tho constant heat, to which the men wen? unaccustomed; the debilitating action of fatigues and priva-
tions: exposure to the elllnvia of badly regulated sinks, half or totally unburied offal fnun slaughtcr-i)ens and excre-
ment ileposited in innuoper places, and the continued occupation of the same camping ground. The chief of the
exciting causes were extraordinary toil, privations and vicissitudes of weather.
Siiniion GKOHiiK W. C'l.li'l'lxcKU, llth Iiiii., Cheat Miiiiiildin, !'«., Dec. 31, 1861. — The sickness was of a peculiar
type, characterized by exhaustion of the nervous system with stagnation of the ca]iillary circulation. This was
attended by hlucness of the skin, which might be considered pathognomonic. The face w.as of .a dull leaden
color and the features bloated and swollen. The particular viseus receiving the largest propintion of the blood
thrown in from the surface of the body bocanui ;it once the seat of disease. This was a<(om]ianieil by fre(iuency of the
pulse, great lassitude, muscular and articular pains, anorexia, dry and husky skin, great thirst, red and parched
tongne and violent pain iu the head with more or less incohere7-.ce. These cases, known familiarly as "camp-
fever," were officially reported as "continued fever." Tho causes were nminestionably protracted and exhausting
labor, exposure to cold and incessant rains, insufficient clothing and sameness of food.
The treatment had in view tho removal of congesticui and restoration of the capillary circulation. When this
was accomplished convalescence was hastened by the administration of tonics. .Sulphate of nuignesia with ii)cc;ic-
uanlia was benelicial, particularly in the early stages. The fatal cases .assumed the gravest appearances of typhoid
fever: tenderness of the colon sii))ervened, with gurgling iu the ciecum and sigmoid lli^xure; intestinal hemorrhage
occurred in many cases and in all that were fatal.
Ain't Siirij. H. M. SfitAGt'K, U. S. A., Sept. 30, ISfil. — About September 1, after having been encamped for a
week in an exceedingly foul locality, there broke ont a severe epidemic w hich has given us our only fatal cases of
disease. When this epidemic ai)peared there was nothing formidable in its external features. The men looked sim|)ly
debilitated. Their history was that for several days, often two weeks, they had been suffering from diarrluea, yel-
lowish and watery, atteniled sometimes with griping and accompanied with debility, listlessness, drowsiness, pain in
the bones, white tiuigue, slight heat of skin morning or evening and some acceleration of pulse, ranging from itl to
106. The disease had the api)earance neither of typhoid nor of remittent fever. I'ont-iiwrtem examination of two
iHidies revealed some congestion of the howels, with moderate enlargement of the mesenteric glands; no ulceration
of Peyer's patches; no destruction of the mucous membrane; no inflammation of the rectum; the spleen was slightly
engorged : the other organs healthy.
II.-TYPHOID FEVER.
It has been a matter of some difficulty to the writer to present the symptoms of
typhoid fever as distinct from those of the so called typho-malarial fever. This has arisen
from the want of records to show what constituted the characteristics of the cases reported
under the latter heading.* But as Dr. Woodward in November, 1863, expressly stated
that the term typho-malarial was meant to include only those cases in which typhoid fever
had its symptoms more or less masked by the coexistence of manifestations of malarial
poisoning,t the detailed cases presented in the "Clinical Records of the Continued Fevers"
• Sw) |>ape '.it:;, Kupra,
fJ. J. WiwDWABD, An'l Surg., U. S. .1., On II hies of the Chief Camp Diteiuet of tlie Viiilal Slala Anrnj, Philn., 1863, p. 74: "Undor tho designation of
'•iMp Krr^n mny bo jnrhlilL-<l * * typlim; * * tjelloie ferer ; * • tifphoid ferer with nr \\it)wnt ticorhiitic cotnpViefitions ; malarial remWenl fever with
or without sforhntif roniiilir.ltious; auil a vast group of mixed cases, iu wliicli tin- malarial and typhoid elements are variously enmbiried with each ntjier
««l with the scorlnitic taint, and for which the autlior propased the name of typho-malarial fever." * * But, on p. 110, in discussing the nature of
tbe diceftMf, he gives utterance to the opinion that the so-called typhu-nuilarial fever was not a merely modified typhoid, but a comi)osite discoiM' or new
bjblid. ''On the one hand typho-malarial fever is not to be regarded as a new disease in tho ordinary acceptation of the term, that is, as an affection
chMlcteriled by some new imthognomonic element. Nor, on tho other hand, is it just to look upon it merely as a modified enteric fever, since the mala-
riKla&d scorbutic phenomena which accompany it are predominant in many cases — perhaps, on the whole, in the greater number. Much rathersliould
ltb« considered simply as a new hybrid of old and well-known pathological conditions, iu which the exact train of symptoms is as variable as the degree
<rf ppeponderance attained by each of the several concurring elements."
SlEi). Hist., Tt. Ill— 35
274 SYMPTOMATOLOGY OF
afforded the materials for determining the symptoms not only of the cases regarded as
typhoid by the attending physicians, but of those which Dr. Woodward would have classi-
fied as typho-malarial. In the chapter on malarial disease, in this volume, the character-
istics of malarial fevers have been illustrated. By studying these in connection with the
fully recorded typhoid cases treated in the Seminary hospital, the latter have been divided
into cases of pure and of modified typhoid.
The paroxysmal type of the malarial fevers stands prominently forth as a diagnostic
mark of the complicated disease, manifesting itself by recurring chills and febrile exacerba-
tions alternating with perspirations or a moist condition of the skin at a period of the clinical
history when, in pure typhoid fever, the febrile action is continued and the skin dry and
husky. But these signs of undoubted complication are liable to be lost in two directions.
On the one hand typhoid fever is marked by daily remissions, which may be detected, in
the absence of thermometric records, by notable changes in the pulse, general surface,
tongue, secretions, etc.; on the other hand, the remissions in remittent fever may be so
slight or transitory as to escape unnoted. Hence, although the absence of the paroxysmal
type does not exclude the possibility of the coexistence of malarial disease, its slightly
marked presence cannot be accepted as indicating malarial complications unless supported
by other and less indefinite evidence. It is impossible to determine in all cases that an
evening exacerbation is due to malarial influences, but when the paroxysmal feature is
strongly developed a remittent or intermittent fever may be regarded as associated with the
progress of the typhoid affection. The frequency of this coincidence, especially in men who
had previously suffered from acute malarial disease, leads to the supposition that the typhoid
onset itself or the exposures and unhygienic conditions which predisposed to it, acted as the
determining cause of a recurrence of the paroxysmal fever. Moreover, it is generally
accepted that in malarious subjects diseases which are not occasioned by malaria oftentimes
exhibit a tendency to periodicity. Nevertheless there are not wanting on the records cases
of apparently unmodified typhoid in which the previous history of the patients embraced a
series of -aguish attacks or other indications of malarial poisoning.
When the complicating element failed to manifest itself by paroxysms and perspira-
tions, which do not belong to the history of typhoid fever, its expression was found in hepatic
tenderness, gastric irritability, epigastric pain and other signs of interference with the
normal action of the liver and upper portion of the alimentary tract. In the absence of
these from the record a modification of certain of the symptoms of typhoid fever may some-
times be attributed to the malarious condition of the patient. If, for instance, the malarial
poison has not been productive of intestinal congestion, diarrhoea, which is one expres-
sion of the local lesion of typhoid, may not be prominent as a symptom, and this is
especially the case when the malarial influence is manifested by frequently recurring
perspirations; the character of the stools may also be altered. At the same time it is
to be remembered that diarrhoea is not present in all cases of distinctly pure typhoid fever;
its absence does not, therefore, constitute an indication of malarial complication except
when in conjunction with other testimony of a more or less suggestive character. On the
other hand, if the malarial influence has expended its force on the mucous lining of the
intestinal canal, there may be diarrhoea and tenderness with other strongly marked signs
of the abdominal lesion of typhoid fever; the tenderness, however, is general, or specially
noted in regions other than the right iliac, — frequently over the tract of the colon, — and
the stools are often of a dysenteric character. But here again there is a want of value for
THE CONTINUKD FEVERS. 275
diagnostic purposes inasniucli as typhoid fever engrafted on an antecedent diarrhoea or
dysentery may give rise to sucli symptoms.
The recorded condition of the tongue furnislies in many instances satisfactory evi-
dence of the presence of a mah^rial complication. In typhoid fever it had at first a slight
coating of a white or yellow color, but redness of the tip and edges was generally manifested
even at this period, and as the tongue dried and darkened on the dorsum the redness
became more noticeable. When a malarial element was present this condition of the tongue
lid not generally obtain ; it was pale, flabby and variously coated not only during the
progress of the febrile phenomena but during convalescence.
The pneumonitic tendencies of typhoid fever were seldom altered by the presence of
the malarial poison, although the latter had apparently a greater proclivity to the develop-
ment of sudden and dangerous pulmonary congestions. Nor were the cerebral symptoms
of typhoid materially changed by the presence of the complicating element except when
this was prominently and perniciously developed, masking the continued type by its irregular
paroxysms and changing the muttering delirium of the febrile condition into the coma of
malarial congestion.
Extravasations of blood under the skin, constituting petechise and vibices, were com-
mon to the continued operation of both poisons; but an early appearance of such spots in
typhoid cases, when combined with other testimony, is suggestive of malarial complication.
Deterioration of the blood, from scurvy or ochlesis, was also occasionally concerned in the
development of these spots.
Lastly, a rapid issue in fatal cases is indicative of malarial disease, since typhoid cases
usually ran a progressive course while the paroxysmal fevers were often fulminant.
By giving weight to these considerations the febrile cases treated at the Seminary
hospital have been arranged into two series, one of pure typhoid and the other assumed,
on more or less satisfactory evidence, to have been complicated by the malarial poison.
From these and other cases submitted above, as also from a series of fatal cases to be pre-
sented hereafter in connection with the j)ost-mortem appearances, the following general
description of the clinical progress of the typhoid fever of the war has been written.
Cases regarded and reported as typhoid fever began with feverishness, depression of
spirits, muscular debility and unusual relaxation of the bowels. Oftentimes the soldier
suffered in this way for several days, attributing his condition to some particular exposure
or indiscretion in diet, the effects of which he hoped would speedily subside. Ultimately
headache, pain in the back, aching in the bones and muscles, loss of appetite and increas-
ing weakness wholly incapacitated him for duty and led him to report as sick. As the
patients were mostly young and inexperienced soldiers, it frequently happened that they
did not realize their loss of health, but continued their usual occupations in an apathetic
manner until their appearance led to inquiries by more experienced comrades or company
oflBcers, when they were sent to the regimental surgeon. In nearly one-half of the cases
the disease was ushered in by a chill which was immediately followed by fever and perhaps
diarrhoea, but not by perspiration: Of fifty-one typhoid cases found in the records of the
Seminary hospital the onset was by chill in twenty, without chill in eleven, while in the
remaining twenty the manner of the attack was not recorded.* Of the twenty cases
•Of jdxty-three cases in which MfBcnisos noted the commencement, paius in the head and limbs, commonly aching but Eomctimes neuralgic, were
■aong the earliest symptoms in fifty-six, and most of these patients also suffered from irre^lar chills, languor and giddiness; rigors occurred in only
mree of the cases. But in several instances, not included in the analysis, he observed decided rigors and in fact all the phenomena of ague during the
*« few days.— Op. cit, p. M5.
276 SYMPTOMATOLOGY OF
that had an initiatory chill five were mild, eight severe and seven fatal ; of the eleven that
began with no marked sensations of chilliness three proved mild, six severe and two fatal.
These numbers are not large, but so far as they go they indicate that the course of the
disease is not affected by the mode of onset. It may be owing to an appreciation of this
fact that few writers advert to the prognostic value of chill as an initial symptom of typhoid
fever. Nevertheless Louis was inclined to regard a severe chill as suggestive of a severe
attack, for his observations showed a greater frequency of chills among the severe than
among the mild febrile cases.*
The course of the disease after tliis onset by defined chills or gradual accession differed
much in individual cases. In some, probably in a majority of those which, anterior to the
issue of the order removing common continued fever from the list of diseases on the
monthly sick reports, would have been reported under that heading, the febrile condition
did not at any time become more marked than during the first few days. The tongue was
somewhat furred or white-coated, with the edges and tip of a deeper red than natural and
with some tendency to dryness at the base and centre; the skin was dry, the face slightly
flushed and the eyes injected, especially in the evening; the urine was scanty and the
bowels relaxed or unusually susceptible to the action of laxative medicines; the pulse was
seldom rapid, full or tense, but was occasionally dicrotic; slight epistaxis occurred at times;
the cerebral inanifestations were restricted to headache, restlessness, drowsiness and inabil-
ity to concentrate the attention or follow up a train of thought; a bronchial cough often
accompanied these symptoms. In a few days the febrile action subsided, the improved
condition being first noticed after a sound and refreshing sleep, coincident with a cleaner
tongue, diminished thirst and recovered appetite; occasionally perspirations, epistaxis or
slight diarrhoea marked the defervescence. The patient, however, remained weak for a long
time after the attack.
But in a majority of the cases the disease was prolonged for two or more weeks, during
which time certain of the symptoms assumed a special gravity. The intestinal symptoms
in some became especially noteworthy, consisting of a more or less active diarrhoea, with
pain in the abdomen, tenderness on pressure, particularly in the right iliac region, gurgling
and some tympanitic distention. The diarrhoea often subsided at the end of the second
week, and this improvement was usually associated with an amelioration of the general
symptoms, free perspirations and the appearance of siulamina. But when defervescence
was effected gradually and without the occurrence of perspiration, relaxation of the bowels
was prone to continue, with diminishing tenderness, perhaps for eight or ten days longer,
during which recrudescence was not uncommon. The patient continued weak after the
subsidence of the active symptoms, and at any period of the prolonged convalescence he
was liable to dangerous recurrences of the diarrhoea from slight indiscretions in diet or
other faults in the sanitary regimen.
The cerebral symptoms in other cases constituted apparently the special characteristic
of the disease, for they were often present in the absence of diarrhoea and abdominal ten-
* Chills occurred in thirty-one of thirty-three fatal cases in which he was able to learn anything definite on this point ; of forty-five severe though
not fatal cases, all except three had chills or a greater sensibility to cold, while in thirty-one mild cases chills were reported in twenty-four only. —
{Recherches Anutomiques, Pat]uih>ijiijni>it ct Thtrajieutiques sttr la ntdladie comtite sons les iioiiis de Gastro-entirite, Fi'vre ptitride^ adijiiam'njiie^ lUaxiijHe^ tijplut'itte,
etc. Ch, a. Louis, Paris, 1820, t. II, p. 2o'J.) Nevertheless, if the fifty-eight cases recorded in the work just cited are examined in reference to this
point, it will be found that chills are not recorded as frefiuently as the above statements would lead us to anticipate. Forty-five of these cases are
regarded as undoubted typhoid, the observations 4G-58 being variously classified as doubtful, simulated, etc. In twenty-two nf the forty-five cases chills
are noted as having occurred at the beginning uf the attack, and in one on the fourth day of the fever ; in the remaining twenty-two cases either no
mention is made of the symptom or it is positively stated that it was not present.
THE CONTINUED FEVERS. 277
derness. The wakefulness and restlessness which aflfected the patient during the first week
of the disease increased at night, until sleep became disturbed by incoherent niutterings.
During the day he was drowsy, and when aroused was found to be dull and stupid, held at
attention for the moment but relapsing immediately into a semi-somnolent or mildly deli-
rious condition. In such cases the tongue became dry and dark-colored, retaining how-
ever the redness of its margins, and with diarrhcsa present the stools were often passed
without the consciousness of the sufTerer; the urine was also sometimes evacuated involun-
tarily, or retained, causing hypogastric distention and pain until removed by the catheter.
In most cases at this period sordes accumulated on the teeth and gums. But at the close
of the second week, coincident with a moist condition of the skin, epistaxis and sudamina,
the tongue became moist, the mind clear, the appetite improved, and refreshing sleep, enjoyed
for the first time since the occurrence of the attack, ushered in the period of convalescence.
Generally in cases which ran a two weeks' course to defervescence the rose-colored
eruption, viewed by most of our medical officers as characteristic of the disease, was dis-
covered on the chest and abdomen from the seventh to the fourteenth day. In several
instances the appearance of this eruption about the end of the second week was associated
with improvement, and was the only concomitant of defervescence entered on the record.
Death seldom occurred before the fourteenth day except as the result of accident con-
nected with the febrile condition, as in case 41 of the Seminary series, in which the patient
was killed by jumping from a window in his delirium, or by some intercurrent attack, as in
20 of the post-mortem records, in which pneumonia proved fatal on the thirteenth day.
When defervescence failed to take place about the fourteenth day the protracted
course of the disease was usually due to the occurrence of intestinal or pneumonic compli-
cations. Diarrhoea became aggravated and prolonged the duration of the case for several
weeks, or an exhausting attack was speedily followed by collapse and death. Intestinal
hemorrhage increased the prostration of the patient, adding gravity to otherwise mild
attacks and sometimes leading; directlv to a fatal issue. The suffering occasioned l>v
abdominal distention appeared in some ca,ses to be the cause of the failure to convalesce at
the end of the second weel<; indeed death at a later period was occasionally due to exhaus-
tion induced by a continuance of the abdominal distress. Peritonitis supervened in many
cases, the mesentery becoming affected by the condition of the glands or the peritoneal coat
of the intestines by the inflammatory processes in their interior tunics; but, more frequently,
m cases protracted by the unfavorable progress of the abdominal lesions, the occurrence of
exquisite pain, vomiting, hiccough, cold perspirations, collapse and death, indicated perfora-
tion ot the intestine and the escape of its conrcents into the peritoneal sac.
With or without the continuance of diarrhoea the course of the disease was often
prolonged by the development or aggravation of cough, pain in the chest, hurried breathing
and the physical signs of pneumonitic processes. Patients subject to bronchial cough
from the early days of the attack were specially liable to this complication; the mucous
expectoration became purulent and bloody, sometimes viscid and rust-colored. In favorable
cases the duration of the sickness was much lengthened by these attacks, and if no serious
mtestinal or cerebral symptoms were present, the lung disease assumed a prominence which
led in many instances to a diagnosis of pneumonia by medical officers who had not observed
the case from its commencement. In others in which an extensive and manifest implication
of the lung was coincident with low delirium and great prostration the disease, in the absence
of a knowledge of its previous history, was frequently reported as typhoid pneumonia.
278 SYMPTOMATOLOGY OF
Nevertheless, in most of the cases in which defervescence at the end of the second week
was prevented by intestinal or pneumonic complications, a close study of the details of the
daily record of progress reveals an effort on the part of nature to establish convalescence at
that period. The tongue became less dry, the skin moist, the pulse less frequent, delirium
subsided, or the patient was recorded as being more intelligent or less stupid or drowsy or
as having passed a better night than usual. But this favorable change in such cases was
transitory: with some aggravation of the existing cough, pain in the chest and accelerated
respiration, or with increased tenderness and distention of the abdomen, with or without an
exacerbation or recurrence of the diarrhoea, the tongue became again dry, the skin hot, and
a febrile condition, proportioned to the extent and severity of the local lesions and the
depressed vitality of the patient, was re-established.
When cerebral symptoms were specially prominent during the third week, the exist-
ence of serious intestinal lesions might not be manifested by their usual symptoms; gen-
erally, however, stools passed without the consciousness of the patient were loose and
frequent and in a proportion of the cases hemorrhagic. Under similar cerebral conditions
extensive congestion of the lungs or numerous foci of catarrhal pneumonia were at times
developed without expressing their existence by local symptoms.
When complications prolonged the febrile condition into the fourth week the patient
became greatly emaciated, his pulse rapid and weak and his prostration extreme. At any
time during the course of the disease sudden death from failure of the heart's action or
heart-clot was a possible occurrence. Fatal syncope not unfrequently attended the effort
to rise to stool or followed the unconscious impulses of an active delirium. During or
before this time there often occurred a swelling of the parotid glands, whicli usually termi-
nated in suppuration and extensive disorganization, if the death of the patient did not mean-
while interfere with the progress of the local affection. Not unfrequently, also, at this time
deafness and headache, both of which were often obscured by the presence of delirium or
stupor, indicated the probable occurrence of inflammatory processes in the ear, a complica-
tion which sufficed of itself to prolong the apparent duration of the original febrile attack, for
the untoward symptoms sometimes disappeared and convalescence was established on the
free issue of purulent matter from the affected organ.
If the conditions mentioned did not prove fatal by the fifth week the activity of the
morbid processes referable to the direct action of the typhoid poison in the blood appeared
to subside; diarrhoea became less active or ceased; pneumonic symptoms improved; delirium
and "other cerebral manifestations abated. Sometimes the return of consciousness about
this time, after many days of low delirium or stupor, gave rise to hopes of a favorable issue
which were not realized, the patient dying shortly afterwards of asthenia but retaining
his recently recovered intelligence to the last. In other cases the tongue became clean,
usually of a lighter red than in health, and sometimes patched with white or yellow fur;
the appetite returned, and the patient showed a languid though increasing interest in the
affairs of life. But he was generally extremely prostrated, and bed-sores, which had formed
latterly, were slow to heal and caused much suffering; in fact his condition was such that
the slightest adverse influence was sufficient to precipitate a fatal issue.
Irrespective of the direct influence of the typhoid poison on the blood a morbid quality
of this fluid necessarily resulted from the continuance of the febrile condition by its inter-
ference with the healthy action of the blood-forming and blood-purifying organs. This
THE CONTINUED FEVERS. 279
deterioration was occasionally manifested at a late period of the typhoid attack by the devel-
o|)nient of petechial spots and even of larger extravasations. Abscesses were formed in
various situations, and sometimes these became gangrenous in character. Gangrene of the
toes and feet, simulating that from frostbite and necessitating amputation, was recorded as
a consequence of the typhoid affection.
Even in favorable cases convalescence was tedious, and in its duration generally pro-
portioned to the severity of the antecedent attack. Muscular strength and mental power
alike required a long period for the return of their former vigor. Nor was the conva-
lescence progressive: Diarrhoea was a frequent and oftentimes dangerous accident.
Chronic pneumonia resulting from processes set up during the febrile attack often proved
fatal as a sequel. Pain in the muscles retarded the return to health, keeping the patient
for months in hospital under treatment for so-called chronic rheumatism. Various paralyses
also appeared in the list of the sequelae. Rarely a well defined relapse occurred marked by
the presence of rose-colored spots on the chest and abdomen, diarrhoea, tenderness in the
right iliac region, tympanites, epistaxis, tinnitus aurium, deafness, delirium and such other
symptoms as were present during the primary attack.
But an analysis of the symptoms presented by certain of the cases that have been
submitted will be of more value than the above generalizations in conveying correct impres-
sions of the typhoid fever which affected our troops.
Temperature. — At the present day the course of a case of typhoid fever may lie represented by a temperature
chart with a few notes to indicate the prominence of a particular class of symptoms and explain anomalous devia-
tions in the temperature curve. This curve is generally divided into three stages: In the lirst, that of gradual
accession or ascending oscillations, the temperatures on each morning and evening are about a degree of Kalirenheit's
scale higher than those of the preceding day, liut the morning temperature is usually ahout two degrees lower than
the temperature of the previous evening. The daily rise begins about noon and reaches its height between 7 and 12
p. M.; the fall begins at midnight, and between 6 and 8 A. M. the lowest temperature of the day is recorded. The
highest evening temperature is usually attained from the fourth to the eighth day, and is generally 104°, 105° or 106°.
The second stage is that of stationary oscillations in which the morning and evening temperatures remain at about
the same height on each day, the former being a degree or more lower than the latter. This continues in mild cases
until about the twelfth day, when, coincident with absorption of the deposit in the intestinal glands, the morning
remission is strongly emphasized, and the third stage or that of descending oscillations commences. During this
stage the febrile heat is that of a declining remittent fever. In its latter part the morning temperature may be at or
lower than the normal, rising in the evening considerably above it, and constituting an intermittent period in the
defervescence of the typhoid fever. In more severe cases, with ulceration of the intestine taking place about the
twelfth day, the second stage, that of stationary oscillatious, is prolonged into the third week; but after that, in
favorable cases, the temperature declines, as in the milder cases, I)y remitting and intermitting stages. Accidents
and complications are manifested by deviations of the curve from this typical course,
A consideration of the thermometric cliart and of its anomalies in complicated cases shows the clinical ther-
mometer to be an instrument of value not only for diagnostic but for prognostic purposes,* But the thermometer
was unfortunately not in use in our hospitals during the war. The records do not show at a glance the gradual
accession of the fever by evening increments and morning remissions, its vibratory continuance between its morning
and evening maxima nor its decline by remittent and intermittent stages. To place on record an appreciative view
• Considf ring it in tlie former light, Lieoermeisteb, in ZimnMen^ Cijdopedia, American transLation, New York, 1874, Vol. I, p. 77, says: "The
diagnosis of fever can nsually Im> made from the fever-cun-e alone, and this is true not only of the simple cases, but also of the obscure and complicated
ones, provideil that the physician is acquainti-d with tlio onlinary deviations." One of the rules of thermometric diagnosis deduced by WirNOEKLlcii
from his oltS4.Tvations, wjis that the disease in which the toiniwratun^ has not risen in the evening of the fourth day to :i!),5° Cent. {l(i:J.l° Fli.) is not
typhoid fever.— See C. A. Wcxdekuch On llu Trniperalure in Dheme, Sydenham Society's Transactions, London, 1871, p. 203. But MriicinsiiN teaches that
adiagnnsis of typhoid must not bo excluded if tlie leni|ierature does not reacll Va° Fh.— .See his treatise On Oie Qmlinued Fcversp/ Great Britain, second
e<iitiou, Londnn, 187:1, p. *)li<. Considering the temiterature as an element of prognosis, Liebermfister, op. cit.. p. l:t3, says that tlie tiistories of more than
*«! .ii.«s in the liospital at liasil were talmlated » illi refea'tice to the nuLViirium axillary t.niperature, and that, "Of those patients in whom 104° or more
WHS not oliwrved, 9.G ikt cent, diinl ; of those in whom 104° wiis re.iched and passed, 21t. 1 |kt cent. ; finally, of those in w Ihr«- axilla the temiierature rose
t<i UI5.80 anil over, nioiv than half died." And he insists also on the prognostic value of the daily lluctuatioDS on the ground that a fever which shows
notable remissions is more eitsily borne than one which remains at the sjime height. In this connection, E. Seoui.v's volume on .IM/uw? Th-rnunnetry,
New York, 1.S76, i>. Ill, may W' (pioted: "The tem|ierature indicates the sereri/i/ of the disease about the middle of the si'cond week, rarely earlier. A
single oljsen-ation dot's not do it, a whole day's observation gives it ; but two or three days are still better. It indicates, liest of all signs, the irrrgnlarUift in
the course ; the mmplinifionx that no other means can detect ; a retapt^ after the patieut'ha^ liegnn to recover ; warns of Iht^lentlenaj towards death ; rft;u-
Una thr potency of iheragsutic operations ; shows the tendmey lo eouralfKXnit: w ith great deflnitcness, etc. ; besides the most important fact that a large
thermometric experience in typhoid fever has rendorvd possible the knowledge of its course and the certainty of its diagnosis and prognosis, which were
AtMfolutely impossible with the previous means of observation."
280 SYMPTOMATOLOGY OF
of the progress in a given case our medical officers had to oliserve and note the changes which took place in the gen-
eral condition of the patient as manifested by the state of the surface, the tongue, pulse, respiration and muscular
system, and by the extent and intensity of the cerebral implication as well as the influence exercised on the general
condition by the i)rogres8 of visceral and other local inflammatory processes. Enough of carefully detailed work of
this character was performed, especially by the officers of the Seminary hospital, to authorize the statement that in
their eases of typhoid fever the essential or primary fever tended to defervescence at the end of the second week. In
many of the cases borne on the Midictil Dcscriptirc Lists which give little information other than that embraced in
names and dates, improvement, quickly followed by couvalescence, is noted about the fourteenth day. In one
hundred and twenty-one recoveries from typhoid fever in Hospital No. 1, Nashville, Tenn., there were, according to
a report of Act. Ass't Surg. B. Brandies, U. S. A., sixteen cases in which couvalescence was pronounced at the end
of the second week ; these presented rose-colored spots and other symptoms regarded as pathognomonic. In twenty-
five of the fifty-one cases of unmodified typhoid fever found in the records of the Seminary hospital the date of
defervescence can be ascertained, and in eight of these, cases 2, 4, 7, 8, 9, 10, 13 and 27, a decided and permanent
improvement was manifested about the period stated. But although defervescence may be said to ha^e begun
about this time, its progress was so gradual that convalescence, as marked by the ability of the patient to walk
about the ward, was delayed for a week later. In these cases it must be assumed that the specific inflammatory
processes in progress in the intestinal canal at this stage of the disease were so limited in their extent or degree that
the constitutional disturbance accompanying them was insufficient to maintain the febrile condition, while at the
same time the patient remained free from accidental or secondary lesions which, if present, would have been mani-
fested by a maintenance or recurrence of the pyrexia.
It does not follow from the facts stated that the mild and uncomplicated cases of typhoid
among our troops differed in their period of duration from those observed in civil practice
before or since that time. Dr. Jas. E. Reeves, of Wheeling, West Va., in his delineation
of the enteric fever of Virginia as presented to tlie practitioner shortly before the war,
gives a table of the duration of the disease in sixty-four mild cases, i. e., cases in which,
in the absence of serious intestinal or pulmonary lesions, the attack ended with the cessa-
tion of the primary fever, or was prolonged, but in a mild form, by the existence of limited
intestinal inflammation. The calculation was made from the time when the patients
became unable to pursue their ordinary vocations to the cessation of febrile symptoms and
the return of appetite. The duration was from nine to fourteen days in twenty -four cases,
from fifteen to eighteen days in thirty-seven and over eighteen days in three cases.*
Observations of this kind were open to error at both extremes of the period. The
insidious approach of the disease in many cases rendered the date of onset obscure, and in
the absence of more delicate means of determining the cessation of tiie febrile movement
than were used by our medical officers during the war, and by our medical men before that
time, it was impossible to assign a date in all cases as that on which convalescence was
established. The return of the patient to the state of health was so gradual and unmarked
by striking phenomena that arbitrary lines had to be drawn. Thus, Louis considered the
patient convalescent when he commenced to eat a little bread.f But on the other hand
the onset was oftfen distinctly marked by chills and other notable bad feelings, 'as headaclie,
pain in the limbs and weakness, and although the date of convalescence might not be indi-
cated with certainty, there was usually no difficulty in assigning a particular day as that
on which the patient showed the first manifestations of improvement.!
Since the war the duration of mild cases of typhoid fever, as usually stated, is three
* A Praclu-al Tretttise on Enteric Fever, by James E. Reeves, M. D., Philadelphia, 1859, p. 102 el seq.
•f Ch. a, Louis, Rechcfches Anatomiqnes, etc., t. II, note to page 12.
J: Dr. Austin Flint in his Clinical Reports oil Continued Feve>; Buffalo, 1852, p. 116, argued that the (lay of convalesrence might be determined from
the general symptoms with sufficient accuracy for all practical purposes. "If a febrile movement, as determined by the heat of the skin, acceleration
of pulse, etc., have ceased, clearness of the intellect returning, with refreshing sleep, and the patient has a desire for and a relish of food, he may be
pronounced convalescent. Some one or more of the above conditions, in some instances, may be wanting, and, still, the other circumstances be such that
convalescence may be properly declared. Judgment and some experience are requisite to decide correctly; and with every qualification on the part of
the observer, it will not infrequently be a matter of some doubt as to the particular day which should limit the termination of the febrile career. Dif-
ferent practitioners would not fi.x upon the same day in all cases, owing to differences in the mode of estimating the circumstances upon which the
opinion is based. Perfect exactitude and entire uniformity, in short, as respects this point, are not practicable; and yet sensible physicians, in the
majority of instances, will act with sufficient correctness for all practical purposes."
THE CONTINUED FEVERS. 281
weeks, or three periods of five or more clays, corresponding witli the ascending, stationary
and declining stages as marked out by tliermometric observation. The clinical thermom-
eter has defined the date of convalescence as that on which the temperature does not rise
above the normal at the hour of its usual post meridian increase. This instrument, by
exactly defining the close of the febrile movement, has added to the duration of the disease
as stated by physicians; but at the same time, by determining with equal delicacy and
exactitude the heginning of the period of defervescence, it has shown the accuracy of our
medical officers in noting slight changes indicative of improvement in mild and uncom-
plicated cases about the end of the second week. In point of duration there was no differ-
ence between these cases and those that since then have been studied thermoraetrically by
the profession.
Cases in which the disease ran a longer course may be divided into two classes. The
first were characterized by the occurrence of a short interval between tlie commencement
of the decline of the primary fever and the accession of a fever symptomatic of secondary
lesions. The second presented no sign of improvement at the end of the second week,
the symptomatic fever having been developed prior to the subsidence of the specific or
primary attack. The former were usually cases in which the recurrence of the fever was
due to a late development of pulmonary complications. The latter comprised those in which
diarrhoea or in some instances pneumonic symptoms were jsrominent from an early period,
as in 17, 26 and 39 of the Seminary series. But sometimes the progress of the intestinal
lesion was such as to permit a manifestation of temporary improvement to be shown about
the usual time, an improvement which was speedily lost in the constitutional disturbance
attending the progress of ulceration or sloughing of the agminated glands. Thus, in case
21, the tongue became morst on the thirteenth day, but the skin continued dry and the
diarrhoea was prolonged until the twenty-ninth; in 47 a marked improvement was man-
ifested on the twelfth day, corresponding with the occurrence of rose-colored spots, epistaxis
and a moist condition of the tongue, but a mild degree of febrile action was continued for
some time, and the case had a fatal issue by a sudden aggravation of the diarrhoeal symp-
toms. In other instances the condition of the kidneys appeared to exercise an influence in
the prolongation of the febrile movement: In case 28 a tendency to improvement about the
sixteenth day was followed by fever symptomatic of inflammatory processes in the intes-
tines, kidneys and lungs; in 12 the fever declined in part at an earlier date than the four-
teenth day, although convalescence was delayed until the twenty-eighth day, a result chiefly
due, so far as'indicated by the symptoms, to the condition of the kidnevs.
Pn.SE. — The pulse during the primary fever was not uiueh accelerated. In many casc.s it ranged fioni 80 to 90,
in others from StO to 100, Imt it sehlom ro.se above 100 per ininnte. even wlien the fever was at its acme. Tlius in twenty-
seven of the Seminary eases the pulse did not exceed 100 at any period of the attack, while many, characterized during
their later stages by rapidity of pulse, recorded a le.ss frecjuent beat in the progress of the primary fever. In eleven
of the twenty-seven eases the rate did not exceed 90; in seven the rate was between 90 and 100, but did not reach
the latter number, while in nine 100 was reached but not exceeded. This slightly accelerated pulse was generally
(liiiek; indeed the febrile condition was manifested rather by sharpness or increased impulse than by acceleration.
It was oftentimes small and weak, rarely full and strong, and if so, only for a short time preceding the appearance
of the eruption or the occurrence of a free perspiration, which changed its rate and quality. When defervescence
took place toward the close of the second week, the pulse lost its sharpness, becoming at the same time less frequent
and more feeble, but regaining strength, volume and sometimes fre(|uency as convalescence advanced. When the
primary fever was associated with a pulse-rate of 100 or more, there was generally a notable suti'nsion of the face,
injection of the eyes and not unfrequeutly epistaxis, especially if the pulse, as in cases 12, 21 and 2S, was at the
same time strong and full. In seven of the Seminary cases in which the pulse-rate exceeded 100, the acceleration
was chiefly due to the primary fever, although sonietimes, as in 47, the prostration caused by an active diarrhcea
rendered the pulse rapid and weak at an earlier period than usual.
Wed. Hist., I'r. Ill— 3G
1
282 SYMPTOMATOLOGY OF
It would seem from these analytical results that in the typhoid cases of the war, as
illustrated by those treated in the Seminary hospital, the average frequency of tlie pulse
was considerably less than in the disease as it attacks civilians. Murchison has published
some statistics which may be used in effecting the comparison.* The pulse exceeded 100
in 85 per cent, of the cases mentioned by him, but in only 43 per cent, of the Seminary
cases. Most authorities agree that, excluding certain exceptional instances, the gravity of
the disease is proportioned to the frequency of the pulse.f This would imply that the
typhoid of our soldiers was of a milder type than is generally encountered, a deduction which
is negatived by the positive testimony furnished by the percentage of fatality. The rela-
tively slow pulse must therefore be attributed to some other cause than the mildness of the
affection.
The Seminary hospital records show that when the febrile condition was prolonged
beyond the second week the pulse became frequent and feeble in proportion to the increas-
ing prostration. Symptomatic fever was manifested by quickness, but occasionally, and
especially in some pneumonitic cases, the frequent pulse was full, soft and ii'ri table. During
the persistence of low delirium, subsultus and involuntary passages, the pulse was rapid,
120-130, small and weak; occasional exceptions occurred, as in 48, in which, with typhoid
delirium, it was 95 shortly before death. Usually in delirious cases the condition of the
pulse was an index of the patient's strength; but in some exceptional instances, as in 42,
violent muscular efforts were associated with an almost imperceptible radial beat.
Perspirations and epistaxis occurring at the end of the second week lowered the pulse-
rate and lessened its impulse ; but their recurrence at a later date, especially if frequent and
profuse, induced the rapid pulse of typhoid prostration. This prostration, when the disease
was prolonged by secondary fever, was as manifest in the action of the heart as in that of
the voluntary muscles. Slight exertion was followed by aching in the limbs, great weari-
ness and exhaustion; the patient's legs trembled under his weight when he rose from bed,
and when unable to rise tremors might be seen in the movements of the hands or in the
protruded tongue. Correspondingly the pulsations at the wrist became weak undulations
that could not be counted; hypostasis occurred in the lungs and the activity of the capillary
circulation in the skin became diminished; the hands and feet were cold and clammy,
the face pale and features shrunken. This condition of prostration is well outlined in
case 31 of the post-mortem records. In some instances, as in 150 of the same series, col-
lapse occurred with a slow and imperceptible pulse. Many of the sudden deaths i-ecorded
as having taken place when the patient was at stool or subsequent to some violent delirious
* He states that the pulse exceeded the normal standard nf frequency in all but one of one hundred cases. It exceeded 90 in ninety-seven cases;
IWI in eighty-flve cases ; 110 in seventy cases ; 120 in thirty-two cases ; 130 in twenty-flvo cases ; 140 in ten cases ; and l.W in two cases.— Oj). cU., p. 618.
t Dr. .Tames Jackson, in his Report on the casefi of tt/phoid /ever or the eoiumon contiinied ferer of New EiUjlaiul, which oeciirred In Ike MitSBaehtUielts Gnieral
Hoapital from September, 1821, to the end of 1825, Boston, 1838, gives on page 11 the following table of the frequency of the pulse in tliis fever:
Average of__
In 200 cases, in all of which the pulse was sufficiently noted _.---..-----
In cases which terminateil favorably, taken alone __.---.-------
In those which terminated unfavorably, taken alone ----,
In the males among the fatjil cases --_..--.--
LlEBERMElSTEE stiitcs that thc frequency of the pulse runs a ccjurse parallel to the hcigbt of the temperature. — Op. eit., p. 82. MuttClIISON gives
positive data on this question : "As a rule those cases are most severe in which the pulse is quickest, and the prognosis is usually bad when, iu an adult,
the pulse persistently exceeds 120. Of thirty cases where I found the pulse never exceeded 110, not one died ; whereas of seventy cases whore it was
above 110, twenty-one, or 30 per cent., died ; of thirty-two cases where it was above 120, fifteen, or 47 per cent., died ; of twenty-five cases where it was
above 130, thirteen, or .52 per cent., died, and often cases where it was above 140, si.\ died. Two of the patients who recovered irfter the pulse exceeded
140 wore under ten years of age."— Oji. eit., p. 619. But Louis, in considering the fact that in 8 of 41 fatal cases and in 21 of 67 severe but not fatal cases
the pulse did not rise above ninety beats per minute, came to the conclusion that a moderately accelerated pulse is of favorable omen as suggesting that
the attack will not be prolonged, while a slow jiulso awakens fear as to the length of the disease and its issue. — See his ItevhercheF, t. IT, p. 276.
Least fre-
quent pnlse.
77.07
Most fre-
quent pulse
10(5. M
74.10
91. 8S
85. 50
102.08
12'J. 29
124. 211
THE CONTINUED FEVERS. 283
effort are attributable to failure of the heart's action. Death from this cause also occurred
unexpectedly during convalescence.
Epistaxis was noted in sixteon of the til'ty-oiie Semi nary lios)iital cases. In six it oeinnieil iliuinf; the early
part of tlie attack and iu three during the second week ; in none of tliom did the loss of blood ai)i)oar to iuUuenco the
progress of the disease. Nevertheless, in seven cases in which it took place or recurred at the end of the second
week or later, a favorable change was coincident. These cases were Nos. 12, 18, 25, 28, 45, 47 and 49. In the first
three eases, as also in the relapse, 49, the epistaxis was closely associated with general symptoms of defervescence.
In 28 and 47 the improvement was of a transitory character, as the secondary alVections ultimately caused death. Iu
45 the loss of blood was so profuse that the pulse could not be counted; yet the patient rallied satisfactorily. The
improvement in this case must be referred to a free discharge of jms from the ear rather than to the epistaxis, for
previous losses had been followed by no amelioration of the patient's condition.
This proportion of cases is similar to that recorded in civil life by Flint and MuRcni-
SON ;* epistaxis was, however, of more frequent occurrence in the experience of Louis.f
In many cases the quantity lost was so small as to be without influence on the condition of
the patient; sometimes it amounted only to a few drops. When it took place in the early
period the febrile accession was uninterrupted by its occurrence. The cases in wliich there
is a probable connection between the loss of blood and the defervescence which speedily
followed are of interest in view of the positive assertions of so many observers that epistaxis
occurs without relief to the symptoms. J When the febrile movement was at its height, the
pulse full and comparatively strong, the skin hot, cheeks flushed and eyes injected, it is
difficult to dissociate the flow, if sufficient to create an impression on the sj^stem, from the
improvement which followed. But defervescence was in these cases about to commence,
and would have commenced irrespective of the occurrence of the epistaxis, as is indicated
by the progress of those cases in which the fever declined without an accompanying loss of
blood. The epistaxis must therefore be regarded as essentially a coincidence which may
have emphasized the first remission of the declining stage of the fever and rendered the
improvement that subsequently followed more marked than it would otherwise have been.
Of the few post-mortem cases which are preluded by a summary of symptoms, epis-
taxis is mentioned only in six, in all at a late period of the disease. The loss of blood does
not appear to have in any instance materially affected the progress of the case; the quantity
was nut estimated, but in 17 and 297 it would seem to have been small and mainly induced
bj' the patient picking the nostrils with his fingers.
Condition of the Skin. — In the majority of the Seminary cases the skin is said to have lieeu hot and diy,
and this condition persisted to the subsidence of the primary fever.
In the typhoid cases of civil life the skin is not unfrcquently moist or perspiring,
especially at night or towards morning, even before the occurrence of the strongly marked
remissions which indicate the decline of the fever.§ There is here a distinction between
the typhoid fever of the war and the disease as seen in civil practice. But it may be said
that tills distinction is an arbitrary one; that the Seminary cases did not in fact present this
continued dry state of the skin, but only that proportion of them which has been sepa-
rately submitted as illustrative of unmodified typhoid. If, however, those cases which
*Dr. Fust found epistaxis in 8 of 30 cases. Usually it was slight, occurring at an early period, and producing no apprccJal>1o ofTcct on the
progrpw of the dise.-u*.— Oji. rit., p. OV. MruclllsoN noted its presence in IR of .58 cases : "All observers agree," he says, " in stating that the bleeding is
noTer tnllowed by any n-iii-f to tli,.- symptunis, while on the other hand it may be .so profuse as to be the immediate cause of death." Several examples
of death from epistaxis eaiiii- undi-r hia notice. — '^i. cit., p, 543.
t Loeis says that the epistaxis was less frequent in niihl than in severe cases, it was present in II of 24 mild cases ■ '27 of .■i4 severe cases, and 1 1
of I(J fatal cases, and was nearly always without the slightest relief to the symptoms. — Op. cU., t. II, p. 219.
J See the opinions expressed in the last two not<-s.
§ Lovis says that the skin was almost always dry in one-fourth of his fatal cases, and w;is covered with more or less iierspiration in the others
after the ovcning exacerttation or during sleep at night ; in the severe but not fatal cases similar conditions prevailed, and also in the mild cases,
altliough the heat was less intense. — Op. cit., t. II, p. 2Grt. According to Likbkiimkistkr: "The skin is usually dry; sometimes, eslHU'ially in the morning,
it is moist and even covered with sweat, but this latter circumst^ince has no favonible signilicance." p. ItO.
284 SYMPTOMATOLOGY OF
were characterized by softness of the skin, moisture or free and recurring perspirations, be
closely examined, the majority will be found to have presented other symptoms of malarial
implication. Moreover, in many of these the perspirations had a notable influence on the
pulse and general febrile condition; while most authors agree that the occasional moisture
on the skin of typhoid patients does not exercise any controlling influence on the course of
the fever.* It would seem, therefore, that a hot and dry condition of the skin was in reality
a characteristic of the cases of unmodified typhoid among our soldiers.
During the continuance of the primary fever the 'rose-colored eruption made its
appearance usually from the seventh to the fourteenth day. The skin rarely became cool
or moist before the eruption appeared; but it frequently happened, especially in the milder
cases, that defervescence associated with free perspiration coincided with the discovery of
rose-colored spots on the chest and abdomen.
In cases prolonged by the existence of secondary lesions the skin generally retained its
febrile heat and dry husky state; but at times a moist condition alternated with this, and
free persfjirations were not uncommon. In this respect these cases did not differ from sim-
ilar cases of typhoid as delineated by medical authorities. The perspirations were sometimes
of nightly occurrence and so copious and exhaustiiig as to suggest the necessity of special
medication for their suppression. Occasionally improvement dated from tlieir occurrence,
but in other instances their favorable import was not so manifest, although, as will be shown
hereafter, they may have exercised a beneficial influence on the morbid processes in j^ro-
gress in the intestinal canal. In cases characterized by extreme prostration, as in 47 of the
Seminary cases, and in 19, 150 and 199 of the post-mortem series, profuse perspiration
attended the fatal issue.
An eruption of stlflftlilinn was occasionally noted as an accompauiment of the perspirations, especially of
those occurring at the beginning of defervescence. These miliary vesicles are mentioned in thirteen of the fifty-one
cases, and in eight of these they were associated with a moist or perspiring state of the skin. It does not appear,
however, that this condition was essential to their development, for in four of the cases, 7, 25, 30 and 45, the skin
was not moist at the time of their appearance, nor had it been moist at any previous period of the attack, and in 46
the skin was dry at tlie time of the eruption and had been dry for some days before its appearance.
This eruption may not be regarded as of special significance, although it occurred occasionally as one of
the concomitants of defervescence, for it often appeared in the history of fatal cases. It was present in ease 39 of
the necroscopic series; the breast and abdomen were covered with sudamina in 163, while the patient was in a coma-
tose condition from which he did not recover; the vesicles were noted as a post-morkin appearance in 170; they were
present also in other eases, as in 7, 38 and 118.
There is nothing in these facts to suggest a diff"erence between the typhoid fever of our
camps and that described by medical writers. Most authors and observers refer to sudamina
as of more frequent occurrence in this than in any other acute disease.")" The eruption is
therefore regarded as possessing diagnostic value in so far as it tends to confirm a diagnosis
already made. As an element of prognosis it is evidently valueless; although the opinion
* Dr. Flint found that free perspirations occurred once, twice or several times in 33 of 60 cases. These were exclusive of the instances in which
sweating was coincident with or occurred shortly hefore convalescence or as a precursor of death. He at first concluded that *' we are not warranted
in predicating expectations of speedy convalescence or of recovery upon either of these symptoms [moisture and free perspiration] disconuected
from other circumstances, nor do these results aflbrd any grounds for supjwsing that to induce moisture or sweating by therapeutical means will be
likely to prove beneficial." This conclusion was derived from the observation that a moist condition of the skin was in a large proportiou of instances
not succeeded at a short interval by convalescence, and that perspirations occurred in nearly one-half of his fatal cases. But he subsequently changed
this opinion on finding that free perspirations were followed by a fall in the i)ulse-rate, and that the average severity, as manifested by the pulse and
the duration of the attack, was less in cases characterized by an occasional moist condition of the skin than in the febrile cases generally. — Op. cil., p.
333. Unfortunately his observations on this head were not extensive. The opinion of Lieuekmeisteh, given in the last note, is that of the profession
generally. See also page 296, infra, on the probable influence of perspirations on the diarrh<ea.
t E.VOCH H.\LE, in his Itemnrls on the Pathojogy of the Typhoid Fever of New Engl'iinl, read at the auuual meeting of the Massachusetts Medical Society
May 20, 1839, and published in the Transactions of the Society, says, p. 193. that this eruption was present in T.t of 197 cases treated in the Massachu-
setts General Hospital, absent in 15, while in 107 the records made no reference to its appearance. Murchisox noted it in about one-third of his
cases, p 515.
THE CONTINUED FEVERS. 285
generally expressed by recent writers that it is associated with perspiration and has no
special connection with the poison of typhoid fever may well be doubted.*
During the primary fever tlie face was goneraUy flusInMl. a (•(niditinn wliicli in some instances was noted as
ajjjjravatfU at the evening visit. Sometimes the Hush was deserihi'd as dark-red or dusky, as in 19, 27, 28, Ii2 and
38 (if the Seminary cases and in 17, 18 and oO of the jw,st-moitrm series. At a hiter stage the face hecame pale and the
fealurt's sliriiiiki-n.
Hos^'Coioi'pd spots were ohserved in forty of the fifty-one cases treated in the Sfininary hospital.
They usually made their first and in souu' mild cases tlicir (tnly noted ai)pearanre just hefore the moistening of the
skin and the abatement of the fever towards the close of the second wctdc. The eruption may have been present in
sonu^ of the eleven cases in which no record of its existence was made, for in miv case, 1, the history is incomplete;
in 2 and .'> the record begins about the i>eriod of defervescence; in 41 the jtatient died on the twelfth day from the
eftVcts of a fall: in 13 the record docs not begin until the sixteenth day; in 19, 20 and 51 the patients were not
admitted until late in the progress of the disease, and in 33 and 35 the results of the fever and not the fever itself
were under observation; even in 13 there was time for the spots to have appeared and faded unnoticed, as the
patient was not examined xiutil the twelfth day. Thus in forty cases which were observed daily during the greater
portion of the febrile continuance this eruption was present in all.
In the cases recorded in the books of other hospitals and on the medical descriptive lists the existence of
lenticular spots is fretiuently noted, although more frciiuently, owing to insutficicncy of detail, no mention is ma<le
of their presence; but only in two cases, 13 and 330 of the post-mortem records, is their absence specially reported.
In the former the patient was not examined until the twelfth day: the latter is therefore the only case in which it is
stated that rose-cohned spots were not observed, although the patient was under medical supervision during tiie
whole course of the disease. It is worthy of remark, hoAvever, that the soldier in this exceptional case was treated
in quarters for six weeks as a case of bronchitis before he was taken into hospital: that after his admissittn the
solicitude of his nuHlical attemlant was mainly aroused by the condition of the pulmonary mucous membrane, and
that the diagnosis of typhoid fever was consequent on necroscopic revelations. Under these circumstances the
statement that rose-colored spots were not observed in the progress of the ease does not have a positive value.
We must conclude from these tacts that cases of typhoid fever which were not char-
acterized by the appearance of rose-colored spots were exceptional ;f and that our medical
officers were fully warranted in regarding the eruption as pathognomonic, since its occur-
rence had not been observed in connection with any other disease.^ That it was looked for
• Loris recognized thnt the miliary vesicles were not always proportioned to the perspiration ; in fact, be sometimes found them numerous when
there had Iwen little perspinilioii and al>s4-nt when there had been much. Bloreover, in forty ensues of acute disease other than tyi>hoid fever, attended
with fret- perspiration, sudaniinu were found in but three cases, although special attention was directed to their detection. Mis observations led him also
to consider them more numerous iu severe than in miht attacks of typhoid ft^ver. lie therefore looked upon these vesicles as of much import^mce in
the history of the fever, conceiving them to be dependent on some unknown condition of the skin which was more pronounced in serious than in slight
cases. — Op. cit., X. II, p. 214 ; see also second ed., 1841, t. II, p. 110. This opinion no doubt gavL- rise to the impression that they were of critical impor-
tance. Some practitioners liave looked for them with anxiety about the period of defervescence ; Reeves, p. 59, instances this fact, although himsell
attaching littlv importance to the eruption. Indeed the general tenor of medical opinion regai-ds it as having no siHicial significance: See Chomel,
p. 25, and Wood, p. 320. LiREtEKMEisTEit says that it is found in |tatients who liave not perspired very freely, p. 94. Mubchison, on the other hand,
p. 515. believes that it usually appears with perspinitions, and is, jierhaps, equally common in all febrile diseases attended with sweating. BI. J. Via
MONTvus, in his thesi-* /Jh [tiu^noMic t^t tbi TVaUemmt de la FUfre Typho'ide, Moutpellier, 1877, emhoilies the present view of the eruption as deduced from the
literature of the subject, where he says: "Los sudamina ne constituent pas un caractere sp<*citique dc la nialadie : ils n'out pas une grande valeur diag-
noetique ; on les a rencontres dans beaucoup d'autres maladies : pneumonic, rhuniatisme articulaire aigu. Cette Eruption est tout simpleraent li6e aux
tucurs plus on moins abondantes du malaile." J. C. Wii^on has exiirtssed the prevailing opinion in this country in his Treatise on the Continued Feventy
New York, 1S81, p. 1G9, where he sa>T5: "They [the sudamina] are very common in typhoid fever, but are without specific character, and occur with
perhaps equal frequency iu other febrile affections." In the absence of observations on the frequency of sudamina in acute diseases, such as intermittent
fevpr, pueumonia, acute rheumatism, etc.. attended with perspirations, the statement of their connection with i>orspinitions is hanlly warranted;
while the acknowledged fn-quency of fliu eruption in typhoid fever, and its appearance in that disease when the skin is not even moist, seems to
authorize- the doubt which has been expressed iu the text.
t L"Tis found the tarhe^ roses /en/ttn/m're« in 20 of :J5 fatal cases, but acknowledged that thej* may have been present in more than this number, as
many vf the patients came to the hospital at a period when perhaps the si>ots had disjippeared. In .'i7 severe but not fatal cases they were present in all
bnt3, in two of which the patients did not come under observation until late iu the dise^ise, and in the third no examination of the surface was made except
U'tween the seventh and eleventh days,— t. II, p. 231. Enoch Hale believed them to be always present. He says— in his Remarks on Uie Pathologij of the
T*fphoiti Feter of New Enijlnnd^ Trans. Mass. Med. Soc., Hn19, p. 191—" Of the lit? ca.*;es that 1 have analyzed for this paper, rose-spots are recorded in 177.
In the greater part of the remaining 20 it is apparent from the record that sufficient attention was not given to them to tender it by any means certain
that they did not exist. Moet of the omissions are in the earlier part of the period 1 have specified, before the importance of this ap|>earance, as a diag-
nostic mark, was fully appreciated. In a few cases the patient xvas brought to the ha^qtital at too late a period of the disease for them to he visible.
With Ibis exception 1 have, for a long time past, seen no case that could with any propriety be regarded as decidedly the typhoid fever, in which rose-
tpots were not found, and I think it is not assuming too much to consider them a constant attendant u|H>n that disea.*ie.' In three scries of cases
reported by Dr. Flint the eruption was present in 23 of 3<) cases, in 12 of 20 cases and in all of 14 cases. Bartlett rarely failed to find it when properly
looked for, — p. 60. Acconling to Mvrchison, these spots were observed in 4,00r. of .5,088 cases or in TG.92 per cent, of the typhoid cases admittetl inl>i
the London Fever Hospital during twenty-three years, but in some of the remaining oases the fact of the spots not being observed was perha|>8 due
to their not having been looked for with suthcient care,— p. 511. Keeves seldom failed to find them at stimo period of the disease,— p. 57. Liebe«-
■EiSTER says they are frequently entirely wanting in slight undeveloped cases; but "whether there are well developed cases without any roseola through-
out the entire c*jurs« of the disease I am unable to decide; in all cases which I examined sufhciently often, I have found at least a few spots,"' — p. 93.
XCnouzL—I^rvns de Clittitpie Mutieale, Paris, lS:i4— probably influenced by the positive statement made by Louis in 1829, as to the occurren<-e of
roi»-6pots in certain diseases other than typhoid fever, sf>eak8 of their eruption, — p. 21 — as "aussi rare dans lee antrcs affections aigues qu'elle est cum-
unne dans la fii-vr© typho'ide, et que dans lescas rares oii on I'observc dans le cours d'line pneumonic, d'uno entente, ou d'autres affections aigues, jamais
286 SYMPTOMATOLOGY OF
with care iu febrile cases is evidenced by such reports as 7 of the 27th Conn, record and 4:1)
of the Seminary series, in which one or two rose-spots were recorded as having been discov-
ered on the chest, or 11 of the 19th Mass., in which one or two equivocal spots are said to
have been seen. Occurring in connection with an otherwise satisfactory complexus of symp-
toms, the presence of a few doubtful spots might be accepted as constituting a specific mani-
festation; but in obscure cases such an appearance could hardly be regarded as of diagnostic
value. Chomel did not consider the eruption present unless fifteen or twenty spots appeared.*
When Louis first looked for these taehes roses lenticidaires in acute diseases other than the
typhoid affection, he discovered them in twelve of fifty cases — once in two cases of pneu-
monia, twice in twelve of diarrhcea, once in three of rheumatism, three times in eight of
catarrh, once in four of gastro-enteritis and four times in ten of gastric embarrassment;"}"
but he afterwards concluded that he had in these instances mistaken ordinary pimples for
the spots in question.^ Since this close observer had to acknowledge an error of this kind,
some hesitation may be shown in accepting one or two spots as a specific eruption unless
the diagnosis has been completed, irrespective of their presence, by the concurrence of
other symptoms.
The spots generally presented their usual well-known characters. They were circular
or somewhat oval in outline, half a line to two lines in diameter, rose-red in color, slightly
elevated and with well-defined margins; they disappeared on pressure. Their customary
site was the chest and abdomen, but occasionally they were noted on the back and thighs.
They were observed for the first time usually during the second week, but in some, as in
cases 7 and 17, they appeared as early as the sixth day.§ In many instances the records
take note of but one crop, which faded as defervescence progressed; fresh spots may, how-
ever, have erupted in these cases without having been noticed or recorded by the medical
officer, for his interest would naturally have diminished as the favorable issue of the case
became a certainty. In mild cases, when the spots appeared at an early day, fresh crops
were developed during the second week as those first formed were fading. In prolonged
cases a succession of spots was the rule, lasting, as in case 37, from the thirteenth to the
thirty-first day, or as in 26, from the eleventh to the thirty-fourth day.
It does not appear that this eruption had a prognostic value or was connected with
any special condition of the skin, for although in some, as in the case last mentioned, its
recurrence corresponded with fever, delirium and diarrhcea, in others the symptoms during
its continuance were by no means grave: In 37, rose-colored spots and abdominal tenderness
were for some days before convalescence the only symptoms explanatory of existing weak-
ness and disability, while in 4 the patient was able to walk and was in a fair way to recovery
when the eruption appeared on the fourteenth day. Nor did the number of spote present
at a given time bear any relation to the character of the attack : The eruption was profuse
elle n'est aussi alK>ndante que daus la fievre trphoide, on concevra pourquoi nous attachons il cette eruption one si gronde valeur ponr le diagnostic
de la fievre t\T»holde." Loris himself, as indicated iu the test, after a longer exjierience in the study of the rose-colored spots, concladed that he
hiul mistaken simple pimples for this eruption in the cases mentioned; for, after the publication of the first edition of his work, he Tainly ^ught
for the spots in patients affected with other acute diseases. Mcrchison, after describing the specific characters of the rose-colored spots, says, p. 513 —
"At the London Fever Hospital I have had occasion to examine many thousand cases of acute diseases of every form, and my opinion is that an eruption
which presents all the characters above mentioned is peculiar to enteric fever."
*CU05IEL, page 18. fLoris, Ed. 1S29, t. II, p. 212. JEd. ISU, t. H, p. 107.
§MrBCHisos gay3 the spots appear from the 7th to the 12th day (inclusive) — p. 511. .\ccording to Chomul, p. 20. tbey erupted iu twenty-
seven cases as follow^: In two cases from the Gth to the Sth d.'iy; in thirteen from the 8th to the l.">th day; in seven from the loth to the 2>lth day; in
four from the 20th to the 30th day, and in one on the 37th day. Jenner, On Tt/phottl trnd T>jphu» Ffr>T — Mimtiily Jour. Mfd. Sriettce, E<linb., Vol. IX,
1849, p. 676 — ^has expressed the opinion that except in cases of relapse rose-spots never appear after the 30tb day, but Mcrchisox met with several
instances iu which they appear^ daily as late as the 3Dth day, and in one mild case he noted the almost daily appearance of fresh spots from the 14tb
to the OOth day— p. 517.
riiK i'()NTiNn-:n kkvers. . - 287
in the mild case 12 of tlie Seminary hospital as well as in 14 of the post-vioiievi series; it
was scanty in the mild cases, 9 and 40 of tlie former, and equally scanty in cases 31 and 41
of the latter series.*
Occasionally the eruption was of a darker color than usual; In '27 and 2S of the Sem-
inary series it was dark-red in color and did not disappear on pressure; in these cases the
deeply flushed face, suflTused eyes, heavy expression and intensity of the cere])ral symptoms
were suggestive of a typhous condition. In other instances the spots did not present what
was regarded as their iiurmal characteristics: In 2 of the post-mortem series some red
blotches were observed on the face, arms and chest, and in G of the Seminary cases the
typhoid rash was preceded by an anomalous eruption. Excluding the duskiness of the
spots presented by certain of the cases there is nothing in these facts to base a distinction
between the typhoid cases of the army and those seen elsewhere. Flint observed that
some typboid spots disappeared but partially on pressure,f and many autliors refer to eruj)-
tions which precede or accompany the rose-colored spots.;};
In none of the records of typhoid fever is mention made of the pale-bluisli spots, the
tachcs blciuUrcs of the French writers.
PefechUv seldom npitoarcd on tlu' .skin. They Jiro mentioned in case 32 of the Seminary series, in which
tbey were noted on the fifteenth day, or one day after the ernption of the typhoid spots ; this case recovered. They
were also noted in 21, 3(>, 45 and IM of the post-morinn series, sitnated nsually (tn tlie ehest and uhdomen, hnt in the
last-mentioned case exteudini; to the thi^dis: their numher was not recorded. Kcchymoti(; spors of larger size,
reported as vibices, appeared at a late period of the attack in several cases, «:;enera]ly during or after the fourth week.
They must he considered a grave ])rognostic: of the Seminary cases in which they were noted tlnee eases, 24, 3*> and
49, were severe, and three, 4(), 47 and 51, were fatal.
As the rarity of ecchymotic spots in typhoid fever is generally conceded, § the frequency
• Following Loris, who nbscrvptl tlmt in thrt'o-fonrtlis of his fatal cases the rose-colored spots were few in number, Ed. 1829, t. H, p. 231, A. P.
Stewaut — in his article entitled Some consideratioits an the nature and pathologtf of typhus and typhoUl fever, applied to the solution of the question of ideutUij or
mm-ideutity of the two dis^eases. Edinlmrgh Med. Jour.^ LIY, lS4n, p. 320— was led to consider that the more copious the eruption the less the severity of tlie
cast*. He found the spots few in utiniber or absent, although carefully looked for, in a deadly epidemic which prevailed in Glasgow in 1830, au(i after-
wards observed them more or less numerous in sporadic cases presenting a much less intense form of the affection. But after further inquiry ho came to
the eonchision that this opinion, although to a certain extent correct, was not of general application. Thos. B. Peacock observed— 3fe<i(ca/ TimeM and
Giizftte, XXXIV, London, !**')(», p. 1^2— that the cases in which there is a copious eruption are of a sthenic type and terminate favorably; but he
ai-knowledg«^'s that in many c.ises in which therr- is no fruption at all the disi-ase is also mild, while in others it is severe and often proves fatal. MuR-
niiwix dis[K^^s of the 4|Mestion by the stat«'ment that there is no relation between the presence or absence of the eruption and the severity of the fever, —
p. .112. In this country I>r. Jas. E. Rkkves considered that the number of spots diminished in proportion to the extent of the intestinal changes.
Wilson summarizes the prevailing opinion of the profession at the i)resent day in his assertion that — "There is no relation between the abundance
of the eruption and the severity of the symptiim:*,''— p. 1G8. As R^:KV^>;' experience was dmwn from the country districts of a State, Virginia, which
afterwards furnished the Seminary bwpital with its typhoid cases, his remarks on the ernption may be of interest : *'In mild awes of the diseiuse, in
which the diarrlnea is not troublesome, 1 have several times seen the patient spotted from head to foot. At other times the eruption was iirincijMiIly
confined to the abdomen, chest and inner piirt of the thighs. In other iusUinces it was scattered upon the extremities, even to the fingers and toes,
while upon the trunk it was either entirely absent or only a spot here and- there to be found. Again I have seen it thickly set upon the back ; and I am
inclim-d to believe that it more frequently occupies this locality tliari is generally supposed. It is not so convenicaitly sought for in this region as upon
the nUlnmcn, chest and extremities; an<I therefore results, jH-rhaps, the larity of its being spoken of as occupying this region. All this I have observed
in mild cases of the disease. In the intermediate form (»f the disease I have occasionally observed it largely spread over the diffensnt parts of tin*
nirface, but this was rare when compiired with its frequency in milder ciises. In this form it is mainly confined to the abdomen, with, perhaiw, a patch
How and then to be seen upon the breast and shouhh;rs. It is also somewhat later in its appearance than in the mild form. In cases of still greater
» verily— those belonging to the malignant form — it is, as a gt^neml rule, still more tai-dy in its apiKiarance, and does not occupy as much surface at u
lime as is nsually seen in the preceding f»Tms. It h:u* been in tlm wm-st cases of the disejuse that I have ob.served the smallest am<)unt of this ernption.
In a very few instances I have seen it thickly spread upon the abdomen, chest and shoulders, with a few spots on the back and thighs; but in the
majority of severe cases it occupied only the region of the alHlomen. It does not always make it^s appearance upon all of thf." si'vcnil parts of tin-
surface named at the same time, but comes out in successive crops — sometimes abumiant in one region, and at other times only one, t^vo, three ur four
»p(»ts in the next locality. When the first patch begins to fade a second will make its aj'pearance, and so on, until the eruption ceascts or is lost in tin*
larger and more livid discol orations known as i)etechia, which in very grave ciises show themselves. The time occupied in this fading and recurrence of
the eruption may vary from five to twenty-tive days. The greatest duration of this process I have noticed, almost invariably, to occur in those cases which
pas«i-d through the milder forms to the malignant, and jKirticularly in those cases which terminated in death. In the majority of these cases but few
Bp..ts could be found at a time after the most careful search."
t Flint, op. cit., p. 322.
tThus Hale— p. I't2— says that in some instances there are interspersed with the rose-colored spots true papula: of the same color but larger,
slightly elevated and hardened and not disap|>earing on pressure ; they are generally quite numerous, extending to other parts of the body than the
ntHionien and chest, and are (»ccasionally attended with consirlerable iiching, Jkxnf.r — On tJie identity or non-identity of Typhoid and Typhux Feeerx, Lon-
don, 1850, p. 12— called attention to a psile and delicate scarlet tint of the skin which sometimes preceded the typhoid ernption but never lastc-d mon*
than a day or two; the skin resembling in tint that of a person shortly after leaving a hot-bath.
f.MtRniisoN met with pe,ecnial spots and vihices in rare cases, several of which recovered. To support his own testimony he cites TROi'ssEAf,
CltMique Mt'dicule de r//W<7 f>iVii, Paris, 1861, p. 159, as having recordi-d a case in which there were extensive vibices,— p. 015. Wilson, who has given to
the pritfession in tliis country the latest complete view of the fever, says that true petecUiw are rare, and does not even refer to the occurrence of larger
ecchymotic [utches.
288 SYMPTOMATOLOGY OF
of tlieir appearance in these Seminary hospital cases suggests a difference between them and
the typhoid fever cases of civil life.
Continued pressure and the lowered vitality of the patient led to the formation of bed-SOres over the
sacrum, trochanters and other bony prominences during or after the fourth week of the attack. Cases 24,28,36 and
51 of the Seminary records may be mentioned as illustrations; but these observations are perhaps e(iually common
in the clinical liistory of typhoid as seen elsewhere."
Herpes labitliis is not mentioned as having been present in any of the cases.t
A pecttlifli' odov from the body was noted in case 19 of the Seminary recordsjt but the animoniacal odor
from the patient in some of X\\e post-mortem series was probably due to involuntary micturition.
The Nervous System. — Headache was the most frequent cerebral manifestation observed in cases of unmod-
ified typhoid fever. It is mentioned in thirty-six of the Seminary cases; delirium was recorded in twenty-nine,
deafness in twenty -eight, more or less stupor in twenty -.seven, drowsiness in fifteen, tiiinilus aurium in sixteen, and
dizziness in eleven. But these numbers do not express the relative frequency of such cerebral developments. When
delirium alone was noted, it is probable that at some period of its course the case presented headache, drowsiness,
hebetude of mind or deafness, which was not recorded or perhaps observed on account of the greater prominence of
the delirious condition and the higher importance attached to it as an indication of gravity.
Headache was generally frontal; l)ut in 38 of the Seminary series its seat was the
temples. It was usually dull; in case 1 it was reduced to a mere sense of fullness, and in
13 to a heaviness over the eyes; but in many it was severe and distressing. Head pain
was a symptom of the period of accession ; in but one case, 40, is it expressly stated that
there was no headache during this period. Occurring after or without chilliness it was
accompanied by pains in the limbs and l>ack, thirst, anorexia and other general symptoms
of the febrile condition. It usually persisted during the first week, and was not unfre-
quently associated with dizziness, restlessness and inability to sleep. During the second
week it subsided or was obscured by drowsiness, mental hebetude or delirium, which set in
about that time. It is probable that in most instances there was a real abatement of this
pain, for exceptionally, in some, as 22 and 25, it was a source of complaint when delirium
was present.§ Sometimes headache was i-eported at a later stage ; in 29 it occurred without
delirium in the third week, subsiding as the last crop of eruption faded, and in 47, in con-
junction with dizziness and deafness, it preluded a recurrence of delirium.
Drowsiness, which generally terminated the period of wakefulness and headache, was
developed gradually; the patient became dull and stu})id and was aroused with increasing
difScultv. Frequently tinnitus aurium and deafness were associated with this mental
dulness. In more severe cases delirium, usually of a quiet and asthenic character, was
developed; drowsiness during the day gave place to restlessness at night, the patient mut-
tered in his sleep and was incoherent for some time after he awoke, and, afterward, this
condition of muttering delnium became continuous.
Delivilim was present in twenty-nine of the fifty-one cases — in eight of ten fatal cases and in twenty-one
of forty -one recoveries. In the fatal cases, 44 and 46, in which delirium was not reported the records are not
carried out in detail to the end. Of the twenty favorable cases in which there was no delirium, the cerebral symp-
toms in two cases, 3 and 14, consisted of headache only; in 7 and 12 there was also drowsiness, to which tinnitus
* "Vitality is BO feeble in the skin that blistered surfaces often slough, and gangrenous eschars are produced in jiarts exposed to continued pres-
sure, as over the sacrum and upon the hips." — Woon's Pntclice, Vol. I, p. 317.
t The rarity of herpfs Utbialijy in typhoid cases is acknowledged by Flint where he says ; "An herpetic eruption about the mouth was observed in
one case. Lest the occurrence of this symptom may suggest a suspicion that the disease was, in this case, remiltinij fever, in which herpetic eruptions in
that situation are apt to occur, it may be stated that no doubt could exist as to the diagnosis, the characteristic mucnlte, together with other distinguish-
ing traits being present," — p. 75.
J CuoMEL — p. 40 — says the whole cutaneous surface exhales a fetid odor. Bartlett — p. 61 — frequently noted a semi-cadaverous and musty odor, -
esi)ecially in thclater stages. Flint — p. 213 — was uuable to satisfy himself as to the existence of this odor. "The sisters at the hospital, and some of
the students, have frequently assured me that they were sensible of a distinctive odor arising from the bodies of fever patients under my charge, hut I
have always failed to verify, to my owu satisfaction, this diagnostic. It would be assuming too much to distrust the ability of others to recognize the
disease by the olfactory sense, and the probable as well as the more modest inference is, that the ill success which has attended my efforts is due to a want
of sufficieut acuteuess to appreciate impressions received from that source." Wood says that a peculiar unpleas;iut odor often exhales from the body. —
Vol. I, p. 317. Murchison's statement is that there is rarely any peculiar odor given off hy the skin in enteric fever, — p. .518.
§ Louis argued that the cessation of headache ou the development of somnolence or delirium is not always to be attributed to an incomplete
perception, for many of his patients complained of pains in other parts of the body while giving assurance that they were free from headache, — t. II, p. 132.
Till'; rONTINUKD KEVliRS. 289
h;in addiul in 2 iiiul dizziness in I, V.i and IM: dizziness and linnitns were |iresiMil in f<, stnimr in 10 and lit with dizzi-
ness in the former: deafness in 6, with tinnitus in 2it, dizziness in it, tinnitus anil dizziness in 11, tinnitus, dizziness
and stupor in Hit and stupor in II) and 17. Cases ;i3 and o"> shouUl not lie admitted into this iininieration, as d<^lirium
is not known ti> liave lieen aliseiit from their history.
IHftifafion i>f thv piii}il aeeoni])anied doliriuni in 20 and :^8; hut in 21 it was !i8.sociated with drowsi-
ne.ss, inaliilit.v to artieulato. and other symptoms of the conuitoso condition, iu counoction with which it is mentioned
in some of the pout-morion series, as in cases 18, 117, 2!)7 and 299. Nevertheless there was uo manifest obscuration
of the mental faculties iu case 31 of this series notwithstaudiu}; the great prostration of the patient and tlio dilatat ion
of his [inpils.*
Cerebral symptoms which did not cuhninate in delirium usually ceased with the decline
of the primary fever, drowsiness becoming dissipated, tlie liearing less obtuse and the
i'X|iression intelligent. Tinnitus auriuiu was in some instances no doubt caused by the
administration of quinine.
Tlie delirious condition lasted from one to many days ; in case 28 there was an almost
continuous delirium for three weeks. Usually it was manifested by quiet incoherent mut-
terings, although sometimes the patient became possessed with a desire to get up, and
required constant watching but seldom restraint to keep him in bed. The soldier in case 41
was killed lor want of this watchful care. In mild cases delirium was of short duration,
-iibsiding with the other cerebral symptoms at the close of the primary fever. In pro-
tracted cases it oftentimes alternated with periods of stupor, from which the patient was
aroused to incoherency with difficulty. The return of intelligence was frequently observed
111 the morning after a less troubled night than usual: on such occasions the patient's face
was pale and shrunken, his eyes clear and bright. In other instances the delirium left head-
ache with more or less of stupor and deafness for some time in its train, and in this event its
recurrence was probable as an accompaniment of lung complication, aggravation of intestinal
■onditions, aural, parotid or other inflammations. But even when the intelligence was
apparently uniiujiaiivd delirium was prone to return ou the advent of these untoward com-
plications. In fatal cases with strongly developed cerebral symptoms death occurred by
coma and exhaustion ; the patient becoming unconscious and greatly prostrated, the pulse
almost imperceptible, the eyes glassy and half exposed, the lower jaw dropped, and the only
visible movements those of respiration and muscular spasm. /SubsuUtiS tendimcm was fre-
quently associated with the delirious condition. Occasionally, in protracted cases, when
delirium had given place to unconsciousness or coma vigil, the mind became clear for a
short time during the extreme prostration which preceded death: 50 and 51 of the Semi-
nary series are cases in point. In the post-mortem series death from coma is occasionally
noted, as in 17, 18, 163, 171 and 235. Generally the cerebral symptoms of this series
were similar to those observed in the Seminary hospital, but one or two anomalous cases
maybe noted: In 119 the restlessness which preceded the delirium persisted during its
continuance in the aggravated form to which the term jactitation has been applied; in 25
there was extreme nervous agitation; in 160 the strangeness of the patient's manner led to
the supposition that he was crazy ,t and in 299 the symptoms were referred to congestion of
the brain.
• Sir W, Jexxfr wad ttio first to point out the dilated condition of tlic pupil in enteric fever oa contra.sted with the small pupil of typhus ; of 23
lw»l caws he oliti<-ned dilut^itiou iu 7 aud contraction in 2. SIl'KcHi.-iox — Continued Fevert^ p. 541 — says : " Iu fully three-fourths of uiy awes the pupils
were ahuornially dilated at some stage of the fever, and Dr. \V. T. Gairdnek has made similar ohservations at PMiuburgh. Pilatatiou of the pupil
mfty he oliserviil after the tenth day in cases where there is no delirium or impairment of the mental faculties, or it may coexist with delirium, and
wpecially with that eondiliou appritfiehin;; to hysteric coma already deserihed."
rSKntiA and Oi'tNiLZER^t*- yhmrifm-nt Mi'ili'til, 1872. p. VA — sjiy that it is not rare to find typhoid fever [iresenting only nervous phenomeiui and
nmuutuip a ue-utal affi-clirin. In three ejLses in which MfiirinsoN was consulted the illness had at first been rejiarded as acute mania, and in two of these
the n'moviit <.f the |«tients to a Innalic asylum had lieen contemplated. lie cites M. Motet, .lrc*ic. frii. ile Mil., 18BS, XI, p. 5(M, as having recorded a
tam ofthi-s kind in wliicli the |vttient was actually sent to a« asylum before the real nature of tho malady was discovered, — p. 535.
Mki.. Hlst., I'T. III-37
290 SYMPTOMATOLOGY OF
At first sight it might be considered that the nervous symptoms of the Seminary cases
did not differ in any respect from those generally recognized as characteristic of typhoid.
Headache, restlessness, confusion of thought, giddiness, hebetude, somnolence, deafness,
incoherence, muttering delirium and coma are daily under observation by the practicing
physician. In the frequency of delirium, and the increased gravity which attached to its
occurrence, the typhoid fever of our camps did not differ from that described by observers
elsewhere."'" Moreover the occasional exceptional or anomalous cases which have been men-
tioned are seen to have their parallels in the literature of the subject. But if the character
of the delirium as it occurred among our troops be compared with that of typhoid delirium
as usually described, it will be found that the former was generally less violent in its
character than the latter. Murchison says delirium is at first often active and noisy, the
patient screaming and shouting and being with difficulty kept in bed.f In Jenner's cases
it varied much in character, being sometimes so violent that the patients left their beds and
even ran screaming through the wards, while at other times it showed itself by slight delu-
sions only discovered to exist by accident.| Baetlett states that in many cases, partic-
ularly such as are rapid in their march and of great severity, delirium is attended with cries
and screams, and that the constant presence of attendanfs with occasionally no slight degree
of force is required to keep the patient in bed.§ Among thirty-eight fatal cases recoi'ded
by Louis, delirium was accompanied in twelve subjects, especially during the night, with
violent agitation, necessitating the use of the straight-jacket; it was so considerable in one
patient that the strongest means barely sufficed to keep him in bed on the tenth day, the
day preceding death. The greater number of his patients, ten out of twelve, uttered cries
so loud as to prevent their comrades in the same ward from sleeping.|| Indeed, the straight-
jacket figures as one of the essentials of treatment in the practice of this great authority.
Now, although watchfulness on the part of hospital attendants was often required to
prevent a patient from attempting to rise under the influence of some incoherent fancy,
restraint was seldom needful in the wards of our general hospitals during the war. The
intense prostration which characterized the attack rendered force unnecessary, even when
the patient developed a persistence in the attempt to carry out his delirious impulses.
Usually he was docile as a child, requiring only a kindly hand to be laid on him to allay
his fears or soothe his irritation. Certainly the violent agitation which was a characteristic
of so many of the cases instanced by the authors cited formed no part of the general clin-
*The recorded experience of Loris shows delirium to have been present in 38 of 46 fatal cases; in 39 of 56 seTere cases, and in none of 31 mild
cases, — t. II, p. 150. Jackson noted its existence in 108 of 303 cases, and of these 75 had a favorable and 33 a fatal issue; the fatality among the
delirious cases being 30.6 per cent, as against 13.86 per cent, among the cases as a whole. He considered it probable, however, that slight delirium
occurred at night in many cases in which it was unobserved and remained in consequence unnoted as a symptom, — p. 47. Mvrchison iouiul 67 of
100 cases to present delirium or mental confusion, but in many of these the delirium was slight and occasional, occurring chiefly at night, while at
other times the patient was quite rational ; of the 67 cases 18 were fatal, but in only 22 cases, of which 11 were fatal, was there at any time complete
unconsciousness, — p. 534. .\ccording to Liebermeister, among the typhoid p.atients treated in the hospital at Basle in the years 1S65-6S, there were 983
in whom the disease ran its course without any specially noteworthy brain symptoms; of these 34 died, or about 3.5 per cent. Slight delirium, excite-
ment of low grade, lusting for only a short time or appearing only during the night, occurred in 191 cases, of which 38, or 19.9 per cent, died ; well-
marked delirium occurred in 176 cases, of which 96, or 54 per cent, died ; stupor and coma were present in 53 cases, of which 30, or 70 per cent died.
t Murchison, p. 534.
J "Ten of eighteen patients, i. e., more than one-half, or in the proportion of 55.5 per cent, of those who -were delirious after they entered the
hospital, and of whom notes on the point were made, left their beds to wander about the ward." — Jenner, p. 22. Dr. Reeves also, p. 38, refers to the
occurrence of violent delirium: "\Mien the delirium is violent it usually requires constant restraint to keep the patient in bed. He cries, laughs and
makes use sometimes of the most obscene language. At other times he seems in a fit of anger, and in some imaginary encounter strikes at the ijcd-
posts, the wall or at the attendants with all his strength; his consciousness being embarrasr'sed 'by false presentations, illusions, phantasms — a condition
in which he is haunted by spectra analogous to those visual and auditory sensations which arise in connection with disease in the optic or acoustic
nerve; a state in which the centre of consciousness, abnormally excited, forges subjectively all manner of images of incident and circumstance, with a
self-assurance of their objective reality.' — Simou^s General Pathotogif, p. 153. A very conmion impression with such patients is that they are absent
from home and surrounded by persons who take particular delight in doing them an injury to both person and property; and harassed by these impres-
sions, they leap out of bed and, if not at once arrested, make for the door, or in the attempt fall exhausted upon the floor."
g B.\etlett, p. 66. |[ Louis, t. II, p. 150.
THE CONTINUED FEVERS. 291
ical history of the disease during the war. The patient was rarely noisy, but lay mutter-
ing in a low tone; when roused for the administration of food or medicine, he took without
objection whatever was presented to him and sank back into his former condition. Active
di'lirium was exceedingly rare, the only instance in the Seminary series being case 38, in
which it was associated with dilated pupils and temporal headache.
TiiK Bir.KSTlVK Systkm. — Anorexia was a constant synijitoni of the primary fever It was manifested
from tlie occuvrenoe of tlie chill of onset or accompanied the heljetu<le, headache and pains in the limbs which marked
the dejiarture from the state of health. Thirst "as also common. Imt it did not attain its maximnni until aliimt
the emiilivf period iu cases which ran a course uuobscured by the intensity of the cerebral symptoms. Gustric
irrHilhilitu was rarel,v noted among the earlier manifestations of the disease; it occurred only in the two cases,
y and 17, and had no manifest inHuenco on their progress.* In case 25 it was noted at tlie acme, and in 39 nausea
was associated with the intercurrence of pneumonia. When vomiting occurred at a later period it was ominous of
dangerous intlammatory conditions in the abdominal cavity, although in the only case, 24, in which it was noted as
having allVcted the patient late in the history of the attack, it did not possess this sinister meaning. In cases 19, 32
and 226 of the pusl-uiortein records vomiting was associated with perforation of the intestine, and iu 243 with gan-
grenous conditions in the abdominal cavity. It was also noted at a late period in 165 and 166; iu 280 it occurred
earlier, but persisted to the end. Nausea in 150 was an accompaniment of the onset of peritonitis.
In only three of the Seminary cases, 15, 32 and 50, was the breath mentioned as having been offensive during
the progress of the fever.
The tongue was at first moist, coated at the base with a white, gray or yellow fur, and
with the margins and tip of an unnaturally red color. Gradually the base and centre lost
their moisture and became brown in color and rough, the edges continuing as before.
Sordes gathered on the teeth, lips and tongue, and were generally regarded as a-n exponent
of the typhoid condition, in view of the great prostration, muttering delirium and semi-
unconsciousness which were usually present with these accumulations. The dry, brown
tongue became cracked, and blood which oozed from its fissures added to the mass of sordes.
The patient when roused for the moment seldom expressed a desire for food or drink, but
swallowed, although sometimes with difficulty, whatever was placed in his mouth. Later in
the attack the tongue lost its dark fur, becoming red and glossy and afterwards moist, or it
cleaned gradually, leaving brown or yellowish patches at the base or on each side of the
mesial line far into the period of convalescence.f When cerebral symptoms were not
strongly developed the patient sometimes showed a desire for food notwithstanding the dry.
•Jacksox, iu bi!<anat,vi>b of 303 cases, fountl nausea and vomiting to be frequent symptonie, particularly at the commencenieut of the fever, — p.
;w. Dr. Flint, on the contrary, considered that /luring the febrile career nausea and vomiting are not only absent iu the majority of cases, hut aro
mimpt^rtant as symptoms, occurring at irregular periods, seldom recurring or persisting and possesijing no special significance, — p. 172. AVoon states
that the stomach though often retentive is sometimes irritable. — Vol. T, p. 316. Louis found that in thirty fatal cases twenty had nausea, vomiting or
I*ins in the epigastrium. Each of these symptoms reganied by itself he conceived to be of little value as an indication of the condition of the stomach,
I'Ut his necroi>sical observations demonstrated that the mucous membrane of the stomach w.is more or Ic^ altered in all the cases (five) in which epigas-
tric [win w:iM aj^ficiated with vomiting of bile. — t. II, p. 4.'>. Mueohison was inclined to regard vomiting at the commencement of the attack as a
(avonible symptom, liut cites Peacock, iMnccI, ISGo, Vol. I, p. 117, as expressing an opposite opinion. WiusoN sjiys that nausea and vomitin,:; occur
tri the early stages of a small proportion of the cases, and that so far as his own observation goes, early vomiting has been followed by the severest fonus
■f the diseajie.— p. 171. .\11 authorities agree as to thegenerally deadly signification of vomiting in the later stage* when associated with other symptoms
indicative of {M'ritoiiitis or perforation.
+ In .Jackson's cases the tongue was characterized as dry, dark or denuded, — p. 37. Bartlett says that in a certain proportion of cases, severe as
well as mild, it b but slightly altered in appearance ; even in fatal cases, terminating early, it may be merely somewhat dry and coated. In mild cases
it b often alm(«.t natural in appearance or covered only with a light yellowish coat, while in others of a similar grade of severity it is smooth, mod-
•ntcly n-il and moist w*itli a tenacious adhesive matter which is common in the severe forms as well as in the mild. In grave or protracted ca,si.'S it
trnidaally luTtimi-s dry and brown along its middle and red at its tip and edges ; later it becomes dark over its whole surface, — sometimes nearly black, —
glaxitL stiff and eross*-d by cracks and fi.ssures. The dry crust peels off in flakes and iiatches. leaving the surface red and shining; sometimi-s there is
ft whitish aphlhnus exudation on the mucous coating of the tongue and mouth ; at other times late in the disease-, the tongue is morbidly red, some-
tlnm swollen, iminful and lender and occasionally ulcerated, — p. 72. .\ccording to Wood, the tongue, from tteing moist and clammy, often becomes quit©
dfy. assiiines a brown color and is at times gashed an<l sore. He reganls its condition in the later stages as an element of jirognosis : A favorable termina-
tion is iiidicate<l by the tongue liecomiiig moist and clean ; but in other instances, especially in severe and protracted cases, " instead of cleaning gnuliiatly
ftwn the i^lges it throws off its fur in flakes, generally at first from the centre or towards the base, leaving the surface smooth, red and somewhat
ihliiing. as if the ]<ipillary structure had been [lartially destroyed. This state of the tongue is sometimes preceded by soreness of the fauces ; and the
Telum pendulum and half arches will, if examined, t>e found covered with an exudation which they are iKiginning to i>art with. This is usually a sign
of an appnuiching amelioration of the symptoms. If the tfuigue when thus cleaned remain moist, convalescence may be pretty confidently exiK-cted,
though it i^ always tr-<]ious. In some instances the tongue coats its<-lf over again, ami again becomes clean ; and this change may tak>' place more than
once. Oir:k,itiiially. Ion, an aphthous exudation a[iis>ar>i uikui the surface ; but still, if the moisture continue, the progn<»sis is ultimately favorable. If,
bovpTer. at any lime during the atiove cleaning prisess, or evin after it has lieen completed, the tongue should become permanently dry the symptoms
^»re again aggravated and the [latient again thrown into danger."— Vol. I, p. 317.
292 SYMPTOMATOLOGY OF
brown and fissured condition of the tongue: In case 43 of tlie Seminary series tlie appetite
was good although the teeth were covered with sordes; and in 48 it is said to liave been
retained until the day of death.
In forty-eight of the Seminary cases in wliich tlie condition of tlie TotlffllB was recorded during the progress
of the fever, it was red at the tip and edges and variously coated brown, gray, yellow or white on the dorsum in thirty-
two cases. Indeed it may be said that these eharaetcristics were present in thirty-four cases, if the description given
in case 3, "smooth, tissured, red, dry, quite clean anteriorly, but with a brown fur posteriorly," and that in 22, "red
and slightly coated yellowish-white," be accepted as eciuivalent to red at the tip and edges* Of the remaining cases
the tongue was dry, brown and fissured in 10, 19 and 24; red, dry and glossy in 6, 7 and 16; smooth, glossy and dry
in 46; brown in 14 and 50; moist and coated in 17 and 41; dry and coated in 39; dry, red and with enlarged papilhe
in 5; and yellowish-white when first noted, and afterwards white in 2.
In two cases, 4 and 18 of the thirty-four in which what may be called the characteristic tongue of typhoid was
present, it is mentioned as having been at one period flabby. In the first of these the early appearance of moisture
on the skin, and the benefit following the administration of quinine, suggest the possibility of a malarial complica-
tion; but in the other the flabbiuess of the tongue was unaccompanied by other suggestive symptoms.
The tongue when protruded in the earlier stages of the disease was often tremulous, participating in the
debility which aft'ected the muscular system. In the later stages it was protruded with difficulty, and the mouth
was frequently coated with a tenacious glutinous mucus.
Sordes gathered on the teeth and lips of twenty-one of the fifty-one cases, and five of these had a fatal
termination. Five of the thirty cases which did not present these accumulations were likewise fatal: 41, killed in
his delirium; 42, died of pulmonary congestion; 47, from a recrudescence of the diarrhoeal affection; 51, from exhaus-
tion, and 46, from some unstated conditions several months after the primary attack.
Prom these facts it may be inferred that althougli sordes and tlie generally accompany-
ing dry, dark tongue were symptoms of great gravity, the disease was nearly as prone to
end fatally in their absence as in their presence.
The condition of the mouth and tongue was alone sufficient to account, in many cases,
for the dysphagia or disinclination to swallow which was sometimes manifested; but owing
to the difficulty of examining the throat in patients laboring under typhoid prostration, it is
probable that inflammation and ulceration of the fauces and pharynx were more frequently
present than appears from the records.f Dysphagia in case 40 was due to pharyngeal inflam-
mation ; but in other instances, as in 197 of the -post-mortem cases, it must be attributed
mainly to the deep stupor in which the patient was plunged.
Diarrhcea was present at some period in the progress of most of the cases, varying fi'om
a slight relaxation of the bowels to an attack giving six, eight or more stools daily. Occa-
sionally the intestinal affection was manifested by a want of consistence of the passages
rather than by their frequency. The discharges were usually thin, small and yellowish,
sometimes watery, often fetid, and generally painless. J
* The recognition of tbis condition of the tongue as characteristic of typlioid fever has tlie autliority of Sir W. Jenner, who says that : "The
small dry tongue with red tip and edges, smooth, pale brownish-yellow fur, and fissured — the surface seen between the fissures being of a deep red — may
be considered ditferentially as a diagnostic sign of typhoid fever." — Monthhj Jounutl of Jl/crf. Scienct; Edinb., Vol. X, 1850, p. 310. "I have observed,
indeed have learned to regard it as almost characteristic, that the tongue in typhoid fever shows at the tip a wedge of reddish or brownish surface free
from coat." — J. M. DaCosta in Tt-aiis. College Phyaieimis, Phila., 1S77, p. 104.
f Jackson found a difficulty in deglutition more or less strongly marked in 21 of his 303 cases, and of these four were fatal. He considered that
were he to count only those cases in which the dysphagia was very great this symptom would be an indication of much danger, — p. 38. Of thirty-two
grave but not fatal cases in which Louis examined the mouth and fauces with care, there was inflammatory redness in twenty-one ; the tonsils were
swollen in three of these cases, tlie velum in two, the pharynx to some extent in one ; the roof of the palate w.as in one instance covered with a number of
whitish pellicles which wei-e easily separated from it ; ulceration was present in three cases, the pillars of the fauces being affected in two and the lower
lip in the third, — t. II, p. DO. And in connection with these signs of inflammation most of the p.atients complained of pi.in, pricking sensations, dryness
and more or less difficulty in swallowing. But among his fatal cases there were several in which the pharynx and cesophagus were more or Jess
periously affected with no symptom to indicate their altered condition. In explaining this anomaly by the presence of delirium, he took occasion to
remark that an obstinate refusa' to drink on the part of a delirious patient may be regarded as an index of the state of the throat and generally of tho
(irgans of deglutition, — t. II, p. 130.
J "The stools may be only one or two daily, or more frequent, up to ten, twelve, or more. They are generally yellowish or brownish, and
apparently healthy except in con'-^stence. This is one of the remarkable features of the disease. While in other severe fevers the discharges are almost
always greatly altered, in this they often remain nearly natural, with the exception alluded to, throughout the complaint." — Woon, Vol. I, p. 310.
Bartlett compares the liquid, turbid and yellowish stools to new cider ; but says that in a considerable number of cases they are of a dark-brown color,
fetid and offensive, — p. 75. flluRCHlsoN represents the stools as liquid and of the color of yellow ochre, offensive and often ammouiacal in odor and
alkaline in reaction, — 4;. 524. Watson characterizes them as somewhat like pea-soup, — p. 1097. Liebermeisteb sjiys ; "The stools are thick or watery,
light-brown or yellow, often like pea-soup ; after standing they separate into two layers ; the upper is a turbid brownish fluid, the lower is a brownish
flocculent mass ; the re.action of the fluid is alkaline ; it contains little albumen. In the sediment wo find fragments of food, detritus, mucous corpuscles,
fungous spores, accidental substances, often crystals of triple phosphate,"— p. 92.
THE CONTINUED FEVERS. 293
Omitting cases 33 and 35, there are forty-nine cases in the Seminary records in whicj the condition of the
bowels was stated from day to day. In forty-live of these the diarrho'al tendency was more or less marked; never-
theless in nine of tlieni at some period of their history it was deemed advisable by the medical attendants to adopt
sonic means to eft'ect a movement of the bowels: In two, 30 and Ki, eneniata of soapsuds were employed with
the intent of relieving abdominal pain and distention associated with constipation in the one case and a quiescent
condition of the bowels in the other; in the former no recorded cllect was produced, and diarrha'a did not occur
until several days later; in the latter the enema appeared to determine a condition of relaxation. In 30 and 10
castor oil was administered without producing any over-active effect; but in 6 its exhibition was followed by umbil
ical pain and a necessity for the administration of acetate of lead and opium. In 38 and 39 calomel and jalap were
employed without apparent harm to the intestinal tract. In 9 and 13 blue-pill and Epsom salt were administered, but
the induced action did not persist. Of the four cases which were not characterized by marked diarrhceal tendencies
the bowels are saiil to have been regular in one, the mild febrile attack, 2, in which castor oil was given towards
the conclusion of the case; in two cases, 8 and 1.5, the bowels were quiet and calomel and jalap did n(-t cause undue
action : in the fourth of these cases, 29, there was notable constipation, no passage having been procured during the
stay of I he patient in hospital except by the use of castor oil.
It is somewhat difficult to compare the relative frequency of diarrhoea in typhoid cases
reported by different observers when numerical statements only are made the basis of the
comparison. This appears due to a bias given to the clinical records by the pathological
knowledge of the reporter. The recognition of an intestinal lesion as the anatomical
essential of the disease and the connection of diarrhoea with an ulcerated condition of the
intestinal mucous membrane have probably led many physicians to regard and report as
diarrhoea in typhoid fever that which would not have been recognized by so formidable a title
had it occurred in the course of a pneumonia or other acute disease. Laxness of the bowels,
or even a tendency to relaxation, manifested by a diminished consistence of passages of
natural frequency, may by some have been considered as establishing the diarrhoeal condi-
tion. To draw conclusions from statements regarding the frequency of diarrhoea it is need-
ful to know precisely to what conditions of the bowels the terra was applied. It is clear
that Louis recognized one passage daily as a typhoid diarrhoea; he graded this symptom as
fort, modere and faible, and the last included cases that might not by every one be considered
diarrhoeal.*
Nevertheless, in view of the acknowledged absence of diarrhoea in a notable propor-
tion of typhoid cases observed in civil practice, there appears no room to doubt that the
cases which occurred among our soldiers during the war, as illustrated by those preserved
in the records of the Seminary hospital, were characterized as a whole by the prevalence of
a more severe and protracted diarrhoea than is usually associated with the disease.f
•Lons's statistics Ix'ariDg on the frequency and severity of diarrhcca in typhoid fever are a^ follows : Of 120 cases diarrlicca was present in all
bat two. Of 32 fatal cases an active diarrhoea of eight to ten or more sXwM in the twenty-four hours was present in 18 ; a moderate diarrhcea of from
foor to six sI'hjIs daily in 7 ; and a mild diarrhcea of one or two stools daily, rarely more, also in 7. In 57 severe but not fatal cases tl:e diarrlicea
WM violent in 14 {utieuts who had from eight tfi twenty stools daily; less severe iu 22 cases with two to four stools daily; and moderate in 21 others in
which the nnmlNT of the stools is not indicated. The diarriuea iu ;il mild cases was less intense and of shorter diuutiou than iu those already
state,!; it was cousideraMe iu 4 crises, absent in 2, while in the remaining 25 the degix'o of severity is not stated in direct terms, but the presum[>-
tinn is that it ilid not excei^d one or two stools daily,— t. II, pp. 17, Si and 25. Uale, in his analysis of the cases of the Ma-'ssaclnt etts General hospital,
conclud^ti — p. 22J — that the princiiml difference between the typhoid fever of New Knglaud and that of Paris, as delineated by Louis, was the greater
ftt^uoncy of diarrhoea in the latter. In bis hospital cases he found diarrhcea in 107 of 2*.I7 cases, or in .W per cent. ; and in 197 cases of which he had
the histories in detail the proportion was still less, 00 caises or 49 per cent. Hut he found a similar difference in regjinl to the prevalence of diarrho-a in
other acute diseases according as they were recorded in Slassachusctts or Paris ; Louis reiwrted 01 cases of diarrlueji in 273 of acute disease other than
typhoid fever, which is nearly :UI per cent., while in 1.50 cases of similar dis»^ase in New Kugland, diarrhoea wai* present in only 18 cases, or 11 per cent.
Kniin these facts he conclndetl that the more frequent oecurrenco of diarrhoea in the fever of I'aris was not to Iw attributed to any peculiarity in tlio
chanu-teristies of the disease ilself as comiiared with the typhoid of New Kugland, but to some more general cause affecting other acute diseases in an
equal proiMirtion. It is poesible that the more general cause may have been, to some extent at least, a want of precision iu the application of the term
djarrhwa.
t MirirnisoN conidders iliarrhcea to be aliseut in fully one-fifth of the cases, — p. 524. See also the preceding note giving the okservationa of Louis
and Halk. Iu Flixt's Vliniral Itiyttrtu oti Coidinurd Feerr he states that tliarrhfea monj or less in degree or duration was prescuit in 12 of l;i cases of
typhoid fever, in 7 of which it was mild or slight, iu 1 severe and in 4 subse«ineut to the operation of cathartics, — p. 80; iu 0 of IS cises and in 14 of 29
eaaes, — p. 17:t; and in Vi of 14 cases, iu all of which it was mild auil e;isily restmined by opiates, — p. 310. With few exceptions, jiroliibly not more than
thlre or four, no cathartic or laxative meilicine was administered in the eases analyzed by I>r. Fli.st, consequently the condition i>f the bowels as n'S|x!ets
freonency of the dejections and other symptoms were such a."* lielong to the disease uninHueneed by medical interference. The facts conttined iu tho
histories uf s^.me of his eas4's he cousiilers to be of interest and imp<irtance, and believes that they will be a siirpriw to some of his Headers .is showing
that oftentimes instead of diarrhieaa state of al>sidut'- eimstipation was pn-sent. He gives sevenil c;i.st'S in illustration, of which the following is quoted
as a s]A-cimeu : *' Vote 3. In this case the bowels had not moved for tlirrr days jirior to admission. They remained quiescent for /ir« days after admission
294 SYMPTOMATOLOGY OF
111 general terms, the gravity of the affection was proportioned to the severity of the
diarrlioea.* In mild cases the diarrhosal attack was slight; in severe cases it was aggra-
vated, and death in many instances was precipitated by its violence. The frequent occur-
rence of involuntar}^ passages shows that an implication of the cerebral system did not
interfere with this manifestation of the morbid condition of the intestinal tract. But there
were many exceptional cases in which, with moderate diarrhoea, perforation of the intestinal
tunics took place and death resulted from the escape of fsecal matters into the peritoneal
cavity. The subject of perforation will be submitted to better advantage in connection with
the post-mortem records. Cases also proved fatal from the gravity of pulmonary lesions
without being of necessity associated with an aggravated diarrhoea.
Hemorrhage from the bowels occasionally added to the exhaustion consequent on the
diarrhoea and prostration due to the specific action of the fever-poison. In case 28 of the
Seminary series the bleeding was profuse, and occurred about the end of the third week, no
doubt from an invasion of the vascular walls by the ulcerative process; the case terminated
favorablv. It is probable that bleeding in small quantity, dependent on a congested state
of the intestinal mucous membrane, occurred in some instances at an early date without
exercising any marked influence on the progress of the disease; but it is certain that the
profuse hemorrhages of a later period were symptomatic of grave, immediate and possible
dangers. Occasionally severe hemorrhage occurred in cases which were otherwise free from
alarming symptoms; of this Brigade Surgeon George H. Lyman has furnished an instance.f
Fatal exhaustion sometimes followed the loss of blood, as in case 27 of the i^ost-mortem
records. But if the patient rallied from the loss, the possibility of a fatal recurrence or of
peritonitis with or without perforation, as suggested by the depth of tissue necessarily
involved in the ulcerative process before a hemorrhage of this character could take place,
was such as to occasion the most serious forebodings.^ It is probable also that fatal exhaus-
tion was sometimes the result of hemorrhage which did not manifest its existence by the
and moved spontaneously on the third day, i. e., on the sixth day after the last preceding movement. On the day following another dejection occurred,
which was moulded and perfectly natural in appearance — a phenomenon which is not likely to fall under the ohservation of practitioners who are
accustomed to admtni;dter cathartics daily, or erery other day, during the progress of the disease:" — p. 175.
* MimcHisoN is very positive on this point. He says, p. 524 : " Twelve years ago I found that in 34 cases, where the diarrhoea from its severity or
duration was noted as excessive, 10 died ; but that only 10 died out of 50 cases in which the drarrhcea was moderate or slight. Since then I have had
under my care more than two thousand cases of enteric fever, and no fact appears to me to be better established than that the severity and danger of this
disease are in direct proportion to the intensity of the diarrhoea. " Natuas Smith in 1824, writing of the fever as it prevailed in New England, expressed
a similar opinion : "The danger of the disease is in proportion to the violence of the diarrhtea ; when the patient has not more than four or five liquid
stools iu the twenty-four houi-s it is not alarming, as it does not seem to weaken him much, but if they exceed that number serious consequences may
be apiirebended,'" — j). 37.
f See his letter to the Bo^on Med. and Surg. Journal, Vol. LXV, 18fi2, p. 389 : "One case of continued fever so mild in its type as to call for little or
no treatment was complicated with intestinal hemorrhage to an alarming degree."
J Hemorrhage from the bowels occurred in 31 of Jackson's 303 cases, and of these 20 terminated favorably while 11 died. "In some instances
the hemorrhage was followed by relief, and in a few by well marked and permanent relief. But in most there was great weakuess and sense of exhaustion
iu consequence of it,'' — p. 39. Notwithtanding his statement as to the relief occasioaally obtained, this author's observations show distinctly the
increjised danger in cases attended with hemorrhage, for while the general death-rate based on his 303 observations was 13.86 per cent., the mte
among the hemorrhagic cases was 35.5 per cent. Hemorrhage amounting to over six ounces occurred in 5& of 1,564 cases under Mvbohison's tare, or iu
3.77 percent. In IS of 60 hemorrhagic cases the antecedent symptoms were mild, and iu 8, of which 6 were fatal, the bowels up to the occurrence of the
hemorrhage had been constipated. Of the 00 cases the bleeding commenced towards the close of the second week in 8; during the thinl week in 2S;
during the fourth in 17; during the fifth in 1; during the sixth in 3; during the seventh iu 1, and during the eighth in 1, while in 1 case the ilate of its
occurrence wjis not recorded. In three cases where it took place on the sixteenth, eighteentl^aiid nineteenth days, it recurred on the forty-ninth, thirty-
fieco!id and forty-fourth days. This author never observed benefit from its occurrence, but on the contrary has frequently seen patients die unexi»ect-
edly by syncope a few hours after a copious bleeding. He therefore agrees with Bsetoxseai', Chomel, Loris, Jexner, Bell and others in regarding it
as a dangerous symptom, although he cites some authors who taught otherwise: Gr.wes, in his Clinical Lectures, Dublin, 1848, Vol. I, p. 20(), as speaking
of certain cases in which the occurrence of hemorrhage was thought to be productive of marked benefit; Kennedy, Edinburgh Med. Jour., 1860, \k 'I'JiG,
as of a similar opinion, and Trousseau, Clinique Mtdicale, Paris, 1S65, 1. 1, p. 225, as urging that it is a less dangerous symptom than is generally thought,
inasmuch as in seven yeare he had known only three cases to prove fatal, — pp. 525-29. Liebeemeister, although failing to concur with Graves and
Teousseau as to the favorable import of hemorrhage from the bowels in this fever, does not on the other hand regard it as having so dangerous a signifi-
cance as was fonnerly thought. His mortality statistics agree with those of Jackson given above : 38.6 per cent, of his hemorrhagic cases died, while
the general rate was only 11.0 per cent. Nevertheless he points out that a i>atient seldom dies as the direct result of hemorrhage or during the conapse
that immediately follows it, and he considers the statistics inconclusive, since bleeding occurs most frequently anjong the gravest cases iu which the
mortality without hemorrhage would still be highest. He concludes, therefore, that "while intt-stinal hemorrhage must bo regaitled o» the whole a«
affecting the iirognosis uufavoi-al.ly, yet each individual ca.se must be judged un its own njerits,"— p. 1411.
THE CONTINUED FEVERS. 295
presence of blood in the stools.* Although no clinical history is recorded in case 176 of
the post-mortem series, the possibility of the occurrence of death without external man-
ifestations of erosion of the intestinal vessels, other than those involved in the supervention
of sudden collapse,f is strongly suggested by the condition of the colon, which was found
filled with blood for eighteen inches of its length.
Diarrhoea occurring during the course of tlie primary fever was associated with heat and
dryness of skin, and in mild cases its subsidence was concomitant with the decline of the
pyrexia. Moreover, when it persisted at a later period along with a persistence of the febrile
action in more dangerous cases, its abatement or absolute cessation was often coincident with
the appearance of moisture on the skin and especially of free perspirations. Thus in eleven
of the Seminary cases a moist condition of the skin was followed by more or less quiescence
of the bowels, and in one, 49, the recurrence of acute diarrhoea was associated with sup-
pressed perspirations and increased heat of skin. On the other hand, in five instances, 16,
27, 34, 46 and 47, looseness of the bowels persisted notwithstanding the occurrence of "per-
spirations; in two, 14 and 37, it followed their appearance, and in one, 26, it abated with
diminution of the febrile heat some days before the skin became moist.J
Although diarrhoeal stools w^re usually passed without pain, the patient generally
suffered from pain or tenderness in the abdomen at some period of the disease. In many
instances the tenderness was limited to the situation of the ileo-colic junction, and although
in others the suffering was not thus localized, it was nevertheless more acutely felt in that
region than in other parts of the abdominal cavity. It was frequently associated with
tympanitic distention and gurgling on pressure. § These symptoms usually accompanied
the diarrhcea, sometimes preceded it, and often persisted after its subsidence.
Tenderness was present in thirty-nine of the forty-nine Seminary cases, tytnpanites in twenty
eight and gurgling in nineteen.
Tenderness was recorded as having aflected the aljdomeu generally in eighteen of the thirty-nine cases, hut
in ten of these certain regions were, in addition, specitically indicated as the seat of sufi'ering; in three the right
iliac region was particularized, in tn-o the right iliac and uiiihilical and in fire both iliac regions, — one of these having
the umliilieal and another tlie hypogastric region also atlected. The right iliac region was mentioned alone as the
Bite of tenderness in fifteen cases, and in association with other regions, in addition to the cases Jnst mentioned in
connection with general al)doniinal tenderness, three times — with the umliilieal once, the left iliac once and the
hypogastric and umbilical regions once. The last-mentioned region was principally affected in one case, 6, in which
the tenderness was probably due to castor oil administered; pain in the epigastrium was reported in one case, 17, in
which the onset of the disease was characterized by the presence of nausea; lastly, in one case, 48, tenderness was
associated at different times with ditterent regions, as the left iliac, epigastric and umbilical, the track of the colon,
and on one occasion the right side.
In these thirty-nine cases of abdominal tenderness the general surface is mentioned eighteen times, the right
iliac region twenty-eight times, the left iliac seven times, the umbilical seven times, the epigastric three times and
the hypogastric once.
• MracHisON bas known profuse bleeding to talce place into tlio bowele and tbo patient die before any blood bad l)eon voido^I, — p. 520.
t*'In any rase of intestinal bemorrliaj^e tbe tenilM-nitnre suddenly fulls sometimes below the uorniul standard, Init it speedily regains its former
height or rises lieyond it." — M|'iu-his<)N, p. .WO. "If .s«'vere bemorrbajjes supervene in tbe course of abdominal typbus, piirticularly hemorrliagea from
the bowels, a considerable fall of teniiwratur* may txt met witb, even to Ixdow nonnal; but tbe temperature usually rises again epeedilj to tho previous
height^ or even alwve tliem." — (.". A. WuspE-Lirii, 0» Ihr Ti^iiitrattire in I)uu:tuifx, New Sydenham Society, London, 1869, p. 313.
tSee notes on pp. 2.*»;l and 284, mpra^ indicating tbe greater frequency of perspirations throughout tbe attack of typhoid fevor in the diat^sc as
described by the authorities than in the cases depieteil t>y our nu^dical officers during tbe war, and tbe opinion that such perspirations have no favonil)Io
influence on tbe progress of the disease. Speaking definitely as to a possible relationship between perspinitiou and diarrhowi Lol'is siys, t. 1 1, i>. 2ttC,
that in grave cases which recovere<I the skin was onlinarily dry during tbe day and a part of tbe nigbt, while during tbe remainder of tbe night thero
was nearly always sweat;; which were no umre influencctl by the diarrho-a and had no more influence on it than in the fatal ca.ses; and he bad already
shown that tlirve-fourtbs of tbe latter bail been affected with copious i)erspiration8. ilo also mentions—^ 2G7 — the caso of a patient witll obstinate
diarrbtea in whom the perspirations lasted for eighteen days.
^Gurgling, as elicited by pressure with the band on the lower part of tho abdomen and especially in the right iliac region, was regarded by
CnoMELas of diagnt«5tic importance. In his experience it was as rare in other diseases as it was common in typhoid fever, — t. I, p. 12. ItAttTLBTT
conaiilinM it a di.agnostic element,— p. 78. Kef.ves found it a constant accoiniianinicnt of enteric fever,— p. 20. Mcrchisok noted it in 31 of 44 cases,
hut sulisetinent ex|(erience satisfieil him that it is absent in a larger propi,rtion of cases than is indicated by thesfl figures,— p. .'i23. Wll-sos considers
that this s>iuptotn, when nssm-iatt^l witb tenderness, has an undoubted diagnostic value, but as it occurs so constantly in other affections attended with
diarrba-a it launot \t*r iooki-d upon as a characteristic phenomenon of enteric fever, — p. 174.
296 SYMPTOMATOLOGY OP
Tendoriiess, although usually not a source of much coniplaiut, was sometimes very acute ; iu 10 it was recorded
as exquisite, aud iu 30 the patient objected to having the abdomen touch(^d.
Iu three of the four cases which were free from diarrheal tendencies there was nevertheless some tenderness
of the abdomen. Among these is included case 29, iu which the bowels were moved by the action of castor oil; the
only case which presented no clinical sign of an enteric lesion was the mild and apparently unspecific attack recorded
as case 2.
Of the ten cases in which there is no record of abdominal tenderness, /oitr, 2, 4, 12 and 14, were of a mild type.
In one, 34, which was more severe, the presence of tympanites on the record suggests that the absence of tenderness
may have been due to an omission on the part of the recorder. A similar remark is applicable to the three fatal cases,
44, 45 and 51. In one case, 39, the gravity of the affection was dependent on chest complications, and in one, 41, the
record was cut short by the accidental death of the patient.
Distention of the abdomen was usually present in severe cases and absent in those of
a mild type.* Generally it was associated with diarrhoea and abdominal tenderness. It
was, however, sometimes present in the absence of decided diarrhoea, as in 46, in which
an enema was given for its relief. In four cases specified in the last paragraph tympanites
appears on the records, while tenderness is not mentioned; but in some of the cases it is
stated that although the abdomen was tympanitic there was no tenderness: In case 12 it
does not appear that the abdomen was at any time tender, and at one period in the history
of 26 there was much tympanites, but no tenderness until some time later when the right
iliac region became acutely affected. On the other hand, in 10, with much tenderness the
abdomen was reported as scaphoid, a term ambiguous in this connection, but probably used
to indicate a concavity of the surface; but in 48 there is no uncertainty as to the condition. —
the abdomen became flat shortly before death.
The frequency with which tympanites was present in fatal cases may be seen by a
reference to the pos^-mori!em records. In case 19 of this series, the only instance iu which
meteorism is stated as 7iot present, hardness and tenderness of the abdomen were associated
with symptoms of intestinal perforation. Pain and tenderness in cases fatal by peritonitis,
with or without perforation, were usually extreme, but not always confined to the anterior
aspect of the abdomen ; in 249, the pain, which was so exquisite as to occasion loud outcries,
was referred to the back.
In connection with the symptoms referable to the abdomen it may be mentioned that
in no case do the clinical records refer to enlargement of the spleen as a characteristic of
this fever. That it existed is certain ; necroscopic observations leave no doubt of the fact,
but the attention of our medical officers does not appear to have been given to its detection
during life."]"
*Hale recognized meteorism iu 130 of 197 cases; in 43 it was not present, and in 24 his records did not show whether it was present or absent, — p.
100. MuRC'liisoN found tlie distention greatest in the gravest cases ; it was present in 20 of 21 fatal cases ; of 17 in which it »vjis extreme, death occurreii
in 7, while of G2 in which it was moderate or slight only 14 died, and of 21 in which it wiis absent nrtne died, — p. 522. Jenner pointed oiit that the
"convexity is from side to side and not from above downward. The patient is never pot-bellied but tub-shai»t;d, the cause probably being that the flatus
occupies the colon, ascending, descending and transverse." — MojiHihj J<mr. Med. Scwiice, Edinburgh, Vol. IX, 1849, p. 820.
fSince Louis first called attention to enlargement of the spleen in cases characterized by tumefaction and ulceration of the patches of Peyer this
condition of the organ has assumed an increased importance in the o])inion of the profession, being generally regarded as one of the most constant and
characteristic sjTuptoms of typhoid fever. Jackson in 1838 wrote that : " Enlargement of the spleen was discovered in various cases ; some before we were
aware of M. Louis's observations on this point, and many more after. But it was not a matter so carefully attended to, in every cise, as to give value to
our observations," — p. 57. The tumefied spleen was felt during life iu 19 of Enoch Hale's eases, not felt in 21 and not noted on the record in 1.'j7 cises.
He says : "Enlargement of the spleen, as perceptible during life, is not of much value as a pathognomonic sign. This organ is occasionally felt below
the ribs, or by jiressing the lingers under the cartilages during a full inspiration ; but in many «ases it cannot be perceived even where examination after
de.ath shows it to be much enlarged. A careful percussion would aid in discovering it. But since there is mnch uncertainty in regard to the enlarge-
ment itself, as a constant occurrence, and some difficulty in ascertaining it when it does occur, we can attach very little importance to it in diagnosis," — p.
190. But althouKli these observers thus long ago called attention to the enlarged spleen as a symittom and aid to diagnosis in typhoid cases, the
changes in the organ were mentioned by Bartlett, Woon and Dickson only as of post-mortem interest, and to this is probably due the failure of our
medical officei-s during the war to note splenic enlargement in their clinical records. Murghison says the si)leen is often much enlarged and can be
felt through the abdominal wall, — p. 523; and Liebermeister, tliat the enlargement begins early, and can usually be demonstrated after the middle of
the liret week, increasing in the second week, diminishing in the fourth week, and at the height of the disease reaching to double or treble its normal
size,— p. 104. Christian Baumi.er — Can the Nildest Forms of Enteric feeer be distivijnished from acute Febriie but uon-specijic Gastro-eiiteric Catarrh f—UiibltH
Joitrital Med. fieieitces, \o]. 70, 18K0, ]). 384 — answers bis query in the affirmative by the statement that a decided enlargement of the spleen existing from
the beginning of the attack clearly points to the infectious nature of a given disease. His experience leads him to doubt the existence of a "go-stric
fever," ;, e., a cnf.-inb of the niMcn^ nieiotoMi f Ilie sl.noarli, ..r jierliaps also of the small intestine, accompanied by jiyrexia of a week's duration or
THE CONTINUED FEVERS. 297
Chest Symptoms are luentioucil in tliirty-oueof the lifty-oue Seminary eases.* Bronchial cougli was freciucutly
an early symptom of the attack; sometimes dry, at other times attended with frothy expectoration, it usually cou-
tiuued to the end of the fever, and in occasional instances, as in o5, persisted for some time loni;er. Hut in iiuiny
eases it was not developed until towards the end of the primary fever.
In aliout two-thirds of the thirty-one eases the cou^h was slifjht and did not add uuirh to the sulforiufis of I ho
patient. In twelve eases (he chest symptoms were severe: In "> and 11 there was marki'd bronchitis ; in 2!S couj^h,
which was present friun the liejiinninj:, tiecame associated at a later period with sibilant rales and hniried respira-
tion; in oi' it was troublesome from the lirst, and prevented sleep at a later stage; in 15 also sleep was prevented,
and the lung complication certainly caused death: in 'M and tO there was consolidation of the lower lobes of the
lungs and bronchitic sounds in the ujiper lobes; in 42 death occurred from pulnwnary congestion; in 50 pleuritic
signs and hurried respiration were noted, and in 51 pain in the chest and increased fre<iueney of tlu^ respiratory
movements; in IW the cough was slight at first, buttho patient from the twenty -fifth to the thirty-second day labored
under a pueumouitic attack, manifested by pain in the chest, hurried respiration and rusty s])nta, and associated
with a recurrence of febrile delirium; lastly, in 10, one of the few cases in which the chest symptoms were of a serious
character during the early stages of the disease, an attack of pneumonia preceded the typhoid onset.
It is to be observed, however, witli regard to the occurrence of blood-streaked sputa,
that tlvis in some instances was not a syniptoin of an engorged or eroded condition of the
pulmonary membrane or tissues, but was considered an accidental result of a trivial epistaxis.f
Bronchial cough was sometimes associated with hoarseness, indicating the participation
of the laryngeal mucous membrane in the inflammatory processes. Fost-viortem observa-
tions showed in so many instances the presence of ulceration of this membrane that inflam-
matorv redness in the fauces during life must be regarded as stroncjly sugccestive of the
e.xistence of more extensive and dangerous lesions. J The voice generally became low-toned
or whispering, symptomatic of general prostration, and in the later stages of fatal cases the
power of articulation became lost.
In a large number of such of the j)ost-morteni records as enumerate more or less of the
symptoms, cough is found to have been present with accelerated or difficult respiration and
pain in the chest. Generally this affection of the respiration was due to congestive or pneu-
monitic processes, although in many cases the breathing was hurried during the first stages
of the disease as a result of the general febrile condition; but the clinical records do not
set forth with sufficient precision the condition of the lungs in these cases. The fatality of
this fever among our troops as compared with that of the same disease in the experience of
civil practitioners, together witli, as will be seen hereafter,§ the great frequency of lung
complications in the fatal cases, gives definite testimony as to the greater frequency and
severity of such complications among the typhoid cases of the war.
Other Clinical FE.\TruES. — Jlicturifion vras frequently involuntary. Sometinu's the urine was passed
with difficulty, as in 12, 28 and 35; in the lirst of these dysuria during the fourth week was accom])anied with pain
and the passage of blood from the bladder, and in the second the use of the catheter was required to alh^viato
hyjiogastric distress. But pain and swelling Ln the hypugastrium were not always indicative of retention of urine,
as may be seen in case 2U of the ^)««/-»i«r(f»i records, in which an abdominal abscess was the cause of these symptoms.
It may he ohserved. however, that this case is not recognizable from the record as one of typhoid fever.
The urine was scanty and high-colored during the primary fever, but its characters at a later date were seldom
specitied. In the Seminary. case, 28, the liquid removed had a strongly alkaline reaction and contained blood,
more and by general febrile symptoms. Ho must therefore have met with few cn-ses in which percussion failed to outline an enlarged spleen. Ncver-
Uu'Ii-!*;, LiKBKRMF.isTRR ubserves that enlargement is sonu-tinio^ ulHtent, esiwcially in old persons, in whom the anomaly is explained by a thickening of
Ilie (-ai>!>nU' or struma of the organ, or by the poss<'ssii>n of a spleen smaller than the normal before the commencement of the disease ; and he cites IbipF-
MAXX BA having stated that the essential changes can be. and usually are. pn-sent, although the spleen is not strikingly enlarged.
* lu Locis's experience cough was pres<'nt in oO of Ct~ subjects who bad severe attjicks of the fever, but it was genenilly so slight and infrequent,
that its existence would not have been recorded bad he made note only of that which came under his personal observation ; and it W!W hut little less
ffeipient in the ca.ses which were niiMly affected,— t. II, p. 28:5,
t Locis indicates blood-tinged sputa as due occjisionally to epistaxis, — t. II, p. 2S;j. Fust also notes — p. 199 — that "in three cases sputa expecto-
rate*! were obsentxl to be streaked with blood, which may have been derived from the posterior nares, liiU this is not certain."
J W. "W. Keen- — On llie Siirjical cfniiptimliuiiit mnl Wf/«e/s of Uie Cttniinued Ferertt^ Washington, Smithsonian Institution, 1877 — regards hoarseness
and s<inietimes complete apboni.a, followi-d by iMiroxysms of dyspiuea, especially at night, .as the symptoms of laryngeal implication. Hut even tin- first
|«riixysni may l<e sudden, unexpectea an<l fatal, {larticularly in supni-glottic cedemu. He shows laryngeal disease to be a cause of dysphagia, which is
pr>-senl in cricoid and arytenoiil necrost-^ ; for in sixteen such )"is«*s the pharynx wjw normal in ten and inflamed in only six cases, — pp. :i;'i, 2(1.
I S<-e i»(Vu, p. 430.
Med. Hlst., Pt. Ill— 38
298 SYMPTOMATOLOGY OF
mucuSj pus, epithelial scales and excess of phosphates ; iu 50 it was acid and albuminous, and in 38 allmminous during
the later stages, -when pneumonia was preseutj but normal chemically and microscopically earlier in the attack.*
Diminished secretion of urine, so frequently reported in the early period of the disease,
was often followed by delirium or stupor, but it does not appear that any causal relation-
ship existed between these phenomena; the urine was scanty in many cases that were not
cliaracterized by prominent head symptoms.
The pavotid fflmids became aft'ected in two of the Seminary cases, 44 and 50, and in several of those
detailed in the jfost-m or tern records.!
The inflammatory action was rapid in its progress to suppuration and disintegration
of the glands. As this complication is not mentioned in any of the recoveries its presence
must be regarded as significant of extreme gravity; moreover, as it is generally accounted
a rare complication of typhoid fever, the frequency of its appearance among our cases during
the war must be received as distinguishing them from the typhoid of civil life. J
Befl-sores were developed on the parts subjected to continued pressure in cases 24, 28 and 36 treated iu the
Seminary liospital, and in several of ilie jwst -mortem series.
JPains in the loiver eoctr entities were reported in four of the cases as having added much to the
sufferings of the patients at an advanced stage of the disease : In the feet, on the subsidence of the primary fever,
iu 32,- in the legs for a few days during convalescence in 33; in the heels and legs about the beginning of the fourth
week iu 28, and in the legs, which were greatly emaciated, late in the progress of the fatal attack, 46. But as these
manifestations belong to the sequelae of the disease rather thau to the primary attack or its complications, they will
1)6 referred to hereafter in their appropriate connection. $
Relapses. — It need hardly be pointed out at this stage of the analysis that the febrile
cases under examination seldom ran a regular course from their accession to the establish-
ment of convalescence. On the contrary diarrhoea and painful meteorism were prone to
recur after they had apparently subsided or been controlled by medicine, and latent lung affec-
tions were liable to become suddenly aggravated to a dangerous intensity. Coincident with
these recrudescences delirium might return, the skin acquire a greater heat and fresh crops
of the rose-colored eruption make their appearance. The duration of the attack was thus
in many instances either prolonged or brought to a speedy and fatal termination.
* According to Murchison the urine is scanty, high colored and acid, its specific gravity 1025 to 1030 during the first two weeks, but afterwards,
and especially during convalescence, it is copious, pale, feebly acid or even alkaline and of low specific gravity. He has known it as low as 101).t or
1003, — p. 530. The amount t»f urea excreted during the febrile period is in excess of the nurmal. Parkes gives the increase at one-fifth ur a total daily
excretion of 480 grains instead of 400 ; but it is occasionally greatly in excess of this amount, Vogkl having in one instance found 1200 grains and Parkes
880 grains. An altered condition of the kidney, as shown by the presence of albumen and tube-casts in the urine, may prevent the elimination of urea
and induce symptoms of ursemic poisoning, a result which may also be due to reabsorption. Murchison found in several instances that the quantity of
urea diminished on the advent of cerebnil symptoms and increased on their cessation. In one case the quantity, which was 292 grains when the patient
was delirious and unconscious, rose to 004 grains when the delirium abated and consciousness returned ; iu another the quantity which at first was
422 grains, fell to 352 on the appearance of delirium and stupor, and rose to 4&0 when these symptoms ceased. During the att-ack uric acid is inci'eased
and chloride of sodium diminished. This author holds that albuminous urine coincides with the occurrence of cerebral symptoms. He sums up the
observations of Parkes, Brattleu, Beij^ueeel and others, and finds that albumen was present iu the urine of 157 of 549 cases of typhoid fever, or iu 28.6
jwrceut. of the cases,— pp. 531-532.
t See infra, p. 420.
I Parotid swellings and suppuration are more frequently associated with typhus than typhoid fever. Of certain cases studied by W. W. Keen,
typhus was the preceding fever in 352 and typhoid in only 26, — p. 53. Murchison met with six cases of parotid bubo, which he regards as a rare compli-
cation of typhoid fever,citing Lot;is, Chomel and Gairdxer as each reporting but one case ; two of his six eases died,--^p. 583. Suppurative parotitis w;u4,
however, more frequent and less fatal in Hoffsiann's experience .at Basle. Of l,GO0 cases of typhoid fever the parotids became inflamed in 10 ; iu Hi of
the cases the inflanwnation ended in supinu-ation, and of these only 7 proved fatal ; the right side was affected in 9 instances, the left in 0, and both sidi-s
in 4, — p. 178. Oorn-spondin-ily in this country, while Hale and Reeves make no mention of parotitis as a complic^ition of their cases, Austin Flint
riruids 3 cases of parotid inflammation in 7;i of fever. In his first series the parotid was inflamed twice in 30 cases ; in his third series once in 14 eases,
while in his second series of 2'J cases this complication was not present. Commenting on these dissimilar results iu his fii"st and second series of cases.
Dr. Flint points out that "parotitis is not to be regarded as an intrinsic element of the disease, but one of the events which are due to certain special
tendencies incident to the disease at particular times or places — tendencies the nature of which are not susceptible of explanation with our present knowl-
edge of the pathology of fever," — p. 171. In his first case the right parotid became affected on the tenth day of the attack and the left on the following
day. The large livid-red, tender and painful swelling immediately proceeded to suppuration. There was no diarrhoea in this case, and but slight delirium
and moderate somnolency. The patieut sat up on the twenty-eighth day, and on the thirty-second, when the last entry was made in the recoiii, tliere
was still some discharge from the abscess. In the second case the right parotid began to swell on the seventh day. This case was cliaracterized by mild
diarrhiea, tenderness, meteorism. passive delirium and sonmoleucy eventuating in coma, the patient dying on the ninth day while the jMirotid cnntinned
< iilarged and lesii^ting to the touch. In tlie third case the right i)arotid became affected at the period of couvaN^scence ami jtroceeilrd to sujipuratioii ;
till- iMitieiit recovered. Dr. Jackson noted four cases, of which one was fatal, in 31 13 of typhoid fever; suppuration took place in but one of tlie cases, the
issue in this instance being favorable, — p. 57.
gSeoi»/r«, p. 309,
THE CONTINUED FEVERS. 299
But cases which with accuracy might be called relapses were not common.'^' Possibly
some which ran a lengthened course may have been instances of what Ikvine has called
intercurrent relapse,f but this appears to be a needless refinement in clinical study based
upon the assumption of a regularity in the progress of the disease which is not found in
nature. Viewing a relapse as a return of the fever with all the symptoms of tlie primary
attack some time after the recognized establishment of convalescence, the Seminary records
* MuRruisoN records 80 i\'hi|>^'ft in 2,591 awi.'j* of typhoid ft-vor in the wards of the Loudon Fevor haspitnl, or in ;i per c«nt, of the ciu>08 ; ho citi'S
(■RiC5iN<tERa8 huving noted thoni in 0 |H>r cont. of 4(Kic:Lsi'S at Zurich, IIi'man in 8 per cent, of ri48 at Leipzig, and Maclaoan in 13 catw» or above 10 \)or
ct'nt. of 128 raiit's at Dundee. It wcnis clear from these varying percentages that rehvpscs are of more frequent occnriTnce in noiiie epidemics tlian In
others. Jackson called attention in thin countrj' to the iiatsihility of relni)se in typhoid : " Au error in diet and regimen in often followed by a new
tniin of symptoms after convaleeicencc from this disease ; and these appear to me to he such as belong to this fever. It is, liowever, true that they aro
not always so strongly characteristic as to leave no doubt on the subject. If, however, they aro carefully noted, they will not ho found to acconl with
any other disease. 1 hope by thesfe remarks to call such exact attention to the subject as may decide this point hereafter," — p. Gl. But he gives only
one case to point his remarks. Dr. Flint's experience was of greater intenst. In his first series of thirty cases there was no relajwe, and as, up to that
time, be liad n?ver witnessed what might properly bo called a relapse after the career of continued fever was ended, he was surprised at the st^itementA
made by some writeii on the subject. Unt in the secontl series of cases "my attention was freijuently called to the fact that during convalescence, aiul
after patients had so far recovered as to sit np, and even walk about the ward, they were attacked with febrile movement, sometimes preceded by a chili
ftcconiiKiuied by anorexia, deiirinni, etc., these symptoms contiiniing for several days, when they again began to convalesce. In sonni instances I was dis-
posed to attribute this recuiTeuce of fever to imprudence in diet, exposure to cold or over exertion, but it appeared to occur when no such cause could he
n»<ignt>d ; and as respects the mauagemont of convalescence, the imtionts had the benefit of the same prerantions and care as those whoso histories Wi-ro
embmci'd in tin- first collection, and in the latter this sequence of the disease did not occur in a single instance. Moreortr, the febrile movement and
nt«iM'iate<l symptoms were out <)f i>roportion to thtxso which might be expected to follow the imprudences just mentioned. The patients in fact appeared
to |siss through a second febrile career of short dumtion," — ]>, 22-1. Nine cases of relapse occurred in this series of twenty-nine ty|ihoid rases. I u bis
thinl series, enibnu-ing fourteen cases, relapse occurred in but a single instance. Maclagan's experience runs parallel to that of Dr. Flint. The i:t
D'taiises in his 12S c-ases occurred within a period of two years, and most of them during one outbreak of the disease spreading over a jjcriod of fifti-en
months, — Kdinb. .Ifcrf. Jour., April, 1871, p. S"8. The largi' percentages mentioned at the commencement of this note are therefore not of general appli-
cation. Conceruiug relaiwes MrucnisoN states that after a convalescence of ten or twelve days there is a recurrence of the traiu of symptoms which the
patient ex|»oriencwl on the first attack, but their course is usually more mpid. In fifty-three cases — p. .'j,'>2 — the nieuu duration of the primary attack
was 27 days, the extremes being 14 and 4ti days, the mean and extremes of the intermission 11.76, A and 2o dajTs, and of the relai)se 10.4, 7 aiul :j'.) days.
The relapse is milder thau the fii-st attack ; but in one-third of his cases the symptoms of tbe former were of great severity, and death occurred in seven
v»f the casei*. Rose-spots appear on the third, fourth or fifth day, and MfiicnisoN bases the diagnosis on the presence of this eruiition and the absence
of any local iufiammation to account for the pyrexia. Seoi'in does not describe the thermouietric course of relapse, but leads us to infifr that it is similar
to that of tlie primary attack Iiy indicating the trmiH-raturt' curve of the first few days as pathognomonic of typhoid processes, — ]). 124. Later author-
ities desi-ribe a ditTereuce between the accession of the primary fever and that of the relapse : Irvine (see next note) considers the temi)erature curve
diagnostic : "It is asserted," he sjiys, "hj'all authorities that the tempenitnre of relapse rises to its highest level more tjnickly thau in the j)rimary dis-
ease ; and this is true, but it would be more correct {Judging by the instances given) to say that there aro not in relapse the typical evening exacerbations
and uioruing remissions met with for the fii'st few days in the onlinary fever. The rise in ndapse in the great majority of cases is to the fifth day all
but uninterrnpted, and where great interruptions occur, there are accidents enough to account for them. The maximum evening tempeiTiture is
n-m-hed by the fifth day, as occurs in primary typhoiii ;" — here the author, recognizing that the experience of most observers indicates the third day as
that of highest temperature, invites attention to his own charts in support of bis statements, after which he continues : " Hut afterwards tin- curve pre-
sents a decided contrast to that of the latter, iu which to tlie twelfth day the fi-ver remains high, though with a ntaximuui scarcely so high as in the
fonnh to sixtli days. * * * The second stage in ndapse, as comiMired with that of the primary attack, is cut short ; and the same is true of the third
stage. In relajise this stage is marked by decided fall of the teiupeniture to the normal, and there is no fouiih ircrk in whicii deeji curves prove the end
of onlinary attacks of primary typlioid. The absence nf those exacerbations and remissions mot with at the end of typhoid fever, in the cases of relapse,
was striking ; Init in many chartjii of mild (primary) typln»id which arc given by several authorities this absence is met with," — pp. i;il-KJ4. In fact this
author represents the temperature curve of a relajwe as diftering from what is cousidered the typical curve of typhoid fever only by a lessened (leveh)p-
meut of the diurnal oscillations during the periods of accession and deelimition, and by a shorter duration of the fastigium. This is well ; hut the curve
of mild cases of typhoid fever being very similar to that of relapse, ho does not hesitate to suggest that niauy of the cases reganled as mild typhoid
attacks are iu reality relaix«es in ]>atients by whom the primary fever has been disregarded. Here the argument appears to be ])nslied to the extreme.
According to Da Costa — liemnrks on ItehtpM'i in Typhn'ul Fecer — Tram. Col. Phifstdnm, Phila., 1877, the relapse gonenilly comes on in the second or third
wwk uf assured convalescence, and in the second oftener than the third. Abrujttly and almost without warning the patient passes fr(pm comi«irativo
licullh into a decided febrile condition. The eruption conies on earlier thau in the primary attack, generally abovit tlie fouith day, and is ius a rule
Mimewhat coarser and redder. It iloes not disappear so readily on pressure, and the fii'st erupted spots are more likely to last until the wlude rash fades.
Ills description of the t<'UiiHTature curve does not agree with that given later by Irvine : " Unlike the graduated ascending cfpui-se until the evening of
till' fourth or fifth day, which is the rule in ordinary instances of typhoid fever, the temperature bounds within twenty-four houi-s to a decided fever tem-
pemture. reiuits 1 to li° the uext morning, and by the evening of the second day is a degree or more higher than on the first day, the theniiometervery
commonly marking 1«>4° degi-ces. Then for from five to seven days, according to the severity of the attack, the evening figures read about tlie sjunit ; and
a morning n-iuiN>«ion of al^out 1°, or somewhat more, hap|)ens, very similar to what wo observe in the first attjick after the initial period has passed. Sub-
tt><iuently iK'i-nr the sjime more marked moniing remissions and less severe evening exacerbations, until the temjHMUtnre iu a zig-ZJig manner approaclu's
to the normal that we uljserve during typical cases of the typhoid attack. Yi-t, Jis here, until couvalescence is established, local complications arn-st or
revt-r*- thi' daily descent. Neither do we always find during the height of tlie relapse that the temiKirature is as regular jw describi'd. It may sink
almtKit continuousty for the first three days after it Inis reached the height occasioned by the returning fever, and then for three or four days more
grwlually ascend without any morning remission, yet subsequently, as defervescence sets in, show the characteristic zig-/Jig decline allndcttl to," — ji, lori.
Ilf> invites attention to the interference with tho growth of the nails in typhoid fever and typhoid relapse, pointing out that "with the relapse of
typlitiid fever the second ridge of the altered nail growth comes to tell us how completely in every respect the fever has been rejiroduced; and the first
ridge may in obscure Citses give us the tnie meaning of doubtful symptoms, and prove conclusive of the diagnosis." A year after this [taper was read Dr.
Da 1'<»sta, in a Cliiii'?ul Leihtn: on U^-Uipmrx iu Ttjphmd IWer, I'hilaihlphin Med. Timett, Vol. VIII, 1877-8, p. 433, is reported as having stated that it is tho
mie for the eruption to reapjiear almost coincideutly with the first symptoms of relapse, in the case which formed the basis of his remarks convales-
cence fn>m the primary attack iM-curred at the end of the thiitl week, and a few days later the temperature wsls at tho uornuil. Two weeks afterwards,
the imtietit being so far recovereil in the mean time ;is to be alhiwed to dres.s ami leave the wani, ixU' very largely of chicken and builod potatoes. This
was fulluwetl immediately by alslomimtl luiiu ; the temperature ran up to 105 and the rose-ruiih reapi»eared within twenty-four hours ; at the end of the
fifth day the teni|»>-ritnre was again declining.
I H>:Utpf4- of Tirphuid /Vrrr, by J. I'. Ikvink, London, Ht80.
300 SYMPTOMATOLOGY OP
are found to present but two illustrative cases, 48 and 49, while the post-mortem series
furnishes but one case, 32. In neither of the former is the history of the primary attack
given in detail ; but in the latter, the patient, who remained under the observation of the
recorder from first to last, was considered convalescent on the thirtieth day; twenty-five
days later he was seized with symptoms of typhoid fever which soon became characteristic,
death ultimately taking place from chest complications.
The foregoing analysis of the cases set aside as illustrations of pure typhoid, by weed-
ing from the continued fevers of the Seminary hospital such as appeared to present definite
indications of a malarial element, has determined the existence of certain differences between
the typhoid fever which affected our troops and that recorded by writers of large experience
as prevalent among the civil population of this and other countries. These may be sum-
marized as follows :
The relative infrequency —
Ist. Of iian.sea ami vomiting at an early period;
. 2d. Of a moist skin during tlie continuance of the primary fever; and
3d. Of tlie pnl.se during the same period.
The greater preuitence —
1st. Of diarrlitra during the whole of the attack;
2d. Of dangerous congestions of the lungs and grave broncho-pnenmonio complications;
3d. Of ataxo-adynamic delirium;
4th. Of dusky spots and ecchymotie patches, simulating typhus maculaa; and
5th. Of suppurative destruction of the parotid glands.
But these differences will be discussed to better advantage after the symptoms of
modified typhoid have been considered.
m.— MODIFIED TYPHOID FEVER.
Instead of illustrating typho-malarial fever by febrile cases recorded under that heading,
the writer has l^een constrained in the first instance to determine what ought theoretically
to be the probable symptoms of a typho-malarial fever, and, thereafter to collect appropriate
illustrations from the records of the camp fevers, whether registered as typhoid, typho-
malarial or remittent. This mode of procedure exposes its results to the criticism that
the fevers submitted as typho-malarial in this report are not such as were called by that
name by the medical officers in attendance on the cases, but merely such as the mental
bias of the editor has led him to assign to that class. Undoubtedly the first half of this
criticism is well taken, for the cases presented are seldom those which were regarded
as typho-malarial in our camps and hospitals. The nature of the reported cases of typho-
malarial fever will be investigated hereafter.* But with regard to the latter half of the
criticism, certain considerations already suggested^ indicate that the method adopted, while
the best available for determining the characteristics of the fevers wliich should have
been reported as typho-malarial in accordance with Dr. Woodward's views, is susceptible
of yielding as accurate and trustworthy results as can be obtained in a medical inquiry
concerning the consequences of unknown causes; and this is the more gratifying inasmuch
as not only are the characteristics of a so-called typho-malarial fever a subject of uncertainty
and corresponding interest at the present time, but the more important question of tlie
relationship between the morbid causes of malarial phenomena and febrile conditions attended
with a specific intestinal lesion are necessarily to a large extent involved in the discussion.
"Iiifm, p. 372. ^ Supra, p. 273-6,
TllK CO.MJiS'UKD KKVERS. 301
On8kt. — The accession of the fever in cases properly typlio-malarial was not gradual
anJ progressive as in unmodified typhoid, but was marked by distinct remissions or even
intermissions in those having the febrile action of the typhoid poison j^receded by a malarial
attack. Perspirations or a moist skin formed iwd part of the clinical record of typhoid until
defervescence was in progress; but in cases complicated by the presence of malarial fever
the skin was at times hot, dry and rough, and at other times soft, moist or perspiring. In
some the remissions seemed but an exaggeration of those which the thermometer always,
and the general symptoms frequently, indicate as occurring daily in the progress of typhoid;
but in others paroxysmal activity was developed at an unusual hour, as at noon-time on
alternate days, or, if occurring at irregular intervals, it was unaccompanied by local condi-
tions to whicii the sudden access of fever might be attributed. Assuming the alleviation
or abatement of these paroxysmal features by a free use of quinine, the febrile action per-
sisted and was associated with many of the symptoms peculiar to typhoki fever, modified
in many instances by thfit deteriorated state of the blood whicli has been seen to be one of
the formidable causes of danger to life in malarial cases. Death from sudden cerebral or
pulmonary congestion as in pernicious malarial attacks, notuufrequently cut short the course
of the fever at a period when unmodified typhoid rarely proved fatal. But in the absence
of such fulminant demonstrations, defervescence began about the end of the second week,
usually with exaggerated remissions and profuse perspirations, or the case was prolonged by
intestinal, pulmonary or other visceral troubles, at any period of which paroxysmal manifesta-
tions were prone to recur.
Of the Bixty-foiir oases of modified typhoid treated in the Seminary hospital, the febrile condition was devel-
oped, so far as is shown hy the records, without initiatory chills in nineteen, but in five of these the continued type
was assumed by cases which at their commencement were regarded as remittents. Of the remaining forty-five cases
the continued fever was said to be sequent to the chills of aguish attacks in seventee)i; it was preceded by chills,
fever and perspirations in eight and by chills in nineteen; in one case, 70, there was a chill on the eighth day of the
increasing indisposition. From the terms of the record or from the context it appears that in most of these cases
the chills recurred on several occasions before the febrile condition reached its acme; but in 59, 6fi, 67, 74, 93 and
111 it is definitely stated that a single chill preceded the febrile attack.
Five of the nineteen cases that were not characterized by chills, and twelve of the
forty-five that showed more or less evidence of a paroxysmal type in the early period, proved
fatal. These results manifest, so far as the small number of cases will permit, that typhoid
fever was deprived of none of its dangers by the concurrent action of the malarial poison.
The malarial character of these typho-malarial cases is sustained in most instances by
other evidence than their paroxysmal onset. Chills are insufficient to establish the malarial
presence, since they have been developed in cases of apparently unmodified typhoid. Con-
cerning these, however, it may not be out of place to inquire whether malarial possibilities
have been excluded from their causation. The typhoid and malarial influences are so closely
allied that it is often impossible to say of a symptom which seems common to both that it
is due to one and not to the other; but recurring chills, especially when followed by heat
and perspirations, are so essentially manifestations of the malarial poison that when they
occur with regularity as a prominent feature of the clinical picture the probable presence of
that poison is strongly suggested.*
Pulse. — In one of the sixty-four cases the rate of the pulse was not recorded, and in three it was character-
ized as rapid, but the number of beats was not stated. In forty-two of the remaining sixty the rate did not
exceed 100, except on the occurrence of pulmonary or peritoneal inflammation or in the onward progress of fatal
exhaustion, as in 85, 86, 93, 98 and 99. In eleven of these cases its quality was not reported ; in one it was considered
• L'lns frf qiif nlly ohgen-otl recorring chills id the *>arly period of his typhoid cases, — t. II, p. 259; in his foi^y-fonrth observation aguish parox-
ysms recurred for many Jays. Sec also supra, note ♦, p. 284.
302 SYMPTOMArOLOiiY OF
thready, in six weak or feeble, iu tltnc nuick, in two of fair strength, in Jive strong, in four quick and strong, in
five strong and fnll, in one quick and full, in tico full, in one strong and tirni and in one quick, full and firm. In
the febrile cases already presented as examples of probably pure typhoid, fulness aud strength were qualities rarely
found in the pulse, but the sthenic character of the arterial excitement in those now under consideration is very nota-
ble and appears to have been connected with the existence of the malarial element. In 79 the pulse, seemingly under
the influence of quinine, fell during the tirst week from 95 to 70 and two days later to 45, while the typhoid element
was manifested by the appearance of the specific eruption ; in 91 also the pulse-rate fell under the influence of quinine,
and in lt)2, although the rate during the initiatory paroxysms was not stated, it is evident from the history that it
must have been higher than later, when the rose-spots were almost the only indication of the presence of typhoid
fever. Strength of jjulse is also recorded in many of the cases iu which its rate exceeded 100 during the primary
fever; and in these the sthenic character seems to have been definitely associated with paroxysmal manifestations.
In the onset of the relapse, 91, the pulse was 120, full and strong; in 95 it was rapid, full and bounding iu the third
week notwithstanding the occurrence of perspirations ; in the interesting case, 105, the pulse exceeded 100 during
the paroxysmal period of the attack, fell Ijelow that rate during the accession of the continued fever and rose to
110 at its acme; in 119 a high rate coincided with remissions and a lower rate with the progress of the continued
fever until its termination iu fatal peritonitis; in 104 and 110, also, the rate was higher during the early period when
the febrile action remitted than later when it was continued, and in 113 and 114 rapidity of pulse was associated with
paroxysmal symptoms.
From these observations it may be concluded that although the pulse was not in general
more rapid in these cases than in those of pure typhoid, it was fuller, stronger, quicker aud
firmer in proportion to the activity of the paroxysmal element.
The febrile disturbance was accompanied in its onset by headache, pain in the limbs
and back, lassitude, anorexia and thirst. In a few exceptional instances the appetite was
not much impaired : thus in 89 it was good notwithstanding the brown and thickly coated
condition of the tongue and the bad taste conveyed by the abnormal secretions of the mouth,
and in some mild cases, as 109, it was recorded as fair throughout the attack.
In most of the cases the eyes were injected and the cheeks flushed during the period
of accession ; in a few instances, as in case 100, one side of the face was more deeply suf-
fused than the other. Later in the disease, and corresponding with the development of
cerebral manifestations, the eyes became dull, and at a later stage, when the patient fortu-
nately emerged from the typhoid narcosis, they were usually clear and bright but sunken,
the features pale and the skin cool.
Episfaacis was noted in twenty of the sixty-four cases. In ten of these it was an early symptom, occurring
before the appearance of the rose-colored spots; in six it took place when the fever was at its height; in 74 aud 81
it appeared late iu the attack, and in 90 when profuse perspirations and vibices were foreshadowing the end; in 6
it was of frequent occurrence for a month before the febrile onset, recurring many times during its progress.
It does not appear that any evil effect was attributed to. the loss of blood, even in
those cases in which it was a specially marked symptom; nor can any notable benefit be
associated with its recurrence : In 67 epistaxis was followed by the development of cerebral
symptoms; in 69 its return on alternate days coincided with febrile exacerbations.
Epistaxis occurred perhaps with more frequency, if its recurrences are considered, iu
these cases than in those of unmodified fever. From its appearance during the accession
or continuance of febrile action, paroxysmal or continued, it would seem due in part at least
to circulatory excitement; and since this, as manifested by fulness and strength of jjulse, was
greater in the typho-malarial cases, the greater frequency of its occurrence among them may
be understood. Its paroxysmal tendency was chiefly manifested at a later period when,
coincident with vibices or other signs of alteration of the blood, it occurred on alternate
days in conjunction with the heat, dryness of skin, headache and ringing in the ears which
betokened the intermittent attack.
The Skin, during the continuance of paroxysmal phenomena, was alternately dry and
moist, but when the febrile action assumed a continued type moisture ceased to apjiear.
Occasionally defervescence, as in unmodified typhoid, was accompanied with free percpira-
THK CONTINUED KEVKJIS. 303
tion. Sudamina were frequently observed, but no herpetic eruptioiis were noted in the
Seminary cases.
Tlie rose-colored eruption was uliscnt, not scon, or not stated as having been scon, in twcntj-onu of
thii sixty-four cases. lu tlirir of the t\vent.y-one there appeared au eruption the characters of which are unspocifiod;
in !•>"> this probably consisted of the tyi>hoid lenticuhir spots, and iu 98 of the scarlet rash wliicli soniotinies accom-
panies them, Imt its site on the genitals in W throws doubt upon its nature. Nine of the cases failed to come under
ol>»ervation until after the end of the second week. Nevertheless, an equal nun>ber, cases (iO, 83, 85, 88, 99, 101, KM,
117 and 122, were admitted early enough to have shown the eruption had it been present. Five of those, however,
Ki, Xi>, 101, 117 and 122, had the malarial symptoms jitrongly developed. Indeed, the absence of rose-colored spots
in these cases renders the diagnosis of typhoid fever siuncwliat doubtful, since it cannot be established that the
existence of malarial paroxysms interfered with their development, for cases 102 and 10,5 presented the rose-rash,
although the typhoid atta<'k was mild in comparison with the febrile paroxysms which were its i>relude. If these
five eases be excluded from consideration there remain but four in which the existence of the rose-colored eruption
is uudetorminod,— tiO, a light febrile attack, the history of which is not given with sutticient detail: 99, in which
typhoid tever ap|)ears to have been developed on the tenth day after admission with internuttent i>aroxysms; 101,
iu which the patient was admitted on the tifth day of an intermittent attack, and 88, the record of which was begun
on the ninth dav of the disease.
Kose-oolored spots in the forty-three cases in which they are mentioned as having been present appeared usually
during the second week of the typhoid attack ; but by dating the onset of that attack from the commencement of
febrile symptoms their appearance was in many cases delayed beyond this period. In cases 108, 109 and 110 they
were noticed on the seventeenth, eighteenth and twenty-fifth days respectively, counting from the commencement
of the remittent attack. As in pure typhoid they were occasionally few in number, ease 115 for instance i)resonting
only two spots, while in other cases they were profuse and occurred in successive crops: In 73 they erupted from
the tenth to the thirtieth day and in 75 from the tenth to the thirty-sixth day.
Hut their appearance was not in every instance that which is usually accepted as characteristic of typhoid fever.
There were noted in the typhoid series exceptional cases in which the spots were of a darker color and did not dis-
appear on pressure. Such instances were of more frequent occurrence when the typhoid fever was apparently com-
plicated by a malarial element. In case 62 their appearance on the tenth day was followed by au eruption of a darker
color on the fourteenth: iu 100, rose-spots appeared on the eleventh and tifteenth days, and were followed two days
later by a few dark-red spots which were im))erceptib!e to the touch and disappeared under pressure; in 103, also,
rose-spots on the fourteenth day were followed by dark-red spots on the sixteentii, and it is interesting to remark that
iu both of these eases the skin was jaundiced: in the fatal relapse, 91, the rose-colored eruption was preceded by a
few spots of a dark-red color which did not disappear on pressure: late in the progress of 93 there occurred an er:ip-
tiou of dark, almost black, slightly elevated spots somewhat larger than split peas, some of which afterwards became
of a light yellow color from purulent accumulations: in ease 82 there is said to have been, in addition to the rose-
spots, a profuse eruption the characters of which were not recorded; iu 83 some pustules appeared on the abdomen
about the eighteenth day.
The eruption was seldom nu-ntioned iu the defective clinical histories attached to the j)0»(-«i»/// m records; and
the acknowledgment of its presence in the few exceptional instances appears to have l>een dictate<l by its peculiar
characteristics rather than by its mere presence. Thus in case 115 two or three rose-rod spots of doulitful character
were observed: in 97 a red papular eruption appeared about the end of the third week; in 51 and 8(5 rose-spots
empted, which in the latter case became subsequently of a dusky crimson color and unatfeeted by pressure.
Kose-colored spots usually appeared on the chest and abdomen; but in two cases, 70 and 74 of the Seminary
series, they were found as well on the forehead and face.*
It is seen from this analysis that the rose-colored e-ruption was not observed in .so
large a proportion of modified as of unmodified typhoid cases; but the conclusion is by no
means warranted that the rash was more frequently absent in the one class of cases than
in the other. The date of onset of typhoid fever in a patient presenting malarial symptoms
was often involved in obscurity. Cases have been instanced in which the rose-colored spots
appeared for the first time at a late date, if the initiatory malarial paroxysms were regarded
as the period of onset. Cases have also been presented in which the malarial element
obscured the symptoms of a mild typhoid affection, the existence of which was manifested
during the second week by its specific eruption. It may therefore be assumed that in some
instances, as in 99 of the post-mo7'tem series, ,a mild typhoid may have existed for many
days in patients subject to ill health from the malarial influence without exciting an appre-
hension that there was anything unusual the matter, and that these men would date their
disease from some subsequent well-marked paroxysm. In such instances the eruption, if
* In 8 of 98 cases of typhoid MUBCHISON noted the spota as present ou the amis and legs, and in one case on the face, — p. 511.
304 ISYMPTUMAfOLUGY OF
incouspicuouw and of sliort clui-atiuii, uiiglit escape obsei'vation, and the cases, owing to an
incorrect date of onset, wonld he regarded as having presented no eruption although under
observation at the time when it usually made its appearance. Again, since in many cases
the disease was regarded as remittent fever, it is fair to suppose that in some of these the
specific eruption was not discovered because it was not looked for until late in the attack,
when tlie fever had assumed a continued type and the prostration, diarrhoea and accom-
panying tenderness of the bowels suggested the j^resence of typhoid. The febrile condition
lasted in the Seminary hospital case 110 for twenty -five days before the rose-spots made
their appearance. Physicians in similar instances of prolonged febrile action may have
accepted the absence of the spots and have ceased to look for them, although their presence
might have been demonstrated at a later period. Under such circumstances failure to
observe the eruption does not imply its non-existence.
Moreover, as has been indicated in the presentation of the records of the 19th Mass.
Vols., and as will be shown more definitely hereafter,* there is little doubt tliat many cases
reported as typho-malarial were due solely to the action of the malarial poison. The failure
of a close scrutiny to observe the rash in such cases may have led to the opinion that its
absence was common in cases of modified typhoid. However this may be, the typho-
malarial series of the Seminary hospital presented in so many instances a characteristic or
modified eruption as to render it highly probable that when typhoid was present it was man-
ifested by the rash as frequently in the presence as in the absence of malarial complications.
The occurrence of smlamina appears frequently on the records; In case 6 of the 27th Connecticut the
miliary vesicles coalesced into bulla- containing a turbid yellowish-white liquid, and in 9 they were developed on the
site of existing rose-colored spots.
Peteehiftl and ecchymotic p€lfches. — Petechial spots were found in two of the Seminary cases,
77 and 118, both of which recovered, and larger patches of an ecchymotic appearance in the seven cases, 68, 69, 73, 74,
90, 98 and 104. Usually these blotches were confined to the chest and abdomen, but in the last-mentioned case they
covered the whole body except the face and neck. In 68, t>9, 73 and 74 they appeared about the close of the third
week ; these cases recovered, liut the others were fatal. Ecchymosed spots appeared on the abdomen in case 4 of the
records of the iTTth Connecticut, and spots like small blood blisters on the limbs and trunk in case 6.
It will be observed that these facts do not demonstrate a greater frequency of hemor-
rhagic exudations in this series of cases than was found in that which has been submitted as
representative of unmodified typhoid.
Et'tfsipelns appeared as a complication in several of the cases, as in 92 of the Seminary series and in 74 and
77 of the post-morlim records; the ear and side of the face seemed to be its favorite site. In the first-mentioned case
it was associated with influmnuitiou of the parotid and became gangrenous in its progress.
BeiZ-SOt'HS are recorded in case 113 as having occurred at a late period, but the circulation at this time for-
tunately liecanie improved and the patient was soon able to walk. They were found also in 101 of t\\e post-morUm series
at the end of the third week, over the sacrum, trochanters and angles of the ribs of the right side.
In case 89, during the height of the fever, when the rose-rash was erupting and the patient muttering in his
sleep, a, jtectllidi' Oflof was rejiorted as emanating from his body. In case 6 of the records of the 27th Connect-
icut, an odor like that from spoiled meat was percei\ed about the person of the patient shortly before the occurrence
of the fatal event; he was much emaciated and sufi"ered from bed-sores.
Cerebral Syjiptoms. — In the sixty-four cases of the Seminary hospital series headache was reported fifty-two
times, wakefulness eleven times, drowsiness eleven times, more or less of duluess or stupor thirty-one times, dizzi-
ness seventeen times, ringing in the ears twenty-six times, deafness twenty and delirium twenty-four times.
Delil'illin occurred in thirteen of the seventeen fatal cases and in twelve of the forty-seven recoveries. Of
the four mortal oases in which delirium was unrecorded, one, 85, had the malarial symptoms strongly developed, death
being preceded by stupor; 119 was fatal by peritonitis ; the two other cases, 94 and 111, were not rendered in full
towards their close. Among the forty cases in which delirium was absent or not stated as present, headache was
reported thii'ty-two times, wakefulness six times, drowsiness seven times, more or less of stupor sixteen times, dizzi-
ness ten times, ringing in the ears sixteen times and deafness seven times. As the patients in many instances were
not received until the disease had made much progress, it is not surprising that in twelve oases there is no evidence
that headache constituted one of the symptoms of the attack. In two cases, 102 and 106, neither headache nor any
* /ii/rn, page 375.
TTIK lOXTTXITKT) KF.VEBS. oOo
udier .syiiij)t<iiii referable to the cerebral system appears on tlie veeord, while in 79, 107 and 120 hoatlacho alone; in
r>il. i'4 and 115 wakefulness; in 117 headaelie and wakefulness; in (>0 headache and drowsiness; in I'S headache and
ilizziuess; in 75 and 7S headache and tinnitus, and in S2, 101, 10!l and 121 headache, tinnitus and dizziness formed
respectively the iiulications of the cerebral implication. In two instances, 80 and «1, the patients were in a semi-com-
atose condition, which was associated in the hitter ca.se with spasmodic contractions of unusual strength atl'ecting
the muscles of the face and extremities. This stupor diil not alternate with the low delirium so conunon in uiimod-
ilicd typhoid fever, but left the patients very deaf in both easi's.aiid with slifilit delirium and headache in the latter.
The j)(w/-«i"r/(m record of ca.se 2SI7 compares the convulsive twitchiiiKs of the muscles of the patient to the siiasinodic
movements produced by moderate shocks from a galvanic battery.
Instead of dilatation of the pupil, which was recorded in .si>v<Mal iif the tyiilioid cases, the typho-nuilarial series
of the Seminary hospital presents two cases, 96 and 97, of cotttmvfeil pttl»il' In one the contraction was
associated with delirium preceding the advent of lethal stupor, and in the other with a state of conui vigil which ended
fatally. The pupils were also contracted in 86 of the 7)o«/-moc(c»i ri'cords during the stupor which was the harbinger
of death : nevertheless, in case 12 of the regimental record of the 19th Ma.ss. the pupils were observed to be dilated.
Delirium was generally of the passive character observed in unmodiiied tyjihoid, but there appeared to be a
greater tendency to lapse into the comatose state than was found in cases of that lever. In some instances, how-
ever, the paroxysmal exacerbations were accompanied by more active cerel)ral manifestations; in 91 of the .Seminary
series there was what the record calls walking delirium, and the patient afterwards raved and showeil much strength ;
in 6 of the 27th t'onn. the delirium was at first violent, then sullen ami afterwards of a jocose character. Coma was
iiuleed not unfreiiuently preceded by continued insoiiiiiia, .jactitation and active ilelirium, as in 52 and 111 of the
luiKl-mortem records, or by intense headache, as in 86 and 91 of the same series. In .56 delirium and coma were appar-
ently connected with intlammatory processes in the middle ear.
Death at an early jjcriod was usually due to coma, as in 111 of the posl-mortciii records, which terminated on
the ninth day, and in 94 of the same series, which ended on the thirteenth day, although in 122 of tho Seminary
cases the patient is stated to have been delirious when death took i)lace on the eighth day.
JBxf rente protttrntion and nmseiilat' debilitf/, manifested by the position of the patient in
bed, the treiinilous tongue, occasional falling of the lower jaw and subsultus tendinuin were as frequently noted in
these cases as in those of the typhoid series. Occasionally, as in case 6 of the record of the 27th Conn., the patient
recovered his intelligence while in this state of extreme debility.
Tlie Seminary records shovv' that delirium, although of less frequent occurrence in typho-
inalarial cases, was of much more serious import than in cases of pure typhoid. Delirium
was present in twentv-one of forty-one favorable cases of typhoid and in only twelve of
forty-seven recoveries from typho-malarial fever; but although only eight of twenty-nine
oases of tvphoid delirium resulted fatally, no less than thirteen of twenty-four cases of typho-
malarial delirium had an unfavorable termination. These figures give expression to an
increased gi'avity with which the malarial complication endowed the tyf)hoid disease. It
cannot be allowed that the existence of intermittent or remittent fever tended to repress the
development of the cerebral symptoms of typhoid, since malarial fevers are themselves
associated at times with delirium. Hence it may be inferred that the increased mortality
in typho-malarial cases presenting delirium, as compared with typhoid cases having similar
cerebral manifestations, was due to the coincidence of malarial disease.
The 1)I(je.stive System. — Votnifittfi was noted in twenty-six of the sixty -four cases and nausea
without vomiting in four cases. In 108, lU and 122 the nausea occurred early in the attack, but in 86 the fever
wac at its height when the patient became thus affected. In thirteen of the twenty-six cases tho vomiting was
recorded during the early period (<f the attack ; four of these, 90, 92, 95 and 96, were fatal, but it does iu)t appear that
the vomiting had any prognostic value, for recovery took place in some of the cases in which it was a troublesome
symptom, as in 79, in which it continued for several days, and in 82, in which it persisted for two weeks, ceasing only
on the occurrence of epistaxis and perspirations. In 98, 101, 107, 110 irritability of the stomach corresponded in
time with the full development of the febrile condition, and in 88 it followed the administration of ((uiniue; one of
these, 98. was fatal. The vomiting which occurred at a late period in 6:i, 75 and 80 was not a sign of evil omen,
but in 84, 85, 89, 91 and 97 it was connected with fatal peritonitis or collapse.
Xausea and vomiting were of correspondingly freciuent occurrence in the cases embraced in the poit-mnrtv.m
records. In a few instances ga.stric irritability was unusually distressing and persistent: In 116 nourishment had
to be introduced by enemata: in 95 vomiting was associated with severe epigastric pain and iiiHaimuatory processes
in the gall-bladder; in 280 it occurred early and persisted to the end.
More or less of jautltlice was observed in seven of the Seminary cases: The patient's face was slightly
tinged in 67 and the skin and conjunctiv.'e in 121, at the close of a mild febrile attack; in 84 and 100 the eyes and
skin were yellowish, this condition having been associated with epigastric pain: in 103 Jaundice followed the exhi-
bition of calomel and jalap: it occuired also in 112, in which reniittent and typhoid fevers coincided, and in 118,
Med. Hist., Ft. Ill— ;m
306 8YMPT0MAT0L0GY OF
during the activity of a remittent which was followed by a typhoid attack. lu addition to these there was some
derangement of the liver in 105 during its paroxysmal period. Only one of these cases, 84, was fatal. Jaundice
appeared frequently among the symptoms of the jiost-iiiorlcm series; it was seen in 54, 65, 81, 95, 96, 97, 98, 100 and
111, and in these, as in those already instanced, the coloration of the skin, conjuiictivse and urine occurred generally
in the early period, but sometimes towards the end of the attack.
The greater frequency of nausea, vomiting and jaundice in these cases must be regarded
as symptomatic of the action of the malarial poison, since such symptoms are usual in the
paroxysmal fevers, while, as has been seen, they are so often absent in typhoid that it is
impossible to consider them essential features of its clinical j^icture.
The tongue was more heavily coated with a white, yellow or grayish fur, especially
towards the base, than in unmodified typhoid. Later, as it became dark in color it lost
its moisture, but it did not remain dry and brown during the height of the febrile manifes-
tation with such persistency as in pure typhoid. It varied in its condition from day to
day, being sometimes more or less moist, and at other times dry or coated with tenacious
mucus; but at some period of the disease the red tip and edges, so frequently recorded in
the unmodified fever, were also seen in the typho-malarial cases. Before the accession or
subsequent to the disappearance of typhoid symptoms the tongue was often pale, flabby
and coated as in malarial attacks, and occasionally this flabbiness persisted during the con-
tinuance of pathognomonic symptoms of typhoid. In favorable cases the fur sometimes
cleaned oflf in patches, but more generally a white or yellow coating was observed far into
the period of convalescence.
In twenty-ttoo of the sixty-four cases the tongUB at some period of the disease was recorded as red at
the tip and edges, this characteristic being frequently noted when the rose-colored eruption was visible on the chest
and abdomen; seven of these were fatal, 84, 89, 90, 92, 94, 99 and 122. The red tip and edges ajipeared also in four-
teen cases, in which the tongue was characterized as Habby or pale and flabby — (!9, 70, 74, 75, 80, 81, 83, 85, 98, 100,
109, 111, 112 and 118; three of these, 85, 98 and 111, did not recover. In ten other cases flabbiness was specially
noted: In 59, 62 and 121 the tongue was tiabby and slightly coated; in 65 yellow-patched and afterwards white and
flabby; in 67 dry, red, white-coated and flabby; in 77dry and brown, with subsequent flabbiness and prominent papillie;
in 79 red, glossy and dry, becoming afterwards moist and flabby ; in 82 white or yellow-coated, and afterwards flabby;
in 106 pale, flabby and coated yellowish-brown in the centre, and in 93 pale and flabby. As none of these proved
fatal except the last, it would seem that danger diminished with the distinct appreciation of the characteristics
of the malarial tongue as distinguished from those of the typhoid tongue. In the remaining ciyhteen cases the
tongue was characterized as follows: Coated at the base, but cleaner at the tip and edges in 102 and 108; dry,
rough and coated, but cleaner and moist at the edges in 114 ; coated in the centre, but with the edges moist in 105 and
119; white-coated and moist in 95; heavily coated in 113; yellow-furred and fissured in 115; yellowish in 64; dry
and brown in 104; brown and fissured in 107; dry, brown and fissured in 91 and 96; dry, brown and coated in 66 and
97: brown, subsequently becoming white in 86; red, dry and fissured in 71; red and clean in 73. Six of these cases
were fatal, viz: 91, 95, 96, 97, 104 and 119.
Notwithstanding the oftentimes foul condition of the tongue the hfeatll is said to have been ofiensive in but
two cases, 100 and 113; in the latter it was referred to the existence of oza^na.
The lips, teeth and gums were covered with sofdes in ten of the seventeen fatal cases, and in eleven of the
forty-seven which resulted favorably, so far as the record follows up their history. Of the seven mortal cases in
which the mouth was not reported as having been in this foul state, death occurred at an early date in one, 122; in
two, 84 and 85, the fatal result was due to peritonitis, — in the former the patient's condition towards the close sug-
gests that sordes may have been present though unrecorded; in 92 death was precipitated by gangrenous erysipelas
and in 99 by pulmonary complications ; in 94 and 95 the record slurs the details of the last stages of the malady.
The condition of the tuoutlt, thl'^Hit and larynx in these cases was sometimes, as in pure typhoid,
such as to occasion more or less dysphagia and alteration of voice. The mouth and throat were covered with
aphthous spots in 88; the larynx was probably congested in 77 and 81, as it certainly was in 93; in 87, however,
aphonia appears to have be«n due to prostration, and although in 96 and 114 dysphagia must be attributed to cere-
bral implication, it was in the earlier stages of the latter case probably a result of local inflammatory processes.
Diurrhoen or relaxation of the bowels was present in perhaps the whole of the sixty-four cases of the
Seminary series that have been submitted as illustrations of the coincidence of the typhoid and malarial poisons in
the same subject. As in the unmodified cases, it was sometimes an early symptom, while at other times it was not
developed until late in the attack ; it lasted for a few days in some cases, while in others it not only continued
throughout the fever, but was prolonged into the period of convalescence. It varied in intensity from an aggravated
and exhausting flux to a slight relaxation manifested rather by lessened consistence than frequency of the passages.
The stools were thin, yellowish, watery and often fetid. Usually they were passed without pain, notwithstanding
the existence of abdominal tenderness; as an exceptional instance, tormina was recorded in case 87.
THE CONTINUED FEVERS. 307
Diairha'a was associated with hemorrhage from tlio howels in tlireo of the cases, 85, 92 and 93, all of
which were fatal, though not as a direct couse<iuence of the loss of blood; nevertheless, its occurreuco probably
hastened the fatal event, for in 85 the bloody stools were reported as having caused much depression. Hemorrhage
from the bowels forms part of the record of case 1(19 of X\w pust-mortvm series.
As in the typhoid cases, .several instances occurred in which the diarrhu-al tendency was not strongly empha-
sized: There w as no diarrhii-a in (i8 during the stay of the patient in hospital, but as the intestinal lesion was marked
by tenderness and gurgling, it is probable that dinrrha-a may have been a symptom during the two weeks of sickness
which preceded his admission. In 119 the paroxysmal period was characterized by diarrhtea, but during the pro-
gress of the typhoid fever the bowels were comparatively quiet. In 96 also the bowels were (juiet, but there was
much tympanites. In some cases the use of such purgatives as calomel and jalap, blue pill, compound cathartic
pills, Epsom salt or castor oil shows that at the time of their administration the bowels were not loose. In 62, 63, 67
and lOS these cathartics did not produce undue effects, but in 91 and 103 intestinal symptoms were developed or
aggravated after their administration. In 75, which was characterized by diarrhicu at first but not throughout its
progress, purgative medicines did not intensify the diarrhieal tendency, while in 73, in which the conditions appeared
to be similar, full doses of Kpsoni salt caused frequent stools and iliac tenderness. Lastly, in 79, with constipation
present and some tenderness of the bowels, the cathartics administered were not productive of nudesirable ellects
until the twenty-first day of the disease, when violent action was set up. In some cases submitted from regimental
records the bowels are said to have been constipated, as in 2, 3, l, 6 and 9 of the 19th Mass. and 5 and 8 of the 27th
Conn.: in two of these, 3 and 5, laxative and evtn powerful cathartic doses produced but little eti'ect.
Diarrhiva appears with equal frequency in the clinical histories which precede the posl-morlem records. In 54
and IK) there Avas a recrudescence of the diarrhteal aftection. A few of these fragmentary histories report constipa-
tion as the characteristic condition of the bowels during the attack. Thus in 95 there was constipation during the
initiatory paroxysmal fever and during ten days of jaundice which followed it, nor did diarrluea set in when ady-
namic symptoms were subsequently developed. In 268, also, constipation was present, but in this instance there was
cerebral disease sufficient to account for most of the recorded symi)toms. The bowels were sluggish in 52, a case char-
acterized by its frequent and copious perspirations. Constipation is mentioned also in the records of 86 and 111 ; and
diarrho-a was certainly absent from the history of 116, in which, on account of the condition of the stomach, nutrient
euemata were hirgely employed.
Somet imes, as in uumoditied typhoid, diarrhoea ceased on the occurrence of perspiration at the period of defer-
vescence. Such cases as 72,80 and 113 are suggestive of a connection between the cessation of the liux and the
increased action of the skin, and in 64 and 90 this suggestion is strengthened by alternations of hot skin with diar-
rhcea and free perspirations with quiescent bowels; but it is doubtful if these bore to each other any closer relation-
ship than that of association as results of the same cause.
Jleteorisin, abdominal pain and tenderness. — Of the sixty-four cases of the Seminary series
pain, tenderness and tympanites of the abdomen were mentioned in all except the three mUd cases, 60, 102 and 116,
the markedly malarial case, 121, and the rajiidly fatal paroxysmal case, 122. Pain or tenderness was recorded with
tympanites in thirty-eight cases and without tympanites in twenty, while in but one case, 117, was tympanites
noted without coincident pain or tenderness. Tbemeteorized condition of. the abdomen was generally proportioned
to the gravity of the attack, but in 99, in wliich the fatal result was due to pneumonic complications, the abdomen,
which at times had been tympanitic, became soft towards the end.
In thirty-one cases the abdomen generally was assigned as the seat of the tenderness, but in twenty-five of
these one or more localities were indicated as particularly affected: In seven the right iliac, iu one the iliac, in two
both iliac regions and in one the right side; in one the right iliac and epigastric, and in one the right iliac, epigastric
and nmbilical regions; in ticvlee the umbilical with, in four of these, the right iliac, in one the left iliac, and in five
both iliac regions, one of the last having the hypogastric also att'ected and another the hepatic and epigastric regions.
In the cases in which the abdomen was not mentioned in general terms the localities were specified as follows: In
fourlern the right iliac region with, in two of these, the umbUical, in one the epigastric, in one the umbilical and
epigastric, iu one the hepatic and in one the hypogastric; in six the left iliac region with, in three of these, tlie
nmbilical also, and in one the umbilical and epigastric ; in /our both iliac regions with, in one of these, the umbilical,
iu two the epigastric and in one the ejiigastric and umbilical ; lastly, iu three the umbilical with, in one of these, the
iliac, side not stated, and in one the iliac and hypogastric. Thus, in the sixty-four cases the abdomen was mentioned
in tbirty-oue cases, the right iliac region in thirty-eight, the umbilical in twenty-five, the left iliac iu eighteen, the
iliac in three, the epigastric in nine, the hypogastric in three and the hepatic region in two cases.
Hypogastric pain was connected iu 107 and 119 with retention of urine; in 81 it was probably due to the con-
dition of the bladder in the early period and to peritonitis at a later date. In some of thu poHt-mortem records also,
as in cases 82 and 83, it was associated with peritoneal inflammation. Epigastric pain was connected in some
instances, as 81 and 100, with jaundice; in others, as 85, 101 and 105, with irritability of the stomach; in 78 the
morbid feelins; experienced iu this region was not tenderness but a burning sensation.
iw II I'ff I ittf/ was frequently observed in connection with abdominal tenderness and distention.
Splenic enlargement was not noted during life in any of these cases, an omission probably due to
the cause suggested when referring to this as a symptom of typhoid.
CuEST COMPLICATIONS. — C'otigh was present in thirty-two of the sixty-fonr cases. Generally it was slight
and yielded a frothy mucous expectoration; but in some cases, as 78, 86 and 101, it was associated with pain in the
^hest, and in others, as 87, 90 and 93, with definite pueumonitic signs. The expectoration was blood-streaked iu 87
and 105 and purulent and blood-streaked in 80; iu 114 blood in the sputa was referred to a concurrent epistaxis.
308 SYMPTOMATOLOGY OF
Occasionally, as in 118, niuoous and sibilant rales were Iieard although cougli is said to have been absent. The res-
piration, became accelerated in some, as in 99 and 105; it was hurried also in 106, in which cough did not appear
as a symptom; and in the fatal cases, 93, 96 and 97, the breathing became greatly labored towards the end, although
in the two last-mentioned instances other symptoms of pneumonic complication were obscured by the intensity of
the stupor. Among the cases in the pont-mortcm records pulmonary embarrassment was observed in some, as 100;
pneumonia in others, as 53 and 97. In 65 the cough was paroxysmal and prevented sleep. In 115, which was prob-
ably an adynamic malarial case, the chest affection was attributed to exposure by throwing off the bedclothes during
the night. Accelerated breathing in 111 was probalily due in part to pleuritic effusion.
Other clinical features. — The urine was retained or passed with difficulty in twelve of the sixty-four
cases; usually it was scanty and high-colored. No special record was made of its <|uautity or quality, save in 104
and 113, in the latter of whicli it was pas.sed in excessive quantity notwithstanding the concurrence of free perspi-
rations ; in the former it was acid at first, afterward alkaline, large in quantity and of small specific gravity. From
these cases it does not apjjear that retention or difficult micturition was coteniporaneous with the development of
head symptoms: In 65, 73, 78, 82 and 83 the urinary trouble was noted early, but there were no marked cerebral
manifestations. In 69 also, micturition was affected at an early date, but delirium did not supervene until after
a lapse of ten days. In 70, with difficult micturition on the twelfth day, the only head symptom was some mental
dulness, whicli was shown about six days later. The urinary affection occurred in the middle of the second week
in 121, in the third week in 107, in the fourth week in 110, but in none of these was there any delirium. In the fatal
case, 84, difficult micturition was followed in a few days by the development of cerebral symi)tom8, l>ut as the latter
appeared and became aggravated the former ceased. In 119, also fatal, headache and slight delirium accompanied
a difficulty in retaining the urine, while tlie opposite condition of retention sulisequently developed was not thus
accompanied. On the other hand, although in many cases characterized by delirium and stupor there was an invol-
untary or uncontrolled passage of the urine, case 81 is tlie only instance in which temporary retention was reported
as associated with the comatose condition. In the post-mortem series of cases, altfiougli delirium followed dysuria in
some, as in 65, in others, as 83 and 106, tliere was no association of head symptoms with retention or dysuria.
Parotitis. — Swelling of the parotid appeared about the end of the tliird week in 69, 92 and 98; the termina-
tion was favorable in the first-mentioned case, but the two others were fatal. In 92 a gangrenous inflammation
spread over the face, and death took place four days after the implication of the parotid ; in 98 the swelling increased
so rapidly tliat in a few days the patient was unable to protrude his tongue, and in six days death occurrott with
vibices and aggravated intestinal symptoms. In the post-mortem series parotid swelling was found iu 53, 65 aud 97.
Pains in the Joints and muscles, especially of the lower extremities, were noted at a late period iu
the history of 115 of the Seminary series, 8 of the record of the 27th Conn, and 1, 2, 3, 4 and 12 of those belonging to
the 19th Mass.; in case 4 of the last-mentioned series these pains were so severe a.s to cause loss of sleep and slight
delirium. Ganf/rene of a Ijlistered surface was recorded in case 104; gangrenous erysipelas of tlie face has
already been noted as having Ijeen present in 92; gangrene of both feet occurred in 5 of the records of the 27th Conn,
and in some of the cases of the post-mortem series. Tliese will be referred to hereafter in speaking of the sequelie of
the continued fevers.*
Relapses. — The progress of typho-malarial cases was even more irregular than that
of typhoid cases, for in addition to the compUcations and recrudescences to which the typhoid
element rendered them obnoxious, their course was liable to interruption and prolongation
by intercurrent exacerbations due to their malarial element. But well defined relapses of
the typhoid phenpmena were as infrequent as in unmodified typhoid.
Helapse was recorded in 59 and 91 of the Seminary series and in 56 of the post-mortem series. In the first-
mentioned case the relapse was manifested by chill, fever and perspiration, wakefulness, diarrhoea, thirst and some
febrile heat, while the pulse, although strong and full, was not accelerated, beating only at the rate of 66 per minute;
rose-colored spots appeared on the eighth day, after which defervescence took place, diarrhrea subsided and the
appetite returned. The second case presents a different record: Fever, diairhiea, delirium and unconsciousness were
at once developed; modified red spots appeared on the third day, about wfiich time tlie delirium became violent;
this was interrupted by a severe chill with the subse(iuent establishment of the typlioid condition, during which, on
the sixth day, rose-colored spots erupted; death occurred on the seventh day from perforation. In the third case the
details of neither the primary fever nor the relapse are given ; Itut it is stated that during the sufisidence of the
febrile action delirium, coma and death occurred in connection with inflammatory processes in the ear.
Fatality. — Lastly, it is of importance to point out that the fatality of these cases was
considerably greater than that of the typhoid series, — in fact, their percentage of fatality was
greater than the sum of the percentages of typhoid and malarial diseases. Of fifty-one Sem-
inary cases of unmodified typhoid ten were fatal or 19.6 per cent., while of sixty-four cases
in which this disease was influenced by the coincidence of malarial phenomena seventeen
or 26.6 per cent, ended fatally. These results are consistent with medical experience in
*See infra, page 309.
THK CONTINUED FEVEtlS. 309
■analogous oasos. No onr- will deny that when pneunioiiia occurs in the progress of typhoid
or malarial fever the patient's danger is correspondingly enhanced.
In summarizing the differences between the symptoms of the typhoid affection -per se
and the same disease as modified by the intercurrence of active febrile conditions usually
attributed to the malarial influence, the following points require mention as generally char-
acteristic of the latter:
1. Paroxysmal invasion with perspirations;
2. Greater strength anil t'rc(|uenc,v of Mit; jinlso dnring the febrile access;
3. Intercurrence of fel)rile paroxysms at any stage;
4. The panixysnial recurrence of opistaxis;
5. A (loubtfiil infreiiueucy of the erui>tion and an iintloulili'd niodilicatiou of its characters in certain cases;
6. The pale, tlaliby, moist and coated condition of th(^ tongue;
7. The greater frec|uency of nausea, vomiting and jaundice;
8. A more defined tendency to constipation in the few cases not characterized by relaxation or positive diar-
rhcpa, and the fre<iuoncy of abdominal tenderness beyond the limits of the right iliac region, especially towards the
epigastric and left iliac regions;
i». The greater gravity of the cerel)ral symptoms and tlie earlier period at which death was, in some instances,
occasioned by uuiiarial coma;
10. A greater fatality or ratio of deaths to cases.
It appears, therefore, that when these cases as a whole are compared with those of
pure typhoid, there are manifested certain clinical differences which were marked in pro-
portion to the activity of the malarial phenomena; when the latter were pronounced there
was no difficulty in determining the interference with the course of the typhoid fever, pro-
vided the occurrence of the characteristic symptoms of that fever indicated its presence.
But, as may be seen in the records of the 19th Mass., there were occasionally presented
obscure cases in which it was impossible to say whether the sub-continued fever which pros-
trated the patient was due solely or chiefly to one or otlier of these fever-poisons, since the
characteristic symptoms of neither were distinctly marked, while well defined cases of each
of these febrile conditions were occurrins; at the same time in neighboring commands and
had occurred only a short time before in the regiment itself.
Further inquiry into the nature of the typho-malai'ial cases of the war must be post-
poned until after their presentation from the post-mortem standpoint.
IV.— TYPHOID FEVER, MODIFIED AND UNMODIFIED.
SequeLjE. — But whether the febrile cases that occurred among our troops were typhoid
or typho-malarial certain sequelae were prone to follow. Persistent debility, occurring
alone or in association with tubercular developments or some local morbid conditions, often
incapacitated the soldier for further military service. Diarrhoea was the most frequent of
the engrafted diseases, owing to the prevalence of its causes and the condition of the intes-
tinal lining in convalescents from fever: Following it in order of frequency were inflamma-
tory processes in the lungs. Diseased conditions of the liver, spleen or kidneys were also
found. Many of the cases already submitted illustrate these occasional consequences of the
febrile attack, and others of a similar tenor will be found in the post-morte7n records.
Perhaps the most interesting sequel presented by the records is the pain in the feet and
legs which constituted a prominent and distressing symptom in many of the cases. It
occurred, but not with frequency, in the Seminary cases ; it constituted a characteristic of
those treated by Surgeons Dyer of the 19th Mass. and Baer of the 36th Ohio,* and it is
mentioned in the report of Surgeon McLaren's Board of Inquiryf and in several of the
•See report, infra, p. 327. t^"/'''^ P- "5.
310 SYMPTOMATOLOGY OF
cases taken from the records of various general hospitals. Occasionally it is noted in Sani-
tary reports, as in the following: ■
Surgeon Harvey E. Brown, 70th X. T. Vols., Camp Mahan, Ta., Octvher 16, 1862. — A number of severe cases of
typhoid fever presented the peculiarity that during convalescence there Tvas a remarkable tenderness of the feet and
ankles ; the patient would crj' out with agony at the mere weight of the bedclothes, and a touch of the hand gave
excruciating pain. I found but little relief in this distressing symptom from cooling lotions or poultices; perhaps
I was more successful with the use of hog's lard smeared over the foot than with any other remedy. In most of the
cases this soreness gradually disappeared, but loss of jiower in the feet remained for many weeks, although the
patients in other respects grew strong and well. In one case large abscesses formed on the dorsal surface of the foot ;
these discharged and the foot got well.
Owing to the meagre character of the records it is difficult to appreciate the cause of
this pain in the cases in which it is mentioned. In some it was probably due to fatigue
induced by the first efforts of the convalescent to test his returning strength. Muscular and
rheumatic pains may also be ascribed to degenerative changes arising from mal-nutrition,
the poverty or abnormal state of the blood being manifested by an oedematous condition of
the feet and ankles or by boils, subcutaneous abcesses or ecchymoses. But the occurrence
of gangrene in cases 40-42, from the records of various hospitals, and in six cases of the
post-viortem series,* is of importance in this connection. The severe pain mentioned as the
only abnormal phenomenon in some cases, as in those of the 36th Ohio, was associated with
swelling in others, in two of Surgeon Kekdall's cases with discoloration, and in certain
cases with ulceration, superficial sloughing and even gangrene necessitating amputation
above the ankle joint. Surgeon Bark viewed the occurrence of this pain as a favorable sign
indicating the commencement of convalescence, but a larger experience showing its probable
connection with a deadly lesion supplies ground for regarding it with much anxiety.
Surgeon J. H. Tayloe, U. S. Vols., in his report, April 10, 1863, on the occurrence of
gangrene of the toes in the Third Army Corps, Army of the Potomac, attributed this morbid
condition to exposure to cold. In the field hospitals of tlie corps he found six cases, one of
which was manifestly a true frost-bite. In five the gangrene set in during convalescence
from typhoid fever, but in the history of each there was detected an exposure to which, in
the debilitated condition of the patient, the local injury was ascribed. In one of these cases,
that of Adam Hayerd, 122d Pa., amputation was performed at the upper third of both legs,
subsequent to separation of the feet, and at the time of Surgeon Tay'loe's enquiry the stumps
were healed. Gangrene in this case set in during the intensely cold weather that followed
the battle of Fredricksburg and while the patient was under treatment for typhoid fever in
the regimental hospital. A suspicion that scurvy was concerned in the development of
these cases was not sustained by the results of the investigation.
In the cases above reported the disease Las presented a remarkable uniformity in its commencing stages and
In the parts attacked, invariably beginning at the ends of the toes and generally with the greatest severity in the
little toes. I failed to detect in a single instance the evidence of its having manifested itself at any point above the
ankle joint or anywhere except in the parts immediately involved as already indicated.
In every case the constitutional symptoms have been severe and such as ai'e usually found in mortification
supervening on injuries involving sudden loss of vitality. Great depression of the vital powers, rapid and feeble
pulse, with cold sweats in some instances, have marked the course of the disease. It is true that most of the cases
were enfeebled and debilitated by typhoid fever at the time the disease in question manifested itself, and that a great
l)art of the depression might be due to the primary disease; nevertheless the change was decidedly marked, particu-
larly in the pulse, which became more frequent and irritable. This change took place immediately upon the accession
of the gangrene and not, apparently, from the gradual dift'usion of any scorbutic taint or latent cachexy. From the
absence in every case of general symptoms indicating scurvy as the cause, and the evidence connecting the gangren-
ous condition with exposure to cold, I am compelled to assume the latter to be the cause. It maybe alleged that in
two of the cases the patients were not exposed to a sufficient degree of cold to iiroduce freezing at the time the
disease manifested itself^ — that they had been in division and regimental hospitals for some time previous, where it
* See infra, p. 432.
THR CONTTNURK FKVRRR. f^l 1
Was not prohalile that such an iiijuiy wimlil happen, lint by nuting tlio facts wo find that in (inc caso tho i>aticnt
was Ki^nt from regimental to division hospital on tho 4th of March, and that immediately after becoming warm in bed
he was seized with severe burning pains in the ends of his toes, and that tho following morning gangrenous patches
were observable. It is reasonable to infer that this patient was frost-bitten while Wing conveyed from ono hospital
to another. The case becomes nnich stronger when wo remember the man's condition at tho time, and know that
such accidents were of fre(iuent occurrence during the Crimean war, even where tho sick w(>ro transferred to no
greater distance than jirobably intervened between the hosjiitals iu question. Tlie history of the otlwr case is very
similar. The patient had been sick in division liosi)ital lour weeks with typhoid fever; he was returned to his regi-
ment .lanuary 27, where he remained aliont two weeks, when ho was again sent to division hosi)ital. Within forty-
eight hours after his re-admission symptoms of gangrene were manifested in the ends of his toes. Tho same inference
is deducible iu this caso, — that tho man was frost-bitten while being conveyed from one hospital to another. It will
be remembered that ho was in hospital for six weeks prior to the attack of gangrene ; that his diet had been generous
aud varied; that at tho time of bis first admission and during the conjiuuance of his stay no symptom of scurvy
was discernible, but that immediately after being removed from one hospital to another mortification set in.
In conclusion I will add that it appears to me scarcely possible for scurvy to so affect the system as to ihimIucc
ten gangrenous spots each in the end of a toe without manifesting itself still further through some one or more of
its ordinary concomitant symptoms. — Suryeoii .). 11. rAYi.oi<'.s Hrport.
Sloughino; of the cornea Ofcurred iu case 39 of the records of various hospitals.'''
Bwelliug of the parotids with frequent suppuration, which has been mentioned in con-
nection with both typhoid and typho-inalarial cases, occurred as a sequel or late coinpli-
catiou in the cases 43-50 from various hospitals. Surgeon Baer gives the only reference
to a similar condition of the submaxillary gland.^, and records tho testicles as Imving been
affected in two instances. Purulent deposits in other parts of the body are noted in. cases
3-4-36 of the series last mentioned and in several of the ■post-mortem records.f
Sequelte involving impairment of nervous power are illustrated in cases 51-61 iVom
various hospitals. These cases do not differ from those described by Murchison, Nothnagel
and others, as occasionally occurring after ordinary typhoid fever. They consist of partial
paralysis of various parts and include one case, 59, of paralysis agitans, in which the tremors
persisted notwithstanding the return of muscular strength, one, 60, of cerebro-spinal fever,
with death from coma on the second day of the attack, and one, 61, of pura]ilegia from spinal
meningitis, in which a gradual imjirovement took place, so that in about fmir months the
patient was able to make very good use of his legs and was strong and healthy in his general
condition. In 51 the right leg became oedematous and paralyzed; the oedema disappeared
in two weeks, but a considerable time elapsed before the power of free motion was restored.
In 52 the lower extremities were partially paralyzed, the result being discharge from service
on account of a slow and unsteady gait; in 53 paraplegia was associated with some atrophy
of the right leg, but the patient, after a course of crutches and canes, was eventually returned
to duty; in 54 there was progressive loss of motion and sensation in the lower limbs until
a state of almost complete paraplegia was reached, after which tlie patient inipruwd, but
was discharged 'at the end of six months as incapable of further service; in 55 liemiplegia
improved rapidly, but left the soldier unfit for duty owing to contraction of the right leg;
in 56 there was no improvement in a paralyzed left side at the end of four months. All
these cases occurred during convalescence; in fact, in 54 the patient is described as having
been doing well for seven weeks, when he was taken with the gradually increasing paraple-
gia. But in 57 aud 58 the patients were prostrate at the time of seizure: In the former
hemiplegia occurred during the height of a sequent pneumonia; this man was discharged
after several months, able to walk with the aid of a cane but with the arm powerless. In
the latter the right arm and left leg were paralyzed during the unconsciousness of a late
• Dr. WooDWABD says, in the second part of this worls, p. 501, that no case of corneal nicer occurring in the later stages of fever was brought to the
notice of the Surgeon General's Office during the war. See also Case 48 of tho j)o»?-niorfcm records.
t See tn/ra, page 432.
312 SYMPTOMATOLOGY OP
period of a severe typhoid attack ; the case ended in discharge twelve months afterwards on
account of atrophy of the leg and inability to flex the foot.
Relapses. — Besides the instances of typhoid relapse in the typhoid and typho-mala-
rial cases, 48 and 49, 59 and 91 of the Seminary series, and 32 and 56 of the post-mortem
records, 63-65 from various liospitals were regarded by their medical attendants as cases of
relapse in typhoid fever. In 63 the details of the primary attack arc not given; but the
patient died, after passing hemorrhagic stools, on the fourth day from the second access of
fever, typhoid symptoms and rose-colored spots having been developed in the meantime. In
64, three weeks after the apparent establishment of convalescence, tlie patient was seized
with severe diarrhoea, which terminated fatally in twenty days; but there is nothing on the
record to show that it was a true relapse. In 65, which ended favorably, both tlie initial
and sequent attacks are detailed, but the evidence of the presence of typhoid is by no means
convincing.
Second attacks. — The records of the series from various hospitals furnish only two
cases, 66 and 67, of typhoid attacks in men who had suffered from the disease at a previous
period. In one case the second attack was well defined and under observation, but
the first rested on the testimony of the patient, corroborated, with some details, by his
father; in the other a clear history of the anterior attack is furnished, and the second,
typho-malarial in its character, is also described with precision. The patient, in 75 of the
Seminary series, is said to have suffered from typhoid fever two years before his admission
with a pronounced typho-malarial attack.
Extracts from reports, etc. — A few papers on file in the office of the Surgeon
General give clinical descriptions of the continued fevers which prevailed in our camps
and hospitals. These are herewith presented. Abstracts of most of the journal articles
on this subject are appended as notes.*
* J. J. Levick, — Med. and Surg. Reporter, Phila., Vol. VITI, 1862, p. 283, — ia a clinical lecture on sis cases of miasmatic typhoid fever from tlic seat
of war summarizes the principal features of tlie disease. In some there had been an ill-defined forming stage during which the patients, althougli
much trouhled with diarrhi^a, would attend to their ordinary duties; in others the attack was sudden, coming on with chilliness and intense lieadsu^he.
Diarrhcea was a const.-mt symptom ; chilliness or rigors affected all the liatients ; a flushed face aud slight cough, with the usual hronchitic rales, were
also noticed in every case. ,\t the beginning there were exacerbations and remissions, and in connection with the latter was found a moistness of the
skin at certain periods of the day, the forehead being covered with large drops of perspiration ; but this was in no instance critical, — it ceased and
recurred. Headache, present in varying degree in every instance, was sometimes described as splittiiuj or hailering; there was always a sense of weight
and weariness in the eyes, severe pain in the back of the neck and between the shoulders rather than in the loins, and restless aching in the lower
limbs. The tongue was more or less furred, but not heavily coated nor disposed to dryness as in typhoid fever ; thiret was moderate ; loss of appetite
complete. The pulse in two cases reached 120 ; but with these exceptions it was rarely above 90, and in one it was as low as 60 ; it was soft although in
no case alarmingly feeble. Epistaxis wa.s not always present. The abdomen was more or less prominent, but not decidedly tymjianitie. There wsis
none of the mental dulness of enteric fever, so that even in the compaiutively advanced stiige of the. disease (questions were answered intelligently and
the patient showed interest in what passed around him; in no case was there well-marked delirium. In another article — Amei: Jour. Med. Sciencf, Vol.
XLVII, 1864, p. 404— he recapitulates the substance of his former lecture, and adverts to the invariable presence of the rose-colored eruption and dis-
ease of Peyer's patches, the latter indicated by diarrhcea which was either present or readily induced by a small dose of castor oil. Sasford B. Hi'.nt,
Surgeon U. S. Vols., in a communication to the Bnfaln Med. and Surg. .Tour.. Vol. II. 1S02, ]>. 202, describing the cjinip fever which he observed in a recently
recruited New York regiment, says that for a few days the patients felt weary and stupid, had heailache and pain in the back, loss of appetite aud fever, —
f^kin hot and dry, pulse 100 or more, tongue dry and brownish. Suifering little pain, they frequently were cheei"ful throughout, seeming rather lazy
than sick. Diarrhoea set in ; the pulse reached 120, but seldom rose higher ; sordes collected about the teeth and the tongue became cracked, .\ftera time
these symptoms declined, the tongue being the last to regain its normal state. \ good appetite on a dry tongue was not uncommon. Joseph Klapp,
.\ct. .\Bs't Surg., U. S. A., in an article on Ttiphoid Fever iu our MilUarg HosjtUah, — Med. aud Surg. Reporter, rhiladclphia, Vol. IX, 1862-63, p. 18, — says that
a large proportion of the fever cases admitted into the hospital in which ho served bore a considerable resemblance to ordinary typhoid. In giving a brief
notice of the more obvious feiitnres of the army fever, he remarks that deafness was infrequent and slight; five cases had the dull, heavy, stolid expres-
sion of countenance so often found in pure typhoid ; delirium was present only in the most unfavorable cases; sleeplessness was scarcely complained
of. In most cases there was diarrhcea, the discharges being thin, yellow and more profuse perhaps than in enteric fever; pain on pressure was felt in
the right iliac regii3n and over the .abdomen generally, but in a less degree than is usual in typhoid. The rose-colored ernptitm was present in most
instances, sudamina in but few. Convalescence was more rupid, and as soon as it began the countenance acquired a brighter and more cheerful expres-
sion; severe cases had a listless, indifterent, yet not stupid expression, a dark mahogany color of the face, sordes about the teeth and a dry tongue disposed
to become aphthous in the progress to recovery. Chronic rheumatism, never complained of before, affected many, hut not until they had in a great measure
recovered their strength. Most of the patients came from the region of the James and Chickahominy rivers and were benefited by quinine. AVhen
tenderness of the abdomen, tympanites and acute diarrhosa co-existed with well-marked typhoid symptoms, oil of turpentine was given, with good nourish-
ment, wine, whiskey or milk-punch; warm rnbefacient cataplasms over the abdomen afl'orded great relief. IIe.vrv M. Lvm.i.s, .\ct. .^ss't Surg. U. S.
A., writing from Univel-sity Hospital, Nashville, Tenn., .\ugust 0, 1862,— .lijier. 3ferf. Times, N. Y., Vol. V, p. 109,— says that typhoid fever was of frequent
occurrence in the spring of 1862, and that " if all the cases of fever attended with rose-colored spots upon the skin, diarrhcea, etc., are to be reported as
J
THE CONTINUED FKVERP. olS
Rrmarln on the Typlmd Fercr of the Army hj .Ui't Hiirfl. Jos. R. Sjiith, V. S. J., Semiiiari/ hoxpital, Grorgetoun, D.
C. Sept. 30, l><ti2. — \Va.shiuj;lou and its environs seem to have lieeii a favorite habitat of intermittent fever for many
years past. lu connnon, however, witli many other places in tliis country, the type of prevailing fever has been
steadily nnderjroing a change, intermittents gradually giving place to remittents and the latter in tnru to typhoid.
Two hundred and eighty-eight cases of fever liave been treated during the past quarter in the Seminary hospital;
twenty-two were iutennittent cases, one hundred and tliirty-.seven remiltent and one liundred aiul twenty-nine
typhoid; one of the remittent and twenty-three of the typhoid eases were fatal.
Tntermittent and remittent cases presented no peculiarities, and generally yielded pruiiiptly to the free use of
nuinino. Those cases, however, which proved most obstinate assimilated gradually to typhoid, and in a number
there was doubt as to the diagnosis. The cases of remittent fever diminished in frequency during the month of
September, and those of typhoid increased in a greater ratio. This was probably owing not simply to a greater
prevalence of typhoid, but to the fact that stringent orders were issued prohibiting the sending of light cases
of disease from camp to general hospitals; in consequence light remittents were retained for treatment in camp,
while those febrile cases that were more unpromising in their appearance were sent to the various general hospitals.
Under the head of typhoid fever 1 include only tho.se which presented typhoid symiitoms finm their recep-
tion into hospital, though some of them, according to the history obtained from the patients them.selves or their
former physicians, evidently commenced as remittents. According to my own observation nearly half of the cases
ori"inated as remittent fevers, — at all events they presented well-marked daily remissions and exacerbations. In
the hospital, where in such cases the utmost attention of the attendant medical officer was given and even the shade
of a remission watched for, that the great specilic, quinine, might bo administered, either only a slight trace of a
remission would bo discovered; refusing frankly to doelaro itself under appropriate doses of cuiinino, or a continued
fever would be at once established with all its usual and familiar symptoms. Cases typhoid »!> orifline were usually
recognized as such within a very few days. They began with chills or sensations of chilliness, headache, pains
in the back and aching limbs, Soon followed by a rapid pulse, hot skin and feelings of debility and weakness. Cases
of this kind presented in general the greater part of t>he following symptoms : Chills, headache, pains, feeling of pros-
tration, hebetude, deafness, tinnitus aurium, subsultus tcndiuum, heat of skin, delirium, capillary congestion, opis-
taxis. accelerated pulse and hemorrhage, sudamina, petechi;e, eruptions, sweats, tongue foul and coated or dry and
harsh, sordes on teeth and lips, meteorism, l)orborygmus, iliac or abdominal tenderness, constipation or diarrluea
with involuntary evacuations, vomiting and gastric irritability, peritonitis, retention of urine and apparent conva-
le.scenco followed by relapse. The disease was ordinarily ushered in by a chill with cejdialalgia and pain in the back
and limbs. AVithin three or four days, however, these symptoms almost entirely gave place to a sens.ition of muscu-
lav weakness. Hebetude was marked in most of the cases. The patient could be easily roused from a state of stupor
to answer questions: he would protrude his tongue if asked to do so, but would often forget to draw it back. The
hearing was frequently impaired, although the patient might not recognize his deafness. Delirium was a constant
symptom; it was rarely violent, generally low, accompanied by luutteriug or talking and a desire to leave the bed
for some senseless object, a desire which he endeavored to gratify w henever the attention of the nurse was with-
drawn: but even when delirious he could often be roused to give a sensible answer. Tinnitus aurium was fre-
quently absent, but subsultus tendinum and general jactitation were among the constant symptoms in severe
caws of tjphoiJ. wo must conclmlp tlial the disease is nioilifleci in many |>articulars by its intimate relation with the causes of the remittent form wliich
hiu thus far marked at least nine-tenllis of the cases of fever which, during the last three months, have been placed under my observation." The same
ji.iinial. in its ii«ue of July 12, 1862, has an editorial headed Bepr.rt. of HospUaU, which, in referring to the e.^iperieuco of the Ladies' Home hospital, Ke»
York City, states that the malarial fever met with tliere had its symptoms mingled with those of tnie typhoid. Dianliiea and rosc<olored spots were
almiist constantly present, and the fever exhibited a marked disposition to cviicevbations and sometimes to collap.se,— patients presenting nothing untoward
in their condition, and with the mind iKrfectly clear, would, in three or four hours, and occasionally in less time, bo found pulseless, the snrfiice moist
an.l cold and death imminent. When in this condition they would converse intelligently and express themselves well enough to sit up. When asleep
the decubitus was dorsjil and the appeamnec of the countenance that peculiar to severe cases of typhoid fever, but the patient could readily be roused,
and when awakened showed no bewilderment. In severe cases the tongue was dry and disposed to crack. The appetite generally was not much impaired.
Scorbutus was a frequent complication, and suppuration of the parotid gland wiis present in a few instances. Ibvi.ng V. Lvox, House Physician, Bolle-
vue hospital, commenting on parotitis as a complication of typhus,— .tracr. Meil. Timet, X. V., Vol. VIII, 1864, p. 87,— states that in the summer of 18C2
he (aw in the"ho3pital near Corinth, Miss., about one hundred and fifty cases of typho-malarial fever with parotid swellings in ten per cent, of the cases
and on both sides in half of the number affected. Suppuration almost invariably took place if the patient lived long enough. This was regarded as
an unfavorable complication. Patients who recovered after having betm thus affei-tM were slow in gaining strength, the discharge from the gland con-
tinuing for a long time. S. K. Towle, Surgeon :iOth .Mass., in an article Au/« of Praclice in llie V. S. A. Cenerul HospiOd, lUibm Wnuje, La.,— Boston 3tat.
ami Any. Joiinutl, Vol. LXX, 1804, p. 4'.t,— speaks of the mixed charictcrs of the fevers prevalent in that section. The remissions in remittent fever
were less marked, and often nearly disappeareil after two or three days, while, with the continuance of the fever, enteric rather than gastric symptoms
became prominent. He holds that cases registen.<l as typhoid fever were without doubt of malarial origin. These had not the rose-colored eruption,
and on admission had already lost the early diagnastic features, retaining only the prostrated, low vitiated, semi-conscious condition of the last stage of
«-Ten! typhoid fever. The mortality was much greater than in pure typhoid, and iu those that eventually recovered convalescence was slow and halting.
" I do not rememtier to have seen this sejison amongst those who had spent last year in this department a single case of typhoid fever such as we see in
Xew England, and most of the cases occurring amongst the new-comen* after they had been here two months were decidedly modified by the mi:>snuitic
tum.nndiugs. Indeed, one conld almost tell liow long a Sew England fever patient had been iu this section of the country by the type of his disease,
a genuine rase of uncomplicated typhoid being strictly pathognomonic of a recent down-east Yankee. * * During the spring I saw at the different
regimental hospitals, by invitation of the surgeons of several Xew Kngland nine-months regiments, a great many severe cases of typhoid fever (then
qnite prx-valcnt in the new regiments here), acul although most of them did not exhibit any remiisions, and hence had not been thought complicated at
all with malaria, yet the fact was indisputable that they did better after the introduction into tho treatment of full doses of quinine during the fir^t
I«n of the disease ; and in cases in which quinine had not been given at first, it often, though not invariably, was of apparent benefit in somewhat snmll
doses in the later stages." After adverting to the various influences that modify camp fevers he remarks: "Hence it follows that few of the s<ricjns
cases of malarial disease one is called upon to treat after six months service in the army arc cither simple, vrelWeflned or exactly dc-icribcd by any nf
th* old terms, as intermittent, remittent or typhoid, but partake in some degree of tho nature of all ; and from the pnivioas surroundings of the patient
are inclintnl to rapidly lissume a ditrided typhoid type."
MivD. Hist., Pt. 111—10
314 SYMPTOMATOLOGY OF ^
cases. In aggravated cases the nervous system seemed entirely prostrated very early in the disease, the above-
described symptoms being developed by the fifth or sixth day. Capillary congestion was well marked in the majority
of cases; the brown color of the cheeks, disappearing on pressure and but slowly returning after the removal, helped
much to impart that expression of the countenance known as the fades typliosa. Epistaxis was of rather infrequent
occurrence; in two cases, however, it was so severe as to become of serious import. Hemorrhage occurred from no
other part except the bowels as an eifect of erosion of the walls of a bloodvessel. In every case that I noticed the
pulse was accelerated from the beginning of the attack, ranging from about 90 to 110, but in many cases it diminished
in frequency coincidently with the disappearance of headache and pain in the back and limbs, so that after three or
four days the pulse ranged from 8.5 to 100 or a little more. I have been accustomed to consider the frequency of the
pulse and its strength or weakness as furnishing important prognostic indications. Cases in which the pulse
exceeded 128 seldom ended favorably; sometimes in fatal cases it ranged for days beyond this number, gradually
running up to 140 or higher, until, with imperceptible pulse, the patient died. An unfavorable result was common
also in those cases in which there was a want of correspondence between the force of pulsations in different parts of
the body, as indicated by the action of the heart and the beating of the carotids, the abdominal aorta and radial
artery, sometimes a labored cardiac action producing but a weak arterial pulsation. Petechiit and vibices were
present in many cases, particularly on the abdomen, less frequently on the chest and bnt rarely on the limbs. Sudamina
were of constant occurrence, profuse all over the abdomen, but in no instance upon the limbs or face. These sweat-
vesicles burst shortly after their appearance, and in many cases reappeared in a succession of crops during the whole
attack. Their presence or absence seemed of but little value as an index of mildness or severity. The typhoid erup-
tion was not an invariable symptom. When ijresent it appeared usually during the second week, chiefly on the
abdomen and thorax. Sometimes only two or three spots were discovered after a careful examination of the sur-
face, and in a certain number of cases no eruption whatever was observed. Some of these non-eruptive cases
were as severe as any, and when fatal exhibited no variation from the ordinary post-mortem lesions. The digestive
system early shared in the morbid actions constituting the febrile condition. From the beginning the tongue was
covered with a white coating which seldom disappeared during the disease, or with a black coat, the tip and edges
being red and angry-looking: it was often moist, sometimes flabby, and frequently dry and harsh, much fissured and
covered, like the teeth and lips, with sordes. In fatal cases this state of the tongue persisted to the end, but in
favorable cases it cleaned from the centre to the edges or rice versa. One of the most encouraging apjiearances pre-
sented by the tongue, noticed chiefly about the period of convalescence, was the assumption of a delicate film of
white on the cleaned surface. Sordes could in general be wiped or washed away, and attention to this apparently
trivial act was productive of much comfort to the patient. The pathological changes taking place in the abdom-
inal cavity early invited attention by their local indications. The skin, particularly that of the abdomen, was
apparently much raised in temperature, this being sometimes so striking as to constitute the color mordax of the
books. I noticed a very frequent connection of this symptom with violent delirium. The abdomen was some-
times flat or cup-shaped, with every pulsation of the abdominal aorta plainly visible, at other times tumid and swol-
len or meteoric, resonant and rumbling on the slightest pressure. In several instances distention was decidedly
relieved by the introduction of flexible tubes pm- anum to allow the gas to escape. Tenderness on pressure was one of
the umst fre<[uent phenomena, markedly exhibited in the right iliac region. When slight this generally displayed
itself by an involuntary shrinkiug or a contraction of the rectus to protect the parts beneath from pressure. Some-
times the tenderness extended along the course of the colon into tlie left iliac region, and occasionally the whole
abdomen was affected and the patient so sensitive as to shrink from even a motion to bear upon the parts. The
bowels were generally irregular, sometimes constipated, but more frequently affected with a persistent and debilita-
ting diarrhcea, the stools usually blackish in color, of a very offensive odor and occasionally bloody. Vomiting and
gastric irritability were by no means prominent symptoms ; in a few cases, however, it was found impossible to relieve
them, the matter vomited being sometimes yellowish and smelling of bile, sometimes watery, sometimes black and
in one instance containing blood corpuscles. Toward the end involuntary dejections added to the disagreeable
symptoms, though some cases recovered after reaching this stage. The muscular coat of the bladder seemed para-
lyzed in quite a number of cases and required the regular use of the catheter; this, however, did not indicate
their gravity, for many such cases recovered.
The fatality of the disease has been 23 in 129 cases, or one in a little more than five and a half cases; but this
rate has presented great variations. Thus, in the first fourteen days of September, 15 deaths occurred. Not only
was this owing to the fact before mentioned, that at this time the custom of sending only the most serious cases to
general hospitals was strictly adhered to, but it seemed as if some fatal epidemic influence struck suddenly all
those who were laboring under this disease. Those who entered the hospital at that date came under its influence,
those who had been in hospital a longer time were equal sufferers, and the same mortality extended to the other
hospitals in the city, both the neighboring and remote, thus proving its independence of local causes. I have been
unable to discover anything to account for this increased mortality, which sulisided toward the end of the mouth.
The question of diagnosis, while of much interest, is one which an elementary report like the present cannot
pretend to treat. Where an assemblage of symptoms such as I have enumerated was j)resented there could be of
course no doubt in the diagnosis ; but so great was the variety in the nature, number, severity and combination of the
symptoms as on several occasions to arouse the suspicion that two distinct diseases were present with certain features
in common. The closest and most careful investigation of the symptoms and post-mortem appearances failed at the
time to confirm such suspicion, and every day and every new observation since has convinced me of its incorrectness.
To illustrate: There has entered the hospital a jiatient whose previous history exhibits all the symptoms of an ordi-
nary pyrexial attack. At present, however, the symptoms are as follows: Pulse 80 to 95; face but little congested;
■ THE CONTINUED FEVERS. 315
boat of skill lu'arly natural or not much iiicreaseil ovct alulomen; tongue clean or somewhat dry; very slight or no
pain or teuilerness in the abdoiueu; bowels regular; appetite iiiipaireil; complaint of slight weakness, much inereasod
by exertion; sudamina and profuse perspirations but no eruption. This assemblage might easily escape recognition
as the combined symptoms of a fever case. If this patient be carefully treated, coulined to his bed, the state of the
sccivtious watched and regulated and all stinnilatiiig food disallowed, the pulse in two or three weeks will fall to
or below the natural standard, the tongue assume the delicate whitish appearance I have spoken of as characteristic
of convalescence, and with returning appetite, strength and health will reappear. Should, however, the case be
neglected and the patient continue his customary or other work, overlooking the premonitions of approaching dis-
ease, soon the unheeded warning will speak in language not to bo misunderstood. Accelerated pulse, gastric irrita-
bility, high fehrile action, alidominal tenderness and other typhoid symptoms are speedily developed and death is the
usual issue. Now the question arises: What are the elements common to two such dissimilar conditions as are here
described f Is there anything that may serve as a connecting link liy which these apparently isolated diseases may
be .joined as one, or are these features of resemblance mere coincidences that might be expected ec|ually in a case of
delirium tremens or carciiioinatous degeneration f I shall endeavor to give my impression of what is common in all
these cases : I have found abdominal tenderness one of the most constant phenomena of some stage of this disease ; in
fact, without a particular reference to my notes, I do not recall a single instance in which pressure over the right
iliac region or some other portion of the abdomen less frequently, did not elicit symptoms of tenderness or uneasi-
ness, either an acknowledgment of pain or an involuntary shrinking from the pressure. The occurrence of sudamina
and profuse sweating, without possessing any great pathological significance that I am aware of, has yet seemed to
me to possess more or less diagnostic value, and though some cases of fever ran their entire course without them, in
the majority several crops have made their appearance, filling up, bursting and leaving the skin in a sort of brawny
desquamation. The tongue is generally altered in this disease, presenting the appearance I have before described.
To be sure it is sometimes coated in other diseases, but to me the typhoid tongue, with sordes on the teeth and lips,
has a pathognomonic appearance. The slight acceleration of the pulse, too, invariably directed my attention to the
true state of the ease, being neither natural nor yet sufliciently rapid to arouse suspicion of iullammatory )>yre.via,
but remaining for a number of days at a certain state of moderate acceleration; and here I desire to call attention
to a phenomenon in the natural history of the disease which I have hitherto neglected to mention, viz: the occur-
rence, in frequent cases, of a more or less perfect apyrexial period amounting, in some instances, to almost apparent
convalescence, Avhieh lasts for several days and is followed by secondary fever sometimes more severe than the
preceding stage, but generally milder. This could not be considered a relapse, for generally it seemed one of the
natural occurrences, a part and portion of the history of the first attack, whose termination appeared to approach
inditlcrently either by some "crisis," or natural evacuation, or el.se by some gradual, slow and regular subsidence of
the febrile action.
But more conclusive than any of the above symptoms as to the perfect identity of these differently mani-
fested conditions are the poxt-moi-tem appearances. Autopsies were held in most of the fatal cases, and the lesions in
every case diagnosed as typhoid fever were identical and perfectly satisfactory as confirmation of onr diagnosis.
The following are the principal and most constant lesions that I have noticed — (and here let me state that thu j>uiit-
mortcm examinations in these cases were directed principally to the condition of the small intestine and ca-cum
and the presence or absence of lesions usually recognized as typhoid. In quite a number of cases, however, the
whole intestinal tube Avas examined and all the abdominal viscera.) In the ileum: In every ease that was exam-
ined Peyer's patches presented enlargement and ulceration, generally extending for several feet up the intestine.
In only two or three instances was the disease so little advanced as to present nothing more than the shaven-beard
appearance; but generally the glands were ulcerated, sometimes only enlarged so as to remind me forcibly of the
appearance of "wheals" upon the skin, and in one instance so large as to project over one-third of an inch into the
cavity of the intestine. The solitary glands presented similar appearances, being enlarged to the size of a split-pea
and many of them ulcerated. Both the solitary and Peyer's glands contained the typhoid matter in the sliape of a
blackish granular dei)osit. Sometimes the whole mucous membrane of the ileum seemed covered with a similar
adherent material, and at other times it seemed as if the matter were deposited beneath the mucous membrane in
great black blotches. In some instances the walls of the intestine were congested both externally and internally
between the ulcerated and enlarged patches. The greatest extent of pathological change was found towards the
ciecal end of the ileum, gradually diminishing iu the upper part of the gut and extending to a greater or less extent
in different cases: but in every instance was found enlargement and ulceration of both Peyer's and the solitary
glands and tyjdioid dejiosit. The upper end,of the colon presented similar ajipearances. The ileo-Ciecal valve was
often thickene<l ami black. The mesentery and mesenteric glands were generally much congested, the latter enlarged
to the size of acorns, and blackish-red from engorgement with venous blood. The omentum often presented an
appearance as if it had been for a long time macerated. Sometimes the small intestine was nearly empty and packed
down in some corner, — occasionally bound down by inflammatory adhesions; at other times it was much distended
with gas. Where perforation had occurred redness and peritoneal ett'usion were generally present. Nothing patho-
gnomonic was oljserved in the other viscera; the liver, pancreas and kidneys seemed healthy although sometimes
slightly softened; the spleen was generally much congested, enlarged and softened: the stomach occasionally con-
gested and its mncons membrane softened, smuetiiues over the whole organ.
A few words are needful regarding complications. Bronchitis, pneumonia and inflammation and abscess of
the parotid were the principal. In no case wa.s any antiphlogistic treatment directed against the intercurrent
iuflaniniation more than blistering, expectorants, dry cups and, distrustfully, tartar-emetic. The tieatimMit ado])ted
iu all these cases was stimulating and supporting from the outset. Carbonate of ammonia, wine-whey, milk-punch
316 SYMPTOMATOLOGY OF
and essence of beef formed our chief reliance, adniiuistered in greater or less quantities according to the prostrar
tiou of the patient; the pulse was our principal guide to quantity. The regulation of the bowels was generally
attempted by opiates and astringents; I have found opium a very reliable remedy not only for this purpose but for
calming nervous excitement, relieving jactitation and delirium and producing sleep, — its combination with tartar-
emetic in the most violent cases of nervous excitement was sometimes followed by the happiest effects. Quinine
was used in many instances, but with little if any benefit. Blisters and other derivative applications to the surface
were freely used for the relief of the many distressing abdominal symptoms, sometimes with, sometimes without,
success. Emulsion of turpentine was also employed, and in a small proportion of cases with benefit. Hoftmann's
anodyne was, next to oiiium, the best anti-spasmodic. But after all our main oljject was to support the patient,
not to break up the disease, for whi(-h latter purpose no medicine was of any avail.
Typhoid fever in this hospital has shown no sign of contagion. Two of my medical officers, as also two med-
ical cadets, were affected during the epidemic with slight symptoms of temporary derangement.
I shall not attempt to discuss the cause of the disease. The change of life from home to camp, and exposure
to fatigue and wet under new auspices, seem to have developed it. The season has been a remarkably wet one, but
as far as I have been able to ascertain not an unhealthy one among the residents of this vicinity. No epidemics
have prevailed save the cases of typhoid fever; and the cases of disease outside of military camps and hospitals
have been substantially the same as those occurring in our own experience. The regiments from which our sick
were derived have generally been actively employed erecting fortifications, laboring in the trenches, felling trees
and standing guard, — not as much exposed to fatigue or inclemency of weather as our troops have ordinarily been
on frontier service, — and generally provided with good water aud the best of food. Their clothing has been suit-
able to the season of the year and the men themselves have, as a rule, been clean and temperate.
Surgeon C. J. Walton, 21s( Ky., March 81, 1862, Green River, Taylor County, Ey. — But the disease from which
our troops suffered most was typhoid fever. This is not to be wondered at when we take into consideration their
situation with the circumstances attending them. Almost every possible predisposing cause was in operatiou at
the same time: Badly prepared food; sleeping upon the damp giound; unusually warm and wet weather for the
season with sudden changes in the temperature of the atmosphere; want of personal cleanliness; camped in the
bend of the river and almost surrounded by it; standing guard during rainy nights; leading inactive lives, not drill-
ing one day in seven on accovint of mud and rain, aud, in a word, almost everything that tends to lower the vital
energies. We called it typhoid fever, for we could not, as it appeared in our regiment, term it anything else, There
seemed to be no essential difference between it and the ordinary typhoid of private practice except that the symp-
toms were greatly aggravated. Some practitioners whom I have met do not consider it typhoid but camp fever.
They contend that it is a disease peculiar to camp life ; but I am unable to trace any distinction except as above stated,
iu the aggravation of the symptoms. Those who were taken down had generally some premonitory symptoms : Diar-
rhoea, dull headache, pains in the bones, some soreness of the flesh, lassitude, general debility and loss of appetite.
After taking to bed many manifested the greatest indifference to their condition, resting quietly and asking for noth-
ing; when enquiry was made how they felt, they would answer very well, or I feci better to-day; a few, however, became
conscious of their danger. Some were delirious from the beginning, — furiously mad, aud constantly attempting to
get up and leave their tents; others became delirious after a few days. In these cases typho-mania and coma vigil
were common symptoms. Hemorrhage from the bowels occurred in two cases. A few cases had no diarrhcea aud ran
their course to a favorable termination without any alarming symptom aud with but little treatment. There was in a
large proportion of the cases a very sluggish state of the circulation, — the hands, feet and face presenting a purple-livid
appearance which disappeared temporarily on pressure, — a condition which I have seldom seen to any considerable
extent in private practice. I attribute it to the greater degree of constitutional depression arising from the peculiar
circumstances under which our troops were placed. Our treatment was altogeth-er expectant. After the disease was
fully develojied we gave nothing but that which seemed plainly indicated. We generally began with a few doses of
quinine and opium : but these were discoutinued after the disease was fully developed. I am not able to give a favor-
able opinion of the use of quinine in typhoid fever, although I have, both in private practice and in the army, giveu
it a fair trial. It is often at first impossible to determine to what extent the case is influenced by malaria, and, con-
sequeutly, to be on the safe side, it is well when doubt is entertained to begin with a few doses of quinine, — if remit-
tent the case will be controlled, but if typhoid, my opinion is that no good will be effected. Acting on the view
that it is a self-limited disease I do not attempt its arrest, but endeavor to enable the patient to live through its
usual period of eighteen or twenty days. Hence our treatment was opium, tannin aud acetate of lead for the diar-
rhoea, and stinnilauts with nutritions diet and scrujiulous personal cleanliness for the general condition. Every case
was well washed at the onset with tepid water and soap. When the fever was at its height the patient was sponged
with cold water, which exercised a very salutary effect. Brandy was administered freely from t"he beginning. In a
word, everything calculated to husband the resources of the system was employed. The patients were fed regularly
whether they wanted to eat or not. Xitrate of potash was given in solution with some benefit. After all, I think
that opium and brandy are the sheet-anchors. The bowels must be controlled and the patient stimulated ; I consider
him safe when the bowels are properly checked. I feel no uneasiness if they are not moved for three or four days;
I have never seen any bad consequences follow their being cheeked suddenly. I have used turpentine in a few cases
in which diarrhoea was obstinate; Ijut this is more applicable to cases that are troubled with tympanites. I gave
twenty drops every two hours, apparently with good results, for two or three days; but every case that liad tympa-
nites died. In one case tympanites disappeared for two or three days and reappeared before death. In a few cases
I gave minute doses of calomel, but they did no good, — I think harm. We had no hospital and had to treat our men
iu quarters during the first si.x weeks. After this we had good hospital shelters and nearly all our cases did remark-
ably well excei)t those that had been on hand for a considerable time.
THE CONTINUED FEVEES. 317
Surgion M. K. (Iaoe, '2'tlh U'ix., Columbus, h'y., .Ui/nA 31, 1863. — Typhoid fevfi' is very insidious in its approach.
Many days or even weeks soiiietiiiies elajise. diiriii}; whicli tho patient feels not well nor yet snlliciently ill to give up
or take lo bed; he will be found nuire or less coniplainiui;, his aspect dull, stupid and anxious. Ou the oeciirieiico
of delirium he is either animated or lost iu ajjathetic bewilderment. Often diarrh(ea comes on early, accompanied
with pain, tenderness and hardness of the abdomen, which sometimes l>econu's tympanitic. Usually as the disease
progresses the diarrhica keejis pace with it, and is, no doubt, the result of intestinal irritation, indanimation and
ulceration. Kjjistaxis is frequently jjre.scut and .sonu'tiuics troublesome; at first it seems to j^ive relief to thefeelinjj;
of oppression about the head, but if ciuitinued is i|uite likely to become a sourceof debility, and needs watching lest,
before we are aware, the patient be found succumbing to its depressing inHuence. Sometimes we observe upon tlii^
chest and alidomen the scattered eruption said lo bo characteristic of typhoid fever.
Surgeon Jas. V. Kendall, on the fevvm in Ihc camp of the li9lh X. T., in the itinter of 18(i3. — A large number of
the cases at the camp at Aipiia Creek commenced grailuaily, the patient scarcely recognizing that he was sick; slight
derangement of the bowels; tongue nearly nalural: eyes dull or yellow: urine in about one-half the cases nearly
natural at lirst, though many had paid no attention to this; loss of appetite; slight rigor, after which there would
lie an aggravation of all the symptoms: Prostration great: urine liigli-colored and in some cases turbid; diarrhica
increased unless checked by anodynes or astringents: tongue red, afterwards dry; some tenderness of liowcls and
tymjianites. Usually there has been no great ditliculty in restraining the discharges, which in many cases were
liquid and yellowish and in a few cases bloody; tenesmus was present, but seldom. In two there were large inflam-
matory swellings under the angle of the right jaw; these suppurated and required incision; one proved fatal and
the other will probably terminate in the same manner. Three cases, after having been sick for three weeks, com-
plained of severe pain and tenderness of the feet; in two of these the feet began to swell and became purple, as if
sphacelation was threatening. Uy the use of warm applications the pain and swelling diminished and the feet are
now but little discolored. But tin; worst cases have been taken down with nunOi more violence, without derangement
of the bowels: Perhaps the tirst report the surgeon would have of them would be that they were crazy in their tents.
It is probable that they had been taken with a sudden congestion: l)ut the fact could not be dclinitely as<'ertained.
These eases ran their course rapidly to a fatal termination or to convalescence. Some continued wild till near the
fatal ending and then liecame moderately comatose: these appeared like typhus cases, showing early vibices, sordes
and a general implication of the nervous system, manifested by involuntary stools and micturition, but without any
troublesome diarrlicea. In one case, that of C:iptain Wheeler, Company 1), the patient came in from duty and was
suddenly taken with spasms, becoming stupid and remaining so for several days. Gradually his intelligence returned,
the fpbrile symptoms diminished, the urine, which had been thick with sediment, became clear; he had some ajiiietite;
his bowels were costive, but easily moved by aperients; in two weeks he was able to undertake the journey to
Wijshington, and has since gone to his home at Syracuse.
Surgeon W. \V. Granger, Post hoxpilol, Houston, Mo., Dec. 31, 1862. — On the character, course or treatment of
fevers as developed in this jiortion of the army I have nothing to add to my report of September 30 except in relation
to typhoid fever, of which only a case or two had then fallen into my hands. The largely increased proportion of ca.ses
during the last quarter calls for an outline of the symptoms and treatment. The small, frequent pulse, dry skin,
continuous but rarely intense pyrexia, narrow-pointed, dry, red-edged and glossy or cracked tongue, sometimes heavily
at others slightly furred with shades varying from grayish-white to yellowish-brown or rhubarb-colored and even
darker, with the sordes-coated teeth, are symptoms too constant to be overlooked. Those which point to the cerebral
and epigastric regions are less constant in their occurrence as well as more variable in their character. Great and
persisting wakefulness iu some cases, which no prudent amount of opiate seems to overcome, is a frequent but by no
means regular symptom. An ecjually unyielding lethargy prevails with as many more. Delirium and perfect clear-
ness of intellect are equally distributed, whether among the comatose or the wakeful, and no greater fatality seems to
attend one class of cerebral symptoms than the other. Nausea and cmesis are occasional but not frcciucnt symptoms.
Tenderness on epigastric pressure is a frequent but by no means certain occurrence, and while some of the patients
have diarrho'a in the course of the disease, as large a ])roportion, from first to last, require purgatives to procure
alvine discharges every forty-eight hours, and not a few have regular evacuations throughout. The treatment has
been in all cases tonic from the start, with terebinthinate, vinous or, in the absence of the latter, dilute alcoholic
stimulants in the low stages, close attention to incidental or transient symptoms and a bland and easily digested
diet. Anodynes (opiate when not contraindicatcd hy cerebral symptoms) and diaphoretics have been employed
as occasion demanded. Tepid and cold sponging have proved most efficient in soothing the disturlied brain and
restoring healthy action to the skin. Mercurials I have rarely had occasion to, use in this disease, but in one or two
instances decided benefit followed the use of calomel and chalk in small doses for the jiurposc of exciting the secre-
tions, especially the salivary. In no case has it been necessary to push the remedy to ptyalism or even to fetor of
the breath. Quinine, turpentine and wine, cold or tepid sponging and cleanliness of person, bed and clothing, with
well ventilated wards, have proved so reliable as curative agents that I have not yet lost a case of this disease.
Asst .SKrfl.CiiARi.KS E. Cady, 138<;i. I'd., Uehni House. Mil., Oct. 31, 1862.— Many of our ca-ses of typhoid fever
were of a highly aggravated character. The invasion was frec|uently most rapid and prostrating. In several cases
the men performed duty on the day before reporting themselves ill, and on the third or fourth day all the patho-
gnomonic symiitoms would be unmistakably present. Our mortality has bten as low as is usual in private practice.
The treatment adopted was that in use in the Pennsylvania hospital, Philadcl]>hia: Good, full and easily digested
diet; milk and brandy in punch; eggs; Dover's powder, castor oil, sinapisms, neutral mixture, etc.
Surgeon J. T. Calhoxjn, Uth X. Y., Dec. 31, 1861.— One of the patients while convalescing from typhoid fever
318 SYMPTOMATOLOGY OF
very impniduDtly ate a quantity of peanuts and jelly; a fatal lelajise ensued. This was the first death from disease
that occurred in the regiment.
Surgeon J. B. Potter, 30tl: Ohio, FayetteviUc, April 2, 1862. — Our typhoid is not the disease so recognized by
medical men in private practice, but a continued fever of a typhoid type, modified l)y change of habits and to a
certain extent by climate. Many cases -when first reported are delirious, with cold e.xtremities, congestion of the
superficial capillaries, free perspirations, rapid and feeble pulse, 120 to 160, and profuse watery diarrhoea. These
terminate fatally in forty-eight to seventy-two hours. Such cases require quinia, carbonate of ammonia, brandy,
etc., from the commencement.
Surgeon B. EoHREii, 10(7i Pa. Reserves, Camp Pierpont, Va., December, 1861. — We have had much less disease of
malarial origin than was anticiiiated from our near location to the Potomac. Citizens long resident here say that
they have had less ague in their families this season than for manj' years, and attribute the favorable change to the
frequent heavy rains which flooded the streams and thereby removed the cause. Intermittents, with few exceptions,
have been of the (juotidian type and readily yielded to quinine ; recurrences have been infrequent. Remittents have
been somewhat peculiar in their character: Many have shown symptoms which are generally considered pathogno-
monic of enteric fever, such as rose-colored spots aud sudamiua, and in consequence have been recorded as typhoid
by several surgeons of adjoining regiments. I have been occupying the same apartment with the sick, giving them
my whole attention, observing them closely both day and night, aud have come to the conclusion that the fever is of
malarial origin and of the bilious or remittent type. The grounds for this belief are: 1st. Absence of epistaxis,
hemorrhage, obstinate diarrhoea, tympanites, deafness and stupor or delirium after the fifth day, the delirium being
invariably an early symptom. 2d. The early convalescence of all and no new cases occurring after one or two heavy
frosts. Nearly all when brought to the hospital were delirious, that being the first symptom to attract the atten-
tion of their messmates, who thought them either drunk or crazy. In conversation they seemed rational enough,
but when left to themselves they would give way to incoherent expressions or endeavor to make their escape.
Several succeeded by stratagem in getting out of the hospital aud ran to the quarters, half a n\ile distant, at night
with bare feet over the frozen ground. The patients complained of being chilly, although their surface was warm
to the touch and they were well covered and surrounded with bottles of hot water; the pulse varied from 100 to
120, the tongue was slightly coated and there was great thirst. This condition lasted from six to thirty hours. The
cerebral disturbance in some instances continued two or three days, and as it abated and the patients became more
rational they complained of i)ain in the head, tenderness upon pressure in the epigastrium and general aching and
soreness. The skin was hot and dry; there was a tendency to diarrhoea, no matter how mild the purgative, and
the evacuations were dark, at times almost black. After the third or fourth day the pulse became less frequent
and the tongue dry, smooth, glossy and red or cracked; the tenderness over the epigastrium was aggravated, the
urine scanty and high-colored and the eyes slightly tinged with yellow. From the sixth to the ninth day the rose-
colored eruption and sudamina made their appearance, also a dry bronchial cough, and by the twelfth or fifteenth
day, with one exception, they were sufliciently convalescent to move about the room. If delirious when brouglit
into the hospital wet cups were applied to the back of the neck, and if these aftbrded no relief a blister was applied
over the same place. A purgative of calomel was followed by castor oil, and in the morning from 4 to I'D o'clock,
when I couhl discover a slight remission, from fifteen to forty grains of quinine were administered: during the day,
at intervals of four hours, small doses of calomel and ipecacuanha were given. Turpentine was used when the tongue
was dry and cracked. Milk diet was employed and barley-water used as a drink.
Surgeon DeWitt C. Van Slyck, 35th X. Y., Falls Church, Fa., Oct. 20, 1861. — During the months of August and
September more than five hundred eases of fever were treated; the duration of these was from four or five days to as
many weeks. The first cases were intermitting in type, with a tendency to enteric disease. The fever soon after
took on a remitting form and finally assumed a low typhoid grade, in many cases exceedingly malignant. The treat-
ment consisted of a mild mercurial laxative, generallj- blue mass followed by large doses of quinine, and occasionally
anodynes and sudorifics. From twenty to sixty grains of sulphate of quinine per day were admiuistered, aud if these
doses did uot entirely eradicate the disease within the first week they modified and reduced its malignancy and
duration. No other method of treatment was effective. Mixed aud complicated cases were treated according to
the indications. During the last stage stimulants were given with manifest advantage. In nearly all the malignant
cases sudamina and petechi;e covered the abdomen. From the al)dominal tenderness and olistinate diarrha'a which
these cases exhibited it was evident that the mucous follicles of the intestines were seriously involved ; this conditicra
was frequently protracted and greatly retarded convalescence. It is regretted that no opportunity was atlorded
for post-mortem examination in the two cases that proved fatal. Convalescence was slow, and in many cases relapse
followed imprudence in diet and exercise.
Surgeon A. P. Maylert, U. S.V., General Field Hospital , Arm g of the Ohio, before Corinth,18G2. — The cases of disease
treated in this hospital were very similar in character, yet were such as could scarcely be correctly named by any
term in nosology. The patient was usually much emaciated, the skin of a light waxen or rather clay color; the
pulse small, compressible, variable in character and quickened under the least exertion ; the tongue thin and broad,
moist, and, with the fauces, almost natural in color, or perhaps of a darker tint than in health; in many the gums
were spongy and bled readily upon pressure. The skin was generally moist; there was seldoui much fever. The
appetite was somewhat capricious — usually no desire for food was manifested, but when fresh vegetables or fresh
beef, suitably cooked, were offered they were evidently relished except in the graver cases. The alvine evacuations
were more frequent than natural, thin, but otherwise healthy in ajipearance, except, perhaps, somewhat darker, and
in some cases slightly tinged with blood; they were not often attended with pain. There was rarely tympanites,
and usually but little tenderness on pressure. In many cases one or both parotid glands were extensively inliamed;
THE CONTINUED KEVEES. 319
this occurred iu the later stages of the disease and teriuiiiated occasioually in suiii>uratiou. I'robablyouc-half of these
were fatal. I know of uotliiug, iu the eases which recovered, to distinguish them fnini those which terminated
fatally except that i>erhai)s in the former suppuration was earlier established. The functions of the brain and
nervous system were often considerably impaired: In all cases the patient was languid, weak and disposed to bo
<iuiet and sleep as much as possible; there was almost total want of .judgment, the memory was defective and the
mind wandering; the delirium was always mild in character. In short, this disease was termed variously remit-
tent fever, typhoid fever, diarrluea, dysentery or scorbutus, according to the symptoms. In oaoli case was a dyscrasia
resulting diietiy, as I apprehend, from exposure and lack of suital)le nourishment. Ponl-mvttim examination usually
showed a congested condition of the small intestine, seldom amounting to decided inllauniiation and rarely attended
with ulceration. There was generally a dirty dark-red ap]>earanee of the mucous meniliraiu^, which was somewliat
softened, being readily renmved by rubbing with the back of the scalpel. Invaginations of the small intestine
v.ere fre(|uently found lint were never strangulatitl. The gall-bladder was often distended with bile. The ventri-
cles of the brain and the pericardial sac contained a little more seium than natural, Fre(|uently a tibrinous clot was
found in one or both ventricles of the heart, and sometimes this was so large as to distend the heart or at least keep
it of normal size. No ot her abnormal appearances were constant except general emaciation and a llabby and atrophied
condition of the muscular system. In many cases the blood appeared thin and uncoagulable in both arteries and
veins. A few cases of sudden death showed a degree of pulmonary congestion, or even pulmonary apoplexy, evi-
dently induted by heat exhaustion in patients already greatly reduced by blood-poisoning. The treatment consisted
mainly ip careful nursing with nourishing diet, where it could be given, and stimulants combined in some cases
with ijuinia.
Suri/ioii ,1, 15. .Jaoksox, 121,1* U. S. Colored Infantry, MaysviUe, Ey., February, 186.5, — Edward Gray, Taylor Tbillips
and Kobert Nelson were brought to hospital about the same time in a state of collapse, with cold extremities, slow
and weak pulse, a vacant stare and numtal hallucinations; subsultus teudinum was present, especially on attem])t-
ing to move. They loathed food and presented a scorbutic appearance. There seemed to be an engorgement of the
whole system, particularly of the liver. They would not acknowledge themselves sick, and came to hospital by order
of the company conunander, who said he considered them nearly dead. Hepatic agents, counter-irritants, stimulants,
tonics and anti-scorbutics were employed, without manifest effect except that in Taylor's case heavy bilious stools
were procured ; but there was no response on the part of the nervous or circulatory system. The patients, if allowed,
would rise and walk almost to the hour of their death,* Gray died on the second day after entering hospital and
Phillips on the fourth ; Nelson lived some days longer: Diarrhoea set in about the sixth day, the most simple diet pass-
ing unchanged; injections were tried Imt none were retained. He continued with littlo change of mind or body,
except emaciation, until death.
These men had been in camp about three weeks. They came from the rvual districts and had been accustomed
to fresh air and mixed diet. When they joined the weather was intensely cold at night. They were shut up in their
tents tilled with coal-dust and smoke, and of course lived on the soldier's ration. They suffered severely; subse-
([uently they were renuived to a largo building, well lighted but with a low ceiling and only one stove. The
intensely cold weather nuule it necessary to partition off a room aViout 2,5 Ijy 30 feet, where for about ten days fifty or
sixty men were crowded together day and night. During this state of things these three cases were developed, and
all cases of measles, fever, diarrha-a, etc, from that company assumed a malignant type and inclined to tyi)hoid or
scurvy. The commanding officer was made aware of this, and as soon as possible had his ([uarters expanded, drilled
Ids men every day in the open air and furnished them with plenty of mixed diet. In little over two weeks all
diseases became more amenable to treatment,
Extruet from the reeonis of the Chimhorazo Bonpital, Richmond, Vii. — The typhoid fe\ers observed during the
winter 18t>3-G4 have been generally prolonged, but less so as spring approached. There has been almost uniformly
a loose state of the bowels, the (characteristic thin stools, but less ofi'eusive than is usual when turpentine and chlo-
rate of potash, which are the routine here, are not employed. Few have exhibited much abdominal tenderness,
• Epward B.4TWKLI,, Siirgfoii 14th Mich. Vet, Inf., in an account of a fever that prevailed at Camp IJig Springs, Miiss., in June, 18G2, publitilied
in Vol. XIII, -Vcd. aiid Snr<j. Ueporter, i'hila., 186fj, p. 3(»4 ei «■//., reports that after the evacuation of Corinth, and during the movement of the pursuing
army towanis B^xinsville, intense heJit succci'ded to » copious miufalt, during wliieh the soldiers were exposed without tents or suflieieiit clothing,
having left these behind iu the camps at Kanuington. As there was a dearth of pure water, the stagnant contents of pools were drunk by men and
inalc« alike, the strong sulphurettwl water of the artesian wells being used only in urgent necessity. At this time chills and fever apis'ared among the
troo[«, the febrile action tinally becoming coutinue^i and of a low type, .\fter falling buck to Big Springs an anomalous fever invaded the anny. It
commenced with malaise ; the skiu was cool, the tongue moist and natural, the pulse never above 00 and the urinary and alvine secretions regular. There
was '* no chill, no fever, nothing to indicate anything wrong ; the appetite, if anything, was increased ; no want of sleep was complained of, nor did a
single symptom present itself indicative of diseased action. Despite all this there was a look about your patient, an expression of countemkuce that
firmly convinced you that it was not a case of malingering you had to treat. This condition lasted for some days, when restlessness and a tendency to
delirium supervened." There was an irresistible proi>ensity to walk about ; nothing but force could keep the {Nitient from leaving his lied, and this
peculiarity became more marked as the case approached a fatal termination. From the commencement of the complaint there was a rajiid losvsof flttsh and
the pulse t>e,-ame languid and feeble. Restlessness lasted from about the twelfth to the twentieth day, after which then- wa^ less disposition to begin
walking, but the patient would move over a greater dist;ince. .\fter one (if these walks he would express himself as fe<ding better, go to bed and die in a
'flw minutes. There occurre^l eighteen of these fatal cases in the regiment, all varying but little in their symptoms. The mortality was also great in other
Rgiraents, some of the sick dying on their way to general hospital. The diseiuse was called typhoid fever by army surgeons, but RATWKr.i. says that he
"faib^i to tiace a single point of similarity of the symptoms," A local practitioner of whom ho made inquiries described the disejise accurately, calling
it the %enUiiug .frrcr, and saying "it was peculiar to that section of Slississippi, and that change of location alone exercised any influence over it; that
strangers were more especially attacked, and it gt^nerally proved fatal." Little benefit was derived from treatment, which, fniin the absence of anything
that might have been considered a positive indication, was "entirely expectant or rather empirical." Quinine, stimulants, counter-irritants, alteratives
were tesiirted to as trial remedies. '• PtiM-nmrleni examinations were made but they failed to developany lesion ; all the internal organs seemed of a healthy
character and nothing indicated diseased action," •
320 SYMPTOMATOLOGY OF
Bome none at all. Sub-deliriuni has been frequent; violent delirium has never occurred. Macute have been absent.
The gastric type has been rare; few have complained of irritation induced by turpentine, which is given in emul-
sion in ten-drop doses. Neither cupping nor purging has been employed. In some cases calomel, ipecacuanha and
opium have been given, seldom with appreciable benefit. The stimu'ant method, with whiskey or brandy toddy,
egg-nog and animal broths has been employed from the first in nearly all cases, and continued to convalescence.
The intervals between the evening and morning meals have been too long for some patients, and it is to be noted
that no soups or food'other than dry bread is usually kept over night in the wards. It is desiral)le that attention
should be directed to this point and that the intervals of nourishment as well as of stimulation should be distinctly
described. Bronchial irritation has been common as a comi>lication and pneumonia not rare. The hospital phar-
macy is deficient or has been so in pectoral remedies. Cough mixture often lacked some of its intended elements and
afforded but slight palliation. The balsam tar-water, sanguinaria and asclepias tuberosa would form important
additions to the pectoral bvidget. Some cases jiresented, without violent delirium, the most intense irritation of the
nervous centres — continual twitching of features, muscles, etc., and working out of bed and throwing off the bed-
clothes. The resources of the hospital in the way of antispasmodics are deplorably limited.
Bemarls on the Sequela' of Chickahominy Feinr, Act. Asu't Surg. J. M. Da Costa, U. S. J., Dec. 31, 1862. — Among
the soldiers returning from the Peninsular campaign a form of fever was observed marked by features of uncommou
character. It is not my purpose to attempt a description of this malady, but rather to speak of the morbid states
met with after the fever proper has left, and which may therefore be regarded as its consequences or sequehe; nor
can I say that my delineation will include all the possible results of this grave disease. Others may have encoun-
tered other issues. I can do no more than sketch what I have seen and endeavor to reproduce those outlines which
I believe to be most significant, and which have become familiar to me from personal observation; and first of the —
General appearance. — A striking sign left by the fever is great emaciation. The patient rises from his sick bed
the shadow of his former self. In some cases the loss of flesh is so excessive that the muscles of the body appear
literally to have been absorbed. The hair falls out in quantities and the whole appearance is that of a person hope-
lessly reduced ; yet, unless diarrhcea be present, the flesh is, under generous diet, rapidly regained. Nay, I have seen
individuals soon acquire more than they had lost by the attack of fever. The countenance, produced in part by
emaciation and in part by a peculiar hue, is strongly characteristic. No disease has a more remarkable physiognouiy.
The eye is not heavy nor reuuirkably languid; the conjunctiva is clear or injected, never yellowish, thus forming a
marked contrast with the pallid and yellowish color of the face. The peculiar look may last for a month.
DehilHij. — Both body and mind remain for a consideral)le period enfeebled. The weakness of the former shows
itself in an inability to bear exercise or undergo fatigue of any kind, whilst the debilitated state of the latter is
plainly seen in the loss of memory so constantly complained of. The exhaustion of strength is at times so great
that the patient who for a week or two has been able to leave his bed is found to be again losing ground and lapses
into a typhoid state in which he perishes:
P. Purcell, 49th N. Y.; age 45; was admitted August 7 from Harrison's Landing. He was just recovering from
the fever and was much exhavisted by his journey from the James River. After a few days careful nursing he rallied
and was soon able to walk about. He continued to gain .slowly until the 20th, yet was easily fatigued, and, though
craving alcoholic stimulants, was unwilling to eat much. From this time, without any assignable cau.se, he lost
strength daily, and by the 30th was confined to bed. All appetite was gone and it was with the greatest difficulty
that he could be persuaded to take any nourishment whatever. He commenced to vomit green matter; his eyes
were injected, pul.se feeble and skin cool. His stools were at times liquid, at times natural and not of unusual fre-
qncncy. On September 4 the irritability of the stomach had to a great degree subsided; but a violent diarrhoja
set in attended with severe pain and uncontrolled by opiates and astringents. On the 8th he died in a state of utter
exhaustion, yet retaining his senses almost to the last. Post-mortem examination: Extreme emaciation. Both
lungs with old pleuritic adhesions, but the organs themselves healthy. Heart flabby; right ventricle contained a
small clot. Spleen lake-red in section. Liver somewhat enlarged and fatty. Stomach and intestines distended
with air. Inflammation in patches in the ileum; its glands healthy. Inflammation of ciecum and sigmoid flexure,
a less degree in rectum and a feeble degree in ascending and descending colon; there were also a number of small
ulcers about the size of a pea in the sigmoid flexure and rectum. Solitary glands with black deposit but otherwise
healthy. Kidneys normal.
In looking over the history of this case the question suggests itself, was not this rather a relapse of the orig-
inal malady? The absence of fever, of cerebral disturbance and the post-mortem evidence seem to disprove such an
idea. The man's death was, I think, produced by progressive exhaustion, and hastened by an attack of colitis
which his enfeebled frame was unable to withstand. In one other case the same result took place, except that there
was little or no preceding diarrhiea Another case recovered, the irritability of the stomach yielding to mercurial
purges and rei)eated doses of dilute sulphuric acid.
Changes in the blood. — In a large number of cases the blood is profoundly altered. The clinical evidence of
this is found in the pale look of the tongue, the pallid face, the blood murmurs and the spots that appear on the
skin. These spots are like those of purpura; they do not disap})ear on pressure. Sometimes they are isolated, at
others confluent, giving a purple or dark-bluish look to large patches of skin. In the following case this appearance
was very marked :
Thomas Rose, 49th Pa.; age 20; was attacked with diarrhtea while on duty on the Chickahominy. This,
after the lapse of a month, was followed by fever attended with great prostration and mental wandering. In this
condition he came under my care on August 7. He was stimulated and carefully nourished, and by the 14th the
fever had subsided, the diarrhtea remaining. This was treated with pills consisting of the sulphates of morphia
THE CONTINUED FEVERS. 321
and iron, for which, on the 27tih, tannic acitl was sul>stitntc(l witli tlio happiest eft'ects. From Reptenilior 1 Ktose-
nesd of the howels ceased to be a prominent symptom. About this time dark-bliiisli spots were noliceil on his
chest, nnchan-^cd by jircssnre and of varying size. Soon afterwards they made their appearance on the abdomen
:ind then on tlie extremities. On the trnnk phices of a foot in diameter conW be fonnd on which no healthy skin
could bo seen, nothing; but dark spots on a variously tinted purple back ground. The gums were tirm and heallhy-
looking, the tongue clean, the abdomen Hat, certainly not distende<l, the skin cool, pulse feeble and 102 per minute.
There was very great emaciation and <lebility and occasionally sore throat; the voice wa-s husky and rarely raised
above a whisper. The bowels were on the whole regular, one or t wo watery pass.iges occurring daily. Tlu! patient
icniained much in tliis condition until liis death, neither the mineral acids, the salts of iron nor a liberal and varied
diet checking tlie spread of the pur)>urous spots. I'onl-morlrm examination : Body considerably emacialed and every-
wliere ecchynmsed. l.ungs normal. Heart healthy: a while clot in the right ventrieleextending into the pulmonary
artery, another in the left auricle and a third in the commencement of the aorta. .Spleen, liver, kidneys, supra-
renal luidies ami jiancreas natural. Stomach with inllummatiou of the mucous membraiu' more or less dill'used,
mingled with small patches of greater intensity. Inllammation in patches of the nnieous membrane of the ileum,
increasing in intensity towards the termination; solitary glands enlarged, inllamed and containing black matter;
aguiinaleil glands with black deposit but otherwise apparently healthy. C'oli>n distended with air, except descend-
ing portion, which was narrowly contracted and not intlamed; ca'cum, ascending and transverse colon inllamed;
solitary glands conspicuous and containing black matter.
I'n fortunately uo chemical examination was made of the blood in this case — one of a series, including many
lighter ones, which have been confounded with typhus fever. But the ditference is palpable in spite of the simi-
larity of the eruption to that of some of the stages of typhus, — there is an utter absence of the high fever, the cere-
bral syin|itonis, the ])liysiognomy and the early cutaneous rash which mark that disease.
( ur'tiiic ilimriliTs. — The wards of all the hospitals are crowded with men compl.aining of a disease of the heart.
What the nature of it cnuimonly is let the following cases answer:
.1. B. Waters, corporal, Co. A, Jd X. V.; age 21; was admitted August 10 from Harrison's Landing, where he
had been sick wilh fever since .July 11. The disease was preceded by dysentery. The febrile symptoms sul)sided
within a week after his admission, but the man remained prostrate and was unable to sit up until the last week in
August. During this slow convalescence he suffered much from Hatulencc and was troubled with palpitation and a
feeling of uneasiness in the cardiac region. An examination of the heart showed increased action without iucreased
percussion dulness. The second sound was very distinct; the first was replaced by a soft systolic murmur markeil at
the base but also extending towards the apex. This state of things continued until December, the blowing sound
lieeoniing gradually fainter and only being distinctly heard after exercise. The patient is now, the 12th, in good
Iteneral health, and does not sutler unless he walks much, when his breathing becomes oppressed; the respirations
are still ([uick, thirty a minute, and he cannot sleep on his left side; an examination of the heart shows the trans-
verse jK-rcnssion dulness to be three and three-fiuarter inches, the longitudinal three and a half inches ; the impulse
remains forcible and is felt in two intercostal spaces; the second sound is very distinct, but the first dull ; a slight
hum is yet heard in the cervical veins. The treatment comprised the administr.ation of fjuinine, iron and strychnia,
replaced by veratruin viride when the heart's action was violent; the cardiac nneasiucss was much relieved by :i
belladonna plaster worn over ihe heart. This case is typical. The appearance of the heart trouble after the fever,
its long continuance, the systolic blowing sound and its gradual disappearance, the irritable state of the organ
riMeaiuiug long after the general health was iu every other respect fully reestablished, all form a clinical combina-
tion of very great interest and freijuency. Many such patients are thought to have hypertrophy .and valvular dis-
ease, but although here and there a case of doubtful diagnosis may occur, it is generally not diliieult to distinguish
between these cardiac maladies. The previous history, the absence of increased percussion dulness, the temporary
duration of the blowing sound are just the opposite from the visibly augmented size of the heart and the perma-
nent murmur of valvular disease. Then, too, the character and site of the murmur are jjeculiar: It is never rough,
always attends the impulse and is very often associated with a hum in the jugular veins. It is phiinest at or near
luidsternum and is thence transmitted iu the course of the aorta or pulmonary artery; it is rarely distinct over the
apex of the heart. It is frequent, biit it would be a mistake to suppose it invariably present in the class of cijses
just described. Very often the first sound of the heart is dull, short, ill defined and unattended with a murmur; the
second sound I have invariably observed to be clear and sharp. In some i)atieuts the impulse is very irregular
and the cardiac rhythm much changed.
.John Bricker, 8th I'a. Cav.; age 21: was taken sick at Riir Oaks Station, June 7, with severe diarrhcea accom-
panied with excessive griping pains and followed by the discharge of considerable blood. About the 21st he was
seized with fever connnencing with rigors,- pain on the left side of the chest and iu the loins. He noticed that any
attempt to stand brought on dimness of sight and dizziness, and also that his tongue was very dark, loaded and dry.
About the 2i)th, while the fever still existed, he was moved to Harrison's Landing, then to Fortress Monroe and
thence to this hospital, where he arrived July 7. On his arrival he had little or uo fever, but the diarrhiea was still
liad, from five to six pa.ssages daily, not, however, containing blood. He stated that he had expectorated blood
once or twice shortly before he was sent here, and that liefore the attack of fever he had been in good health.
Shortly after his admission he had a slight hemorrhage and complained much of pain in his left breast, which he
deecribed as constant, of a sharp cutting character, not iucreased iu intensity by any circumstance he noted, and
reaching at times from the lower ribs np to the third or fourth. As soon as he commenced to walk about he
observed palpitation of the heart: the action of the organ was very irregular and attended with a blowing sound.
He improved much under treatment, and now has a very good appetite and enjoys his food. The diarrhcea has
Med. Hist., Pt. Ill — 11
Q
22 SYMPTOMATOLOGY OF
disappeared and ho has nearly regained bis strengtli; but any excitement or labor agitates bim and brings on
violent beating of the heart. Percussion gives him pain ; it shows, if performed with care, the transverse diameter
to be slightly increased. The apex strikes at its normal position, but the impulse communicated to the finger is
every now and then of a tlirolibing character, extended and intermitting. On auscultation the first sound is ilull
and a murmur of low pitch is perceived with the systole following the marked intermission; a blowing sound is at
the same time heard in the carotid; there is also a continuous lium in the cervical veins. The pulse is about SIO,
intermitting every third to seventh beat. It is very likely that here the walls of the heart have undergone some
cliauge, and that tlie lack of tone nuiy lead, if it has not already led, to a dilatation of the ventricles. Tliat organic
changes may indeed be produced by the unvaried abnormal action I have no doubt. I have seen such cases. One
was for months under my observation in the hospital, the signs of dilated hypertrophy developing themselves
more and more clearly. If it, then, be possible for organic disease to follow long-continued functional disturlvance,
the very grave fjnestion arises whether men convalescing from fever, with the state of the heart described, are
fit for further service. I think not; certainly not when this condition of the organ outlasts a marked improvement
in the general health. Amendment is slow, and for perfect recovery to take place long rest of body is essential.
Active exercise would be the means most likely to lead to organic disease. The medical treatment which I have
found best suited to the class of cases under discussion consists in the administration of iron and nux vomica; to
this l)elladonna, both externally and internally, may be added with advantage, especially if there be much pain
in the cardiac region. When the heart's action is very violent I have lowered it by veratruni viride, temporarily
suspending the tonic medication, or sometimes employing both agents conjointly.
I'hltfjmaxia alha dohns. — -Two cases of this strange morbid condition have come under my notice. Poth occurred
during convalescence from the fever, and in both recovery took place. In the first the tense smooth swelling occu-
pied the whole thigh of the left side, especially the upper and inner Jjart. It was particularly hard in the course of
the sapheua vein, which seemed enlarged. A blister was applied over the course of the vein and the swollen thigh
kept constantly swathed in lead-water and laudanum. The tumefaction subsided very gradually and did not
disappear entirely for several months. In the second case there was much pain along the course of the femoral vein
and in the calf of the right leg, which was much increased in size for four or five days, sensitive to the touch,
o'dematous and partially paralyzed. After that it slowly resumed its natural appearance, but the man does not even
now walk without lameness.
Iiifidmmution of the parotid gland tending to suppuration is occasionally encountered in this fever. Of four cases
that canui under my notice three recovered, one proved fatal. In one of tho.se having a favorable termination both
glands became seriously affected. Here the disorder appeared before the febrile signs had left. In the following case
the inflammation set in after the commencement of convalescence:
Jacob Risley, Co. F, (ith Pa. Cav., was seized with fever and diarrhoea about July 11 at Harrison's Landing.
Wlien admitted into this hospital on August 7 he was very prostrate and suffered much from diarrhoea, but had
little or no fever. He soon commenced to improve and after a few days was able to sit up. On the 16th a tumor
was observed at the angle of the jaw attended with much pain. It soon increased and appeared to involve the
whole right side of the face. It was moderately tender on pressure, not accompanied by much external redness and
unassociated with any signs of inflammation of the tonsils or throat. An effort was made to produce resolution by
painting with iodine, but it did not succeed. An indistinct fluctuation soon showed that suppuration had taken
place. The abscess pointed at the angle of the jaw and was opened, discharging a teacupful of offensive matter.
The discharge continued six weeks; the cut then healed, but to this day the patient frequently coniplaihs of pain in
the region of the duct, which can be felt, hard and round, just lielow the malar bones. Otherwise he is now in per-
fect health. The diarrhtea yielded, before the discharge ceased, to the use of sulphates of copper, iron and morphia.
Diarrhaa. — This is one of the most frenuent and at the same time one of the gravest sequels of the fever.
Indeed, hardly a case of Chickahominy fever recovers without great irritability of the bowels remaining for months
afterwards, and under unfavorable circumstances this irritability lapses into uncontrollable diarrhaia. The relation
the diarrhwa bears to the fever is very close. It generally precedes it, sometimes by weeks, is a prominent symptom
throughout its course and outlasts it. It rarely if ever occurs where it has not been present during the fever. In
describing its characteristic traits I shall draw rather from a group of cases that I have noted than give the history
of any one in particular: The man who is the subject of the disease convalesces from the fever very slowly. He
takes but little nourishment, since if he eats much frequent stools are the result; yet he has scarcely any gastric
disturbance, does not vomit, does not loathe food; his tongue is moist and clean. The abdomen is distended with
gas. the seat of a dull pain but not painful on pressure. If asked what troubles him most, he generally refers to the
flatulency, points to the inability to button his clothes, and may often be heard to declare that he is less annoyed
when he has many passages than when they are checked, since in their absence he becomes bloated. His features are
pale; his eyes clear; he does not bear fatigue well, though on the whole it is often a matter of wond('r that the
countenance is so healthy-looking and his strength not more impaired than it is. He may remain in this condition
for weeks, either slowly gaining or on the other hand slowly losing ground. In the former case he is liable to the
diarrhoea, which h.as been checked, breaking out from time to time; in the latter he becomes much emaciated, aiul
dies utterly worn out after months of suffering. Among the symptoms mentioned the state of the tongue and gums,
the stools and the abdominal pains require a more extended notice. The tongue is smooth and moist, sometimes very
pale, but almost always clean; only in a few cases is it observed to be coated. The gums are generally hard; now
and then, probably from antecedent scurvy, they are spongy and red, but this condition is not nearly so fre(iueut as
the former, nor can I say that I have found where it existed any difference in the other symptoms,— the diarrhcea did
not seem to me either to yield more readily or to be more intractable. TVse stools are always thin and remain so long
THE CONTINUED FEVERS. 323
after they are reduced in frequency. lu color they are mostly yellowish, sometimes greenish, rarely dark or very
ortVnsive. In not more than one case in fifty do they contain blood. They are frcinieut, varying from live to twenty
or upwards in the twenty-four hours. The passages are not attended with much pain or tenesmus, still there are
numerous exceptions to this rule, and then hemorrhoids seem to result from the constant bearing down. Abilomiiiitl
piiin is often complained of by the patient. It is, perhaps, a sense of soreness and uneasiness more than of pain,
increased from time to time by exacerbations of colic. It is not as a rule augmented by pressure, and this absence
of tenderness is very remarkable. When any tender spots exist they are j;enerally discovered in the course of the
lar^e intestine. Some few speak of a weighty feeling in the region of the spleen, which organ, on percussion, is
founil to be increased: yet enlargement of the spleen, contrary to expectation, is not a fre<|nent sei|uel of the fever.
In some cases the urinary organs are deranged : Tliere is a constant disposition to pass water, which becomes a source
of great annoyance to the patient. The urine voided is copious and i)ale,of low specific gravity and contains neitlier
sugar nor allmuK'n. The diagnosis of the diarrhoM is very easy. There is only one complaint with which it may be
confounded— dropsy: but careful percussion soon shows that the <Ustention is owing to wind and not to liquid.
Dropsy is, indeed, very rarely met with after Chickahominy fever; I have encountered but one instance of the kind,
and there it was associated with albumen in the urine. The post-mortem appearances are, as far as I have been able
to pursue the matter, the same as in the Chickahominy diarrhrea without preceding fever. There is an absence, for
the most part, of ulceration or thickening of the mucous membrane, accounting thus for the want of tenderness.
There are |iatches of intlannnation near the ileo-c:ecal valve, in the colon and sometimes throughout the ilonm. The
agmiuated glands arc prominent and contain blackish pigment, and so do the solitary glands. The exciting cause of
thejie curious morbid changes is veiled in obscurity. This much, however, appears. There must be in the poison
giving rise to the fever something capable at the same timcof jiroduciiig thediarrho'a. — in other words, the same cause
may occasion both. The trealnu-nt of the diarrha-a consequent upon the fever is the same as that of the diarrho-a
without antecedent fever. Hot h are alike obstinate and ditlicull to inlluiMice. In both all medicines often fail. The
tiest results have in my hands been derived from carefully regulating the diet and administering large doses of tan-
nic ai-id conjoined with opium, live grains of the former with from one-fonrth to one-third of the latter, in pill, four
times daily. The medicine can be borne for weeks at a time svithout nauseating. The subnitrato of bismuth, the
snljihate of copper and the nitrate of silver stand next in efficacy, and sometimes succeed where tannic acid fails,
The jiernitrate of iron, given iu from fifteen to thirty-drop doses three times a day, is occasionally of service; but ou
the whole it has disappointed me. Opium alone does not answer, although useful when Joined to other .agents.
Opium suppositories or enemata give the patient rest at night and are thus of benefit. The tinctures or infusions
of catechu and kino only act advantageously in light CLses. From ac^etate of lead, tincture of the chloride of iron,
turpentine, the mineral acids, Hope's mixture, quinia, strychnia, saline purgatives and Dover's powder I have seen
little or no good etlect, although I have given each of them a fair trial. Carminatives exert only a temporary
inlluence on the flatulency. In one case both this troublesome symptom and the diarrlnea viclded to charcoal. Diar-
rhn>a is the last of the issues of Chickahominy fever I shall notice. .\ few of the less iiromincnt, such as pain in the
limbs, the occasional occurrence of tympanites without diarrlnna, 1 shall merely indicate without specially describing.
In taking a survey of the symptoms thus strung together the similarity to those encountered during protracted con-
valescenro from typhoid fever becomes at once apparent, but the dissimilarity is also manifest. Where, for instance,
arc the ]mlmonary troubles so common in the latter complaint f Any further discussion is, however, here out of place.
To ascertain whether Chickihominy fever be modified typhoid fever or a distinct disease would require further
data and other trains of reasoning than are here admissible. Let, then, this report bo accepted as an unbiased
clinical contribution to the history of one of the most interesting but unfortunately most destructive forms of fever
that this generation of physicians has been called npon to study.
v.— TYPHUS FEVER.
There seems no doubt that occasional cases of typhus fever were treated in the general
hospitals during the war, but it is probable that in most of these the disease was due to civic
and not to military contagion. We have the high authority of Dr. Austin Flint for two
of the cases, 7 and 8* that have been submitted, in one of which it is explicitly stated
that the fever was contracted while the soldier was at his home in New York City. Cases
5 aud 6, treated at the same time in the Cuyler hospital, Philadelphia, Pa., the subject in
one instance being a contract nurse, and in the other a patient who had been in hospital for
nearly three months with a rheumatic affection, appear also to have been true typhus; and
in this connection 389 of the post-mortem series may be referred to, as presented by the
records of the same hospital, showing restless delirium alternating with comatose quiet, sup-
pression of urine, petechise and death on the fourth day with no abnormal condition of the
mtestines. Case 1, which occurred in a patient recovering from gunshot injury in the hos-
pital at Annapolis, Md., was probably typhus, as the clinical record is supported by the
* Supra, p. 209.
324 SYMPT0MAT01>0GY OF
possibility of contact with true typlm-i tln-n recognized as present in one of the wards.
Case 9. in the Lexington avenue hospital, New York City, may also have been typhus, hut
in 10, fronx the records of the same hospital, tlie evidence is insufficient to show that the
soldier contracted this fever at Sandy Hook, Md., or in camp prior to the date of his ship-
ment from that point.
In fact the records do not furnish a single instance of undoubted typhus as having
occun-ed among our troops in the field. In cases 12 and 13 there is nothing to substan-
tiate the diagnosis. In 11 the disappearance of the. eruption under pressure, the diarrhosa,
tympanites, epistaxis and bronchitis suggest typhoid rather than typhus fever. In 3 and 4,
both received about the same time from the 119th El. regiment at Quincy, 111., the pre-
sumption is in favor of typhoid; in the former a recrudescence is recorded, with death from
the gravity of tlie intestinal lesions, hastened by exhaustion from copious hemorrhages;
in the latter a history of typhoid with violent cerebral symptoms, diarrhoea at first but not
in the later stages, perspirations, red spots on the bod}^ and face on the sixteenth day, and
death on the twenty-second. In 2, which may have been typhus, the patient was a hospital
inmate convalescing from measles; his face was suffused and spotted, and death occurrcil on
the thirteenth day, but the other symptoms were such as were frequently found in douljtful
typhoid cases.
Moi'eover, the experience of other armies shows definitely that if the contagion of
typhus had gained access to our camps, no search of the records of individual cases would
have been required to substantiate the fact. The death-roll of our medical officers and.
hospital nurses would have been a sufficient demonstration.*
Undoubtedly there occurred in our camps a number of febrile cases presenting dusk-
iness of skin, intense cerebral symptoms, dark-colored spots and petechise on the chest, abdo-
men and even on the face, unaccompanied with well defined symptoms of an enteric lesion.
It is not surprising that such cases were regarded as typhus by some of our medical officers,
for in an epidemic of typhus fever they would certainly have been ascribed to the epidemic
cause, and even occurring as they did in isolated cases, their generally rapid and fatal course
was sufficiently striking to warrant those who saw them for the first time in fearing that
they had before them something dangerously different from the familiar typhoid. But as a
larger experience demonstrated the comparative non-contagiousness of these cases, and joo.s^
mortem examination showed in them the characteristic lesions of typhoid, they became less
*See, for instance, FlLix Jacquot — Da Typhus de VArm.:e (V Orient^ Paris, 1S58, p. 50 el mj. — The two typbns epidemics in the Crimea began with
the first hard frosts of December, 1854, and December, 1855. Originating in tiotb years in tlie Crimea, the disease showed itself in the distant hospitals
one month after its outbreak among the troops in the field. These hospitals became in their turn active foci whence the fever was propagated by conta-
gion, and where probably, according to M. Jacquot, it also originated in some instances, in view of the concourse of so many individuals reduced by
exhaustion and privation and affected by scurvy and other diseases. The English troops were the first to liecome infected, but in a little time the
French army coramenced likewise to suffer. The condition of the latter, though rel.atively better than that of the English, who became engaged in a
great continental war without being prepared for it, was nevertheless far from satisfactory. The Russians, according to Drs. MiERlNG and .\LrERIEF,
were tainted with typhus even before the allied armies showed any sign of it. The Russian and Turkish troojis in Asia equally fell a prey to it. In a
word, typhus was developed wherever were found aggregations of men exposed to fatigue and anxieties, badly quartered, poorly clad, and whoso nourish-
ment was not of such a nature as to countei-act these hygienic drawbacks. About a nionth alter its development in the Crimea it broke out in all tlio
French hospitals in Constantinople, as also in the English hospital at Scutari. * * * In December, 1855, the English, who in the meantime had com-
pletely modified their system and reformed their administration, who were better located and quartered, better clothed and fed, less fatigued and exempt
from scurvy, which prevailed fearfully in the French arnij', escaped visitation from typhus, while the latter suffered from it to a far greater extent than
in the previous year. The Italians were a little less affected than the French. In January, 1856, typhus was imported into Constantinojde ; but the Kng-
li.sb hospital at Scutari escaped, as did their troops in the Crimea. All the French hospit.als were invaded, those situated on the plateau extending Iroui
Ramis-Chiflick to Daoud-Pacha and the Candilifi hospital on the Bosphorus. There were, including extemporized establishments, twenty hospitals in
and around Constantinople, and not one of them escaped. Tlie dise.ise appeared also in the hospitals at Gallipolis and Nagara on the Dardanelles, The
crews of merchant and government vessels engaged in the transport of sick and wounded were decimated. Typhus was introduced into the hospitals
at Marseilles, Toulon, PorqueroUes, Frioul, Avignon and into the Val-tle-Grace in Paris ; and isolated cases died in many localities, as at Cllalon-enr-
Saune, Neufchateau, etc. Fortunately, in Constantinople as well as in France, the disease did not spread outside of the hospitals ; but in besieged cities
or overcrowded places where troops were quartered in barracks side by side with the population, as for instance in the village of Tciiistinakaia near
Simferopol, the civil population was more or less affected. In Russia it passed from the Crimea to Odessa, Nicohaieff and several other localities ; A ania,
occupied by the French, was likewise affected, and finally the Turkish and Russian armies in Asia Minor paid a heavy tribute to this fever.
THi^ CONTINUED KEVERS. 325
I'ruquently reporU'd as tvjiliiis. Tlie clinical features of idiopathic felirile aH'octious arc not
circumscribed but confluent. It has already been shown in this volume that it was not pos-
>il'lr in all cases to determine from the symptoms alone that a fever was malarial or typiioid.
So in cotemporaneous epidemics of typhus and tyjihuid, it is not possible in all cases for the
clinician to distinguish between them.* Even in typhoid epidemics the practitioner is some-
times at first uncertain in his diagno.sis.f Tlie disease in its onset seizing those who liave
the strongest jiredisposition, may run a quickly fatal course in individual cases, leaving to
future cases or post-mortem inquiries the determination of the specific form of fever. Thi-
first case may be considered typhus, but when the typhoid nature of the epidemic has been
established, other such cases occurring thereafter receive a proper recognition. Again, in
malarious districts fulminant febrile cases with cerebral symptoms terminating speedily in
death by coma and attended with cutaneou.s hemorrhagic blotches were, when first seen,
regarded doubtfully as typhus, cercbro-spinal meningitis or congestive malarial fevers, until
a larger experience showed tlieir etiological relations with malaria rather than with other
specific causes of disease. Thus are explained the typhus cases reported by our medical
officers in the field during the war. The relatively large number during the first year, 2.84
per thousand of strength, decreased during the second year to 1.44, and continued to decrease
to .52, .51 and .30 respectively during the third, fourth and fifth years covered by our statis-
tics, as these fulminant cases were found to lack the contagiousness of true typhus and to be
associated,, from the etiological point of view, with the typhoid and typho-malarial cases
which were prevailing in our camps. |
Thus, Surgeon Zenas E. Bliss, U. S. Vols., noted a fatal case of typhus in his command
while at Yorktown, the patient dying with superficial ecchymotic blotches and hemorrhages
from the nose and bowels; no post-mortem examination was held in this instance, but at the
same time about forty cases of typiioid fever were under treatment, and in such of these as
proved fatal the patches of Peyer were found to be ulcerated. § Brigade Burgeon J. II.
Warren and Medical Inspector Peter Pineo, U. S. A., reported early in the war the pres-
ence of typhus fever in the camps near Washington, D. 0. About the same time Surgeon
Barr, 36th Ohio, recorded the assumption of a typhus character by fevers prevailing at
Summerville, AVest Va., and Surgeon Irish, 77th Pa., and Act. Ass't Surg. 0. K. Rkynolds,
U. S. A., 15th U. S. Inf., reported similar cases from Camp AVood, Mumfordsville, Ky. At
a later date fulminant typhoid among undisciplined recruits at New Albany, Ind., gave rise
• Thus a certain nuinlxr of the oases forming the basis of Flint's Clinical Ileporls mi Contimied Fevert, liiiflalo, 1852, were reported as ilimbl/iil ; his
nues nnnilKTi^l IM, and nf thesi' 73 were undoubted eases of typhoid alul liri equally undoubted cases of typhus, but 20 wore cases in which the diagnosis
as iK-tween typhus and typhoid was not positively determined. The otficial Meiiitutl and Hnrijieal Uislonj of the lirUixh Army whirh nrn-ed in 'IVrknj mid the
(ViMM^i dariitij Ihr inir wjmu»l Jtnjwiu in Ihr. ijmrtt 18'>4-.').'i-.5<;, London, 185H, does not attempt to <lifTereritiate between the malarial and typhr.id f<;verH which
pn-vailetl among the troojvs while operating in Hulgariu, nor between the typhoid atiti lypbiis wbidi scourged them during the winter of \H'y\~h:t in the
Crimea ;but Dr. ItoBKKT D. I.vons, in bis llejmrt <nt Hie I'mJudi,,/!/ „f Uw biarascs ../ thr Ariiiij in the Rwl, London, 1S6I1, shows tliat at the time of his visit to
the hospitals ami eamjis both typhus and typhoid were prevailing, the hitter, however, being the prominent disease. IJe naiched .Scutari towards the
clone of April, 1S.V>, when all but the expiring eniber* of llie terrible epidemic of the previous winter had disappeared. Again, .ScillVK, in his Urlali-m
M/dico Chirvnjirate de In Cnntpafpic d^ Oienl^ Paris, 1.^57, describes, p. 418, a lijphn^ d forme lyphonte.
t It is at the outbreak of an epidemic that t w tcverest attacks nuinifest themselves. The first two' eases observeil at Lyons by M, Dussouut differed
entirely from thi; stereotyped typhoid fever. They were conseijuently considen*tl typhus cases, especially on account of the nipidity of their fatal term-
inalioli and the absence of intestinal lesions. There existed, no doubt, a co-relation between these two facts, the absence of lesions Is-ing due to tbr- sbort-
ncoi of the malady, for iti all other autopsies madi' during the same ei>iileinic, MM. Mabmv and Al,ix found the usual changes conseiincMit upon typhoid
fever. See Lfos ('..i.in, /Ic ;,i fVrre Ihiidmid,- duns fAnnrr, Paris, 1S7«, Ji. 1«.
{ Ja>|(:s IIrtan, Brigade .Surgeon, liurnside's Kxis-ilition, New Heme, N. C, «<»/<) . Med. and ffiirr,. J.rar., Vol. L.W, 18(12, p. :('Jl, sjiys, in some obser-
vations on the diseases of the army in the Departnii'iit of North Carolina, that typhus fever was not unfrcquently observi-d, and was in some cases of
Eveal malignity, a character w hie h was more |)arlicularly noticed in young fleshy subjects. In one such case the patient Wiis brought into Hie hospital
in an insensible condition, with the cellular tissue of the lu< k fillerl with air and serum and the legs and feet purple. But we have alrcaidy s<en the per-
nicious character of the malarial fevers of this military de|>artnnnt. On the other hand J. J. Levick, in an article on Miivmmlic T/iphoid Ferrr, Ammcan
J<mr. Med. S-iVufy.,, Vol. XLVII. 1864, p. 404, when referring to the aggravated character of the cases that arrived at the Pennsylvania hospital from the
Army of the Potomac in the autunm of 1862, says that in no case was the true ty|ilius fever-rash observed, nor a single instance in which the diseiwe was
known to have been communicated to another, notwithstanding that many cases were much like typhus.
$ Appendix to Part First of tliis work, p. 8.5.
32G SYMPTOMATOLOGY OF
to a report of typluis OT spotted fever. In 1863 Ass't Surg. Waeren Webster, U. S. A.,
who iind seen European typhus in Boston Harbor from 1853 to 1860, became aharmed at
the presence in the 12th Army Corps of some cases which apjaeared to present all the clini-
cal features of true typhus, and in his report to the Medical Director of the Army the
utmost care was enjoined for the protection of the troops against the contagion of this deadly
disease. A month later Dr. Webster was called upon to investigate some cases reported
from the 11th Army Corps, but etiological considerations were opposed to the recognition of
these as r aculated typhus. A few cases of typhus, from two to seven, were reported during
the year 1864 from each of eight regiments in the Army of the Potomac. In accordance
with instructions from the Medical Director of the Army the history of these cases was
investigated, and in every instance in which the surgeon wdio made tlie report was still on
duty with the command, it was found that he had ceased to consider the disease to have been
ty])hus. Concerning the cases reported from the Army before Corinth, Medical Director R.
Murray, U. S. A., was of opinion that if the experience of Surgeon Maylert, U. S. Vols.,
who was m charge of the general field hospital, fui'uislied no evidence of typluis, there was
assuredly none among tlie troops. Surgeon Maylert's report on the fevers of this army
has already been presented.'^' Tliose treated at the St. James lios})ital. New Orleans, La.,f
were derived from General Butler's regiments, which, with few exceptions, had been
crowded to excess on transports from New York to Ship Island, Miss. The passage to
the Gulf occupied thirty to forty days, and many of the troops were closely packed on ship-
board for sixteen days on the trijj up the river to New Orleans. After this some of the
regiments were sent to the forts at Carrollton and others to the swamps opposite Vicksburg,
Miss. The report of Surgeon Eugene P. Sanger, U. S. Vols., gives ex{)ression to the con-
ditions affecting these men and the probable character of the fevers from wliich they suftrred.
BrUjnitc Snrij. J.'H. W.\i:uen, Isi Briijadc, Ctiscy's JHrision, D'anhwi/lon, D. C, Jan. 25, lS(i2.— Tlie 1st brigade
is finel.v situated ou Meridian Hill, a very healthy location, the camp well policed and drained. The internal
arrangements of the barracks are very bad, as the ventilation is not sufficient, and is obstructed by partitions across
the building at intervals of ten or fifteen feet, destroying the free circulation of air. If this defect is not imme-
diately remedied we shall have camp or typhus fever, as it has already made its appearance in the 56th N. Y., and
in one case proved fatal.
Briijadr, Surg. J. H. Wahrkn, on the cuiiditioii of the 11th A'. 1'., Jan. '21, ls(j2. — This regiment is encamped ou
the "western slope of Meridian Hill. The ground, owing to its gravelly and porous nature, is as well adapted for
a camp as any in the vicinity. The atmosphere is impregnated with a malarial odor, arising from an open field
where a laige number of dead horses are deposited on the surface and allowed to renuiin and decompose. This, with
the rather poor policing of the camp, has given rise to typhus fever, from which, I regret to say, we have lost some
ten or twelve men already. The tents are the wedge-tent, and have a wall of boards built up some three feet high,
with the tent placed on top. As they have no door, using the fly as such, the men steji over the boarding down into
this box arrangement, which generates one of the most fetid and vile atmospheres that human beings can possibly
be placed in. I suggested that the banking of earth about the boaiding should be at once removed, and holes made
through the walls near the floor that a free circulation of air may be had. I would also suggest that the regiment
be removed to the grounds opposite the Columbian hospital. The men should sleep ui)on cedar leaves, which can
readily lie obtained at a short distance from here. They should not be allowed to keep fires in their quarters but a
few hours by day and the same at night, nor should they be allowed to wear their overcoats or eat in the tents. A
disinfecting agent should be thrown around their quarters and a strong solution of lime inside and out. Should
these suggestions be adoiited, I think all forms of typhus will speedily disappear from the regiment.
licpori on Typhus by Mcitical Inspector Peter Pineo, U. S. A. — The 23d N. Y. moved Sept. 28, IStJl, from Arling-
ton, where it had been encamped some months, to Upton's hill. Because of what was considered a military neces-
sity, the regiment occupied a hillside facing the northeast, the soil being a tenacious clay; the streets were very .
narrow, the A-shaped tents were close to each other, and the camp confined to the smallest possible space. During
October and November I urged unsuccessfully its removal to a more salubrious locality. The iniportauce of striking
the tents, careful police and cleanliness was also urged upon the colonel and surgeon of the regiment, but without
avail. An almost total neglect of all hygienic precautions ensued, superadded to which was the fact that five or
six soldiers slept in each small tent, and as cold weather advanced, their habit was to hermetically seal the tent as
* Swpi-a, p. SIS. ^ Supra, J), ids.
THE CONTIXUEI) FEVEKS. 327
nearly as possible, sleeping in a space of but little more tbaii one hundred cubic feet. The circulation of air in such
a tent is, it seems to me, of the followin-; character: The canvas permits the ingress and egress of almost no air
whatever. The expired air being heated and lighter rises to the top and sides of the tent, where it is immediately
condensed, and falling to the bottom is again respired; this jiriicess is repeated constantly during the night, pro-
ducing necessarily a condition scarcely rivalled by the ••Hlack Hole."
This regiment was composed of as line a body of stout and intelligent young men as any I have seen in the
army; yet in Novcmlier a large sick report was noticed, and in December the sickness and mortality became so
alarming that I instituted a careful investigation. In one tent was found a soldier who had kept his tent for a day
or two, had scarcely complained at all, but was in itrliculo mortis. The patients generally on first coming under
notice of the surgeon presented grave symptoms: they were listless, stupid and greatly depressed, though uncom-
plaining. Cerebral symptoms were sborlly manifested with sordes about the mouth and teeth, rapid and irregular
pulse and death by coma often in from twenty-fdur to seventy-two hours after entering hospital. There was almost
no convenience foi ponl-mortrni observation, yet in two or three cases autopsies were made by Surgeon WiLCOX, 2l8t
X. Y., at one of which I was present. The external ai>pearance of the body was darker than usual and slight
purpuric spots were present. N'o organic lesion was discovered, but there was unusual congestion of the internal
organs generally. The symptoms above enumerated, with the history of the cauip and the pathological appear-
ances, led me to regard the cases as '"typhus gravior," the result of '"crowd-poison."' It should be stated that mala-
rial fever was the prevailing disease in the regiment previous to this alarming condition. It is also worthy of
special notice that almost every case of sickness of grave character came from the shady side of the strecte where
no direct rays of sunlight ever found access. The 21st X- Y. was situated within a few rods of the l'*l, in a valley,
the situation being nearly or quite as objectionable. This regiment had served in and about Fort Kunyon, and had
strongly marked manifestations of malarial disease; but the police, cleanliness and ventilation were carefully
attended to, and the regiment had only one death from disease in a year.
The camp was at length broken up and removed to a delightful spot: a foundation of logs three or four feet
high was built on which was placed the tent; the streets were broad; cleanliness and ventilation were carefully
attended to; the hospital, which had been in a small house with low ceilings and much crowded, wjis moved to a
spacious church at Falls Church Village, and from being alarmingly unhealthy the regiment in a short time became
one of the healthiest in the army.
Ahfiract of a Report of Siugeon K. N. Barr, 36(A Ohio, for the four months ending Dec. 31, 1861.* [During this
period the regiment lost 27 men by death from disease: 16 of the deaths occurred among S44 cases of fever and 7
among 22 cases of typhoid pneumonia. The mean strength of the command in X'ovembcr was 38 officers and 981
enlisted men. It was stationed at Summerville, West Va.J Fever made its appearance in this regiment shortly
after its arrival at Summerville in September. The troops relieved by it had suft'ered from typhoid fever and left
behind them in a crowded building about 'orty cases of the disease. Even in the earlier cases there were difterences
from typhoid as ordinarily observed: Prostration was greater, and there was severe occipital pain with stiffness and
soreness of the muscles of the neck, jiarticnlarly the sterno-niastoid. The chills in miasmatic cases were slight but
came on at regular intervals, usually in the early part of the day: and in the intermittent forms the febrile .itage
continued until late in the evening. The tongue w as large and broad, indented by the teeth along its margin and
creased in the centre, thickly and darkly coated on the dorsum and red on the tip and edges: it was tremulous
and protruded with difliculty in the severer cases. Diarrhu'a was of frequent occurrence but not obstinate. As the
season advanced and a typhous condition liecanie more and more developed diarrhiea became less fretjuent, and often-
times the liowels would not move spontaneously in two or three days. Antijieriodics, even when remissions were
decided, acted but indift'erently, often increasing the cerebral and vascular disturbance and the dryness of the tongue
and fauces: but during convalescence quinine in small doses, given in conjtinction with wine, had a happy ett'ect.
By the middle of October cases of what seemed true typhus fever nuide their appearance. The pulse was frequent
and feeble, the skin dry and dusky but not hot, the urine scanty and high-colored and the secretions generally
deficieiil: the sclerotic had a bronzed appearance. F'rom two days to a week from the beginning of the attack
delirium or coma, partial or complete, would ensue; sordes collected about the teeth and lips and the tongue became
dry and crisped. There was occasionally troublesome gastric irritability, but seldom any tendency to diarrhu-a; no
tympanites, and, excepting sndamina in rare cases, no eruption. If the patient survived this stage a profuse cold
per^jiiration would come on, the tendency to coma would disappear, and for a few days there might be a (lartial
return to con.sciousness. Hemorrhage from the bowels was not unusual, recurring at frequent intervals for several
days: in these cases tenderness in the iliac regions was found to exist, and occasionally diarrho-a. During this
sweating stage glandular swellings were present in almost every case of any severity, generally affecting the jiarotid
and submaxillary glands, and in two cases the testicles; the swellings were large and terminated in suppuration
more frequently than in resolution. Abscesses in other localities were also common, and from them would come an
incredible amount of purulent discharge. Another singular symptom was the occurrence of an excruciating jiain,
apparently neuralgic, beginning in the great toe, gradually extending to the other toes and sometimes involving
the whole foot and ankle joint: there was no swelling. This ]iain was invariably the harbinger of convalescence.
This was so apparent and uniform as to be observed by the attendants, and Dr. B.mck quotes the nurse as saying to
him: ""Such a man is going to get well, for he has been groaning all night, or all day. with a ]>ain in his big toe.''
At»ont the beginning of December, while the daily average on the sick-list was 240, an onnce of whiskey was given
morning and evening to even,- man on police or guar<l duty, and to others engaged in exhausting labor or exposed to
inclement weather: this allowance was also given to nurses in hospital. Good results were expected "because of
* This report was pablishtxl bj SargeoD Bakb in the Ohio Med. md Bmrg. Jomnul, ToL XIT, 1802, p. 95.
or
28 SYMPTOMATOLOGY OF
the great ilepression of the vital energies and impairment of innervation not only of those on the sick-list but of the
whole camii." It is asserted that almost immediately after this, new cases of fever heeauie infreijuent and of a milder
character, and that in three weeks very few oocnrred. Although the hospital was well ventilated, nurses were
frequently attacked before the use of the stimulant, but after its regular issue such cases became rare.
I!epo}'t on Tyjyhiis hi/ Sin-gron Feanklin Iiiisn, nth Fa. VoJs. — During the month of January, 1862, a few cases
of genuine typhus fever made their appearance in this regiment while encamped at Mmnfordsville, Ky. The cases
all occurred in a period of about ten days during a protracted spell of cold and wet weather which confined the men
to their tents, the mud being so deep in the vicinity of the camii as to interfere with the usual parades and exercises.
The cases presented the regular petechial blotches numerously distributed over the body; they were attended with
sudden and excessive physical prostration and terminated fatally, generally from the fifth to the tentli day, death
being usually preceded a few Iiours by delirium. I believe tliese cases to have been identical witli the spotted or
jietechial fever of the books; in short, typhus fever of a most malignant type. In most instances the disease was per-
fectly intractable, the most active and vigorous stimulant treatment failing to rally or sustain the terribly depressed
vital powers. 1 am unable to trace it to any malarious origin. It disappeared as suddenly as it came, and I do not
know of its having appeared in any of the surrounding camps. I believe it to have been the result of the vitiated
air of the tents, together with the depressing inlUience of long continued cold and wet weather, insufdcient exercise
and depraved diet surreptitiously bought from camp hucksters.
Eeport on Typhus in the loth U.S.Ivf. at Camp Wood,Ky., hy Act. AssH Surg. O.K. Reynolds, U.S.A. — Dining the
period of my service with the 1st Battalion of this regiment, four cases of true typhus gravior were observed. No
similar eases occurred in the brigade, nor, as I believe, in the division. Tlie diseases iirevailing at the time were
chronic diarrhcea, dysentery and tyjjhoid fever, and in many of the febrile cases there were evidences of malarial
inilueuce seen not only in a tendencj- to periodicity, but also in the color of the skin and in hepatic derangements.
In most cases three things were worthy of renuirk : 1st. The adynamic condition of patients when first brought to the
hospital tent. 2d. Intestinal congestions. 3d. The alvine evacuations, wliich were generally of a pale dirty-yellow
color and quite thin, not otlensive at tlrst, but abominably so after a few days exposure in the sinks to a warm sun.
The two hospital tents of the battalion were situated on low ground near the head of a small ravine; there
was a shallow sink not more than twenty-five feet behind one of them and above it, the ground being higher behiud
than in front. The patients lay on old straw which could not be replaced by reason of the scarcity of that article.
Vegetation commenced under the straw, which was kei)t moist by its close proximiti^ to the earth. The four typhus
cases occurred in the tent on the low ground near the sink. These, when first brought in, exhibited few symptoms
that were not common to every case of camp fever, — there was jierhaps rather more debility and nervous jtrostration
than in other cases; but a few days after their admission into the hospital tent stupor and low delirium supervened,
and the stools became less frequent and scanty, darker in color and more offensive; the quantity of urine became
diminished and the catheter was sometimes required; sudamina were seen in all and the rose-colored eruption in
two of the cases, about the end of the lirst week, continuing until death. In one case epistaxis was troublesome.
In all the pulse was snuill, weak and frequent and the tongue dry, brown and fissured; sordes accumulated rapidly
on the teeth, gums and lips, and stupor dee])ened as the disease progressed. Brigade Surgeon Chaui.es Sciiussler,
under whose orders I was then acting, regarded these cases as true typhus. In scarcely.any other cases of fever at
Camp ^Yood did I observe the disorder of intellect attending these cases; the patients were generally rational even
just before death.
Since camp fever prevailed in all the neighboring regimental camps, while few if any other cases of typhus
occurred, these four cases may reasonably be attributed to local causes. These I believe to have been the fetid gas
arising from the sink and the vapor exhaled from the earth saturated with putrescent fluids under the straw on
which the patients lay. But as there were nine men in the tent, it may be asked why did not more cases occur?
Probably because son\e were less reduced ujion entering the tent and others remained only a few days exposed to
its miasms. I believe that any febrile case, if exposed to similar pathogenic causes for a length of time, would
develojie symptoms of a true ty^dius.
Extract from an Inspection liiport of Branch Hospital Xo. 6, A'cic Albany, Inil., liy ilalical Inspector L. Humphreys,
U. S. A., Jan. 14, 181)4. — [The camp from which the New Albany cases were derived is thus described under date
March 8; The troops consisted of seven companies of undisciplined recruits intended for the cavalry service, — present
432, absent with or without leave 219; total 651; number sick in camp hospital 68; severe cases are sent to general
hospital at New Albany. The prevailing diseases are measles, pneumonia and intermittent fever, — typhus reported
present in January has entirely subsided. The camp is in the fair grounds. There is but little natural drainage and
almost no attempt has been made to improve it. The soil is blue water-holding clay which at the present time is
worked up into mud. The water-supply is from cisterns and wells; the well-water contains iron and magnesia and
produces diarrhcea in those who use it. The quarters are exceedingly filthy; the men cook, eat and sleep in them.
The grounds of the camp are covered with garbage and filth. The sinks are so foul from deposited excrement that
they cannot be ajiproached without defilement. The unusually large number of sick in hospital is the legitimate
result of a want of proper cleanliness and disciijline.]
There are a number of cases reported by our medical officers as typhus or spotted fever in this and other
branches of the general hospital in this city. The cases have all occurred among the recruits at Camp Noble, a short
distance from town. When admitted they present delirium, great depression of the nervous centres, with obstinate
vomiting; constipation of bowels and pain in the head; surface of the body cold, with tendency to collapse; pulse
over 100 and compressible; petechia", on the extremities, the spots reddish at first, subsequently turning dark; the
attack generally sudden, running to a fatal termination in a few days. I saw one case just received in hospital
THE CONTINL'KD FEVERS. 329
which liad well-marked symptoms of ceiebio-spiiial meiiiugitis, Itut jiont-mortim examination arlibids uo evidence of
iiitlammation of these tissues. The blood in the cadaver is reported to be In a liquid state, as in cases of death from
electricity. Fifteen or twenty cases of this ty]ie of disease have occurred, many of them terminating; fatally. Some
of the men in Camp Noble, furlou'^hed to their homes, became aflected after arriving at their residences, other
members of the family, in some instances, taking the di.sease apparently by contagion. The cases in hos])ilaI were
all treated witli tonics and stimulants. Nearly all under this treatnumt died. J'vst-mnrtcm appearances indicating
the use of an oxidizing remedial agent, cases occurring subseiniently were treated by a free use of chlorate of potash
conjoined with stimulants, tonics and opiates. Under this mode of treatment nearly all cases of this disease have
recovered. Cases have occurred amongst the citizens of the country about New Albany.
In hospital this so-called '-spotted fever" is isolated in a ward with 3,000 cubic feet of space to each patient.
Jss'l Siirg. AVarren Webster, U. S. A., on Ti/phus in the 12th Armii Corps, Armij of the Potomac, March 5, 18G3. —
[This inspection was occasioned by the reported occurrence during February, 18G3, of two fatal cases of typhus
fever in the 123d N. Y. and five cases with four deaths in the llSltli N. Y. The monthly report of Surgeon Joux
MoSEYi'KSNY, of the former regiment, contains the following remarks: The regiment moved into an old camping
ground situated near Stafford Court House, Va. The camp is located in a hollow between two ridges, near the edge
of a brook. The soil is porous and the water filtering through it is in my opinion impregnated with an undue quan-
tity of vegetable dcbiis. We brought rubeola with us from our last camp at Fain'ax Station. The nu'ii had made a
hard march thiongh the storms of December. The rations were salt and deiicient in quantity. After the first week
of camji life here dianho'a of severe grade showed itself; this was followed by cases of remittent fever, generally
asMiming a low type; then typho-iiialarial, tyjihoid and typhus fevers made their appearance. Two of the cases,
rejiorted as typhus, occurred after convalescence from rubeola. Pneumonias were of a typhoid type and dysentery
assumed the same sinking character. The liiralth of the camp is bad, the situation is bad and the weather has been
unfavorable for us to move; but I have chosen another locality and will probably efl'ect the change next week.]
On my arrival Medical Director McNulty informed me that the only regiments in which the fever had existed
were the 123d and 119th N. Y., and that there was now but one case in each regiment. The case iu the latter regiment
was not, in his opinion, of so malignant a typo as the preceding cases in that regiment, and the case in tho other
command had, he believed, undergone decided ameudmeiit. Ho also infomed nio that the camps of the infected
regiments had been removed to sites offering in his judgiiient the best available combination of sanitary condi-
tions, liotli patients are isolated in separate hospital tents placed at a considerable distance from the old and
new eiicamiuiients of the respective legimeiits.
The reports already made by the medical director have given information of the number of cases of ty]ihus
repiirted by regimental surgeons as occurring in these two regimenls and the number of deaths resulting therefidm :
1 llierefore need not refer to them except to say in passing that while my inquiries lead me to doubt whether all the
cases so rejiorted were genuine typhus, it is undoubted that most of them were distinctly marked ca.ses. Of the two
existing instances there cannot be question. My opinions on tho subject coincide fully with those of Surgeon
McXfl-TV, whose thorough professional training and extended ob.servation of tho disi-ase in New York (Mty make
him especially acute in the recognition of the characteristic symptoms.
In compliance with orders to inquire into the causes of this formidable aii'ection, 1 have to say that 1 deem
the close aggregation of the men of the two regiments iu huts of defective construction and on ground having a wet
sub-soil imperfectly drained and previr)usly occupied by troops, to be a conspicuous promoter of the disease now under
consideration. The 123d legiment was quartered in huts llx(>xl feet, with eight men to a hut. These lints had
lieen recently abandoned by General Sigel's troops, and the New York regiment arriving upon the ground lato at
night occuiiied and remained in them without projier cleaning. Many were within one or two feet of each other.
In the intervening sjiaces human orilure had been deposited; and 1 learned from tho regimental surgeon that much
of it had been allowed to remain there up to a recent time. Offal was also deposited from time to time in offensive
proximity to the camp. Huts originally iutended for the acconiniodation of a single regiment have been inhabited,
since the arrival of the 12th Corps, by two regiments recruited six months ago, and therefore not reduced in numbers.
The thin tent-doth with which the huts were roofed admitted some air of course, when dry, through the interstices
of the fabric, but when wet it was almost impervious. No system of ventilation was practiced, and the drainage of
the camp was unattended to although the face of the ground presented every facility therefor. The reason assigned
for these surprising neglects is that the command was daily expecting to move. This regiment, when organized in
northern New York in August, 18t)2, consisted, I am told, of a fine body of 923 men. It has been in camp at Wa.sli-
ington, Arlington Heights, Pleasant Heights, Loudon Valley, Fairfax Station and in tho locality I am describing,
and at each of these places except the last, camps were generally made on ground not before occupied. Its duty
has Iieeii picket, fatigne, guard duty, marching and the customary drills, and its sanitary condition has in general
been quite good. Diarrha-a, malarial disorders, measles and a few cases of typhoid have occurred. The present
typhus patienf , who fell sick February 5, was in a partially excavated hut, 6x7 feet iu area, in which five men had
slept during the first fortnight. More recently the invalid and one or two well men occupied the hut.
Oil the 3d iiist., day before yesterday, the regiment was, with tho exception of the sick, removed to a new
camping ground selected about a week ago. A new hospital, just obtained, and favorably located near by, contains
the typhus jiatient. On visiting the new camp I found the site good, but the huts built irregularly and much too
close together. As tho result of a conference with Du. McNui.TV and myself, the colonel of tho regiment deter-
mined to immediately tear down the huts, build anew over a larger area, and allow no excavation of the floors
or heaping up of earth on the ont.side of the walls. He resolved also to drain the camp systematically, protect
from surface water by c-atcli-water drains, ventilate the huts thoroughly each day, exercise a rigid police of the camp
Mkd. Hi.st., Pt. in— 12
330 SYMPTOMATOLOGY OF
and interior of the huts, enforce cleanliness by bathing, which had never been attended to, and cause the under-
garments of the men to be frequently washed. An inspection of the persons of the men by me was unnecessary, as
it was frankly admitted that they were in a filthy state. Their physiognomy, however, did not indicate the cachexy
which their wretched habits led me to expect; on the contrary I was surjirised by their comparatively healthy
appearance. I found in the regiment seven grave eases of typhoid fever, which, although not beset by the same
dangerous elements of infection and self-propagation as typhus, still call as loudly for correction of the sanitary
negligence which has given rise to both the allied di.seases; and now that the insalubrious locality, the defective
accommodations of the troops and the tainted atmosphere to which they were subjected have been changed and
isolation with improved treatment of the single typhus case secured, we may confidently hope for the speedy erad-
ication of these formidable disorders of the regiment.
The existence of typhus fever in the other regiment, the 149th N. Y., is attributable to influences similar to
those reported above as having prevailed in the 123d. » * » » Much credit is due Major General Sl-OCUM for
the promptness and energy with which he has employed the measures suggested to arrest the spread of fever and
prevent its a.ssuming an epidemic prevalence. He yesterday issued a' general order positively prohibiting throughout
his command — 1st. The habit of sinking the floors of tents and huts below the surface of the ground. 2d. Occu-
pation, in encamping troops, of spots recently used for that purpose; and 3d. Employment, in the con.struction of
new huts, of any portion of old ones. The practice of using portions of abandoned huts in the construction of
new ones on adjacent ground, in older to avoid the labor of procuring other materials, is so general that it made
necessary the third paragraph of this order. Many points of improvement were urged upon the officers of the infected
troops; but it was deemed unnecessary to request tieneral Slocum to publish them. The troops are now sufficiently
aware of their commanding general's earnestness in the matter to insure observance of verbal suggestions, and the
intelligence and energy of Surgeon McNuLTY will accomplish everything to be desired of the medical officers under
his direction. I think the officers with whom we conversed, line as well as medical, are convinced of the general
injurious consequences certain to flow from overcrowding and defective ventilation, and more especially how nmch
the prevalency and fatality of typhus depend upon the nature of the in-door accommodation with whicli the soldier
is provided. Inattention to the purity of the air in each tent or hut, to personal cleanliness, constant supplies of
fresh clothing and bedding, defective cooking and the accumulation about camps of decomposing vegetable and
animal matters have been pointed out to them as potent influences in the production of camp fever. Advice was given
to the attending medical officers with reference to the management of the disease, and if fresh cases should occur they
will use the promptest means to isolate the patients and will urge the commanding officer to the adoption of any
measure, no matter how extreme, necessary to arrest the evil.
Ass't Surf/. Wakken Web.ster, U. S. A., on siqiposed Typhus iu the lltli Armij Cvrps, Armi/ of the Votoiuuc, April 17,
1863. — I have the honor to report, after careful investigation, that I am not convinced that the sudden death of one
of the quartermaster's employes at Hope Landing, reported by Medical Director Suckley, 11th Army Corps, was,
as he believes, a case of muculaled tijphus; nor do I thinlc that any active hygienic or precautionary measures need be
taken to prevent a spread of the disease existing in the conuuand there.
The two regiments, the 107th and 134th N. Y., composing the command at Hope Landing, have sutt'ered
greatly from sickness since their entry into service about eight months ago. Before and since their arrival at that
point, two months ago, typhoid fever has been very prevalent and fatal, assuming during the autumn and fall mouths
unusually severe enteric symptoms and during the winter marked cerebral complications. The latter symptoms
were by some of tlie medical otticers interpreted to denote typhus, jiarticularly as several of the eases so charac-
terized were speedily fatal and the diarrhiea and meteorism usually attending enteric fever were absent or slight.
I can learn, however, of two cases only which presented cutaneous eruptions ditt'ering materially from tliose peculiar
to typhoid fever, and tliey were ratlier extensive ecchymotic patclies of subcutaneous extravasation varying in size
from a grain of wheat to one's hand, than the peculiar eruption deemed distinctive of contagious tyjjhus: One of
these was the case of the quartermaster's clerk; the other occurred iu tlie 107th New York regiment about a week
ago. Both were marked by nearly the same course, death resulting in less tlum twenty-four liours. The patient
(a few hours before in apparent good healtli) complained to the surgeon of violent pain in the head, back and
extremities, and the appearance of the countenance and hue of the skin presented evidence of great internal conges-
tion. The pulse was small until death, at times almost imperceptible. Persistent vomiting cliaracterizid the last
case. Delirium was not violent, but comatose symptoms soon prevailed. The patients sutt'ered from involuntary
urinal and fiecal discharges. An examination of the first patient a few hours after the attack, and of the other
shortly before death, revealed cutaneous ecchymotic patches of extravasated blood varying greatly in form and
size, and invading the body, limbs and even the face. No jiosl-morUni investigation was made in either case. The
treatment consisted primarily of cujis, mustard applications to tlie extremities and a large do.se of calomel and
rhubarb, with the subsequent emiiloyment of camphor, quinine and alcoholic stimulants. Tliis treatment was
attended witli only partial reaction and improvement of the pulse. The soldier thus att'ected had Ijeen on duty as a
teainster for two montlis previous to the attack, was provided witli good and well-prepared food, an abundance of
vegetables and ample clothing, was represented to be unusually cleanly in liis personal habits, and lialiitually slept
in his wagon, which had no other tenant during the niglit but himself Tlie (luartermaster's clerk was a man of
scrupulons personal cleanliness, lodged in a well-ventilated Sibley lent, and had the reputation of being a free rather
than a spare liver. The favorable relations of these men to air, food, clothing and personal attentions certainly con-
tradict the supposition that they were victims of typhus. The character and stage of appearance of the cutaneous
eruption, and the slight degree of delirium which characterized the cases are also, in my opinion, in opposition to
the existence of the supposed disease. If it be claimed that typhus was communicated to them by contagion, I do
TlIK CONTINUED FEVERS. 331
ijiit iiiuUi>taii(l wlu'ii' was tlio coiitaKinu.s source. No other cases, answering even as well as these to tlie charac-
ters of t vjihus, have existed in the eominaiiil. No exposure to foiiiites is liliely to liave occurred : nor was the scconil
siifterer known to have t)een submitted to contagions propiniiuity to the first.
Surijeon Fl-OOD of tlio regiment in which the tirst of these niysterions cases occurred informed me tliat the
typlioiil fever of tlie command liad, witliin two weeks, ahnost completely lost its tendency to cerebral congestion,
and that pneumonia was now the prevailing eomplicatiou. One regiment yesterday renmved to near lirook's Station:
the other daily expects to change its location. In view of these facts I deem it necessary neither to draw your atten-
tion to the objectionable exposure of Hope Landing to vegetable malaria nor to recommend at present any sanitary
reforms in the regiments lately composing the command.
Siiriieon ElT.KSK F, SANCKIt, C S. I'ols., Third Divinion, lOth Armii Corpn, on the Fevers lliat prcraHid in Xew Orlmnn
and its rivinitij in 18t>2. — Four imjiortant elements entered into the cau.ses of so much disease and such fearful mor-
tality. 1st, Scorbutuf: The diet had been uniformly salt meat, bard bread and coH'ee. The transports were too
crowded to admit of thorough policing, and the i)nblic buildings and cotton presses were too dark, damp or hot.
After long conlincmeut, poor diet and habitual uncleaiiliuess, there was nothing in the surroundings of the men to
excite their pride or arouse them to a proper appreciation of the importance of attention to hygienic measures.
2d. Tj/phna poixon: The entire command had been situated for many months where systematic ablutions could not
be performed. The skin was active and perfornu'd important functions; it supplied the jdaco of the kidneys largiily
in carrying olV the disintegrated tissues. Men lay down in clothing saturated with ell'cte animal matter and were
ciunpdled to breathe constantly the poisonous exhalations of the human body. Keabsorption n(^('essarily followed.
;id, ■/'i//>A(ii(/ i)oiKi>nin<i : Scorbutic diet soon bi'gan to tell upon the stomach, destroying its nervous energy; food fer-
menled, noxious gases formed, the bowels becanu; irritated and imperfect digestion and nutrition followed with
emaciation, debility, diarrhcea and fever. 4th, Mtihiria: As early as May dumb agues appeared, and by .June inter-
niittents and remittents prevailed generally. The city proper was free from malaria. The I4tli Me., while nuartered
in the city during the months of June and July, sulVered badly from typhus but was entirely free from malaria. Un
the immediate banks of the river at C'arroUton the troops were generally exempt from malaria ; the 12th Conn, escaped
almost entirely. On the other hand, regiments in the fortilicatious running back from and at right angles to the
river, toward the swamjis, sutiered terribly, — the 14th Me., stationed at Carrollton during September and October,
was reduced from 700 strong for duty to 56 in about twenty-eight days. About June 1 six reginieuts embarked for
the swamps opposite Vicksburg and remained exposed to the inclemencies of the weather and pestiferous miasms for
more than six weeks.
General Hutler's command originally consisted of seventeen regiments with batteries and some cavalry, and
in the courseof eight months ahnost the entire force suffered from the causes of disease above enumi^rated. The 18th
Conn, was a noteworthy exception: It embarked at New York hite in March, and had a short passage to Ship Island,
where it remained until the city surrendered: at New Orleans it was quartered in the custom-house. It had better
accommodations at sea, was con lined on shipboard for .i shorter period and was more rigid in ]iolii'ing. This rcgiiiiciit
lost very few men during the sunnner.
1 did n(jt test the accuracy of my diagnosis by piial-murlcm examinations, and I have not the record of a case
showing imiili<-ation or exemption of I'eyer's i>atehcs, but the symptoms were sufficiently convini'ing. I invariably
fciund the patients extremely debilitate<l from the first, with early tendency to slipjiing down in bed an<l deafness,
dark-brow nisli and ilry tongue, ]ictechial eruption, snuill ami feeble pulse, tense and Hat bow els, at first eonstijiated,
fidlowed by hemorrhages and diarrlneas. (Quinine, whiskey and beef-tea were the only remedial agents admissible.
I was in the habit of combining a little opium with the (luinine to correct its cinchouizing effects, and ipecacuanha to
stimulate the ca]>illaries. The 14th Me., i[uartered in Lafayette Hall, lost as many as twenty cases of typhus during
June: some of these died at their regimental hos])ital, the others at the St. James. This regiment became so thor-
oughly used up that over 300 men were discharged from it during the months of June and July on surgeon's certili-
eates, and as many acclimated men enlisted at New Orleans. Other regiments had distinctive typhoiil: I remember
seeing in one regiment some thirty well-marked cases — beef tongues, rose-red spots and tympaniti<- bowels.
The regiments that suHered most were the 7tli Vl., 30tli Mass. and 9th Conn. Arriving at New Orleans worn
and debilitated, scorbutic in habit and saturated with zynujtic poLson, they were allowed but a few days at that
city and Carrollton before they were .sent to Vicksburg. Thence they returned to Haton Kougc, partici|)atcd in a
brisk fight on August (>, and were compelled to abandon the place about the end of that month. On their return to
New Orleans these regiments were a sight to behold. The scenes on board the boats which brought the sick beggar
description — the dead and living locked in one embrace. Reduced to shadows by diarrho'a and fever a single par-
oxysm suHiced to snap the cord. Men put on board at liaton Rouge for simple debility were enveloped in their wiml-
ing sheets before they reached New Orleans: I counted seven dead bodies on one boat. These remittents or intor-
niittents had but one paroxym; seldom would there be any febrile reaction. The collapse w.as almost as perfect as
in cholera — features sunken, skin cold and livid, voice husky, pulse small and quick, stomach irritabh^ and mind
torpid. The patients eomplaine<l of burning in the stomach and exhaustion: they seemed wholly unconcerned
whether they lived or died, and continually tossed to and fro until death relieved them from their sult'erings. Warm
frictions, stinnilanis and large doses of i|uinine occasionally revived them.
The 7th Vt. lost 800 men in the eight months from May to December, the 30th Mass. 21.5, and the tith Conn.,
a small regiment of less than 700 men. Kill. During this time I think we must have lost quite 20 jier cent, of the
entire command by death, to say nothing of those discharged for disability.
Nevertliele.'js, altliougli typhus was fortunately a stranger to our camps, there appears
332 SYMPTOilxVTuLOaY OF
strong ground for believing tliat an epidemic of this disease prevailed among some rescued
and paroled prisoners received at Wilmington from Salisbury, N. C, in the spring of 1865.
The number of prisoners was 8,600, and of these 3,400 had to be cared for in Wilmington
as they were unable to undertake the voyage northward. .The disease spread from them
not only to the troops of the garrison but also to the citizens of the town and the residents
of the surrounding country. Surgeon D. W. Hand, U. S. Vols., then Medical Director of
the Department of North Carolina, furnished a special report of this epidemic, which he
considered to be undoubted typhus. It is addressed to the Surgeon-General of the Army
and reads as follows:
Wilmington, N. C, Marcli 10, 1«66.
GiNERAL : I have the honor to report that, in compliance with your instructions, I have collected all avail-
able facts relating to the epidemic fever that prevailed here in the spring of 18G5.
Wilmington siirrendered February 22 of that year, and our troops on entering found the city in a \ery filthy
condition and the inhabitants that remained in a violent state of alarm. The city up to that time had bceu quite
as healthy as usual, and no epidemic had prevailed among the Confederate troops that formed its garrison.
On the 2otli and 2()th of February 8,600 Union prisoners were exchanged at Northeast Station and imme-
diately sent down to tliis city. Of this number about 8, -100 were too sick or weak to bear transportation by common
transports and had to be cared for in hospital. Under the direction of .Surgeon Edwauu Siiippen, U. S. Vols., at
that time senior medical officer in Wilmington, they were placed in public buildings and deserted dwelling houses in
all parts of the town. The sick from the troops on duty near Wihriiugton, and also those sent from Fayetteville by
General Sherman, were admitted indiscriminately to these same hospitals.
During the first week of March or very soon after the arrival of these jirisoners an epidemic, which was
undoubtedly typhus oi jail fever, appeared in the hospitals and rapidly extended to the citizens in the town.
I find that between February 26 and June 30 about 1,200 white soldiers and 300 colored soldiers died of disease
in Wilmington and its vicinity. The epidemic fever prevailed from March 1 to June 1 and caused, so far as can
now l)e ascertained, about 650 of these deaths, viz: 300 exchanged prisoners, 200 other white soldiers and 150 coloied
soldiers. The records of the Wilmington hospitals are so incomplete that no estimate can be made of the number
of soldiers who suft'ered from an attack of this fever.
Owing to the peculiar state of local atlairs at that time the ntimber of deaths among citizens cannot be ascer-
tained; but the resident physicians testify that the fever spread extensively among them and that numy died-
Among the refugee negroes sent down to Wilmington by General Sherman it was particularly fatal ; several thousand
of them were put in camp about April 1 near Fort Anderson on the Cape Fear Kiver, and it is thought over 1,000
deaths from typhus fever occurred among them.
It was noticed by the medical officers that the attendants and other soldiers abotit the hospitals, who con-
tracted the fever from the returned prisoners, had it more violently than the prisoners themselves, — tlie weak, half-
starved prisoners having a better chance of recovery than the strong, healthy attendants. Most of the medical
officers and attendants contracted the fever. Five surgeons and assistant surgeons, two chaplains and about eighty
detailed attendants were anmng those who died.
The evidence on all sides is conclusive that this fever was brought into Wiluiington by the exchanged prison-
ers. No doubt the croAvded and badly ventilated hospitals intensified the poison ; but 1 am satisfied this type of fever
existed among the jjrisoners at the time tliey were received within our lines.
/( was contugioiis. — Several of the most intelligent jihysicians in Wilmington think it only luevailed as an epi-
demic and was no more contagious than yellow fever; but some facts have come to my knowledge which show that
it was more than that. Of the officers and men employed on the steamboats that brought the prisoners from North-
east Station to this place nearly all took the fever and several died. They were not known to have been in or
about the hospitals after the prisoners were lauded in Wilmington. It is known that typhus or a low form of fever
prevailed in the families of several planters in this state, conveyed to them by negroes who had recently returned
from Wilmington. Particularly was this the case in Richmond and Eobinson counties, on the lino of General
Sherman's march. The negroes followed the army to Fayetteville, and thence passed down to Wilmington; hut
finding it a hard place to live in many went back to their old masters in May and June and carried with them the
fever that was prevailing in the city. Mrs. Gilchrist, living near Montjielier, Richmond county, 101 miles from
Wilmington, had some of her negroes come back in this way. Several had the fever after their return. Mrs. Gil-
christ sufi'ered a violent attack, but recovered; her son, aged twenty-one years, died. Other white persons in tlie
same family afterwards had the fever but recovered. Mr. McEahan lives on the Lumber River, three miles above
Mrs. Gilchrist's place; his negroes carried the fever from Wiliuingtou, .and several members of the family took it;
one daughter died. Mr. D. St. Clair, in the same neighborhood, had a like experience and lost his daughter. Dr.
.John Maloy, In Robinson county, had his negroes who remained at home infected in the same way and lost several.
His family was mildly attacked.
The physicians in Wilmington estimated the period of incubation of this fever at from four to twenty days.
Symptoms. — It began like an ordinary fever with a chill, followed by more or less heat of skin and great weari-
ness with pain in the back. The languor was excessive. Violent headache does not seem usually to have acoom-
THK CONTINUKD FKVKRS. 333
pauied it; Imt the eyes were red, walery ami intoleianl of lifllit. The tongue was iliy in the niiilille witli red tip
and edges: soides ai)peared early on tlie gnnis, and there was great thirst. Almost from the beginning there was
uneasiness or pain in tlie stomaeh, witli tenderness over the wliole alxlomen ; gurgling was heard in the right iliae
region, ami gem^rally there was diarrlnea. In the later stages hemorrhage from the howels was not nneommou. The
urine was scanty ami high-c<dore<l, and in had eases frecpiently entirely suppressed. The pulse was full .and slow,
often only !:"> to (il) per minute, hut easily eoniinessihle. The skin was freiiueiitly hathed with perspiration without
the fever or heat of skin abating. I'eteehia' appeared early, and also at times an eruption like urtiearia. Towards
the end spots like purpura often appeared. Jaundice freiiueiitly superveiunl, the skin and eonjunctivar lieromiug
intensely yellow. Vomiting of a. dark-colored thiid, which when dried on a cloth aiii)eared somewhat yellow, was
also not uncommon. Sometimes the patient died on the fourth or iifth day with symi>toms of congestion of the brain
or lungs; but usually the case ran on from fourteen to thirty days.
Front the notes of Dr. .1. K. KlNii, a ]>rominent medical man in Wilmington, who served for sonu) motiths in
18Dr> as a contr.aet physician in the hospitals there, I select two cases as fair examples of the disease:
C,v,.iK I .—Sivnv ; rcKuUinii in rfiii/A.— Ml'. Urynim, citizen ; ago 28 years; weight 17.5 pounds; moderately tem-
jierate: full habit : cn.joying good health during whole life, visited a sick friend in hospital. Two days later, March
11. complained of loss of appetite; was languid and oppressed; had soreness of muscles: took a imrgativo dose of
blue mass. That night hadachill with rigors: much prostration; fulness and tendiMness in the epigastrium; nau-
sea ami vomiting. I saw him ne.xt day: Fever; pulse about SK). full, easily compressible; tongues d;irk, dry, with red
edges, atteuiled with urgent thirst: great exhaustion; breathing accelerated, with occasional sighing and l)ronchial
cough; sordes on the teeth and lips: skin hot and husky: bowels loose: discharges yellow, watery an<l excessively
otVeusive; gurgling in right iliac region; tenderness over the entire abdomen, particularly in the epigastrium; urine
very scanty, pa.ssiug <mly about a tablespoonful, very dark and otiensive; breath extremely fetid. Administered
stimulants; potassa' ehloras in camphor jnleiis; mustard, brandy and pepper externally, etc. The above symptoms
continued until the fourth day, when the countenance became dingy (livid) witli Huslud cheeks; injected eyes,
dark-yellow in appearance and heavy, with unsteadiness of vision and intolerance of light. The whole surface w.as
covered with a miliary eruption and badly jaundiced; violent delirium; great prostration; passed no urine for
eighteen hours: cough dry and freiiuent: nuich nausea; bowels loose. Fi/lh day: Somewhat better; retained a little
nourislnuent : voided about two ounces of urine. Sixlh dai/: About the same. Serenth day, early moniiny: Skin clear;
voided ten ounces of urine during the night; less delirium; retains nourishment and stimulants. 10 .1. .1/..- Skin
jaundiced: delirium violent: involuntary discharges of clotted blood. 3 P. J/.; Surface much paler: abatement of
delirium: skin hot with slight perspiration; bowels checked; great prostration. 7 .". M.: Died. Surfaie of a
greenish-yellow color.
Cask 2. — Mildir: recovery. — Mr. M. .lohnsou, Quartermaster's Department, complained Ai)ril 20 of loss of ajipe-
tite. languor, soreness, fulness and tenderness in epigastrium, followed by prostration :iud rigors with fever: I'ulse
about 100, full, easily compressed; tongue brushed over with a white fur; urgent thirst; nau.sea and vomiting;
breathing somewhat accelerated with slight coug'i : skin rather hot, but chilly when the covering is removed ; occa-
sional attacks of sweating of short duration, unattended with any abatement of the fever; countenance dingy:
cheeks flushed: eyes watery and intolerant of light; pain in back of head; deafness; pain in loins; urine free;
bowels constipated. Fifth day: Not much alteration except red tongue with elevated edges and hard dry centre;
restless and siuuewhat delirious; sleejis only from cftects of opiates. Tieelfth day: Urine rather scanty; bowels in
good condition; skin hot with gentle perspiration: delirium; tenderness over the abdomen: pulse 1H.5. Srveiitiriith
day: Not much alteration except the tongue nuire moist; increased quantity of urine: bowels constipated. I'lien-
tieth day: Decided improvement: tongue slightly coated with a yellowish fur and moist: delirium les.sened ; sleei)s
more (juietly; pulse 110. After this the patient gradually recovered, having been able to leave his room and go
down stairs on the thirty-first day irom the heginning of the attack.
No itost-murlcm cxaminatioiis of an ottieial character were made. This is much to be regretted, but under the
circumstances cannot much be wondered at. The physicians of the city were greatly depressed in spirit and numy
of them sick: and the medical officers of the army were overwhelmed with the vast amount of work so suddenly
thrown upon them. But although no systematic autopsical investigations were instituted the intestines were ex.ani-
ined in a number of cases in none of which was there any affection of the glands of Peyer. Personally I conducted
two examinations for the determination of this point.
Treatment. — Stimulants were re<iuired from the beginning, and rarely could a purgative dose of medicine be
given with safety. Medical olfieers at the hosjiitals noticed that on two occasions, when the supply of stimulants
was exhausted for a few days, the mortal ty l)ecame much increased. Chlorate of potash was useful in snuill doses,
and camphor seemed the best anodyne because of its stimulant eftect. Those patients ajjparently did best that
received little meilicine, but whose strength was sustained by the regular administration of nourislnuent and brandy
or whiskey. Quinine was of no aj)parent benefit. Oil of turpentine does not seem to have been much used, but in
a few cases it was given and appeared to relieve the intestinal irritation.
This fever appears to have prevailed also among those of the released prisoners who
were considered able to undertake the journey to New York; but there is no direct refer-
ence to a contagious qualitv in the only sanitary report which speaks of it.
Medical Inspector Geo. II. Ly.max, U. S. A., on febrile cases at David's Island, .Vein Tork Harbor, May, 1865.— A
form of low fever with eruption prevails among the recent arrivals from General Sherman's troops. It is unusually
334 rOST-MOETEM RECORDS OF
fatal, anil though difteniis Miiiiewhat, from true typlms, liears more resemblauce. to it in its essential features than
any other fever I have met wuh. The released prisoners from Charlotte and Salisbury arrived in pitialde ounditiou.
In some instances both lower extremities were lost from the effects of frost.
IV.— POST-MORTEM RECORDS OF THE CONTINUED FEVERS.
In presenting the post-7nortem records of the continued fevers it has been deemed advis-
able to submit, in the first instance, such cases as may be of vaUie in determining the
nature of the large number reported as ty}>ho-malariul subsequent to .June 30, 1862. Hince
tliis title was intended to include only modified typhoid fever, the post-mortem lesions of that
fever should of necessity have been found in all cases.'"' Dr. Woodward, sixteen months
after the introduction of the terra, described the intestinal lesions of typho-malarial fever
as consisting of tumefaction and ulceration, with the occasional deposit of pigment in the
closed follicles of the small intestines;"]" and from this it may be inferred that ull the (ypho-
malarial cases brought to his notice up to that time had presented ulceration of the intes-
tinal glands due to the action of the typhoid poison. But as has already been shown, the
mortality statistics of the cases reported as typho-malarial are inconsistent with the idea of
an ever-Dresent specific enteric element; and this doul>t as to the nature of these febrile
cases becomes strengthened by observing that the records of the Seminary hospital attach
a higher rate of fatality to typhoid fever when modified l.>y malarial manifestations than
when not thus modified. J
To pursue this inquiry it is needful to compare the anatomical lesions of the two classes
of cases. This has been done incidentallv while arranging certain of the post-mortem
records for publication. Submitted below are: 1st, such febrile cases as have the diagnosis
typhoid more or less sustained by the recorded symptoms; 2d, cases entered as typlio-
malarial, whether accompanied or not by their clinical histories; and 3d, cases which,
although recorded as typhoid, nevertheless present in their history symptoms suggestive of
malarial complications. To permit of the ready comparison of these three sets of cases as
well inter se as with the remainder of iiXie p)Ost-mortem records of the continued fevers, tliey
have been arranged in accordance with the characters of the intestinal lesions so far as it
has been possible to determine these from the records.
* See note, page 273, mpra.
■fin liis OttiUnfif <>/ tht^ Chief Vamp Diseases of the United States Army, PUila., Pa., 18G3, pp. 100 el mj.; "In the solitary follicles of the small intestine
the If'sion is nianifesteil as a gradual enlargement of these organs, the contents of which become soft, pnlp.v and very frequently blackened from deposits
of jfignient. All possible stages may be observed, from a barely perceptible enlargement to a little tumor the size of a pea, or even larger, corresponding
to the situetion of tlie follicle ; the summits of the larger of these tumid follicles are freijuently the seat of a small ulcer. Such ulcers are especially to
be obser^'ed in the ileum, but the enlarged follicles are encountered throughout the whole length of the small intestine. The ulcer, originating thus in
a single closed follicle, may remain of small size {one to three lines in diameter), or it may enlarge, invade the surrounding tissues and produce an ulcer
(six lines to an inch, or even more, in diameter) resembling the ulcerjitions of the patches of Peyer in character, though not iu shape or situation. The
agminated glands or patches of Peyer undergo similar changes. As a general rule, eveiy patch is more or less involved, those high in the intestine being
less affected and the tumefaction being most intense towards the lower part of the ileum. The characteristic ulcer occurring in the patches of Peyer is
oval in shape ; occupies more or less completely the tumid group of follicles ; its edges are jagged and irregular, often undennined. The base of the ulcer
is of a dirty ash color, often with a yellowish tinge, occasionally mottled with dark, blackish points from the presence of pigmei ^. It may occupy any
fraction of the thick jess of the mucous membrane. Sometimes it is limited to the follicular apparatus; in its later stages, however, it usaal'y invau.-
more or less profouluUy the submucous connective tissue, and it may even involve the muscular coat. In the latter event, it sometimes p'-'ietratcs tin
muscular layers, erodes the subperitoneal couiiective tissue, and, in extreme cases, penetrates the peritoneum and produces a perforation, through which
the intestinal contents may find their way into the general cavity of the abdomen and give rise to a fatal peritonitis." .\t this time I)r. Woodwari* was
inclined to regard the ulcerations of typho-malarial fever as characterized by certain peou.iarities often sufficiently distinctive to enable the anatomist
to recognize the fever by the post^nortem appearances alone ; but a larger experience demonstrated to him that these ulcerations differed in no resj)ect from
those produced by typhoid fever. See p. 36 of the pamphlet edition of his Address on Tt/pho-vtalarial Fever in the Section of Medicine, International
Medical Congress, Phila., 1876. ^
X Hiipra, p. 308.
THK CONTINUED FEVERS. 335
Cases in wuk h iiik i)iA(iN(isis, rvpiioin, is mohk du i.kss sustainkd hy tmk riiNicAi. iiisioky — 50 casks.
(.1.) I'li/cr'!' 'niches ulcerated aiul the ilnim or »m<tll iiilestiiic only affected — 20 cufes.
Cask 1. — I'rivato .losliiia \\atsoii, Co. C, 7tb Ela.; ago 40; was aclmittcd Marcli 22, 181)1. lie hail lieeu .sick
for some tiiiii- ami was imich ilchilitatoil; his skill lu>t, toiijrue dry, teeth covoreil with sonles, imlse (luiik ami
small, couiilciiamc dull, cxincssiim vacant; thi'io was trmlcnioss and <;nr};liii}; in the rif^ht iliac r(>{;ioii. On the
2r>th he was smhlonly attacked with syiiijitonis iit' acnto larynsjitis, lesiiltiiif; in death the same day. I'osl-morlnn
oxamiiialiim : The jflottls and sunonndinji; parts wore swollen, apparently from liliriiioiis exndatiou beneath the
mucous iiiemhrane. The patches of Poycr were thi<'ki'ncd and nlcoiated. — Act. Asii't Sur//. M. K. (Uiaiion, Hud: Island
lloKjiilal. III.
Cask 2. — Conscript I'liineas Moody: age 29; was admitted Sept. .3, 18fi3. He was taken sick Angnst 6 with
diarrhoea which eontiinied a week, and was followed liy a chill and fever. On admission the |iulse was 'Mi, the
lonjjiic dry and brown; he had some diarrliii'a, slif;lil didirinm, severe and constant couKh, with nuieoiis rales in both
luiifis, but no rose-colored spots. Two days later some red blotches appeared on tln^ face, anus and chest, and there
was ilnlness with siibcrepitarit rales in the lower lobes of both hini;s. .Six ounces of whiskey were taken dailv, but
(III account of jn'ostration the i|uantity on the lOlh was increased to sixteen ounces. 12th: Skin moist; toiiKuo
furred yellow; no delirium. Whiskey reduced to six ounces. lie continued to iin|)rove under this treatment until
the 2.">th, when fever, dyspnfca and ■;rcat prostration set in, with colliquative diarrluea two days later, and death on
Octobers. /'os^«l<H•^•m examination ten hours after death: liody emaciated; lunj;s congested; liver enlarged and
fatty; spleen enlarged and pulpy; kidneys large and granular; many of Peyer's ])atches ulcerated, es)iecially those
near the ileo ca-cal valve. — Central Park Hospital, ^V. T'. Cili/.
Cask 3.— Private Nathaniel Newell, Co. K, ISfitli N. Y., w.as admitted Nov. .30, IKfil, from City Point, Va.,
where lie had been silk two weeks with typhoid fever; tongue dry and brown; sordes; anorexia: diarrho'a: invol-
untary stools; extreme tenderness over small intestine; low delirium; pul.se 120, weak, Iremulons. lie died next
day. I'osl-mnrtim examination: Peyer's patches much ulcerated; spleen enlarged :ind softened; lungs (edematous
posteriorly. — Third Dirision Hospital, Alexandria, la.
Cask I.— Private James Foster, Co. A, VMHh Pa.; ago 20; w.-is .admitted March 11, 1801. On the 13th the
abdomen became tympanitic and there was gurgling in the right iliac fossa. He died on the 2'lth. I'osl-mortem
examination six hours after death: Peyer's patches extensively ulcerated; solitary follicles enlarged ; other organs
healthy. — Third Dirision Hospital, Alexandria, I'a.
Cask .->.— Private \Vm. H. Hartley, Co. (!, 22d Pa. Cav., was admitted Oct. 10, 1801. 13th: Delirious at night :
petechiio on abdomen and extremities: pulse 120; tongiu" moist ; slight tympanites; subcre])itaut r:"ilcs and friction
sounds on the right side of the chest. Prescribed stimulants, eggs, and twelve grains of sulphate of i|uinine daily
in divided doses. 14th: The soft tissues over the right hip and sacrum began to slough; removed patient to a
water-bed. He sank rajiidly and died at 10 r. M. rost-morlem examin.ition disclosed the lower lobe of the right
lung in the third stage of i)ncunionia .and part of the luiddli^ of the left lung in the second stage; the right lung
was lightly adherent to the walls of the chest, and the cellular tissue in the neighborhood was somewhat emphy-
sematous. The colon, duodenum and jejunum were distended with gas; the ileum contracted; Peyer's glands more
or less inllamcd, and many of those near the ileo-cecal valve ulcerated. — Act. Aes't Surg. W. L. Wells, McClellan
Hospital, Philadelphia, Pa.
Case 6. — Private .Jeremiah O'Brien, Co. (!, 21th X. Y. Cav.; age lit; was admitted .Inly L'l, ISill, having been
sick a week with typhoid fever. On admission his pulse was 88 and full, bowiOs soluble and tongue moist; liut
there was pain in the right iliac fossa, \yitli delirium and slceplesisness. The pulse became nion^ frei|uent and less
full, the abdomen tynijianitie, the stools involuntary and the urine retained, necessitating catheterization. He died
on the 27th. /'o»<-nior/cHi examination: The right lung was consolidated posteriorly; the intestines contained live
himbricoid worms and an nnn.sual amount of f;eces, natural in color bnt soft. Peyer's patches were thickened and
inflamed, those near the ileo-ciecal valve ulcerated; the solitary follicles also were inflamed. — Act. Ass't Surg. Henrij
Gibbons, jr., Douglas Hospital, Washington, D. C.
Case 7.— Private Edward Rrown, Co. H, .35th Mass.; age 18; was admitted Dec. Ifi, 1804, with typhoid fever.
The patient was but partially conscious, had frequent invcduntary stools, epistaxis, (|uick ])ulse, tenderni-ss over
abdomen, particularly in right iliac region, rose-colored spots and well-marked sudamln.i : he bad muttering delirium
and picked at the bedclothes. On the 18th his tongue resembled :i piece of uuiiolished mahogany and his teeth and
gums were coated with sordes. He died next day. Post-mortem examination five hours and :i half after death : The
brain was normal. The larynx and trachea were healthy ; the right lung weighed t wenty ounces and a half, the left
seventeen ounces, the lower lobe of each in a state of red hei>ati/.ation and the inferior portion of the upper lobe of
the right lung congested ; the heart was normal. The liver weighed seventy-two ounces and was somewhat flabby;
the spleen sixteen ounces; several of Peyer's patches were ulcerated; the solitary glands much enlarged and many of
them ulcerated; the left kidney somewhat congested.— .-Icf. Ass't Surg. H. M. Dean, Lincoln Hospital, Washington, D. C.
Case 8.— Private Herbert Vaness, Co. D, ITlst Pa.; age 20; was admitted July 8, 186:1, with typhoid fever of
twelve days' duration, which progressed favorably until the 9th, when diarrhiea set in. On the l.">th there was
delirium, with dry and tremulous tongue, sordes on the ti-eth and swelling of the abdomen ; a troublesome hacking
cough was also present. He died on the 17th. Post-nwrtem examination ten hours after death : The brain weighed
fifty-eight ounces and a half; its membranes were considerably congested and its substance rather soft; a small
quantity of fluid was found in its ventricles. The trachea was much congested, of a purplish-red color and filled
.'iSG POST-IIOKTEM RECORDS OF
witb broiicliial secretion ; the lymphatic glands at its bifurcation were enlarged, blackened and softened. The u])]!! r
lobe of the right lung was highly congested, especially at the apex; the middle lobe was also somewhat congested
and presented evidences of bronchitis jjosteriorly : the lower lobe was intensely engorged, pnrple in color and in
some places almost black. The left lung was generally congested; there was a considerable transndation of blood
beneath the pleura at its middle and posterior part; its lower lobe contained splenified lobules, black in color, and
separated from each other by permeable tissue. The right lung weighed twenty-four ounces and a half, the left
twenty one ounces and a half. A thin fibrinous clot adhered to the anterior wall of the right auricle and extended
through the ventricle into the pulmoiuiry artery; the left auricle also contained a fibrindus clot extending into
the ventricle and attached to the mitral valve. The fundus of the stomach was of a dull lake-red and the pyloric
portion paler; it contained five lumbricoid worms. The liver was soft but of normal color, its capsule easily torn.
The spleen was of a mulberry color and moderately firm. The mucous membrane of the jejunum was rather soft
and the villi were easily scraped off. The lining membrane of the three feet of the ilentn nearest to the ileo-c;ecal
valve was greatly congested, and Peyer's patches were ulcerated though not perceptibly thickened; the first ulcer
was small, superficial and of a darker color than the surrounding membrane; about a foot above the valve a large
patch, softened and very liypera'uiic but not elevated, presented near its border an ulceration about the size of a pea,
with elevated walls and blackened centre. The kidneys were somewhat injected, the cortical substance firm and
pale. — Ass't Siinj. Hdirisoii Alhn, U.S. A., Lincoln Hospital, Washinijton, D. C.
Case 9. — Private William Crigger, Co. E, 20th Ind.; age 19 ; was admitted Nov. 24, 1864, with bronchitis, from
which he recovered and was transferred to Convalescent Barracks Jan. 4, 18ti5. He was readmitted April 8, with
pulse 100 to 110, skin hot and dry, tongue brown-coated with red edges, bowels loose, abdomen tympanitic. Active
delirium, snbsultus tendinum and pneumonic symptoms appeared on the 13th ; after the 15th there was continued
insomnia and on the 17th involuntary stools. I'rofuse sweats and coma ushered in death on the 20th. Postmortem
examination twelve hours after death: The brain weighed fifty-four ounces; there were six ounces of serum beneath
the arachnoid and a large quantity in the lateral ventricles; the cortical portion of the brain was highly congested
and the puneta vasculosa prominent. There were pleuritic adhesions on the right side ; the lower lobes of the lungs
were hepatized. The heart was normal. The sjileen was enormously engorged, weight forty-one onnces ; liver and
kidneys normal; stomach congested in patches; Briinner's glands congested; small intestine congested in lower
portion; Peyer's patches near ileo-ciecal valve extensively ulcerated ; mesenteric glands greatly enlarged; bladder
healthy. — Hospitul, iltuJison, Ind.
Case 10. — Private Daniel L. Keeuey, Co. C, 140th Pa.; age 24; was admitted July 11, 1863, with a flesh-wound
of the right hand, which granulated kindly until the 22d, when small ulcers were noticed on the inside of the cheek
and on the tongue, for which a mouth-wash containing sulphate of zinc and tincture of myrrh was piescribed.
During the next few days he became weak and languid, complaining on the 29th of some diarrhoea. Small doses
of calomel, opium and ipecacuanha were administered, to which, on August 9, a solution of citrate of potassa was
added. On the 12tli he had slight cough with sonorous and sibilant rales, and there was iliac tenderness. Next day
the red spots of enteric fever appeared on the abdomen and chest and the abdomen became tender all over. On the
13th, as the tongue was very dry and the strength failing, the treatment was changed to turpentine emulsion, wine,
milk and beef-essence. Occasional delirium followed, and nnicous, sonorous and sibilant rales became audible over
the right side of the chest. Four dry ctijis, carbonate of ammonia and raw eggs were ordered. On the 18th
inereasmg diarrhcea was recorded with snbsultus tendinum, stupor, difficulty of swallowing and sloughing of the
wound in the hand. Death occurred next day. Post-mortem examination seventeen hours after death: Abdomen flat ;
lungs congested, especially the right; heart, liver and kidneys normal; ileum congested, glands of Peyer thickened
and near the ca;cum ulcerated; jejunum normal. [Specimens 315 and 316, Med. Sect., Army Medical Museum, ulcer-
ation of Ileum, are from this case.] — Act. Ass't Surg. W. L. Wells, McClellan Hospital, Philadelphia, Pa.
Case 11. — Private John H. Winland, Co. D, 116th Ohio ; age 23 ; was admitted Nov. 5, 1864, with typhoid fever.
On admission the patient's skin was hot, tongue dry and bowels somewhat loose, tympanitic and tender. He was
treated with quinine, oil of turpentine and chalk mixture until the 14th, when he seemed very much exhausted,
presenting subsultus tendinum, hurried breathing, anxious countenance and a scarcely perceptible pulse. 'Jnder
milk-punch, beef-tea and camphor and opium improvement took place; on the 24th the tongue was moist, there was
some appetite and no delirium. On December 3 he coughed incessantly and his breathing became hurried. He died
on the 6th. Posi-morion examination thirteen hours after death: Heart soft and flabby; lungs, spleen, kidneys and
stomach healthy; liver much enlarged, weighing five jiounds and a quarter; ileum inflamed in nearly its whole
length and Peyer's patches ulcerated in fifteen places. — Act. Ass't Surg. Sample Ford, V. S. A., Cumberland Hospital, Md.
Case 12. — Private John L. Palmer, 7th Mich. Cav.; age 21; was admitted April 30, 1865, convalescing from
measles. On May 22 the nurse reported him as having been ailing for several days; he had headache, flushed cheeks,
increased pulse, 90, dry tongue, tympanitic abdomen, pain in right iliac region, a good deal of diarrho'a and some
rose-colored spots. Diarrhcea continued troublesome for several days, the pulse becoming more frequent and the
teeth covered with sordes; delirium and jmeumonic symptoms made their appearance and death occurred June 5.
Post-mortem examination: The areolar tissue of the front of the neck was a>dematous, the epiglottis swollen and the
anterior mediastinum filled with lymph and serum. Each pleural sac contained a large quantity of serum; the
whole of the right lung and the lower lobe of the left were much congested. The spleen was large ; the ileum
inflamed and Peyer's patches ulcerated. — Act. Ass't Surg. H, J. Wiesel, Cumberland Hospital, Md.
Case 13. — Private William H. Green, Co. 1, 161st N. Y., was admitted Nov. 19, 1862, delirious and greatly pros-
trated from typhoid fever. He had diarrhcea, sordes on the teeth and lips.ijnd a well-marked rose-colored eruption.
THE CONTINUED FEVERS. 337
He was trcatid with lauilaiitiin anil luaiul.v. essence iif lieef and milk. The iliarrhcea was fheckod .nul the deliiinni
lessened, but the pulse became more IVeiiuent and feeble, the prostration increased and the patient died by asthenia
on the 25th. Posl-morlim examination: An abundant typhoid deposit in the glands of I'eyer and solitary glands
was in process of sloughing ; the niesentorie glands were greatly enlarged. — Ltidiin' Home Iion}>ital, N. Y. City.
Ca.«k H.— Sergt. Edwin Avery, Co. I, IGlst N. Y., was admitted Nov. 19, 1862, with typhoid fever. He had
been slightly sick for live days before admission, his case presenting moderate diarrlnea, meteorism aiul tenderness
in the iliac region, rose-colored sj)ots, much inostration and freijuent, feeble pul.se, but no delirium — indeed, sliortly
befoie death lie gave direction.s with regard to certain family matters. Ho was treated with anodynes in modeiato
ih)ses, alcoholic stimulants and a sustaining diet. Hl^ died by astlienia December 2. i'(w(-«i«)'(<'m examination: An
abundant typlmid deposit in the glands of Peyer and solitary glands was in jjrocess of slougliiug; tlie corresponding
mesenteric glaiuls were greatly enlarged. — Ltidkn' Hume Hospilul, X. Y. Citi/.
Case 15. — Private John Caillot, Co. L, Itli N. Y. Cav.; age 21; was admitted July Ut, ISOH, with hot aiul dry
skin, frecjnent and feeble pulse, diarrhiea, tymiiauites, abdominal tenderness, taclies rouges over chest and abdomen
and muttering delirium. He died on the 31st. /'osZ-moWcm examination eighteen hours after death : Emaciation;
abdomen tumid; lower lobe of right lung congested; heart, liver and kidneys healthy; spleen enlarged; greater
(imiiitum much injected; mesenteric glands enlarged and intiamed; intestines filled with a lii]uid resembling pns;
mucous membrane of small intestine softened; Peyer's patches thickened and ulcerated.— 77ii/rf iJivisiun Honj/iltil,
AUjriindriii, )-«.
Cask Iti. — Private James Heckwith, Co. K, 2d Mc; age 23; was admitted Sept. G, l«til, with ty|)hoid fever
occurring :»s a relapse. The patient had a full strong jiulse, 120, heavily coated and dry tongue, hot and dry skin.
One ounce of sulphate of magnesia was ordered. He rested poorly during the night, having had some head symptoms;
his bowels were moved twice, although by mistake the Epsom salt had not been taken. His skin at the midnight
visit, September 7, was warm and perspiring, tongue dry and brown in the centre, pulse full, 114. Half an ounce of
tincture of rhubarb with ten drops of oil of anise was administered, by which the bowels were moved ra])idly. In the
evening he was nueonscious, and during the night delirious with involuntary stools of a brown color. Next day
there was rather less fever; pulse 104. (Quinine, which had been given the previous day, was continued in eight-grain
doses, with whiskey-punch and beef-essence, and an astringent injection at night. His bowels were moved twice on
this day. the 8th, and he had tenderness in the right iliac region. During the following night there was walking
delirium, and a few minute red spots were discovered, which did not disa|)pear on jiressure. At 11 A. M. of the 9th
he had a severe congestive chill; during the paroxysm his pulse was strong and rai)id; he raved and showed much
strength. Morphia was given to ipiiet him. His bowels were moved involuntarily during the day, and he was very
restless, rec[uiring to be held in bed. On the 10th, after a (|uict night, he was dull and stiii)id. his jniLse 117, skin
hot, lace llushed, teeth covered with sordes : in the evening he became drowsy and was (juiet during the night.
Turpentine emulsion was given. On the 11th his pulse was quick and weak, 130, tongue cracked aiul protruded
with difficulty, stools involuntary, countenance haggard aiul eyes fixed ; he had also subsultus, grinding of the teeth,
rose-colored spots and sudamina. In the evening his skin became cool, the prostration increased and the involuntary
stools were large and fetid. On the 12th the symptoms were: Pulse 137, soft, small and weak; resiiiration 14;
skin hot and moist; bands and feet cold and clammy; face pale; nose pinched; eyes and mouth half closed ; lips
livid; nausea: subsultus: black vomiting. He died at 3 i'. M. /*os(-)Horto« examination : The ileum was much thick-
ened, intiamed and ulcerated for live feet above the ilco-ca-cal valve; Peyer's glands were elevated, extensively
ulcerated and perforated in two places near the valve. No fa-cal matter was found in the peritoneal cavity. The
stomach was not examined. — SvmiiKiiy Hoxpilal, Groryelotni, D. C.
Case 17. — Private James 1). Prickctt, Co. H, 11th Va.: age 21 ; was admitted Sept. 19, 1864, with typhoid fever.
According to the statement of a comrade this man had been in service about two years, during which he had performed
his duties with little interruption from ill health. On admission he was delirious and almost moribund. He had
apiKireiitly been ptyalised by some preparation of mercury before his arrival. Morphia was ordered for the puri)ose
of procuring rest and sleep. On the 2l8t his pulse was 110, feeble and thread-like, tongue dry, red and glazed, gums
spiuigy, teeth covered with sordes, breath tainted with the fetor of salivation, abdomen tympanitic and tender,
countenance darkly Unshed, skin cool and dry; there had been delirium during the night. A hot s]>onge-bath was
ordered, with fomentations to the abdomen, quinine, turpentine emulsion, whiskey-punch and solution of chlorate
of potas.sa as a mouth-wash. Under this treatment the tongue became somewhat moist and the sordes disappeared
from the teeth, but the delirium continued through the night with drowsiness during the day. He had epistaxis,
partly induced by picking at the nose. On the 25th he seemed slightly improved, but next day persistent vomiting
set in with slight hiccough, the abdomen continuing distended and extremely sensitive. He died comatose on the
27th. /'o8/-moWe«i examination seventeen hours after death: Body not much emaciated. There were recent perito-
neal adhesions and a large quantity of serum in the abdominal cavity. The intestines were distended with flatus.
The mucous niembrano of the small intestine was (Congested and of a dark-red color from the pylorus to the ileo-ca'cal
valve: the glands of Peyer and the solitary glands were inflamed and ulcerated, and there were several minute per-
forations. The liver was normal; the spleen slightly enlarged and congested; the kidneys congested and greatly
enlarged, the right weighing thirteen, the left ten ounces. The brain, thoracic viscera and colon were not examined.
Act. AmU Siirg. A. J)'. Holden, Cumherland Hospital, Md.
Case 18.— Private Abraham Lindsley, Co. E, loth N, Y, Cav,; age 26 ; was admitted Sept, 6, 1861, with typhoid
fever. This man enlisted in July, 1863, and had good health until March 10 following, when he had an attack of diar-
rboDa lasting six weeks, for which he was treated in regimental hospital. Exposure in the field during Hunter's raid
Meu. Hist., Pt. Ill — 13
338 POST-MORTEM KECORDS OF
through West Virgiuia hrougbt on a recurrence of his diarrhcea, which continued during the whole of that severe
campaign and for three weeks after its terniination. AVhUe slowly improving in the regimental hospital he accom-
panied his regiment on a forced march, during which his strength utterly gave way, and he was sent to Hancock,
Md., and thence to this hospital. On his arrival his symptoms were those of typhoid fever — pulse rapid and irritahle,
countenance darkly flushed, skin dry, eyes languid and dull, tongue red and dry, abdomen tender and tympanitic.
lie had frequent slimy, watery stools, with some tenesmus, and Was so weak that he could scarcely speak. Morphia
and astringent mixtures, quinine and milk-punch were administered, but without improvement. On the lltli hi.s
tongue had become brown and dry, his abdomen extremely sensitive and his stools thin and fetid. On the following
night he had some delirium, and next day was drowsy and unconscious most of the time, occasionally picking at tlie
bedclothes and fingering the air. He continued thus for two days, his pulse becoming more rapid and feeble and
his tongue swollen, glazed and brown, with red margins. On the 11th there was a slight amelioration of the symptoms,
but next day the pulse ran up to 140, the eyes became glassy, the pupils dilated, and death occurred after an interval
of deep coma. rost-mo)'tcm examination seventeen hours and a half after death: Body moderately emaciated. Exten-
sive congestion of the omentum, recent adhesions and other indications of peritonitis were observed. The intestinal
mucous membrane was red and injected from the duodenum to the ileo-ciecal valve ; Peyer's patches were extensively
ulcerated and several of the ulcers had penetrated. The liver and kidneys were pale and fatty ; the spleen enlarged
and darl<~colored.' The colon was not examined. — Act. Ass't Surg. A. W. Holdeii, Ciimherland Hospital, Md.
C.A.SE 19.— Private S. C. Cole, Co. F, 77th N. Y.; age 26; was admitted Aug. 1, 1864, with diarrhoea, nau.sea,
vomiting, great prostration, weak voice and feeble pulse, 80, which continued, but with some abatement, until the
10th, when he was seized with a sudden and violent pain in the hypogastric and right iliac regions and became greatly
prostrated, the countenance anxious, surface cold and moi.st, voice coarse and husky, pulse small and increasing in
frequency and abdomen hard and tender but not tympanitic. Magendie's solution gave some relief to the pain, but
he sank rapiiUy and died on the 12th. rost-morlciii examination fourteen hours after death: I'eritoneum i)urple,
much congested, unadherent, and cavity containing thirty ounces of a yellow liquid mixed with fa-cal matter. SnuiU
intestine much congested ; ileum within a foot of the Ueo-Ciecal valve presenting many ulcerations of Peyer's glands,
with five circular perforations from three-fourths of an inch to one inch in diameter. — Surg. Henry K. Steele, 8(/( Ohio
Cav,, Hospital, Frederick, Md.
Case 20. — ^Private Henry R. Refior, Co. B, 13th Regulars, was admitted on board hospital steamer U. A. January
March 17, 1863, at Young's Point, La. On admission he stated that be had been sick for some weeks, and from his
description it was evident that he had sutt'ered from a mild attack of typhoid fever. He was convalescing: he slejjt
well and had a good appetite. When about to leave the boat, on March 23, for transfer to the convalescent hospital
at Millikeu's Bend, he was suddenly attacked by severe pains in the lower part of the abdomen and was at once carried
back to bed. He had a pale, anxious countenance and was bathed in a profuse cold perspiration ; pulse 90 and feeble.
Half a grain of sulphate of morphia was ordered and hot ajiplicatious to the abdomen. Castor oil was adminis-
tered and afterwards an enema, but neither relieved the constipation of the bowels. In the evening there was nmch
pain and distention. Sulphate of morphia was given every two hours. He became intensely prostrated and died at
midday of the 26th. There was no vomiting in this case. Post-mortem examination ten hours after death: Thoracic
viscera normal. The peritoneal sac was inflamed and contained a large quantity of greenish fluid; the abdominal
viscera were glued to each other by layers of soft coagulate<l lymph. The mucous membrane of the ileum was in
some places injected, and in its lowerpart near the ca"cum were some cicatrized ulcers of Peyer"s glands; one ulcerated
patch had perforated the coats of the intestine. — Sui'g. Alexuiider H. Hoff, U. S. V., Hospital Steamer D. A. January.
(B.) Peyer's patches ulcerated and the large intestine also implicated — 13 cases.
Case 21. — Private Richard Clark, Co. M, 2d Mass. Cav.; age 21; was admitted July 19, 1863, having been sick
for an unknown period: tongue dark brown but red along the edges; pulse 130; small; delirium: epistaxis: diar-
rhtt'a; abdomen tympanitic and covered with petechia. His condition improved under the influence of camphor,
valerian, ciuinine, acetate of anmionia and sponging with alcohol and water, but on the 24th pain was developed
in the right lung with duluess and crepitant rales over its lower lobe. Cupping was followed by relief; luit his skin
continued hot and dry. On August 2 he passed a quart of blood from his bowels and a small quantity on the follow-
ing day. He died, exhausted, on the 5th. Posf-nioj/cm examination seven hours after death: Right lung congested
throughout; left lung healthy. Stomach bloodless, its coats somewhat thickened and its pyloric orifice contracted;
Peyer's patches ulcerated; ileo-Ciecal valve extensively ulcerated and disorganized; ascending colon containing a
cousideraVde quantity of blood. — Act. Ass't Surg. T. Turner, Third Dirision Hospital, Alexandria, Va.
Case 22. — Private Henry Royer, Co. C, 148th Pa., died June 30, 1863, from an attack of typhoid fever. Post-
mortem examination twenty-four hours after death: Slight cadaveric rigidity: much Idoody froth issuing from the
mouth and nostrils. The mucous lining of the stomach was irregularly colored ; it was of a slaty hue at the pylorus,
mottled reddish and blackish. Beneath the epithelial lining of the duodenum a quantity of gas was found, supposed
to be due to putrefjictive changes. Below this point the mucous membrane was of a dull whitish color, very inelastic
and easily torn. Eight feet from the ileo-c;iecal valve Peyer's patches commenced to be involved; at first the upper and
lower parts of the patch were swollen, livid, not ulcerated, the centre being natural: lower down some were entirely
livid, with no ulceration: about one foot from the valve was one very large patch with thick high walls, ulcerated
centre and numerous small ulcerated points in its area. These portions were of a lighter hue than the non-ulcerated
portions, but none of them perforated the gut ; the largest patches gave the intestine a honey -combed appearance
from the peculiarity of the ulceration. The large intestine was of a grayish-slate color, its mucous memlirane soft-
ened but not ulcerated. — Ass't Surg. Harrison Allen, U. S. A., Lincoln Hosjjilal, Washington, D. C.
THE COIJTIiSUEO FEVERS. 339
Case 23.— Private Diulloy Wliitlook, Co. E, 5th Mich. Cav.; ago 17; was adinitteil Maicli 25, isn;l On April 1
his comlitiou was noted as follows: Woak; tougue dry and coated; pulso 144, coniprossililo; respiration (!li, dil'licuK ;
bowels regular: skin hot and dry; bed-sores on back and hips: urine passed involuntarily; dulne.ss on percussion over
each lung, most marked posteriorly: greatly increased vocal resonance: bronchial respiration: irritable cough. 3d:
Pulse 130; respiration liO; sputa somewhat teijacious. 6th: Stronger; profuse semi-purulent diseluirge from each
ear. 7th: Diiirrhoa, seven stools; pulso 110; respiration 41; tongue moist. 10th: Diarrbua continues: he refuses
MU'dichie. Body sponged with whiskey ; medicine given by enema. 14th: Pulso 158; respiration 21 ; weak; lUatli.
I'lisl-iiiorlim examination twenty hours after death: Kigor mortis; emaciation, lirain normal. Trachea and bronchi
tilled with white viscid sputa; mucotis membrane dark purplish; bronchial glands firm, of a dull liver color nuittlcd
lilarkish in centre. Lungs solidilied and dark purple posteriorly, reddish anteriorly; minnto whitish points in
central portions; pleuritic effusion on left side. Heart contained small white clots on both sides. Liver mottled
pur|de and pale yellow, interlobular areas yellowish; twenty-six drachms of dark bile in gall-bladder. Spleen lirm,
dark mulberry color. (Esophagus pale; mucous membrano of stomach mottled a delicate pink color; deposit of
black iiigment on pylorus. Small intestine in upper part pale yellowish ; duodenum tilled with thick stringy mucus;
I'eyer's patches normal to within eighteen inches of ileo-ca-cal valve, where they were thickened, elevated, congested
:iud in many places indurated and ulcerated, the ulcers having well-deliued edges and in some instances reddish
bases; solitary follicles the size of small shot. Mucous membrane of large intestine i)ale, rugic dark red ; solitary
glands proniiuent, dotted with pigment in centre; lower portion of intestine presenting iruiiiy minute superficial
ulcers Huconuected with solitary glands. Kidneys pale; suprarenal capsules mottled. — .Isn't Siir;/. Jfanhon Alkii,
C. S. ./., Limohi Hospitnl, fl'ti>ihiii<ilo)i, I). C.
C.\SE 24.— Private John North, Co. E, 5tU Mich. Cav., was admitted March 25, 1«()3, having been sick for some
time in regimental hospital. He was delirious and had high fever, a tremulous full pulse, sordes upon the mouth and
teeth, a typhoid fever tongue, some cough and expectoration, pain in the right iliac fossa and diarrlxua, the evacu-
ations soon becoming involuntary and olfensive. He died on the 28th. Poxt-nwrtcm examination twelve hours after
ileath: No emaciation ; rigor mortis marked; apparent age 21 years. The brain was healthy. The right lung was
congested and weighed twenty-five ounces; the left twenty-six ounces, its lower lobe being intensely engorged and
in some parts hepatized. The right side of the heart contained a blackish clot of mrtderate size; the left ventricle
a smaller clot. The liver was pale, its acini well defined, its texture softer than usual, its weight seveuty-threo
ounces and a half; the gall-bladder contained five drachms of deep-yellow flaky bile. The spleen was soft, deep
purplish-black and weighed eighteen ounces. The pancreas an<i kidneys were normal. The stomach was red at the
fundus. Peyer's patches were indurated, thickened and in iiuiny places ulcerated. The solitary glands were so
numerous that on a square inch selected at random fifteen were counted; they were large, about two lines in diameter.
The mucous membrane of the large intestine was generally mottled red, but in the ascending colon it was of a light
slate color mottled with red: the solitary glands in the ca'cum were enlarged and several of them ulcerated. — Aw'l
Surg. Harrison Allen, U. S. A., Lincoln Hospital, Washington, D. C.
C.\SE 25.— Private Edward E. Kiee, Co. D, 123d N. Y., was admitted Jan. 11, 1863. During the interval between
his admission and his death on the 14th extreme agitation, hurried respiration, delirium and tenderness in the right
iliac fossa were noted, rosl-morlcm examination seven hours after death: The lungs were crowded into the upper
part of the thorax by the distended intestines; the left lung was slightly congested posteriorly; the ui)peraml middle
lobes of the right lung were partially congested and solidified, apparently the result of hypostasis; the blood was fluid.
The liver was large and pale; the spleen large, congested .and soft; the kidneys pale and exsanguine. The intes-
tines were inflated with gas; the ileum congested; Peyer's patches enlarged andiileerated, some to a marked degree;
the caecum congested; the mesenteric glands enlarged. — Surg. H. Bryant, U. S. Vol's., Lincoln Hospital, Washington, 1). C.
Case 26. — Private Jos. McVaugh, Co. D, 147th Pa.; age 45; was admitted July 28, 1863. Ho was very feeble
and delirious, with an inclination to stupor; his tongue very dry and red; skin co8l and clammy; pulse 113, small
and weak; bowels moved about ten times daily; abdomen hard and tender, especially in the right iliac region. In.
the progress of the case the stools became less freiiuent, but all the other symptoms increased in severity; the pas-
sages during the night before death were involuntary. He died August 2. Post-morton examination seven hours
after death; The brain weighed forty-five ounces; the pia luatc^r was somewhat congested :ind the choroid i)lexnse8
tilled with minute air-bubbles. The trachea was greenish but contained healthy sputa; the nnicous membrane of
the u'sophagus was pale, .vcllow-stained near the cardiac orifice and presented numerous whitish points. The right
lung weighed eleven ounces and was slightly engorged in its upper and middle lobes. The left lung weighed
fifteen ounces ; its upper lobe was much shrunken and contained but little air; towards its ajiex was a small circular
elevation about the size of a chestnut, surrounded Ijy a livid purplish zone about three inches in diameter; on opening
this spot a quantity of air escaped and a few drops of bloody fluid; the lower lobe was engorged with venous Idooil.
The heart contained a small fibrinous clot in the right cavities and a mixed clot in the left; the pericardium con-
tained two drachms of bloody fluid. The stomach was unusually firm and its mncous membrane pale-red in color
throughout. The liver weighed fifty-three ounces and was slightly congested; the gall-bladder contained ten ounces
of bile of a brownish-ochre color, filled with a flaky substance which did not precipitate. The spleen weighed five
ounces and was flabby, soft and of a mulberry color. The right kidney weighed five ounces; its external surface
was of a bluish color spotted with numerous dark-blue points; an abscess about the size of a horse chestnut, with
ccehymosed walls, containing discolored pus, was found on the anterior surface near the outer margin. The left
kiiiney weighed five ounces and a half; it was much congested; a small cyst containing scrum was found on its
anterior surface. The snuill intestine was healthy to within three feet of the ileo-ca;cal valve, but from this point
downward the mucous membrane was of a reddish-purple color, thin and somewhat softened; Peyer's patches were
340 rOST-MORTEM RECORDS OF
discolored and ulcerated, especially near the valve, where patches of a dark-blue stone color, fully an inch in
diameter, were eroded. The large intestine was greenish but tree from ulceration ; the solitary glands were white
aud consijicuous. — Ass't Surg. Hayrison Allen, U. S. A., Lincoln Hospital, ffashiiujton, D. C.
Case 27. — Private Martin Burnes, Co. G, 164th N. Y.; age 20; admitted July 17, 1865, having been sick about
three weeks without medical attendance. Low delirium set in on the 19th ; diarrhoea, which was troublesome at
lirst, subsided by the 21st. Ou the 23d blood to the amount of two pints was passed from the bowels, and he died
exhausted four hours thereafter. Pusi-moctott examination nine hours after death: The intestines were half tilled
with a frothy, semi-Huid, bloody mass; Peyer's patches were ulcerated into deep excavations bounded by thiekcued
and indurated edges; the solitary follicles were ulcerated throughout both small and large intestines: many of the
ulcers penetrated to the peritoneum. The spleen was enlarged aud softened; the other organs normal. — Acl. Asa'l
Siinj. George 1'. Uanuwalt, Douglas Hospital, Washington, 1). C
Ca.se 28. — Private Castor Seebold, Co. E, 51st Pa.: age 19; was admitted May 7, 1861, presenting some emacia-
tion, dry tongue, sordes ou teeth, tenderness in right iliac fossa, and restlessness, with a freiiueut pulse, 120. Next
day rose-colored 8i)ot8 were observed, and he had epistaxis and diarrhoea, with a more rapid pulse. He was treated
with acetate of ammonia and morphia, milk-punch, eggnog and beef-tea. He died on the 11th. Post-mortem exam-
ination four hours afterdeath: Lungs congested; heart, liver and kidneys healthy; spleen somewhat softened aud
congested: ileum and c;ecum very much congested; Peyer's patches and the solitary glands in the ileum n\uch
enlarged and ulcerated. — Turnei-'s Lane Hosjyttal, Pliiladelphiu, I'a.
Case 29.— Corporal J. B. Richardson, Co. E. 2d Mich.; age 26; admitted Feb. 8, 1863, having been affected for
two weeks with anorexia, tympanites, diarrho-a and cough, and presenting a hot aud dry skin, furred tongue aud
injected eyes; delirium and involuntary stools occurred on the 11th, and death took place on the 17th. I'ust-morlem
examination: The brain was normal. The bronchial tubes ou both sides presented indications of inflammation, aud
the lower lobes of the lungs contained hepatizations from the size of a chestnut to that of a hen's egg. The liver
and spleen were large but unaltered in texture ; the gall-bladder was small and half full of dark bile ; the kidneys
healthy; the jiancreas eularged and somewhat hardened. The mesenteric glands were enlarged and indurated; the
luucous membrane of the stomach much injected; the duodenum .and jejunum inflamed in patches; the ileum con-
gested, thickened and softened, and its agminated glands ulcerated, the ulcers having thick, hard, prominent edges.
The colon was inflamed in patches and its mucous membrane thickened. — Hareieood Hospital, irashingion, D. C.
Case 30. — Private Edgar Sanborn, Co. D,6th N. H.; age 15; was admitted July 24, 1864, with feeble and frequent
pulse, great heat of body, dry brown tongue, sordes on teeth, slight diarrhtea and great tenderness in the right iliac
region. On the 28th his face became dusky and stupor supervened. He died on the 30th. I'ost-uiortem examination:
Much bronchial secretion ; lungs congested : heart aud liver normal ; lower half of ileum slightly inflamed, with com-
mencing ulceration of Peyer's glands and cicatrices of old ulcers; ciecum inesenting two ulcerations; rectum much
inflamed. — Act. Ass't Surg. A. M. Haven, Fairfax Seminary, Va.
Case 31. — Private Oscar Snow, Co. H, 3d Vt.; age 20; was admitted Oct. 1, 1861, with typhoid fever. He had
been sick a week, but he was so dull that he could give but little information concerning the early part of his sick-
ness. A bath was ordered for him, and Dover's powder at night. Next day his face was flushed, pulse 135, full,
skin hot aud dry, tongue slightly moist but thickly coated brown; he had slight delirium, some deafness and ten
or twelve characteristic rose-colored spots; his bowels were loose, teuder aud tympanitic. From this time the
condition of the patient gradually changed for the worse. His bowels for some time were not loose, but tenderness,
meteorism and borborygmus were present throughout ; on October 12 he had three involuntary jiassages. His pulse,
which at first was rapid and full, lost its fuluess but retained its rapidity, becoming small, weak and fluctuating.
His tongue became dry, aud on the 9th he was unable to protrude it: on the sauu> day .sordes appeared on the teeth.
The rose-colored spots disappeared ou the 11th. From being somewhat dull mentally, with occasional mild delirium,
he fell into a prostrate condition, lying on his back with his lower jaw dropped and his eyes open, taking no notice
of anything going on around. On the 8th his breathing became hurried ; mucous and sibilant rales were heard in
the right lung, and on the 12th a leathery creaking sound was distinguished over both lungs. Ou the 11th the
parotid gland was found to be swollen. The treatment consisted of quinine, turpentine, brown mixture, nonrish-
meut and stimulants. On the evening of the 13th his face was ashen-gray in color, lips cold and bloodless, head and
extremities cold; there was some deafness and it was very diflicult to arouse him; he had also a mild delirium,
speaking of going home, and had no idea of his condition. His pulse, about 140, was weak and barely perceptible
at the wrist; the superficial circulation was almost suspended — an impression made with the fingers remained a long
time. He had no hemorrhage from the nose or bowels; his bowels moved occasionally involuntarily, the passages
being very thin; the abdomen was acutely tender and borborygmus frequent. His respiration varied from fifty
to sixty per minute; a rattling sound was heard in the throat during expiration, as though from mucus which
he had not strength enough to eject; his breath was very ofl'ensive for the first time since his illness. His urine, acid
aud albuminous, had a specific gravity of 1011, aud contained mucus, epithelium, urates and a few blood-discs.
The parotid gland continued much swollen. On the evening of the 14th he aroused himself and spoke very rationally;
his eyes shone brilliantly for a few minutes; he tried to rise from bed, but fell back from weakness; the rattling
sound in the bronchial tubes increased, and after a few deep-drawn breaths he was dead. Post-mortem examination
fourteen hours afterdeath: Side of face swollen; parotid infiltrated with pus. The pleural cavities contained a
number of large blood-clots; the derivation of the hemorrhage was not ascertained. The lungs were congested,
but were not closely examined forwant of time. The stomach contained a pint of very ofliensive yellowish matter;
its mucous membrane was thick and congested. The li\er and gall-bladder were enlarged but healthy; the sjdeeu aud
THR CONTINFEP FF.VEKS. 311
kidneys onlarj;cil and congested. Tlio poiitiinriini was much iiillanicd. Thi' glands of I'eyer and the solitary glands
of the ileum were much ulcerated. A foot and a half from the ileo-ca-cal valve the ileum presented a diverticulum
aliout four inches long, as wide as the gut from which it was derived, and like it. blackened and much ulcerated.
The mesenteric glands were enlarged, the mesentery much congested and inliamed. The mucous membrane of the
cohm was dark in color but not iilcerated. — Sniiiiiiirii IJoKpilal, Georgetoini, I). C.
Cask ;tt.— Private Christian Schultz, Co. K, 14th Conn.; ago 42; was admitted Dec. 16, lX(i'J, having been sick
for two or three months with rheumatism. He complained only of pains iu his back and limbs until .Jan. 1, IHthi,
when ho wa-s taken with headache, trembling, a full compressible pulse and other mauifestations of nervous derange-
ment; his tongue was moist and coated with a white fur. He was ordered a teaspoonful of castor oil, which operated
six times iu the twenty-four hours. Ko noticeable change occurred until the Gth, when some tympanites was ob.served
and one taehe rouge close to the umbilicus. On the iUh the pulse became small and compressible, the tongue dry, the
face flushed and the diarHuea persisteut, while an increasing tendency to drowsiness was manifest. Ten days later
the diarrha-a became checked and the tongue dry, raw and cracked; he had herpetic eruptions on the lower lip, a
troublesome cough, and was so much prostrated as to slide down in bed. On the 2l8t his bowels were moved in hard
masses after an interval of forty-eight hours; next day his pulse was strouger, tongue cleaning and more moist
and skin clammy, but the cough persisted and was distressing. On the 30th he was considered convalescent, and
his case, with careful attention to diet, jirogressed favorably until February 215, when there occurred unmlstakablo
evidence of a relapse. On Man-h 8 the patient pieseuted the taches ronges, and was atl'ected with dulness of hearing,
epistaxis, tympanites and dlarrh<ea; on the (Sth he vomited matter which looked like altered blood, and comi)lained
of pain in the left hypochondrlum. During the next few days the vomiting continued and a cough w'lth bloody sputa
was developed. On the 14th the respirations were 5G per minute and the piilse frequent and feeble. He died on the
2(tth. I'lisl-morlim examination: The mucous membrane of the trachea and bronchial tubes was Intlamed; the bron-
chial tubes were tilled with muco-))urulent matter. In the right lung were several hepatlzed nodules the size of
walnuts, the surfaces of which were attached by recent pseudo-membrane to the costal pleura; the left pleural sac
contained about two (juarts of yellow serum mingled with pus and thin jelly-like fibrinous coagula. The heart
was tilled with black and white clots. Foyer's glands were thickened and a number of them ulcerated, three of the
latter having perforated; but there was no evidence of peritonitis. The ca?cum was moderately inflamed and i)re-
sented a number of small ulcers; the colon showed a few streaks of iullammat Ion. There was intralobular congestion
of the liver. The spleen was soft. — .let. Aan't Surg. Joseph Lt-idij, Salttrlee Hospital, Philuddphia.
Case 33. — Sergt. Gustave Van Kcken, Co. F, Independent battalion, N. Y.; age 30; was admitted from I'caufort,
S. C, with typhoid fever: Prostration. ])ulse 120, tongue dry and brown, sordes, diarrlnea, red eruption, delirium,
and, forty-eight hours before death, tympanites. I'ost-mortim examination eighteen hours after death : Peyer's i)atclie8
extensively ulcerated: mucous membrane of large intestine ulcerated; ca'Cum perforated at two points; abdominal
e;ivlty containing a large quantlt}' of f;ecal matter and showing but slight evidences of peritonitis; kidneys fatty;
spleen enlarged. — .lc<. Ass't Surg. S. Teats, Central I'arli Hospital, A", i'. City.
(C.) Condition of Peyer's patches not stated; ileum or small intestine ulcerated — 13 cases.
Case 34. — Private ISenjamin Cunningham, Co. D, 86th N. Y.; age 21; was admitted Feb. 18, 1862, having been
sick for some tinx! with chills, headache, pains in back and limbs, loss of appetite, epistaxis, dlarrh<ea artd iiuiblllty
to sleep. On .March 4 his pulse w.as recorded as rapid and weak, skin warm and moist, cheeks Hushed, tongue
smooth and natural, abdomen tympanitic and covered with vibices and a few sudamina ; he had little appetite, great
thirst and <me or two watery and sometimes involuntary passages; he was somewhat deaf l)ut appeared sensible;
respiration was hurried and there was some cough. Treatment: Punch, beef-e.sseuce, turpentine emulsion and
tincture of iron, with mustard to the abdomen. From this time he Improved: His watery passages gave place to
more natural and regular discharges, — indeed, on the 10th his bowels were noted as rather constipated, he slept
well, his appetite returue<l and his general appearance and strength seemed improving; but his tongue was con-
sidered to be too smooth, and at times his mind did not appear to be clear. He was, however, considered as iu a fair
way to recovery. On the loth he complained that his hips were sore from long continued pressure, and next day that
he had lost the sense of taste — that he could feel his food when in his mouth but could not taste it. 15ed-sores over
the sacrum were noted on the 17th, and great debility with enlarging sores over the left trochanter on the 26th, on
which ilay also he was seized with a severe pain iu the left side. This pain increased on the 27th, the breathing
iH'coniiug hurried and prostration extreme ; his mind was clear, pupils dilated, the sclerotic showing to an unnatural
extent. He died on the 2ilth, dlarrlnea returning a few hours before death. Post-mortem examination: The mucous
membrane of the ileum was much inliamed and ulcerated eighteen or twenty inches above the ileo-cascal valvo. —
Scminarij Hospital, Ccorgetown, D. C.
Case 3.5.— Private Jacob Davis, Co. I, 63d Pa.; ago 21; was admitted Oct. 10, 1863, with emaciation, debility
and diarrh(pa, a dry, brown tongue, cracked in centre, teeth covered with sordes, respiration quick and feeble and
pulse over 90. Hi^ lingered without much change until the 18th, when he died. He was given concentrated nourish-
ment and stimulants, sweet spirit of nitre :ind turpentine emulsion, with nitrate of silver and opium for the diarrhii'a.
Pnst-mnrlrm ex:imlnatlon six hours after death : The suuiU intestine was considerably cinigested and for several feet
was patched with ulcerations, some of which were as large as a quarter dollar; spleen somewhat enlarged. Other
organs healthy. — Act. Ass't Surg. ■!. E. Smith, Fairfax Seminary, Va.
Case 36.— Private Albert Tucker, Co. A, 23d Ohio; age 30; was admitted Oct. 18, 1864, as a convalescent from
Ivplioid fever. He looked pale and weak, had little appetite, but was in good spirits and able to walk about the
w.inl. He had finm six to ten stools daily, which were occasionally streaked with blood; his lower extremities were
342 POST-MORTEM RECOKBS OF
(Pdematons and there was some slight abdomiual eft'usiou ; he had a slight cough, and the heart-sounds seemed distant
and masked. Astringents, anodynes and diuretics were eHiployed. He died rather suddenly on the 24th after an
attack of dyspnoea and severe prsecordial pain. Post-mortem examination : Head and upper part of body ecchymoscd :
lower extremities a?dematous; brain normal : thoracic cavity containing a pint and a half of serum : lungs congested
and lymph-coated posteriorly: pericardium containing considerable effusion; tricuspid valve apparently thickened:
omentum almost devoid of fat: liver and stomach healthy; spleen somewhat enlarged; mesenteric glands enlarged:
small intestine presenting many and large ulcerations, especially near the ileo-ciecal valve; kidneys very much
enlarged but apparently normal in structure. — CuyJer Hospital, Philadcljjhia, Pa.
Case 37. — Private William H. Harrison, Co. B, 11th Ohio: age 10; was admitted June 22, 1864, presenting a
rapid pulse, dry, furred tongue, anorexia, thirst, abdominal tenderness, diarrhoea, restlessness, delirium and the typhoid
rose-rash. These symptoms continued, varying in intensity from day to day, until July 2, when they assumed so
aggravated a form as to leave no hope of recovery. He died on the 4th. Post-mortem examination eight hours after
death: Body emaciated; blood oozing from right ear; right lung firmly adherent to costal pleura, its upper lobe
congested; spleen three times the usual size; liver enlarged, its right lobe congested; left kidney twice the normal
size, its calyx enlarged; lower part of ileum ulcerated, in some places through to its serous coat; mesenteric glands
enlarged and inflamed. — Act. Ass't Surg. C. E. Boyle, Seminary Hospital, Columbus, OMo.
Case 38. — Private Daniel Dewey, Co. E, 196th Ohio; age 23 ; was admitted April 5, 1865, in a very feeble and
emaciated condition: Skin dry and husky, neck and breast coveretl with sudamina, right elbow and knee joints swollen
and very painful, tongue dry and cracked, teeth, lips and gums covered with sordes: he had diarrhoea and a hoarse
cough, with difficult respiration but not much expectoration. He died on the 22d. Post-mortem examination ten
hours after death : Body extremely emaciated. Small deposits of pus were found between the fibres of the pectoralis
major of the right side. The epiglottis was oedematous and ulcerated; the vocal cords ulcerated; the mucous mem-
luane of the larynx, trachea and bronchial tubes intensely inflamed; the left lung hepatized; the apex of the right
lung engorged and infiltrated with sero-purulent matter. The liver was large, pale and soft ; the spleen enlarged
and much engorged ; the ileiim inflamed and ulcerated. There was a large deposit of pus in the cavity of the right
knee joint and an effusion of serum in the surrounding parts. The left wrist joint and the right elbow joint also
contained pus. — Act. Ass't Surg. S. B. JVest, Cumberland Hospital, Md.
Case 39.— Private Franklin D. Hicks, Co. K, l-57th N. Y., was admitted Nov. 18, 1862, with typhoid fever. The
rose-colored spots were very distinct and the sudamina abundant. He died on the 29tb. Post-mortem examination
forty-eight hours after death: In the lower portion of the small intestine the peritoneal coat was much injected and
readily peeled off, and the mucous membrane was extensively softened and ulcerated. The mesentery was consid-
erably injected and the mesenteric glands much enlarged. — Tliird Dirision Hosjiital, Alexandria, Va.
Case 40. — Private Jo.siahCheever, Co. B, 15th Vt., was admitted April 14, 1863: Headache; occasional delirium ;
pulse 100, compressible ; hot and dry skin ; six to eight stools daily: short, dry cough ; sibilant rhonchns distinct over
chest anteriorly; abdomen tympanitic. Calomel, opium and ipecacuanha in small doses alternating with eft'ervescing
mixture ameliorated his condition. The chest and head symptoms subsided, but the abdomen remained distended
and tender and the diarrhoea continued. On the 22d his tongue became cracked and pulse feeble, 120. He died on
the 28th, notwithstanding the administration of turpentine, alcoholic stimulants and ammonia. Post-mortem examina-
tion: Thoracic viscera normal. Mucous membrane of small intestine injected, lower ileum presenting eight large
ulcers; corresponding mesenteric glands enlarged. — Third Division Hospital, Alexandria, Ta.
Case 41.— Private Benjamin Tice, Co. E, 13th N. J.; age 24; was admitted Oct. 29, 1862, with diarrhoea, iliac
tenderness, nervous disorder and four taches rouges; the skin was hot antl dry, pulse frequent but not very feeble,
tongue coated with dark fur; there was also a slight cough, accompanied by very little jjain in the chest but with
most distressing dyspnrea and almost complete aphonia; the chest was resonant on jiercussion. Small doses of blue
mass, opium and ipecacuanha seemed to relieve the chest symptoms and check the diarrluva. Later, dulness on per-
cussion was noted over the lower portion of the right lung. Dry cups were apjilied and stimalauts administered.
After this the pulse became more frequent and feeble, the tongue fissured, the teeth and gums covered with sordes,
diarrhoea profuse and tympanites extreme. He died Noveml)er 6. Post-mortem examination : The heart was healthy;
the left lung extensively congested; the middle and lower lobes of the right lung hepatized. The omentum was
engorged with dark blood; the liver andspleenenlarged; the mucous membrane of the stomach slightly reddened; the
duodenal glands much enlarged; the lower part of the ileum ulcerated in eight large patches. The large intestine
was not examined. The kidneys were healthy. — Third Dirision Hospital, Alexandria, Va.
Case 42, — Private Martin V, Murphy, Co, F, 123d Ohio, was admitted May 4, 1864, from hospital, Alexandria, Va..
He had no hereditary tendency to disease and enjoyed excellent health up to fourteen months ago, when he was seized
with a cold while on a scout at Winchester, Va., which in a few days was followed by fever. This confined him to
bed for six or seven weeks, after which he partially recovered and went home on furlough, where he had a relapse
which disabled him for four or five weeks. He so far recovered from this as to be able to walk several miles and
continued to improve for two months, when he was taken with dysentery, which lasted two or three weeks, and since
that time he has not fully regained his strength. He returned to his regiment and remained with it for about four
weeks while it was in camp at Brandy Station, Va., but during that time he was unfit for duty. When the army
moved he was sent to hospital at Alexandria, where he remained a month, after which he was transferred, as above
stated. When admitted ho was sufl:ering from debility consequent on typhoid fever and dysentery. He was put on
tonics and astringents, with the best diet the hospital aftbrded. He improved gradually until the 14th, when he
compl.aiued of a sharp pain in the lower part of the right breast, aggravated by deep inspiration and coughing; pulse
TIIF. OONTINrKD FEVERS. 343
120 and small: tongue moist and red; cough with wliite frothy expectoration: decabitns on left side: skin very hot.
This pleuritic attack lasted until the 25th, after which convalescence progressed satisfactorily antilJnly 11. when he
complained of diarrhcea with some tenesmus, which steadily increased, resisting all eftorts for its relief. He died
July 2.ith. Post-mortem examination sixteen hours after death: Body much emaciated. A large amount of serum
was found lieneath the dura mater, between the layers of the arachnoid and in the ventricles: the substance of the
brain w:js soft. The right i>leural cavity was tilled with purulent serum and the pulmouari' and costal pleuni- were
completely lined with a tibro-albnniinous deposit : the lung wa.s consolidated by pressure and bound to the iKistorior
wall of the chest : l>oth lungs were tuberculous: one tubercular ulcer in the right lung had perforated the ]mlmonary
pleura. Tut>ercles were diffused over the surface of the heart and pericardium. The liver was healthy : spleen snuiil
and hard : kidneys small in size but healthy in appearance. Ulcers, with their long diameters at right angles to
the length of the gut, were found throughout the small intestine. — Jet. Jsst Surg. Charle* P. Tutt, Sattrrlre Hospital,
Philiutelphin, Pa.
Cask 43.— Private E. J. Williamson, Co. C, 179th X. Y.; age 20; was admitted Nov. 30, 1864, having been sick
fur about twelve months. His tongue was dry. dark and cracked and had a glazed edge ; teeth covered with sordes:
alMlomen tympanitic and tender: bowels loose. There was no rose-colored eruption and but little cerebral excite-
ment. Turpentine emulsion and wine were given, and the case progressed favorably until December 3, when
pneumonia set in. Next day the pulse was 120, the delirium marked, cough harassing and expectonition scanty. He
die<l on the 5th. Po't-morlem examination: I'lccration of the ileum, especially about the ileo-c:ec:il valve. Posterior
portions of Kith lungs hepatize<l. [Specimtn 452, Med. Sect., Army Medical Museum, from this case, shows perforation
and peritonitis to have existed.] — Jet. Jits't Surg. TT. C. Minor, Third Divisiun Hospital, Jlexandriti, I'a.
Case 44.— Private William F. Hart, Co. A, 14th U. S. Inf.. was admitted Aug. 14, 1863, with such symptoms
of typhoid feverasadry and cracked tongue, sordes on teeth, small, weak and rapid pulse, quiet delirium and tymjia-
nites. Abdominal tendeniess became aggravated and he died on the 16th. Post-mortem examination: Perforation of
the lower ileum: 6rm adhesions of intestines. — Third Dirinioii Hospital, JUxandria, Va.
C.vSE 45.— Private Silas Tomlinson, Co. K, 24th Mich., was admitted Nov. 30, 1864. The patient had been sick
for some time in hospital at Cit.v Point, Va.: he suffered much and received bnt little attention during his Journey to
Alexandria. On admission: Pulse weak, thread-like and from 90 to 100 per minute: skin hot and dry: tongue
very dry, red and slightly coated: thirst urgent : appetite small: epistaxis: deafiiess: expression stupid: delirium:
abtlomen generally lender, tympanitic and showing a few sudamina and many petechial spots. December 1: No
change. 2d: Pulse somewhat stronger, fuller and less freijuent : tongue less dry: expression of countenance brighter
and hearing improved: diarrhoea less active, but tenderness and tympanites of the abdomen unchanged. 3<1: Pulse
Wand decideilly stronger: diarrhcea checked: tongue throwing off its fiir: appetite improved: patient intelligent.
4th: The favorable symptoms continued: tenderness of the abdomen lessened. 5th: At 2 a. M. a change for the worse
took place: the pulse became weak and ran up to 100: the patient had slight chills: his tongue became dry and red
and sonles gathereil on his teeth, gums and lips, while the whole surface was bathed in a cold clammy sweat : petechial
spots assumed the appearance of purplish blotches, and the alidomen became exceedingly tender, swollen and tympa-
nitic. Ten hours after this change took place the patient had several involuntary stools of a dark-greenish color,
after which he fell into a semi-smpor from which he could with difficulty be aroused, and when arovi-sed gave imperfect
answers to questions proposed: his face was sunken and there was much twitching of the mu.scles of the u]>per
extremities. He died on this day. Post-mortem examination twenty-three hours after death: A few purple-colored
points, said to be of ante-mortem formation, were noticed on the chest and abdomen : there was also purple hypostasis
of the posterior part of the bod.v. There was a quantity of fluid under the arachnoid at the vertex of the brain, bnt
the substance of the brain was normal. The heart was dilated on its right side and almost completel.v filled by a
large semi-transparent clot. The left lung was crepitant, although somewhat dark colored posteriorly. The right
lung was closely adherent by firm tissue and apparently compressed or drawn over to the right side: the posterior
part of its upper lobe was of a dark brown-red color, softened and with minute points, apparently bronchi, filled with
a yellow froth: the remainder of the lung was normal. The liver was large and of a uniformly pale clay color; the
spleen large and softened: the cortical part of the left kidney of a yellow, semi-fatt.v appearance. About twelve
inches from the colon the small intestine was perforated liy a black-margined aperture the size of a small shot ; recent
lymph glued the perforated coU of the ileum to the bladder and sigmoid flexure. Liquid fa-ces of a yellow color had
to a small extent escaped into the pelvic cavity. — Jet. Jss't Surg. W. C. Minor, General Hospital , .ilexandria, Va.
Cask 46.— Private Thomas Williams, Co. H. 8th Md.: age 32; was taken with fever at Camp Bradford (strag-
gler's camp I Aug. 1. 1863. He was admitted on the 13th: Countenance heavy; face flushed; skin hot ; pulse about
100; respiration ditiicult : diarrhcea with ochre-colored passages ; urine scanty and high-colored. Treatment : Acetate
of ammonia, camphor and quinine, with opiate enemata. On the 15th he was restless and bad considerable subsultus;
the tongue was protruded with dilficulty; respiration was accelerated: much viscid mucus was brought up: auscul-
tation revealed bronchial breathing, and the right lung was dull on percussion. Extract of valerian, sweet spirit of
nitre and carltonate of ammonia were administered and turpentine stupes applied to the chest. On the 19th he was
greatly depressed, the diarrhu-a frequent and exhausting. Carbonate of ammonia in two-grain doses was given
every two hours. Xext day the pneumonic symptoms were unchanged, the sputa adhesive and tinged with blood.
A Idister was applied to the chest. Both iliac regions were tympanitic and tender. On the 21st the patient's extre'hi-
ities were cold. Brandy was substituted for milk-punch, which had been given finely since the 18th. On the 23d
his mind was clearer than at any time since his entrance. At 8 a. m. of the following day he was seized with violent
pain and tenderness in the abdomen followed by persistent vomiting. He died on the 25th. Post-mortem examination
a44 POST-MOETEM KECOKDS OF
shortly after death: The peritoneum showed marks of extensive inflammation and contained ahout eight ounces of
liquid matter similar in character to the dejections during life. The mesenteric glands were enlarged and the ileum,
for the distance of three feet ahove the ileo-ca>cal valve, was inflamed and ulcerated ; a large perforation was situ-
ated fourteen inches ahove the cpecum. The thoracic and cranial cavities were not opened. — Med. Cadet W. L. Brad-
ley, McKim's Mansion, Baltimore, Md.
(D.) Condition of Feyefs patches not stated; ileum or small intestine ulcerated and large intestine affected— i cases.
Case 47. — Private Elias Brink, Co. B, 137th N. Y.; age 53; was admitted Jan. 18, 1863, having been sick two
weeks. He spoke of having hurt his back and ruptnred himself by a fall while on the march, and complained of pain
in his back. Symptoms of what was supposed to be pericarditis made their appearance on February 7, and next day
veratrum viride was prescribed. On the 11th he was noticed to be very deaf; hi.s pulse was slow and weak, and vomit-
ing had set in. The veratrum viride was discontinued. Next day he lapsed into stupor and when aroused with diffi-
culty from this state his answers were incoherent: his breathing was rapid. On the 11th an eruption like that of
typhoid fever made its appearance on his body and extremities; he coughed much and muttered to himself; there
apiieared to be some iliac tenderness; his urine reqniied to be drawn oti' by catheter. Next day his evacuations
became involuntary. He died on the 19th. rost-mortem examination four hours after death : Body emaciated ; rigor
mortis marked. The brain weighed forty-six ounces; it was light-colored, of firm consistence and contained much
fluid in its ventricles. The heart was healthy. The right lung weighed fifteen ounces, the left thirteen ounces ; the
right was full of blood, the upper lobe being somewhat congested and the lower universally so; the ujiper lobe of the
left lung was congested; collapsed lobules were observed in the lower lobes of both lungs; the bronchial tubes were
congested and some of the smaller ones contained pus. The liver weighed fifty-four ounces and was universally con-
gested ; the gall-bladder contained eleven drachms of dark-green bile ; the spleen weighed five ounces and a half and
was of a dark-slate color externally, dark-red internally and moderately firm in consistence: the kidneys weighed
four ounces and a half each and were of a rather dark color ; the stomach was slightly congested. The mucous mem-
brane of the small intestine was softened, especially near the ileo-ca!cal valve; it was slightly congested in the jejunum
and upper third of the ileum, decidedly so in the lower two-thirds of the ileum, where a number of ulcers were observed.
Thec»cum was of a dark-slate color; the rest of the large intestine was normal. The mesenteric and mesocolic glands
were enlarged, especially the latter. — AsaH Surg. George M. McGill, V. S. A., Lincoln Hospital, JTashington, D. C.
Case 48. — Private William Duryea, Co. I, 109th N. Y.; age 21; was admitted May 14, 18G4, with a gunshot flesh
wound of the left forearm, which healed kindly. On the 18th he was furloughed for thirty days, and on his return,
June 18, he was placed on light hospital duty, his wound unfitting him as yet for active service. On July 28 he was
taken with headache and nocturnal delirium ; his pulse 100 and his tongue coated with a dark fur. A few days later
some difficulty of breathing was noted, with slight diarrlueaand twitcliing.sof the tendons, the delirium having mean-
while become constant. His condition remained unchanged, liut for progressive weakness, until August 7, when he
died. Post-mortem examination six hours after death : The lungs were congested. The heart was pale and contained no
clots. The liver was of normal size but congested; the gall bladder filled with viscid bile; the spleen dark-colored,
slightly enlarged and congested; the kidneys normal. The mucous membrane of the stomach was light-colored,
thickened and softened. The lining membrane of the small intestine was soft and somewhat thickened down to
the lower poition of the ileum, in which there were large ulcers at difterent points some distance from each other:
near the ileo-ca>cal valve it was greatlj' thickened and congested, and presented very large ulcers surrounded by red
areoliE and penetrating to the muscular coat. The mucous membrane of the large intestine was greatly congested and
its solitary follicles slightly enlarged. The mesenteric glands were enlarged. [Specimen 352, Med. Sect., Army Med-
ical Museum, ulceration of ileum, was obtained from this case.] — Act. Ass't Surg. 0. P. Sweet, Carrer Hospital, Wash-
ington, D. C.
Case 49.— Private Hannibal Tichout, Co. II, 2d U. S. Sharpshooters ; age 20 ; was admitted Sept. 16, 1863, having
been sick for eight weeks with typhoid fever. His features were sunken, conjunctiva' congested, cornea ulcerated,
lips dry and coated with sordes, pulse feeble, 120, and bowels loose; petechial spots on chest and thighs. He sank
gradually, dying on the 26th. Treatment consisted of lead and opium for the diarrha>a and of quinine, wine and
beef-tea. Post-mortem examination twelve hours after death: Extensive peritoneal inflammation and ulceration of
ileum and Ciecum. — Act. Ass't Sm-g. John FlicUnger, First Division Hospital, Alexandria, Va.
Case 50.— Lieut. J. W. Lowe, Co. B, 9th N. Y. Cav., was admitted Sept. 21, 1863, with his neck somewhat
swollen and stift', the result of a blow from a rebel musket at Brandy Station, Va., Aug. 1, 1863; his general health was
good. On the 30th he went home on leave of absence. He returned November 14 much improved, stating that
during his absence he had an attack of diarrhoea which lasted only a few days ; the attack was preceded liy vomiting,
and was attributed by him to some error of diet. He felt well and expressed himself as able to join his regiment.
But at midnight of the 18th the officer of the day was called to see him as he had lieen seized with a violent jiain in
the testicle, without swelling but with great tenderness. An anodyne lotion relieved him and he fell asleep, but
awoke aljout daylight vomiting a pale-green liquid and with great tenderness over the stomach. The alidomen
soon became tympanitic, the pulse sant, the vomiting became constant and the countenance livid and anxious.
A blister was applied and laudanum given by injection. At noon the vomiting became less frequent and he was
able to swallow small quantities of brandy and water with morphia; the pulse, however, was scarcely perceptible
and the face and hands were covered with cold sweat. He died at 3.30 P. M. after vomiting as much of a pea-green
liquid as half filled a common tin basin. Post-mortem examination: The thoracic viscera were healthy. The peri-
toneal cavity contained two ounces of pus. The whole intestinal canal was in a state of acute inflammation; the
ileum was perforated in several places, some of the openings being large enough to admit the end of the little
THE CONTINURD FF.VKRS. 345
finger. The iiiflaniinatory eoiulitiou oxtomled to all the alulomiual visccia. "IIow this state of things existed with-
out 8,vmptoms for a louger period than fifteen lionrs I am at a loss to explain or even conjectnro. The man was not
emaciated; on the contrary ho had gained in llesh during his visit homo. I am informed hy his brother, who came
for his remains, that he liad complained at times of a pain in the liowels, but of so slight a character as not to attra<-t
nnich attention and which was usually relievcil by a draught of warm ginger-tea." ISjucimni 77. Med. Sect., Army
Medical Mnseum, .showing typhoid ulcer.ition and perforation, is from this case.] — Siirfi. II. II'. Diiniclul, ('. .S. I'.,
Simiitarii Hospital, (linrgctoini, J). ('.
Cases EXTKUED .VS iri-nO-MAl-AKLVL with or WITIIOI'T a KECOUD OI-" SYMITOMS k. -illtST^Us'TlATE TllK
DIAGNOSIS 42 CASES.
(A.) Peiirr's patches ulcerated and the ileum or small intestine onhj affected — 14 cases.
Case 51. — Corporal E. J. Junes, Co. L, 6th Mich. Cav., was admitted Jnly28, 1863. Diagnosis — typho-malarial
fever. On admission he had diarrha-a, debility and slight fever, which was latlier remittent in character at first,
but became typhoid on Augu.st 7. (juininc was given and the diarrhoea was controlled by Dover's powder, lead,
tannin and opium: but the jirosfration increased and a few rose-colored spots appeared on the abdomen. Death
took place on the 10th. I'osl-niortcm examination: Lungs congested: liver enlarged and softened; I'cycr's patches
intlanu'd, thickened and elevated but very little ulcerated. — Jet. Jss't Surg. A. V. Il'illiams, St. .tloijsius l/uspifiil,
U'ashiniiton, I). C.
Case 52. — Private Hyron C. Crane, 18th N. Y. Independent Bat'y, was admitted Sept. 22, 1861, fVom Washington
street prison. Diagnosis — typho-malarial fever. Ho had high fever with daily exacerbations followed by sweating:
his tongue was thickly coaled and there was much cerebral excitement, with twitchings of the hands and fingers
and nundau>ss of the feet and legs. Quinine was given freely and Mindcrerns" spirit every six hours. On the 26tli
there was profuse and almost constant sweating, with hot skin, little appetite, increa.sed twitchings, restlessness and
lint little sleep. Milk-iuinch was ordered and the acetate of ammonia omitted. The sleeplessness continued until
the 80th, on which date consti))at ion was noted. Active delirium set in next day with much Jactitation, andcontiniu'd
until death on October t. I'ost-mnrtem examination twenty-four hours after death: Small intestine extensively
inflamed and Peyer's patches deeply ulcerated; spleen very dark; liver normal : kidneys much congested; lungs
normal: pericardium injeeteil ami containing an increased iinantity of fluid. Other viscera not examined. — Third
IHrision Hospilul, Alexandria. T'a.
Case .53. — Private Henry Williams, Co. D, 141st N. Y.; age 44 ; was admitted July 28, 181)3, having l>een sick for
about a week with fever of a typhoid type. Diagnosis — typho-malarial fever. On admission he had a red, moist
tongue, a frequent and feeble pulse, much prostration, abdominal tenderness and slight diarrluea. Morning remis-
sions were noted on July 31, August 1, 2, 4, 10 and 12, on which days he was treated with from ten to thirty grains
of quinine daily — on the other days opiates and aromatic sulphuric acid were given, but the diarrluea increased to
■six or seven watery stools daily; rales were heard in the lower lobes of the lungs on the 5th, and the ]>arotid
became swollen on the 10th. He became dull and drowsy on the 12f h and died next day. rosl-mortem examination :
Pneumonia of lower lobes of lungs; follicular inflammation and softening of mucous membrane of small intestine:
two typhoid ulcers in ileum; liver enlarged and fatty; heart hypertrophied, weight sixteen ounces, slight thickening
of mitral valve. Other organs healthy. — Stanton Hospital, ll'ashintiton, D. C.
Case 54. — Private Peter A. Ueanson, Co. A, .52d N. Y.; age 38; was admitted Nov. 23, 18()3, having l)een sick
.five weeks with tyjihoid fever (malarial). There was no tenderness in the right iliac region; the tongue was coated
with a black fur and the skin tinged yellow; he had a purulent discharge from the ear. Persistent diarrhiea set in
on December 14, with occafiional delirium and great iirostration. Erysipelas attacked the face on the 17th and the
patient became comatose and had convulsive tw itchiiigs of the limbs. He died next day. rost-mortem examination
on the 19th: Body not much emaciated. The pharynx, larynx and trachea were inflamed and ulcerated ; the mucous
inembrane was of a purplish color except about the chorda- vocales, where it was stoiuj-gray; the epiglottis was ulcer-
ated on both sides, the fold of mucous membrane running from it to the cornu major on the left side was also ulcer-
ated; the mucous membrane over the arytenoid cartilages was nnich tumefied; there was a small abscess between
the cricoid cartilage and the pharynx. The lungs were congested posteriorly bnt otherwise he;ilthy. The liver was
healthy. Peyer's patches were ulcerated but not elevated, the uh-ers I)lackish ami with thick, sharply defined edges;
the bases of some were so discolored that the dark hue was conspicuous through the peritoneum; the solitary glands
were not seen. — Aas't Surg. Uarrisou Allen, U. S. A., Lincoln Hospital, ll'ashingion, D. C.
Case 55. — Private James Underwood, Co. D, 186th N. Y.; age 19; was admitted Nov. .30, 1864, with remittent
fever which became continued on December 3, presenting delirium and typhoid symptoms; afterwards bronchitis
occurred, with an uncontrollable and exhausting diarrhoea and great abdominal tenderness. He died on the 15th.
Posl-morfcm examination : Lungs (edematous, with indications of pneumonia as well as bronchitis; Peyer's patches
extensively ulcerated. — Surg. E. lientley, U. S. V., Third Dirisiou Hospital, Alerandria, T'a.
Case .56. — Private Chauncey O. Parcher, Co. IZ, 13th Vt., was admitted Dec. 14, 18t>2, with typho-malarial fever.
This patient had so far conv.alesced as to sit up a part of the time, w hen a relapse occurred, from which also he
recovered. After this he began to complain of great pain in the right ear. in which an abscess formed and was
discharged with relief to the jjain. But the ear became a second time the seat of severe pain, which extended to the
whole head and was particularly severe in the occiput. Delirium followed and he died Feb. 5, ISdli, about forty-eight
hours after its accessi<m, coma having in the meantime supervened. Post-mortem examination one hundred hours
after death: The body was not much emaciated. Nothing abnormal was detected in the brain. The thoracic and
Med. Hist., Pt. UI— 44
.'vl(3 POST-MORTKM HF.COEDS OF
abdommal viscera appeared healthy with the exception of the ileum, in which, especially towards the ileo-cscal
valve, a number of Peyer's patches were enlarged, inflamed and ulcerated, the ulcers, however, seemed well advanced
in the process of cicatrization. — Tldid Division Hospital, Alexandria, To.
Case 57. — Private William Uncapher, Co. H, 140fh Pa., was admitted Jnly 22, 1863, with typho-malarial fever.
He sank gradually, dying comatose on August 10. Pnst-morttm examination eleven hours after death: There were
pleuritic adhesions on the left side and hypostatic congestion in the posterior parts of both lungs, but otherwise
the lungs apjjeared healthy. The heart was tlabby. The liver was much enlarged; the spleen weighed a pound
and three-quarters; the kidneys were normal; the bladder contracted and nearly empty. Peyer's patches were thick-
ened and ulcerated; the solitary glands of the ileum were enlarged to the size of small shot. The mesenteric glands
were greatly swollen; some presented yellow spots of softening and others contained a creamy dark-yellow fluid.
— Jarris Hospital, Baltimore, ild.
Case 58. — Private Jesse C'assel, Co. C, ITOth Pa.: age 24; was admitted July 2, 1863, with typho-malarial fever,
which, after a few days, became typhoid and accompanied with diarrhrea. Opiates and astringents failed to restrain
the diarrhn?a, which became colliquative. lie died delirious, picking at the bedclothes, on the 26th. I'ost-ninrfem
examination "revealed nothing but slight ulceration of Peyer's glands." — Ass't Surg. C. C. Lee, U. S. J., DoiKjhis Hos-
pital, Washington, D. C.
Case 59. — Private Thomas Hnrten, Company C, 140th Ind.; age 18; was admitted Jan. 29, 1865, with typho-
malarial fever. He died February 8. rost-mortem examination eleven hours after death : Lungs hypostatically con-
gested; posterior pleuritic adhesions on left side; heart flabby. Liver weighed seventy-six ounces; spleen twenty-
eight ounces ; mesenteric glands greatly swollen, varying from the size of a pea to that of an ahnond, some containing
a creamy dark-yellow fluid, and one presenting some yellow points of softening; Peyer's patches enlarged and
ulcerated in the lower part of the ileum, — in the upper part was a patch four inches long; solitary glands much
enlarged, feeling like small shot beneath the mucous membrane; kidneys normal. — Douglas Hospital,Washingtun, D. C.
Case 60. — Private Oscar F. Hunt, Co. H, 9th Mich.; age 20; was admitted Dec. d. 1864, with typho-malarial
fever, and died on the 9th. Post-mortem examination twenty hours after death : Thoracic viscera normal ; large intes-
tine greatly distended with air; appendix vermiformis inflamed; ileum contracted in its calibre, and Peyer's patches
elevated and in various stages of softening and ulceration. — Hospital Xo. 8, Xashrille, Ttnn.
Case 61. — Private James Stone, alias Paul Shay, Co. F, 61st N. Y.; admitted March 3, 1864. Died 14th, of
tyjibo-malarial fever. Post-mortem examination five honrs after death: The body was much emaciated. The lungs
and heart were healthy, hut the pericardium contained a large quantity of serum. The liver weighed sixty-oni^
ounces; the gall-bladder was empty. The spleen, stomach, duodenum, jejunum and large Lntestiue were healthy:
the ileum was much congested and inflamed throughout, and many of Peyer's patches presented large ulcers. —
Ai-t. Ass't Surg. Lloyd Dorsey, Harewood Hospital, Washington, D. C.
Case 62.— Private Eber Elmer, Co. E, 186th N. Y.; age 17; admitted Oct. 21, 1864. Diagnosis— typho-malaiial
fever. Died ■24th. Post-mortem examination thirty hours after death: Body muscular and well developed: sudamina on
chest and abdomen; sordes on teeth; .slight suggillation posteriorly. Lungs congested; lower lobe of left and upper
and lower lobes of right lung hepatized posteriorly ; base of left lung covered with recent lymph ; each jileural cavity
containing two ounces of bloody serum ; brouchi congested and filled with frothy nmcus ; bronchial glands normal.
Heart healthy, small clots in the left and a large clot in the right cavities. Stomach filled with air and dark
grumous Idood; small intestine congested and inflamed; Peyer's patches much thickened, especially near ileo-ca-cal
valve, where there was one small ulcer; mesenteric glands dark and enlarged; colon and rectum healthy. Liver
large, healthy; gall-bladder containing six drachms of dark bile; spleen enlarged, softened, quite dark in color; pan-
creas, kidneys and bladder healthy. — Second Division Hospital, Alexandria, Va.
C.\SB 63. — Private Edward Martin, Co. H, 12th Vt.-, admitted Dec. 12, 1862. Diagnosis — typhoid remittent fever.
Died 17th. Post-mortem examination: The abdomen was moderately tympanitic; recti muscles very much injected
and in their sternal third eechymosed. The anterior portion of the abdominal surface of the diaphragm was coated
with plastic lymph; the omentum was greatly injected and adherent liy recent lymph to the abdominal parietes;
the mesentery was injected; the mesenteric glands greatly enlarged. The mucous membrane of the ileum was con-
gested, especially near the ileo-ca!cal valve; Peyer's patches were ulcerated and the peritoneum corresponding to
each patch was dark-colored. — Jliird Division Hospital, Alexandria, Va.
Case 64.— Private Wallace T. Fowler, Co. C, 42d Mass.; age 19; was admitted ( )ct. 29, 1864, having been taken
sick a week before with a decided chill followed by hot skin, thirst, severe headache and backache and a diarrho a
of two or three passages daily. On admission there was no delirium, epistaxis, deafness nor tympanites; pulse 120;
tongue furred and dry; some bronchial irritation. Diagnosis — typho-malarial fever. He improved under small doses
of blue-pill and ipecacuanha, acetate of potash, squill and sjiirit of nitre until November 12, when his respiration
became hurried and his pulse accelerated. On the 15th he expectorated rusty sputa, although none of the jihysical
signs of pneumonia were present. Until the day of his death, the 17th, he did not appear to be very ill. Pain in
the ejiigastrium, feeble pulse, great prostration and vomiting, at first of green liquid and afterwards of matters
resembling coSee-grounds, preceded death for some hours; his mind was clear to the last. Post-mortem examination
sixteen hours after death: Not much emaciation ; suggillation posteriorly. Omentum inflamed; intestines reddened
and interadherent ; peritoneal cavity containing two pints of a turbid yellow liquid emitting an unpleasant ficcal
odor. There was a perforation one-eighth of an inch in diameter about the middle of the ileum, the result of ulcer-
ation in one of Peyer's patches ISpecinun No. 439, Med. Sect., Army Medical Museum], and there were several thick-
THK CONTINUED FF.VERR. 347
t>m-<l and ulcerated patches near the peiloratiou and in the lower part of tlie ileuiii. Spleen enlarged and softened;
liver dark. Other organs not examined. — Sniij. E. Bcnthy, U. S. I'., Stcond Division nospital, AlexaHdria, Va.
(li.) reijcr's pnlchti vhrratcd and the large intestine also impliealed — 1 cases.
Case 6.5.— rrivate .John D. Kvans, Co. H, 1st Mich. Cav.; age 28; admitted July 20, 18('>l, from Camji Distrilm-
tion.Va. T1ia;;nosis — typlio-malarial fever, lie liad frontal lieadaclie, pain in limlis ami back, anorexia, siel<ness at
stomach, tronldesome <liarrlio>a, Iiectic linsli on cheeks, irritative eougli, ilcafness of riglit ear, tongue yellow-coaled
and eyes snft'used and yellowish. Sinapisms were applied over the riglit lung and liver, and tincture of aconite in
acetate of ammonia was given every two hours, with 8ubse()uently Hope's mixture and wine hitters. He seemed to
improve for some days, hut on August 1 ho refused food altogether; his cough increased, hecomiiig dry, irritable and
paroxysmal, lasting for ten minutes at a time and preventing sleep; liis urination hecanu! dillicult, but this was
relieved by extract of buchu and sweet spirit of nitre; and the right parotid became enlarged, indurated and painful.
Next day there was a very offensive fetid discharge from the nose and muttering delirium set in, followed by dc-ath.
I'ost-mortein I'xamination two hours after death : Kobnst, muscular. Hight lung and pleura somewhat intlamed. largo
abscess in the ntiddle lobe; liver much congested: a"sophagus, stomach and intestines inllamed throughout; I'eyer's
patches, caeuui and cidon ulcerated. — Third Division Iiosj)itul, Alexandria, J'a.
Ca.^e (!t>. — Private .\dam Cull. Co. D, 28fh Mich.; age 2.5: admitted Feb. i;!, 18(i5. Diagnosis — typho-malarial
fever and congestion of lungs. Died li'tli. I'ost-mortem examination fourteen hours after death: Well developed;
large deposit of fat: recent blister-marks on neck and chest: slight suggillation posteriorly; great rigidity. I'len-
ritic adhesions on both sides; right lung congested, crepitant in upper lobe. Stomach distended with air; I'eyer's
patches inllamed, in many places ulcerated; large intestine congested. Liver nutmeg; spleen enlarged; kidneys
small; other viscera normal. — Third Division [lospital, Alexandria, f'a.
Case 67. — Private Asa C. Wentvvorth, Co. H, 19th Me.; was admitted Nov. 26, 186.3, with Jaundice. {Mi'm man
appears on the register of the regimental hospital as admitted on the T8th with typho-malarial fever and sent to
general hospital on the 22d.] Died Jan. 12, 18(U. Post-mortem cxaminatiou twenty-two hours after death: The
pharynx and larynx were inllamed; the soft palate hard, still" and white: the tonsils unali'eeted; between the
pharynx and right arytenoid cartilage was a large abscess with hard, yellowish-white walls; the cartilage mentioned
was the seat of a protuberance, probably a collection of pus; there was also a small abscess innnediately above the
left greater cornu of the hyoid bone; the vocal chords and the upper surface of the e])iglotti8 were <i>dematous.
The pericardium contained seventeen drachms of yellowish fluid; the heart was very soft. The liver was bronzed
and mottled with hard lardaceons spots, the gall-bladder full of dark-brown viscid bile; the spleen was rather small
and extremely soft; the pancreas soft and of a dull-red color; the kidneys congested. In the ileum the villi were
very soft; I'eyer's patches were not raised, but one of them presented an ulcer with low rounded edges, at the base
of which the transvcr.se muscular fibres could be seen; the ileum had the ironcd-out appearance. The colon was
slate-colored, its S(ditary fidlicles whitish, with conspicuous dark-s))ottcd centres. — Ass't Sury. IJarrison Allen, V. S.
.1., Linvoln Honpital, ll'ashinyton, T). C.
C.vsE 68. — Private Charles l>angson,Co. I, 11th Conn.; ago 27; was admitted Oct. lit, 1863, with typho-malarial
fever, lie hiid been sick for twelve days and on admission was in a semi-comatose condition : tongue dry, glazed
and red at the tip and edges; pulse 120, full, bounding and incompressible. On the 27th the pulse was 108 .and scarcely
perceptible at the wrist; the patient had some cough witli thick, tenacious yellowish sputa. The iIeo-ca>cal region
\va,s tender, but no ernption was observed. Death occurred on the 29th. At first tincture of aconite was given,
for which, on the 2.5th, iiuinine, carbonate of ammonia and whiskey were substituted. Post-mortem examination four
hours after death: The trachea was palish hut mottled at its bifurcation; several ccchymotic spots were observed
on its posterior surface. The ccsopliagus was pale and its mucous membrane firm. The right lung was perfectly
healthy: the left lung weighed thirty-one ounces and a half, its upper lobe being congested generally and scdiditied
in its central jiarts and its lower l(d)e mottled with dark-brown sjiots about the size of a pea. The heart contained
fibrinous clots in its right chambers. The liver was congested and weighed seventy-two ounces; the spleen firm,
fourteen ounces and a half: the pancreas normal; the kidneys congested. The small intestine near the ileo-ca-cal
valve was of a darker c<dor than elsewhere; its mucous membrane was healthy to within ten feet of the valve, at
which point it becanu> unusually vascular and softened, I'eyer's i>atelies and the solitary glands being of a deep
pink color: lower down Peyer's glands became enlarged, whitish and hard, with abrupt edges; still lower down
they were tricerated, which condition fre(iuently existed in the centre of a patch while its margins remained
enlarged and hard; the glands near the valve were ulcerated in theii* whole superfiees, some of them looking not
nnlike Ilunterian ehancies; the ulceration did not extend deeper than the raucous membrane; the solitary glands
were enlarged and of a dark-purple color in the lower part of the ileum, and some near its termination were ulcerated.
The mucous membrane of the ca>cum and ascending colon was of a dark-blnish color; lower down it was pale and
in .some places pink; the solitary glands were conspicuous but not elevated, appearing as whitish spots with pig-
mented centres. — Aaa't Surg. Harrison Allen, U. S. A., Lincoln Hospital, Washington, I). C.
(C.) Condition of Peijcr^ s patches not stated ; the intestines rariouslji affeeled — 1.5 cases.
Case ti9.— Henry Reynolds, Co. C, 79th N. Y., was admitted Aug. 21, 1863, having been sick ten days with heaii-
ache and weakness of limbs, followed by fever. Diagnosis — ty])ho-malarial fever. He was weak and somewhat
emaciated; his pulse feeble and compressible; tongue slightly coated; appetite poor; bowels regular. He died on
the •26th. Post-mortem examination thirty-one hours after death: Lungs much congested; a large amount of serum
in right pleural cavity; heart normal, containing a large clot; liver somewhat congested; gall-bladder much dis-
tended; spleen enlarged, congested and softened ; mesenteric glands enlarged. — 1\'esl End Hospital, Cincinnati, (J.
348 POST-MORTEM RECORDS OF
Case 70. — Private Joseph E. Hudson, Co. A, Gordon's Ark. regiment: age 19; admitted Dec. 16, 1864; typho-
malarial lever. On admission be had fever and diarrhtea; his tongue was Nlightly coated, pulse 100, appetite fair,
respiration normal, legs swollen from the knees down. He rested well and in a few days the swelling of the legs
became somewhat reduced, but the diarrhoea persisted. He did not suft'er, but grew weaker and died on the 22d.
rost-morli-m examination : There was emaciatiim with cedema of the legs and feet ; the blood was very poor and thin.
The luusrs and heart were normal: the spleen about three times the normal size; the gall-bladder distended with
bile: the mesenteric glands so enlarged that the mesentery had the appearance of being one continuous gland; the
.solitary gland.s disorganized and the mucous coat of the rectum inflamed and softened. — Act. Ass't Surg. K. C. Xetv-
hirl-,Itoc1c Island Hospital, TU.
Ca.sk 71. — Private Warren M. Burton, Co. K, 28th Ala.; age 33; was admitted Dec. 7, 1864, with typho-malarial
fever. He had been sick for four weeks with diarrha'a and general malaise. On admission his bowels were slightly
relaxed, tongue heavily coated with a brown cracked fur, skin hot, pulse frequent and feeble, countenance shrunken :
he was inclined to sleep, which he did heavily and with the whites of his eyes exposed. Hiccough speedily came on
and he died on the 8th. Post-mortiin ex.amination ten hours after death: The lower portion of the right pleura was
inflamed. The heart contained white clots. The peritoneum was much injected and tinged throughout of a yellow
color. The sjdeen was soft and friable. The stomach contained about a pint of dark liquid with detached shreds
of its mncous membrane floating in it: the lining membranes of the oesophagus and duodenum were also softened
and disintegr.ated. The mucous coat of the bowels vras much congested throughout : f;ecal matter in the rectum was
of normal consistence but white and fetid. — Act. Ass't Surg. J. B. Young, Hock Island Hospital, 111.
Cask 72. — Private James Bozemau. Co. I, 40th Ala.: age 34: admitted Dee. 22, 1864; typho-malarial fever.
This m.an enlisted in April, 1862; he had measles soon after and since then has had diarrhcea almost constantly ami
frequent attacks of fever. He was captured in June, 1864. His present attack commenced December 18, with pain
in the head and breast and chilly sensations followed by fever. When admitted his tongue was coated brown with red
margins: bowels loose; pulse 120; cough and slight expectoration: anorexia and thirst. He died on the 23d.
Post-mortem examination twelve lionrs after death : Great emaciation. The lower lobe of the left lung was congested.
The liver was pale. The intestinal mucous membrane was congested, and in the rectum softened. — Act. AssH Surg.
H. V. Xewkirk, Bock Island Hospital, 111.
Case 73. — Belltield W. Ferguson, a citizen of Mo,; age 63; typho-malarial fever. Died Dec, 20, 1864, Posl-
mortem examination: The body was greatly emaciated. The posterior part of the left lung was congested and its
pleura inflamed. The intestines showed some congestion with disorganization of the solitary glands ; the niesi-n-
teric glands were enlarged. — Act. Ass't Surg. J. M. Witherwax, Pock Island Hospital, III.
Case 74. — James Case, citizen of Mo. Typho-malarial fever. Admitted Dec. 1, 1864: died 26th. On the day
of his death lie had a dry furred tongue which he was unable to protrude; he spoke with difficulty; respiration was
quick and labored: the surface dry and cold and the pulse imperceptible. He had a slight erysipelatous swelling of
the left ear. I'ost-mortrm examination: The lungs were dark and congested posteriorly: the liver was enlarged.
"There were commencing ulcerations of the intestines, with general indications of internal congestion.'' — Act. Ass't
Surg. J. M. Witherunx, Hock Island Hospital, III.
Case 1v>. — Stockton M. Bayne, Co. H, 3d Ga. Cav.; admitted Dec. 3, 1864; typho-malarial fever. Died 24th.
Post-mortem exantinatioit: Right lung normal; lower lobe of left lung hepatized gray; four ounces of dark yellow
serum in pericardium: heart flaccid, both sides containing thrombi extending into the vessels. Liver normal; gall-
bladder distended: spleen enlarged, congested and softened; mesenteric glands greatly enlarged. Mucous mem-
brane of small intestine ulcerated in various parts, and that of colon and rectum highly congested and disintegrated. —
Act. Ass't Surg. J. M. JVithcru-ax, Pock Island Hospital, III.
Case 76. — William C. Norton, Co. A, Wood's Missouri battery. Typho-malarial fever. Died Jan. 20, 1865.
Post-mortem examination: The heart, lungs and liver were normal. The spleen was slightly enlarged; the small
intestine congested; the mesenteric glands enlarged; the rectum ulcerated in patches through the nmcous and luus-
cular coats, some portions appearing gangrenous. — Act. Ass't Surg. J. M. Witherwax, Bock Island Hospital, III.
Case 77. — Jesse Eaton, citizen: admitted Dec. 21, 1864; typho-malarial fever. Died 31st. He sutt'ered from
sore throat, chills, a slight swelling of the right cheek of an erysipelatous character, and had "many symptoms of a
typhoid condition." Post-mortem examination six hours after death: Lungs healthy; heart cont.ained white clots in
right side; liver and spleen somewhat congested: lower portion of ileum presenting numerous small ulcers; descend-
ing colon strictured for six inches of its length, so that an ordinary lead-pencil could scarcely be passed. — .let.
Ass't Surg. W. ilattlieu-s. Bock Island Hospital, III.
Case 78. — Private Francis Scott, Co. K, 41st N. Y.; age 3.'i; admitted Feb. 13, 186,'); typho-malarial fever and
chronic diarrhoea. He was treated Avith quinia, alcoholic stimulants and turpentine. In the jirogress of the case the
lower extremities became cederaatons and signs of valvular disease were di.scovered. He died March 21. Post-mortem
examination: Body much emaciated: lower extremities O'dematous. The heart was slightly hy]iertropliied, itsaortii'-
valves thickened. The liver was enlarged and deeply bronzed. The mucous membrane of the intestines was soft-
ened throughout. — Third Dirision Hospital, Alexandria, J'a.
Case 70. — Private Abraham J. Cooper, Co. A, 186th N. Y.: age 20; admitted Nov. 30, 1864; typhoid fever. LTlie
diagnosis at the Ninth Army Corps Field Hospital, on the 24th, was tyiiho-malarial fever, and at the Depot Fiel<l
Hospital, City Point, A^a., on the 26th, remittent fever.] Symptoms on admission: Pulse varying from 90 to 110.
feeble and thready; skin hot and dry; tongue dry, extremely red and gashed ; teeth, gums and. lips incrusted witli
TIIK CONTINUED FEVERS. 319
sordes; deafness: stupor; low delirium. When undisturbed he lay with bis eyes half elosed muttering liroken and
uncoiineeted sentences; w ben aroused he bad a vacant expression and was unable to answer correctly. During the
first tweuty-lbur hours after admission be liad four passages from the bowels: the abdomen was (ympauitie, very
tender over the small intestine and ea'cum, and marked with a few jietechia' and sudamina. Turpi-ntino emul-
sion, laudannm and niilk-puuch were administered. Next day tbere was a slight ini|)rovcment ; Tbe puls(^ became
somewhat stronger, tbe tongue less tremubms and protruded with more ease: the patient was able to answer a few
((uestions correctly, but the abdominal sym|ilonis continued and there was some epistaxis. On December 2 the juilse
became somewhat stronger and less freiiucnt, the tongue ijuite moist, the sordes partially removed and tbe dianluea
cheeked ; l>ut at !• V. M. the diarrluca returned, several involuntary stools were passed and tbe patient fell into a
stupor from wbieh be never aroused. He died at 3 A. M. of the od. I'ost-mortcm examination eight hours after death :
l.ungs creiiitant Ibroughout: liver |i.ale, with well nuirked nutmeg ;ippeaniuce; spleen of full size and softened; kiil-
ueys full of blood, the jiyramids of a dark-red color; mesenteric glands euorinously enlarged; colon pab' and without
ulceration; ileum injected. — Act. Jss't Surg. If. C. Minor, Third Division Jlospital, AUxaiidria, In.
Case tfO. — Private .\lbert Mathews, Co. A, 174th Ohio; age 19; was admitted .Jan. 28, llSOT), with typlio-mala-
rial fever. When admitted his bowels were loose, skin hot and dry, tongue dry and red, pulse lOll and fccl>le.
On February 5 the diarrhu-a became profuse. A chill followed by fever and sweating occurred on the 12tb and
again next day. (Quinine was freely administered witbout apparent benefit. He died on tbe 27th. I'u.il-niorliiii
examination three hours after death: liody much emaciated. Membranes of brain miicb injected; cerebral hemis-
pheres coated with ooagulable lymi)b : substance of brain much injected and softened ; lateral ventricles containing
serum and a deposit of lymph. Heart healthy; liver and spleen adherent to diaphragm ; gall-bladder distended with
dark bile; omentum congested; intestinal mucous nu-mbrane extensively diseased and portions of ileum gangren-
ous.— Act. Asu't Surg. Savijile Ford, CHinherlaiHt Hospital, Md.
Ca.se 81.— Private William Henry Clay, Co. D, 28tb U. S. Colored troops; age 21: w:is admitted .July 21, 18i>l,
on ai'count of inguinal hernia on the right side and enlarged inguinal glands. On April ti. 180."), the records present
him as feverish and jaundiced, without giving information as to the period of onset. His pulse was 9"), tongue
coaled w ith a yellowish fur, skin dry: he had thirst, anorexia, nausea, tenderuess in the right iliac region and con-
stipated bowels; there was some mental torpor and considerable muscular debility. On the 8th his pulse was
small and frequent; he had a cough and complained of pain in the right side of the chest, lb' ilicd next d;iy. A
nuTcurial purge operated well on the tith; subsequently the bowels were so loose that opium was inii)b)yed. t^ui-
uine and stimulants were freely administered. The case is recorded by the attending i>hysician as cme of ty]iho-
malarial fever. Post-morttm examination: The thoracic viscera were normal. The liver was very light-colored and
soft: the spleen and kidneys softene<l and congested. The whole of the intestinal canal w:is inllanied: the mesen-
teric glands enlarged. The peritoneum was inllanied and the sac contained about half a pint of scro-piunlent
liquid. — Act. .Iss't Surg. Frank liucklund, L'Ouvreture Ilospital, Alexandria, Va.
Case 82. — Private N. Henry Downing, Co. A, 8th 111. Cav., was admitted June 18, 18t)l, w ith ty]iho-nialarial
fever. He had not been in his usual vigorous health for several weeks, but had continued on duty until admission,
wheu he was suHeriug from pyrexia, severe headache I'eferred to the temples, diarrha-a and dull pain in the losver
extrenuties; his eyes were sutfused and painful and bis tongue heavily coated with a dark-yellow fin, tin- edges
being of a livid hue. Quinine, twenty-five grains in the twenty-four hours, and chlorate of jiotassa weic adminis-
tered. Next day he appeared improved, — pulse 80, headache decreased, tongue less dark: but a little pain and ten-
derness had developed in the ileo-c;ecal and hypogastric regions and there was slight epistaxis. The <|uinine was
continued with a saline, diuretic ami diaphoretic mixture. He remained in this condition until the 21th, when his
couutenanee bccinne bright and pleasant and he was free from pain: j)ulse 12U and full ; coating of the tongue lighter
and the edges pale: he vomited a little greenish liquid in the morning and had an exacerbatiou of fever in the after-
noou. Twenty-eight grains of quinine with chlorate of potassa were ordered to be taken in the twenty-four hours.
Next day his skin was moist and cool, pulse 96, but there remained a little pain in the bowels, which afterwards
became a feeling of fulness and was relieved by castor oil and fomentations. On the evening of the 27th he was
suddenly seized with a sharp pain in the bladder and penis and inability to void his uriue; the catheter showed his
bladder to be empty. By next morning the pain had extended over the whole abdomen, which was very tender; his
countenance was anxious; pulse 120 aud small; tongue moist but with the light-colored fur and pale edges; he lay
ou the right side with his thighs Hexed. On July 1 he became some easier under the continued use of mori)hine,hut
later in the day the pain again became intense and he died at 2 a. .m. of the 2d. Fost-mortcm examination ten hours
after death : The liver, sjjleen and kidneys were healthy. The ileum was perforated about four inches from the ileo-
ciecal valve aud there was extensive peritoneal inflammation. [Specimen 321, Med. Sect., Army Medical Museum, is
from this ca.se.]— .Sh/v/. A. Hard, Sth III. Car., Uegimtntul Hospital.
Case 83. — Private Daniel Hare, Co. D, 175th Ohio; age 18; was admitted Oct. 15, 18t>l. with qnotidian iiiter-
mittent fever, which passed into typhoid fever. He was weak and much emaciated from chronie di;irrhu'a, but his
bowels were now regular. He had a chill aud fever daily, for which quinine was freely given with bcnclicial I'tfect ;
but on the 19th diarrhiea set in aiul fever was developed in the evening. The bowels renuiiued moderately checked
by astringents until the 21th, when, as they became looser, the tongue blackened. Turpentine was given. Three days
later retention of urine rei|uired relief by catheter and tenderness over the pubcs called for fomentations. The
suprapubic tenderness continued until the 30th, when a violent chill occurred, lasting lor an hour, and followed by
high fever, profuse perspiration, great abdominal tenderuess, coldness of the extremities and death. Fost-mortcm
350 POST-MORTEM RECORDS OF ■
exaiiiiuation Uveuty-onc horns after deatli : Heart normal ; lungs congested posteriorly. Abdominal viscera generally
interadlierent : ]ieritonoum congested and containing liijuid fa'.ces; ileum ulcerated in patclies for three and a half
feet above the ileo-ca-cal valve, some of the ulcers having reached tlie peritoneum, and two, about two feet from
the valve, having perforated this membrane. Other organs not examined. — Iloxpitid Xo. 8, Nashville, Tcnn.
( D.) Condition of I'ci/er's 2>ulchc» varioiisli/ stilled, hut not ulcerated; intesliiies more or lens affected, hut no uleeralion of the
ileum — 9 cases.
Case 84.— Serg't John H. Peters, Co. E, 120th Pa.; admitted April 20, 1863. Diagnosis— typlio-malarial fever.
Died 3t)th. Post-mortem examination nine hours after death: Some rigor mortis. Brain weighed forty-six ounces
and a half. Mucous membrane of trachea jiale. Kight lung fifteen ounces and a half, healthy; left lung thir-
teen ounces ami three-quarters, dark blue, its apex purple. Heart normal; soft black clot in right ventricle;
small narrow clot in left ventricle. Liver forty nine ounces and a half, dark purple externally, paler on section,
rather soft; capsule of Glisson readily torn. Spleen eight ounces and a quarter, soft, dark mulberry color, trabecuhe
conspicuous. Pancreas four ounces and one-quarter, natural. Stomach mottled dark and pale red. Mucous mem-
brane of small intestine generally pale, with irregular patches of congestion; Peyer's patches pale; solitary follicles,
esi)ecially in lower part, dark purj)le in color, enlarged and ulcerated; mucous membrane of vermiform appendix
dark-colored and presenting two ulcerated patches one-eighth of an inch in length. Large intestine gray through-
out; solitary glands consi)icuous; three ulcers in the lower part of the bowel — the tirst, one inch in diameter, in the
sigmoid flexure, the others, smaller, in the middle portion of the rectum. Kidneys congested. — Ass't Surg. Harrison
Allen, U. S. J., Lineoln Hospital, Wushinyton, D. C.
Case 85. — Private A. C. Starker, Co. D, 15th N. J., was admitted Nov. 23, 1863, as a case of typho-nuilarial
fever: Pulse 115 to 130, irritable; tongue dry as a pine shaving, glossy and red on its edges; sordes on teeth and
gums; urine scanty, densely loaded and very fetid; stools involuntary; friction-sound on right side of chest. In
answer to questions he talked incoherently for a few seconds and then relapsed into stupor; he picked at the bed-
clothes, and drawing his legs ui> would suddenly straighten them in an apparent effort to kick off the covering.
Subnitrate of bismuth controlled the diarrhcra; stinmlauts were freely administered. He died on the 28th. Vost-
mortem examination ten hours after death: Right lung adherent to costal pleura by a strong and dense false nu'm-
l)rane; left lung distended with a black fluid, unadherent: heart normal. Liver very pale, ranch enlarged and
softened; spleen larger than usual and softened; kidneys one-fourth larger than normal and indurated, especially
in their lower fourth, where their substance could not be crushed between the thumb and finger. Peyer's patches
distinct and elevated, their edges ragged and raised one-tenth inch above the surrounding surface; solitary glands
of large intestine ulcerated; lymphatic glands enlarged — one, as large as a walunt, was on section much like the
spleen. — Act. Ass't Surg. W. H. Letterman, Douglas Hospilal, Washington, D. C.
Case 86. — Private Patrick Conlin, Co. E, 25th Mass.; age 36; was admitted March 11, 1865, with symptoms of
typho-malarial fever. He had decided fever with frequent, compressible pulse, hurried breathing, hot dry skin,
furred dry tongue, severe headache and costive bowels; his countenance was dusky, his eyes injected, and there was
great prostration with considerable mental confusion and hebetude. Nnmerous red spots, a line in diameter or less,
were observed chiefly on the chest and abdom.en; they were somewhat elevated and did not disappear conipletuly
on i)ressure. On the 13th the tongue was more thickly coated and brown, the teeth and gums covered with sordes,
the urine scanty and high-colored, the abdomen tender and painful ; no abnormal condition of the lungs was detected
by auscultation or percussion. On the lotli the headache was succeeded by delirium and occasional stupor, with
contracted pupils, drooping of the lids and subsultus teudinum : the bowels were constipated. Later the spots on
the .skin became of a dusky crimson and quite unaftected by pressure. He died comatose on the 17th. Post-morteni
examination nineteen hours after death: A large quantity of serum was found in the subarachnoid space and a
snuiller (juautity in the ventricles; the membranes and substance of the brain were congested. The heart contained
some imperfectly formed clots and fluid blood. The lungs were congested ; the lower portion of the right lung was
in a condition of gray hepatization; the left lung weighed twenty-one ounces, the right thirty-two ounces. The
liver was soft, well filled with blood and weighed sixty-eight ounces; the gall-bladder contained very black bile;
the spleen was flaccid and slightly enlarged; the pancreas was reddened and weighed seven ounces. The intestines
generally were dark and congested ; the glands of Peyer conspicuous and dark-colored. The kidneys were appar-
ently normal. — Ass't Surg. George M. ilcGill, TJ. S. A., Kational Hospital, Baltimore, Md.
C.vsE 87. — Private Niles Ivers, Co. F, 6th Wis., was admitted April 21, 1864, with typho-malarial fever. He
stated that he had been sick for a week with fever, which began with chills. He was much prostrated; his bowels
were loose and his tongue dry and brown with red edges. Quinine, stimulants and nutriment were ordered. In a
few days his respiration became accelerated and he complained of cough and pain in the side, for w hich he was
blistered. Under this treatment he gradually improved, the fever subsiding, but a considerable quantity of liquid
remained in the pleural cavity, for the removal of which iodide of potassium was given in free doses and an occa-
sional blister was applied, but without much benefit; the effusion did not embarrass his breathing. Convalescence
was slow and he was unable to leave his bed, when, about June 1, symptoms of hectic appeared. He failed grad-
ually and died on the 23d. Post-mortem examination twenty-four hours after death: Body much emaciated; rigor
mortis moderate. The left pleural cavity contained about a pint and a half of purulent liquid which compressed
tlie lung against the spinal column; the right cavity contained about six ounces of serum; the right lung was
healthy. The intestines were distended Avith gas; the mucous coat of the stomach and of the intestinal canal was
thickened and softened; the glands of Briinner and the solitary glands of the ileum were enlarged and prominent
but not ulcerated; the i>atches of Peyer presented the shaven-beard appearance. The liver was about one-third
THE CONTINUED FEVERS. 351
larf;ci- than uoniial and contained a number of miuuto abscesses: the spleen was enhuged to tliice times its uonnal
size and also contained abscesses; the kiduej's were healthy. ISpecimtim 3L'.^-G, Med. Sect., Army Medical Museum,
are from the spleen of this case.] — .Isx'l Surg. Gio. A. Miirsick, U. S. F., Stattlon lloxpilul, WusUluijIou, D. C.
Case 88. — Private tileorge I'itchor, Co. II, 2Sd Mich.; age 3(>; was admitted Eeb. U, 18l>,"), with chronic rluuma-
tisni. While under treatment he becanu- attacked, March 18, with symptoms of typho-malarial fcvei. He progressed
favorably until the '2m\, when abdominal paius set in; next day he became semi-comatose and diiMl. l\v was treated
with turpcutiui> euuilsion and carbonate of uunnouia. Poal-murlcm examination twelve hours after di'ath: Liver
much enlarged, bronzed; intestines congested, small intestine showing shaven-beaid appearance of Peycr's iiatclns
and four intussusceptions from four to six inches long. — I'hird JUvinioti Honpilal, Alexandria, Va.
Case 80. — Private Lewis Sage, Co. A, 186th N. Y., was admitted Nov. 30, 18(>1, from City Point, Va., w Iutc he
had been under treatment for typho-malarial fever. On admission ho was in an unconscious condition, with low
delirium, troublesome diarrhiva and a harassing cough; pulso 100, soft. Ho was treated with mill<-|mnch and
anuiuiuia, expectorants and turpentine emulsion with landanuin; but he sank gradually and died December 10.
rosl-iiiorltiii exauiiuatiou: All the viscera appeared to be healthy except the intestiiu's. The mucous membiane of
the ileum was deeply injected throughout and <if a dark purple color; its solitary follicles were (enlarged and some
near the ilco-ca'cal valve were ulcerated; Peyer's patches, which were slightly thickened, presenteil theshaven-beaid
appearaixce. The colon presented a number of din]) ulcers, es]iecially at its extremities; iu the transverse colon sin-
eral of the ulcers were cicatrizing. An intestinal diverticulum, two inches and a li;ilf long, was found in the ih'uni
about three feet aiul a half from the ileo-ca'cal valve. [Nos. 4t>5 and lOti, Med. .Sect., Army Medical .Muse um, are
from this case.] — Act. AsdH Surg. JF. C. Minor, Third Division Hos]>iial, Alexandria, Va.
Case 90. — Private J. T. Pierce, Co. G, 33d Mass., was admitted Juno 10, 1803, with typho-uuilarial fever. He
had frequently sutlered from intermittent fever. When admitted he had been sick for sonui time and was greatly
emaciated; he had some diarrhcea; his tongue was coated in the middle, dry and cracked; pulse 132. After this liis
breathing became hurried, and coarse mucous rales were hoard over both lungs; there was also marked nervous
prostration. He died on the 21st. rosl-morlem examination twenty-six hours after death: liody emaciated; rigor
mortis slight. The brain was normal. The mucous membrane of the (Cso])hagns was of a pale purple color. The
traclie;i contained niuch-Iironchial secretion: its uuic(M1s membrane was i)urplish. The upper ami middle lobes of the,
right lung were solidified except their anterior free borders, which were jiahr and he;ilthy; the lower lobe was con-
gested hy postal ic;iUy l)Ut not solidified. The posterior portion of the left long was in a state of gray hepatization,
the anterior part healthy. The right lung weighed twenty-seven ounces and a (luarter, the left thirty-seven ounces;
the bronchial glands were large, oue of them softened. The pericardium was lined liy recent lymph rongliencd by
papillary elevations; it contained six drachms of llaky serum. The right cavities of the lu'art conlaiui'd a largo
venous clot, tho left cavities a mi.xed clot which extended into the aorta. The liver weighed fifty-seven ounces, it
was pale and slightly softened; the gall-bladder contained a drachm of greenish-brown viscid bile. The spleen was
firm and Aveighed three ounces and three-quarters. The pancreas was firm and white, it weighed two ounces and a
half. Tho right kidney weighed five luinccs and a quarter, the left five and a half, both were pale and llabby. No
pronunent lesion was observed in tho intestines; tho lower part of the jejunum was contracted and its mucous
iriembrane pale: Peyer's patches were rather pale and dotted with points of black pigment; the large intestine was
contracted and its mucous membrane of a pale bluish color. — Ass't Surg. Harrison Allen, U. S. A., Lincoln Hospital,
Wiuhinglon, D. C.
Ca.se 91.— Private Willard Rock, Co. E, 16th N. Y.; age 19; was admitted Aug. U), 1802. He was convalescing
from Chickahominy fever and diarrh<ea: but afterwards, from imprudence, was again attacked with diarrhu'a and
died October 5. Pont-mortem examination next day: Slight emaciation. The heart and lungs were uonnal. There
were old adhesions of the right half of the right lobe of the liver to tho diaphragm, but the organ was sound; the
spleen was very snuUl but otherwise natiiral ; the kidneys pale. There was moderate inflamnuition along the great
curvature of the stomach. In the ileum were three large patches, about fourteen inches long, of intense inflam-
mation, with the intervals between them moderately inllamed; these patches presented many small eccbymoscs.
The colon was much contracted, intensely inflamed at its commencement and moderately inflamed throughout, with
here and there small ecchyuuises. The agminated and solitary glands of the small and large intestines contained
black pigment. — Act. Ass't Surg. J. Leidg, Satterlee Hospital, I'hiladelpkia, I'a.
Case 92. — Lewis G. Haker: age 37; a citizen of Jlo., was admitted Dee. 1.3, 1864, with typho-nuilarial fever.
He stated that he had taken c(dd in November while making his escape from the rebel service. On admission his
tongue was slightly coated, bowels loose, pulse 100, respiration normal, cough and expectoration slight, ap|)ctito
small and thirst notable. Diarrhcea aud increasing prostration were the prominent symptoms during the progress
of tlu> case. Ho died on the 23d. Post-mortem examination twelve hours after death: Emaciation. Gray hepatiza-
tion of right lung; distention of gall-bladder; congestion of bowels ancl disorganization of tho glands. — Act. Ass't
Surg. H. C. Xeirkirk, Pock Island Hospital, III.
Cases ejttered as Typhoib, hut the clinical histories suggestive of mai.aklvl complicatioxs — 21 cases.
(A.) Peyer's 2>atches ulcerated and the ileum or small intestine only affected — .5 cnscs.
Case 93. — Private Daniel Plnnimer, Co. H, 33d Pa.; age 23; was admitted Oct. 2, 1861, with headache, diar-
rhsa, loss of ajipetite and strength. He had been sick five days, having had a chill and fever on each d:iy. A bath
was given, with quinine at night. Next day his face was flushed, eyes injected, skin hot, dry and rough, tongue
coated whitish-gray, pulse 101, full; ho had pain in the bead and back, slight deafness, tinnitus auriuni, insomnia,
352 POST-MOKTEM RECuKDS OF
contusion of thought, ami luutteriiif;; his bowels were tender and had heen moved four times. Treatment — Dover's
j)0\vder and quinine. During t!ie five following days his tongue became dry and brown, pul.se less freijuent, 84,
countenance more anxious and prostration much increased; his bowels were moved about twice daily. On the 8th
the treatment was changed to turpentine, Dover's powder and whiskey-imnch. A gallon of strongly acid urine,
sp. gr. 1009, was passed on the 9th, but later in the disease the urine became alkaline. A blister was applied to the
abdomen on the 14th. On the 16th he craved apples, and next day had some appetite; the bowels were quiet,
having been moved but once daily for several days back. On the 18th gangrenous siJots appeared on the blistered
surface, which was dressed with chlorinated soda solution. Three days later an erysipelatous redness extended
downward to the thigh and the i)atieut was in extremely low condition, lying on his back with his mouth and eyes
oi)cn, unable to protrude his tongue, his lips and teeth covered with sordes and his body generally, except the face
and neck, with vibices. Tlie gangrenous blistered surface was treated with a solution of one drachm of nitrate of
siher in one ounce of water, but without benefit. His throat became sore on the 23d, and he died on the morning
of the 24th. I'ost-mortem examination: The lungs were congested; the heart, liver, .spleen and pancreas healthy;
the kidneys inflamed and suppurating. The peritoneum was inflamed; the mucous membrane of the stomach unusu-
ally corrugated; the mesentery and its glands inflamed — of the latter some were ulcerated; the glands of Peyer in
the ileum shj^ved cicatrizing ulcerations. — ■Hcminary Hospital, Georgetown, D. C.
Case 94. — William L. Layne, Co. G, 2d Ky.; age 28; was admitted Sept. 8, 18G4, having been sick one week
witli feverishness, increased at night, anorexia, great thirst, headache, pain iu the back and limbs, somewhat fre-
quent but small stools, scanty urine, occasional cpista.xis and increasing debility. On admission the headache was
intense; he was listless and disposed to stupor, bis sleep dreamful and unrefreshiug, eyes congested, complexion
venous, breathing slow, pulse 96, tongue brown with red nuargins, stools frequent, watery and fetid; there was tym-
panites, iliac and umbilical tenderness and perspirations, with sudamina on the chest and abdomen. He died com-
atose on the 13th. Post-mortem examination: Colon nmch distended with air; small intestine congested; Peyer's
glands greatly congested, enlarged and in two jiatches iunnediately above the ileo-ca-eal junction ulcerated; liver
dark-colored; gall-bladder distended. — Act.Ass't Surg. M.K. Glcason, Hock Island Hosintal, III.
Case 95. — Private Thomas B. New-comb, Co. M, 11th Vt. Art.; age 26; was admitted Sept 8, 1864, from hospital at
Frederick, Md., where his case was recorded on September 6 as one of coup-de-soleil. He stated that he had been
very sick with constant nausea, vomiting arid general pain for several days. He was treated with hydrocyanic aciil
and morphine, and on the 11th blue-pill, podopbyllin and comijound extract of colocynth were given on account of
constipation. On the 13th he had occasional spasms, apparently of a hysterical character, and his skin and eyes
assumed a yellow hue. Three d.ays Later he became much jaundiced, his tongue dry, face flushed and pulse 90, while
he had frequent attempts at alvine evacuations but passed little each time. The Jaundice disappeared on the 2()th
and well-marked typhoid symptoms set in, but with uo diarrhoia nor abdominal tympimites. His strength faileil,
his tongue becoming dry and cracked. He complained of much p.ain over the region of the stonuich and transverse
colon, and his abdomen, on the 29th, became tympanitic. On the supervention of the typhoid condition he was
treated with turpentine, chlorate of potash and Dover's powder, with hot fomentations and sinapisms. He died
October 4. Post-mortem e's.a.nnna.tmu: Lungs healthy; fibrinous clots in both sides of heart ; intestines near stomach
and liver yellow-colored; gall-bladder disorganized, perforated and with light green bile in and around it; two or
three feet of mucous membrane of Jejunum and whole of ileum congested; Peyer's glands ulcerated and in some
places nearly perforated. — Act. Ass't Surg. Geo. W. Fay, Hospital Patterson Park, Baltimore, Md.
Case 96. — Private Charles Perkins, Co. I, 1st Mich. Eng'rs; age 53; was admitted into Hospital No. 6, Nash-
ville, Tenn., in September, 1862. Etibrts were made to restrain the debilitating diarrhoea with paregoric, Dover's
powder, mercury with chalk, blue mass, ipecacuanha and opium, nitrate of silver and opium, etc; during the exacer-
bations of the fever neutral mixture with sweet spirit of nitre was given; during the apyrexia <iuiuia and iron; oil
of turpentine was tried, but it disagreed and was discontinued. The patient improved gradually under this treat-
ment conjoined with a bland and nourishing diet, and convalescence seemed to be well estalilished. Tonics and
the milder stimulants had been administered for several days, when, all at once, diarrha>a recurred with some tym-
panites, the tongue became glossy, the pulse 130 to 140, the skin yellowish, and sudamina appeared in great pro-
fusion on the neck, breast .and groin; he had a hacking cough, low delirium and subsultus tendiuum; his countenance
became hippocratic and he died October 26. Post-mortem examination: Body considerably emaciated. The peri-
cardium contained two ounces of serum. The right lung was collapsed and pale, its lower portion hypostatically
congested; the left lung was emphysematous. The heart was large; the right ventricle contained a quantity of
imcoagulated blood; the left was empty. The liver was large but normal in texture and color; the gall-bladder
flUed with thin watery bile; the spleen large and soft. There was much venous congestion of the peritoneal coaj of
the stom-ach; its nmcous membrane presented a number of soft blackish patches, and at the pyloric end there was
some ulceration, which extended an inch and a half into the duodenum. The mucous membrane of the jejunum and
ileum presented nothing remarkable except within twenty inches of the ileo-ca'cal valve, where Peyer's patches
were ulcerated; most of the ulcers were only three or four lines in diameter, but the dark tumefied patches were of
considerable size. The mucous membrane of the ileo-ciecal v.alve was tumefied and the vermiform process filled with
pus; the mucous membrane of the colon was normal. The kidneys and bladder were healthy. The blood everj'-
where was in a fluid state. — IFrom Eeport hy E. Swift, XT. S. A., Medical Director Department Ohio and Cumberland.]
Case 97.— Musician William Brandt, 17th U. S. Inf.; age 32 ; was admitted Dec. 11, 1863. Diagnosis— typhoid
fever. Ho had been sick for two weeks and confined to bed for one week: Delirium at night; stupor; tongu<^ dry
and coated; skin dry; pulse98; thirst; occasional pains in abdomen ; bowels relaxed. On the 13th the right parotid
THE CONTINUED FEVERS. 353
glaiid lii'came painful and iiiuch swollen and on tlii> 17tli typlioid symptoms wore manifested; sordes appeared on
the f;iims: his stupor increased and lie was constantly attempting to gi't out of bed. There was some bronchitis with
a little painless expectoration. A red papular eruption was (|uite distinct. Duriuf; the next ten days his coui;li
became more troublesome, and on Jan. (>, IXtU. jaundice and const i pa I ion were adilcd to the symptoms, with increasing
etupor, incoherent talking, glazed eyes, thick and tenacious sputa which he was unable to exjiectorato. He died on
tbeSth. "The autopsy revealed pneuuu>nia as the cause of death and conlirnied the diagnosis of typhoid foyer." —
.lc(. ./«»'/ Surg. Carlos Carrallo, Douglas Hospital, Wanliinnlon, I). C.
( li.) Piyrr's palches iilccraird aud the hirfic inlfstine aho impUcDtid — (> cases.
C.v.SK !I8. — I'rivate Charles E. Mariner, Co. A, I'urnell Legion, was admitted Aug, ](!, 18G3, having been atiected
with slight headache and diarrlnea, two or three evacuations daily, for several days. There was no fever on admis-
sliui, but his tongue was coated and yellow and his eyes Jaundiced, Calomel was given as a purgative and snuill
duses of (|uinine. On the 18th he vomited bile, and next day his tongue was less coated and the scleroties white, (In
the 20th signs of prostration were manifested. Delirium occurred on the night of the 22d, after which he failed
rapidly and died on the 24th, rost-mortrm examination eighteen hours after death: The mucous coat of the stomach
was softened and almost disintegrated, I'eyer's patches were ulcerated and in two ])lace8 nearly perforated; the
solitary glands were greatly ulcerated and in some instances broken down; the ileo-ca'cal valve was disorganized,
its mucous nu uibranc being converted into a pul])y inass. The rectum was ulcerated in three ))laces, each as large as
a dime, A number of the mesenteric glands were enlarged to the size of a pigeon's egg. The liver was pale; the
spleen congested and twice its normal size. The left side of the neck was emphysematous and its tissues engorged,
the result, probably, of an (tnte-mortem blow, — Jet. Ass't Siirij. W. If. Leilermaii, Doiiijhis Hospital, lI'dshiiKjIoii, I). C.
Cask il9, — Private .Jacob Brewer, Co, D, l.'ith Ohio ; age 19 ; was admitted Ajiri 1 1 L', 1864, having had, as reported
by himself, a severe chill followed by fever. He was at first regarded as surt'eriug from remittent fever and quinine
was given; but as the disease after admission seemed of a continued tyjie, with iliac tenderness and dry, dark and
fissured t(mgne, the i|uinine was omitted and stimulants .■idministered. He died on the 17th, I'ost-mortem examina-
tion thirty liiuirs after diath: Hrain snbstan('e white and softer than might bi^ expected from mere cadaveric change;
nuMiinges remarkably i>ale and anaemic; lungs and heart normal: spleen enlarged, very soft and rotten, I'eyer's
patches and solitary glands within ,i foot of the ea-cum ulcerated, those nearest the valves most afl'ected, the ulcers
raised above the surrounding surface, much thickened and covered with mucus and fa'ces. Colon ulcerated in small
spots in its upper part, — Chattanooija Hospital, Teiiii.
Case 100,— Private Hiram Giuder, Co, B, 57tli Pa.: age 17; was admitted Nov, 2, 18G4, his previous history
being unknown. He was deaf but not delirious; skin yi^llow, cheeks Hushed and murky, respiration hurried, pulse
110, teeth covered with sonles, tongue, lips and gums dry, cracked and oozing blood. On the ijth some cough was
noteil ; the res]>iration Ix'came more embarrassed and the cheeks darker. He died on the 7th, He was treated with
turiH'ntine, camphor and spirit of nitre, counter-irrilaticui to chest, beef-essence and milk-punch, I'ost-murtem
examination: Pleuritic adhesions on left side ; four ounces of dark bloody serum in right i)leural sac; congestion of
lungs posti'riorly and hejiatization of part of upi>er lobe of right lung; heart noruuil. Mesenteric glaiuls enlarged
and tilled with dark blood; mucous coat of ileum and c.-ecum thickened and inllamcil; fifteen Peyer's patches, from
one-fourth iiuli in diameter to one anil a half Ijy two and a half inches, thickened and some showing commencing
ulceration. .Spleen Large and soft; liver normal in size but yellow; gall-bladder large, containing three ounces of
bill': kidneys normal. — Act. Ass't Surg. T homas Boiocn , Second Division Hospital, Alexandria, Va.
Case 101, — Private Michael McGowan, Co, A, 154th Ind,; age 18; wiis admitted May 30, 1865, having been sick
for three weeks with a freiiuent and copious diarrha'a followed by chills and fever, acute pain in chest and dry cough
with very little expectoration. On admission he was much emaciated and very feeble; there were large bed-sores
over the sacrum, trochanters and angles of the ribs on the right side. His skin w-as dry and harsh, tongue dry, rod
and glazed and teeth covered with sordes; ho had much thirst, no appetite, pain and tenderness over abdomen, .-i
profuse diarrhtea and hurried breathing. He died on the 7th, Post-mortem examination fifteen hours after death:
The mucous membrane of the trachea was inflamed and ulcerated. The lower lobe and anterior border of the upper
lobe of the left lung, and the upper and lower lobes of the right lung were congested ; the middh^ lobe of the latter
was hepatized. The omentum was intlamed and adherent to the abdominal parietes. The spleen weighed twenty-
four ounces .and was dark and .soft. The mucous membrane of the ileum was inflamed and Peyer's i]atche8 were
ulcerated ; there was also some ulceration of the cacum ; the mesenteric glands were enlarged. — Act. Ass't Surg. S. li.
West, Cumberland Hospital, Md.
C.^SE 102,— Private Austin vSeeley, Co, C, 73d Ohio, was admitted Dec. 18, 1862, He had been treated for inter-
mittent fever in the Harewood hospital, Washington, D, C, from November 19. He died .Jan. 30, 1863. Post-mortem
examination next day: Age about 24; body emaciated. Lungs, excepting a slight bronchial inflammation, healthy;
heart contained a large white clot in its right cavities; .spleen redder than natural ami flabby; liver pale brown anil
on section pale brown with darker intralobular spots; stomach and upper portion of small intestine .apparently
healthy: agminated glands in the lower five feet of ileum sncccssivoly .and gradually increasing in enlargement;
glands in the terminal foot dark-red and bordered by inflamed mucous membrane, those nearest the ileo-colic valve
presenting several small ulcerations; solitary glands apparently healthy; colon greatly distended, its mucous mem-
brane redder than natural, but with no inflamed spots, streaks or patches, and with no visible disease of solitary
Mki). Hist,, Pt, III— 45
354 POST-MORTEM RKCORD.S OF
glands- lymphatic glauds of mesentery and mesoco!<in bluisli-lilaplc, which color on section formed a circle within the
periphery, and nnder the microscope presented the appearance of exceedingly tine particles similar to the black
deposits in the intestinal glands in Chickahominy diarrhoea: kidneys healthy. — {^Spicimcns Nos. 99-101, Med. Sect.,
Army Medical Mnseum, ulceration of Peyer's patches, are from this case.] — Act. Ass't Surg. Joseph Ltidij, SaiterUe
Hospital, rhiliulclphiu, Pa.
Case 103.— I'rivate James M. Fonnan,Co. H, 33d Pa.; age 21; was admitted Oct. 2, IStil, having been sick for
nine days with pain in the head, back and bones, chills, loss of appetite and strength, diarrhcca, epistaxis, pain in
the stomach, nausea and vomiting. A hath was ordered for him with Dover's powder at night. Next morning his
face was flushed, eyes injected, pulse 98, full, skin hot, dry and rough, tongue heavily coated, the centre brownish,
the tip and edges red ; he had anorexia, great thirst, irritability of stomach, diarrhn;a, the bowels having been moved
four times, tenderness in the right iliac region and fonr or live characteristic rose-colored spt>ts. The case continued
for ten days without much change under treatment by astringents, opiates and whiskey punch. The nausea and
vomiting gradually ceased; some degree of deafness was developed; there was occasional tympanites, and blood
appeared in the stools for several days and ou the 8tli in large ijuantity. But on the 12th the diarrluea ceased, the
abdominal tenderness was lessened, the tongue became moist and there were indications of returning appetite.
About the same time, however, the right parotid gland became inflamed and the face much swollen. There was slight
delirium on the 14th, and next day the swelling, which had become erysipelatous, extended over the face, nearly
closing both eyes and presenting a small gangrenous spot on the ear and another on the cheek. The patient walked
about the ward in high delirium, but towards evening became more quiet. At 10 r. Ji. he sprang up snddi-nly,
knocked the pitcher containing his punch from the attendant's hand and endeavored to get down stairs. He was got
back to bed with some diliiculty and innnediately thereafter began to fail. At midnight his pulse was rapid and almost
imperceptible, his extremities cold, eyes fixed and jaws locked; he took no notice when called or shaken and died
at 1 A. M. of the 16th. Post-mortem examination : Parotid gland in a state of suppuration ; side of face dark-colored and
with small patches of gangrene in front of the ear. The mucous membrane of the stomach was congested and softened.
The liver and gall-bladder were large but healthy; the spleen congested, enlarged and soft. The ileum was inllauu-d ;
its solitary and agniiuatcd glands were ulcerated and there was a small perforation in one of the ulcerated jiatches.
The large intestine, from the valve to the rectmn, was very much ulcerated. The peritoneum was inflamed ; the mes-
enteric glands enlarged; the kidneys and bladder healthy. — Scminurii Hospital, Georgetoini, D. C.
(C.) Condition of Peyer's patches not stated; the intestines varioiislj/ affected — 7 cases.
Case 104. — John Freeman, Co. B, 12th Tenn. Cav., was admitted May 7, 1864, in a semi-unconscious state; pul.se
feeble, respiration normal, tongue dry and dark, teeth covered with sordes, skin jaundiced, pupils natural, stools
involuntary. He died next day. Post-mortem examination sixteen hours after death : Unusual injection of meningeal
vessels; hypostatic congestion of lower lobes of lungs; congestion and discoloration of liver; distention of gall-
bladder ; much congestion of sjileen : slight congestion of ileum. — Act. Ass't Sury. Georije E. Walton, Hospital Xo. 8,
Xiishville, Tenn.
Case 105. — Private A. C. Truman, Co. G, 152d N. Y., was admitted April 24, 1863. Diagnosis — typhoid fever.
Epigastric pain and tenderness but no diarrhu?a; vomiting; marked febrile action; tongue coated dark brown;
sordes on teeth and lips: pulse 125; urine scanty; countenance pinched; tinnitus auriuni. He was treated with
quinine, whiskey and turpentine emulsion, and on the 26th was improving. On the 29th blue mass and colocynth
were given for constipation and on May 14 sulphate of magnesia. On the 20th he was seized with a troublesome
cough .and dull pain in the left side of the chest. A few days later diarrluca set in, the cough continuing, and he
died on .Tune 5. Post-mortem examination: Right lung hepatized in its lower lobe; left lung collajised and contain-
ing a few tubercles; heart normal. Ileum extensively congested but not ulcerated: liver, spleen and kidneys nor-
mal.— Act. Ass't Sury. John E. Smith, Douglus Hosj)itul, JVushinyton, 1). C.
Case 106. — Private Pleasant Willett, Co. E. l.SSth Ind.; age 28: w.as admitted Aug. 19, 1864, haviug suftered from
diarrluea for some time. His pulse was 106 and his tongue dry and furred but uot glazed or cracked. Next day a
remission was noticed and on the following day nausea and vomiting were recorded. The diarrhiea became i>rofu.se,
with dysuria and much abdominal tenderness. He died on the 25th. Post-mortem examination eight hours after
death: Brain and its meninges normal. Lungs healthy; heart normal, right cavities containing a firm clot. Liver
much engorged, eighty ounces; spleen intensely engorged, twenty-seven ounces; stonKich distended with flatus and
ftecal matter; peritoneal cavity containing one pint of purulent serum; colon somewhat thickened and softened:
ileum ulcerated in its lower tlrree feet anc' with a perforation six inches from the ileo-c:pcal valve ; bladder congested;
kidneys together weighing fifteen ounces.— Jc(. Ass't Sury. V. (J'. Flora, Hospital, Madison, Ind.
Case 107. — Private Jasper Kemp, Co. H, 11th N. H., was treated in the Fifth Army Corps Field Hospital, City
Point, Ya., from April 23, 1865, for malarial fever, and transferred May 1 to hospital transport "State of Maine,"
where his case was diagnosed typhoid fever. He was admitted on the 2d, and two days afterward was seized with
acute abdominal pain which increased in severity until he died on the 5th. Post-mortem examination: Ceneral peri-
tonitis; ulceration of small intestine with se\ en perforations. — Campbell Hospital, Washington, D. C.
Case 108.— Private Robert Alexander, Co. E, 149th Pa.; age 18; was admitted Dec. 7, 1863, as a fully devel-
oped case of typhoid fever, the symptoms stated being a dry and red tongue. Laboring pulse, scanty and high-colored
urine, with great irritability of stomach and diarrhrea. On the 18th there were involuntary stools and more or less
stupor and subsultus. He died on the 22d. Post-mortem examination nine hours after death: Softening of the coats
of the stonuich: thickening and softening throughout the lower course of the colon, but no ulceration of the intes-
tinal membrane. Lungs comparatively healthy. Liver normal. — Third Dirision Hospital, Alexandria, Va.
THE CONTINrKP KKVERf?. :^;i.)
Case 109.— Privato Mjroii Biilcli, Co. U, 9lli Mich., was admitted April 2, 18(>l, with a fever ■nliich pre.sentcd
distinct renii.ssioii.-i, and wa.s treated with ten ^rain.s of quinine dnrin-jeaeh reniis.sion until the lOtli, w hen he beeanie
delirious, had iliac tenderness, diarrluea and henuirrhasic stools. Stiuiulants were S'^en and persulphate of iron
one grain every two hours. He <lied on the ItSth. I'ont-iiiortvm examination twenty-four liours after death: lirain
and its memliranes ananiic. Posterior three-fourths of uppi'r lobe of right lung hepatized; left lung normal : heart
normal, suuiU w hite elots in both ventricles. Liver fatty: ileum for twelve inches above the ileo-cacal valve, uleiT-
ated in patclu'S varying from the size of a pea to that of a dollar, the largest being nearest the valve; colon injccti'd
anil ulcerated in its n|]ier part. — Jet. .(«»'/ Surji. C. /•'. I.illlr. CliatldiKiiiiiii Ifnspitnl, Tciiit.
C.\SK 110.— Private D. F. >IcLaehl;in, Co. (J. lltli N. Y.. w;is admitted .Sejit. 'JO, 1X(;I. He had bciu taken sick
« ith a chill followed by severe pain" in the head, back and sides, with loss of :ippetit<' and slreugtli. (In ail mission his
skin was warm and jierspiring; pulse !I2, quick and strong; tongue glos.sy and |iale. slightly colorid brown in the
centre anil at the base; bowels moved eight times in the twenty-four hours: there was tenderness in the iliac and
epigastric regions, with metcorism, borborygmus, epistaxis and rose-colored spots (from twenty to thirty) on the
abdomen and chest. He was treated with turi)entiiie emulsion, blue ])ill and opium, and Dover's powder al night.
Next day tin re was slight mental confusion -with ringing in the ears, and his tongue was covered with a grayish fur.
An eight-grain dose of quinine was added to the treatnu-nt. During the wi'ek which followed his eiindilinn was one
of gradual improvement; the pulse did not rise above iUl, the meteorism (lisa)ipeared, his appetite began to return
and his tongue lost its fur. becoming moist and pale, but his bowels continueil slightly relaxed notw ilhslaniliKg the
use of o]iiates and astringents. After this his jirogress was uncertain; at tiuuis he felt pretty well. He was treated
mainly with wine and quinine in two-grain doses three tinuts daily, but on October 1(! the throat and larynx becanio
congested and he had some bionchitic cough. Ulisters were applied to the sides of tlio neck, the throat was swabbed
w ith a strong solution of nitrate of silver and five grains each of calomel and Jala]) were given. He did not rest well
during the night :ind next day was pale and weak, hoarse and .somewhat deaf; his bowels were moved three times
and there was tenderness with tympanites atid borborygmus. During the day Hie bowels were again moved three
times. He continued thus for three days. On the 21st whiskcv-])uncli was substituted for wine. On the 2M his
expression becanu' anxious.pul.se 111, skin hot and dry, the tongue continuing pale and tiabby; he had six thin
evacuations from the bowels: cough was troublesome and the throat symptoms had become so aggravated that ho
swallowed w ith dilliculty and could not s]ieak above a w his])er. The treatment consisted at this time of chlorate
of potash, muriate of iron, beef-tea and whiskey -])uncli. During the following night his pulse rose to 110, and next
day sordes ai)))eareil on the teeth. Soon after this he became delirious, imagining that sonu! large aninuil was in bed
with him: that he was in camp, etc. On the UTth, having iiasseil a better night, he was not so delirious, but ho
looked pale and anxious: his pulse was weak and small, !U ; skin warm and soft; tongue pale, uu)i.st and tremulous;
his bowels were moved involuntarily. At this time there was noted on the skin dark, almost black, slightly elevated
spots somewhat larger than split-peas, without aeeouipanying inllammatiou; those which had arisen more recently
were whitish-yellow, being full of purulent matter. On the 2Sth he was almost uneon.scious ; his pulse weak, small
and irritable, 120; skin warm and soft; tcmgue heavily coated ; mouth moist and its whole surface covered with
white sticky mucus; gums covered with sordes; one side of the face Hushed very dark red; his bowels bad luin
quiet since an injection given on the ]irevious evening, but there was tenderness on both sides; submucous and
sibilant rales were heard in both lungs. On the evening of this day he was quite unconscious, his eyes and mouth
ojuMi, pulse lliO, respiration "lO. During the night hemorrhage /rom the bowels tool; place and recurred on the after-
uoou of the next day. his |)Hlse meanw bile becoming weaker and breathing uujre ra])iil. On the :Wtli his extremities
lieeame cold and at 2 1'. M. he died, rosl-inoitriii examination : The brain, jdiarynx and lesopliagns were nol examined.
The lungs were much congested and hepatized. The Ju^art contained libriuous clots in both ventricles. The liver
and pancreas were nornuil: 4lie spleen soft and souu'what enlarged. The right kidney was small and transformed
into a thin-walled cyst containing a yellowish liquid; the left kidney presented several large cavities containing
pus. "The small intestine showed that inflammation had been rife there .some time ago, but no ulcers were seen
that had been formed lately; there were jdaces where large and recently healed sores were evidently iinlicated."
The mucous membrane of the colon was broken by several large ulcers. The mesentery was quite healthy. — Stiiii-
nary Hospital, (Iconjelown, I). C.
(D.) Condilion of Pcycr's patches variousli/ slated, but not iitrirdtiil; inhstines more or less affevtetl — G (■«»(•».
Case HI. — Private Charles Lewis, Co. (Jj2MU. S. Colored troops; age 21; was admitted Oct. 20, 1865, on which
day he had a chill followed by fever. Dover's powder was given in the evening, but the chill recurring next day
quinine in five-grain do.ses was admiYiistered. There was no chill on the following day; but the febrile action con-
tinned and increased so that on the 24th his pnlse was 120, quick and full, respiration 60, skin hot and dry, tongue
furred; and he was weaker, sleepless and slightly delirious. Small doses of eggnog, chlorate of potash and tur-
pentine with Dover's powder were .administered. Next day his condition was unchanged; castor oil was given to
move the bowels. On the 26th the insomnia and delirium continued; the tongue was dry, brown and coated ; the
eyes jaundiced; the urine passed involuntarily, staining the linen yellow; the abdomen teiuler and tympanitic; a
thin yellow-colored discharge was procured by the oil. Next day the pulse was not so strong, the tongue continued
dry and brown, imt the skin became somewhat moist and the i)atient slept a little. One grain of calomel and two
of ipeeacmniha were given every hour for six hours, with mustard to the back of the iu!ck and chest. He died on
the 28th. I'ogt-mortem examination thirty hours after death: The arachnoid over the interpeduncular space was
thickened and opaque and there was serous effusion in the cerebral ventricles. The Inngs and heart were normal,
but there was eflfusion in the left thoracic cavity. The liver was large, its right lobe houey-combed, full of air and
35G POST-MORTEM RECORDS OF
of a very peculiar appearance, and its left lobe normal in texture hut of a yellow color. The pancreas was large;
the kidneys normal : the spleen large, soft and dark-colored. The colon and rectum were normal ; Peyer's patches
were enlarged, as were also the mesenteric glands. [Sprcimiii 639. Med. Sect., Army Medical Museum, from this case,
shows the honey-combing of the liver by dilated gall-ducts.] — Siiry. E. Beiitley, U. S. V., Slouyh Jloxpital , AUxandria, Va.
Case 112. — Private F. Binder, Co. G, 131st Pa.; age 27; was admitted Dec. 30, 1862, with gangrene of both feet
after typhoid fever. About eight weeks prior to admission he was attacked with chills and fever, but the disease
afterwards assumed the character of typhoid fever. The condition of his feet was supposed to be due to frost-bite
while sick in camp. On Jan. 7, 1863, the skin of both feet was reported as blue from the toes to above the ankles,
where was an irregular border of redness ; below the malleoli the parts were cold and a pin could be inserted without
being felt. Lines of demarcation were formed on the 9th just above the malleoli ; at this time the patient's appetite
was improving and his tongue looking well, but his skin was slightly yellow and he complained of much pain, which
he referred to his feet. On the 22d his bowels became loose, there having been five stools during the day, and next
day the tongue was somewhat dry. He slept well at night and had no night-sweats, but he lost flesh and continued
to suffer from pain in the feet. The right foot separated at the ankle-joint on the 26th, the stump having bled (|uite
freely. Next day both legs were amputated by "LeNoir's" operation, after which the patient reacted fairly and
rested well. On the 30th the stumps looked badly and discharged a grayish pus, while vomiting, hiccough and extreme
depression were developed. Death took place February 2. rnst-mortem examination twenty-four hours after death:
There.were clots in all the arteries of the stumps except the right anterior tibial. On pressing the medulla of the
left tibia a yellowish liquid exuded from the vascular foramina in the compact substance of the bone. The brain
was healthy. The right lung weighed thirty-three ounces and three-qviarters ; in its lower lobe was a circumscribed,
light-colored, consolidated mass and numerous light-colored points, about the size of pinheads, surrounded by irregular
areas of congestion; a portion of this lobe was in the state of gray hepatization. The left lung weighed eigliteen
ounces and a quarter; on the posterior surface of its lower lobe and in the substance of the upper lobe were a number
of discolored spots beneath which the lung-tissue was infiltrated with serum. The heart was pale and contained a
small fibrinous clot in the right ventricle. The liver was pale and firm; the gall-bladder small ; the spleen weighed
seven ounces and a half and was very soft; the pancreas was of a grayish color; both kidneys were small and light-
colored. The stomach was large, its mucous membrane slightly softened ; the upper part of the jejunum was shite-
colored ; the whole of the ileum congested and its valvuhe conniventes indistinct; Peyer's patches were slightly
thickened and some of them congested. The large intestine was congested. — Ass't Surg. Giorge M. McGill, U. S. J.,
Lincoln Hospital, Washington, D. C.
Case 113. — Private John Frink, Co. K, 40th N. J.; age 19; admitted June 4, 1865. Typhoid fever. Severe
diarrhoea, gastric irritability and nervous disorder were the prominent phenomena. Died 23d. Posf-morfent examina-
tion twenty-four hours after death: The lungs were emphy.sematous ; the small intestine much inflamed; the glands
of Peyer congested ; the spleen normal. Third Division Bospital, Alexandria, Va.
Ca.se 114. — Private Benjamin Brady, Co. I, 24th N. Y. Cav.; age 23; was admitted June 5, 1865, with chronic
diarrhtva and intermittent fever. Typhoid symptoms soon became apparent, including delirium and petechial spots
on the abdomen. He died on the 14th. PosZ-Hiiirfem examination nine hours after death: Body mncli emaciati'd.
Lungs normal; spleen enlarged and softened; small intestine ulcerated; Pejer's patches much inflamed and corres-
ponding mesenteric glands enlarged and indurated. — Slough Hospital, Alexandria, Va.
Case 115.— Private David E. Martin, Co. K, 137th Pa.; age 32: was admitted May 17, 1863, with irregular chills
followed by fever from which he had suffered for some weeks. A chill followed by fever and jjerspiration occurred
on the evening of li is admission, but next day he was feeling pretty well. This was repeated on the following evening,
but on the third day there was no recurrence, quinine having been administered meanwhile. On the 21st he was
found for the first time with hot skin, active pulse and headache, his tongue remaining as heretofore, yellow-furred
but comparatively clean at the tip. Signs of nervous agitation were also observed, as tremulousness of the lower
lip and twitching of the hands. Neutral mixture, cold drinks and low diet were substitued for the quinine. He
continued in this condition, so:ne diarrhoea meanwhile appearing, until the 25th, when, having thrown off the bed-
clothes dnring the night, an oppression of the breathing was developed, with sonorous and sibilant rales and some
sluggishness of mind. Acetate of anmionia and wine-whey were given with sinapisms to the chest. A blister was
applied next day, and on the day following infusion of serpentaria and carbonate of ammonia were given. On the
28th , in view of the continued cerebral disturl)ance, indicated by heat of head, some confusion of ideas, and injection
of the right conjunctiva, a blister was applied to the back of the neck. Next day two or three rose-colored spots of
doubtful character were noticed and there was slight abdominal distention. Perspirations were added to the list of
symptoms on the 30th and involuntary discharges on the 81st. He died .Tune 3. Post-mortem examination next day:
Body somewhat emaciated. Heart nonnal ; mucous membrane of trachea and lironchi inflamed, the inflamniatiou
extending to the smaller tubes and in several instances to the pulmonary lobules. About four feet of lower i)ortion
of ileum showing slight irregularly dift'used inflammation ; glands of Peyer generally healthy, but a few of the lower
ones containing some black deposit; ileum, for eight inches above ileo-ca'cal valve, and ca>cum intensely inflamed,
the mucous membrane liver-colored, thickened and in numy places ulcerated, the ulcers varying from the size of a
pea to that of the thumb-nail and the largest extending through to the muscular coat; colon distended with air
and its mucous membrane here and there slightly inflamed and presenting a few scattered ulcers about the size of
pepper-corns; rectum more intensely inflamed and with large and numerous ulcers. Liver large and rather soft;
spleen soft and flabby; kidneys darker than usual, their pelves somewhat injected ; suprarenal bodies and pancreas
healthy. The muscular system and blood appeared to be in sound condition ; a large translucent clot occupied the
right cavities of the heart. — Act. Ass't Surg. Joseph Leidy, Satterlee Hospital, rhiladelj)hia, Pa.
THE CONTIKUED FEVERS. 357
Case 116.— Private Darius GnTiilaw, Co. I, 7tli Me., was admitted Aiiii;. 10, 1862. Ho rcjccti'd all nomi.slimcnt,
and was sustiiiiied by iujectious of milk, biaudy and beef-tea. He vomited frequently a dark-^rcenisb, felid lii|nid;
lUere was uo fever nor diarrho'a; the alvine cvaeuations were sliglit and infremieut. lie died September 1. I'ont-
mortcm examiuation : I!ody not mueli wasted ; apparently al)(.ut 20 years of a-je. In eonsetiuence of the patient ha viufj
had a swollen eye and bleeding at the ears the brain and skull were examined, but both ap|>eared to be normal.
Luufis and heart normal. .Stomach much eontraeted and empty; its mucous membrane inllanied from a-sophafjeal
oritiee into eul-desac and a short distance alon^ jtreater curvature; rnga< of stomach and summits of valvuhe con-
niventcs of duodenum also inllanu'd. Ileum jiresentinj; four small inflamed patches; ui)iier af;iuiiiated glaiuls healthy,
lower jjlands thickeiu'd and <'outaininf; black pii;nient, several of the latter, from one to two inches long, )>resenting
two or three little ulcers )u>t more than one or two lines in diameter; lower solitary ■;land8 enlarged and containing
black pigment. Mucous membrane ol caecum and of part of ascending colon intlanu-d and, in a less degree, that of the
descending colon ; solitary glands blackened. — Act. Ass't Surg. Joseph Lekhj, Sattahc Hospital, ridladdpliia, Pa.
Among the one hundred and sixteen cases submitted above there are fifty that, in
view of their dinical history, and the information ah'eady gathered concerning the symp-
tomatology of the continued fevers, must be regarded as cases of undoubted typhoid. Tlie
post-vwrtem observations in some of those instances were insufficient and loosely expressed,
but, as in others they were more extensive and entered with precision on the record, there is
no difficulty in appreciating the associated anatomical changes. The brain and its membranes
were oftentimes found in a normal condition; the thoracic viscera were frcipu'iitiy afFectod,
but in many cases no morbid alteration was discovered in them; the abdominal contents
were variouslv changed from the healthy state. The character of these changes will be
examined hereafter on presentation of the remainder of the post-mortem records. It is
sufficient for the present to point out that an ulcerated condition of the small intestine,
particularly of its lower part, and perhaps specifically of that part of its extent wliich
corresponds to the position of the agminated glands, was the only constant anatomical
lesion. In some instances the stomach and upper part of the intestinal tract presented
traces of inflammation, in others the large intestine bore similar marks; but all these had
at the same time :iii ulceration of some part of the lower portion of the small intestine.
Of the fifty cases Peyer's glands were ulcerated in thirty-three; and in seventeen, in
which the condition of these patches is not stated, the ileum or small intestine was said to
have been ulcerated.
Had the typho-malarial cases reported by our medical officers consisted of typhoid
fever modified by the activity of a malarial element, there should have been discovered in
all fatal cases the constant anatomical lesion of typhoid fever with such changes in the
cadaver as are known to be occasioned by the presence of the malarial poison. It has been-
seen in a previous chapter that fatal cases of mtilarial fever presented no constant or char-
acteristic lesion. Inflammatory conditions, observed perhaps more frequently in the small
than in the large intestine, were noted, and these had often progressed to ulceration; but
as in some cases the intestinal canal was apptirently healthy, such conditions could not be
regarded as pathognomonic. Ulceration of the intestines, of the small intestine especially,
is therefore to be expected in the typho-malarial cases as the constant accompaniment of
their typhoid essential and as an occasional result of their malarial complication.
Nevertheless, of forty-two cases recorded as typho-malarial, theie wei-e nine in which
the patches of Peyer were reported as having been found in various conditions, but not
ulcerated, and in which the intestines were more or less affected, but without ulceration of
the ileum, except perhaps in two instances. Moreover, of the forty-two cases there were
fifteen in which, while the condition of the patches was not stated, the intestines were
variously aflfected, but in only one-third of these is it stated in terms or inferentially that
358 POST-MORTEM KEGORDS OF
ulceration was present. The remaining eighteen cases were characterized by ulceration of
the jDatches of Peyer.
Of the nine cases, S4-92, in which the condition of the agminated glands was vari-
ously rej^orted, case 84 had the ellipitical patches pale, the solitary glands and the rectum
ulcerated. These are not the generally accepted lesions of typhoid. In 85 the patches
were distinct and elevated and the solitary glands of the large intestine ulcerated, while
in 86 the patches were dark- colored and conspicuous and the mucous lining of the small
intestine congested. These may be set aside as indicating by the glandular tumefaction
the possibility of a typhoid element. In 87-91 the patches presented the shaven-beard
appearance; in 87 the solitary glands were prominent; in 89 these glands, near the ileo-
cecal valve, were ulcerated, as was also the colon; in 88 the intestines were congested, and
in 90, according to Dr. Harrison Allen, they presented no special lesion other than pig-
mentation of the patches. In Dr. Leidy's case, 91, there was, in addition to deposits of
pigment in the agminated and solitary glands, large inflamed and ecchymosed patches in
the small intestine and similar but more diffused conditions in the large intestine. In case
92 the record is indefinite; the expression "congestion of the bowels and disorganization of
the glands" leaves an uncertainty as to whether the glands of the mesentery or the closed
glands of the intestinal mucous membrane were thus affected. Six of the nine cases ].)re-
sumed by the diagnosis to have both a typhoid and a malarial element may thus be reganh'd
as having offered no post-mortem evidence of the existence of a typhoid factor.
Of the fifteen cases, 69-83, in which the condition of Peyer's patches was not stated,
the small intestine was ulcerated in five instances: In case 74, the patient liaving been under
treatment in hospital for twenty-six days before death, there was congestion and commencing
ulceration of the- intestines; in 75 the mucous membrane of the small intestine was ulcer-
ated in N'arious parts and that of the large intestine congested and disintegrated; in 77 there
were small ulcerations in the lower part of the ileum, and in 82 and 83 this part of the intes-
tine was [terforated. Allowing the ulceration in these cases to represent the enteric lesion
of typhoid fever, there remain ten cases in which the small intestine was not ulcerated. In
71, 72, 73, 78 and 81 the intestinal mucous membrane was congested, inflamed or softened;
in the first-mentioned case the oesophagus, stomach and duodenum j^articipated in the inflam-
matory action; in 73 the solitary glands were disorganized and in 81 there was also peri-
toneal inflammation. In 76 the small intestine was concrested and the rectum ulcerated and
gangrenous. In 79 the ileum was injected and in 80 gangrenous. In 70 the solitary glands
were disorganized and the mucous coat of the rectum inflamed and softened. In 69 notliing
is said of the condition of the small intestine, possibly because it presented nothing nf impor-
tance. Negative, as contradistinguished from positive, testimony has its value: The record vi
case 76 of the paroxysmal fevers does not take cognizance of the condition of the small
intestine; but as the diagnosis was remittent fever, few pathologists would doubt its nega-
tive testimony as to the absence of ulceration of the ileum. In 69 of the present series the
diagnosis typho-malarial sustains rather than invalidates a similar negative evidence. That
typhoid symptoms may be present without the co-existence of an enteric lesion is evident
from the followincr case of mistaken diagnosis:
Private William McMillan, Co. I, 15th 111. Cay.: ago 16: was admitted from Washington street prison Feb. 9,
1865, with typhoid fever. He complained of frontal headache and was delirious at times; his tongue was dry and
coated with dark-brown fur, teeth covered with sordes, skiu hot, dry and sallow, pulse 120 and weak, bowels tym-
panitic and tender. He died on the 13th. rost-mor(ciii examination twenty -oue hours after death: The pericardium
THK C0NTIN"L"K1> KEVEK:^. 359
was full of soruiii ami llakos of lyiiiiili. 'V\n- Icfl liiii^ was coated with leecut deposits of lyiiiiili: siinilaf d.-iiosits
glued together the iutestines and other alitloniiual viseera. The liver was pale. The mucous uu uihraiie of tin- ileum
was (|uite iioruuil. — 77iin/ Uifision Ilospitnl, AhjuiKlriii, I'ti.
J3ut even were case 69 thrown out as indetinite in its evidence, there would be no mod-
ification of the general conclusion drawn from this series of cases, to wit: that among them
are to he found cases in which the symptoms warranted a typho-malarial diagnosis in the
absence of the lesion considered pathognomonic of typhoid fever.
This conclusion is sustained by an examination of the post-mortem records of those
cases which, though recorded as typhoid fever, showed by their clinical history that their
course was probablv nioditied by the coneui'rent action of the nvalai'ial })oison. '^Pwoiity-
four such cases have been submitted,* in eleven of which the patches of Peyer were referred
to definitely as ulcerated. In six of the twenty-four cases, 111-116, the condition of these
(TJuiitls was mentioned, and if the enlarcement in 111, the thickening and congestion in 112,
the inflamed condition with ulceration of the small intestine in Hi and the commencing
ulceration of the pigmented glands in I Ul he regarded as representing the anatomical lesions
of tvphoid fever, there remain two cases in which those lesions cannot be recognized. These
are 113, in which, although the patient was under treatment in hospital for twenty days
prior to death, the patches of Peyer presented no other characteristic than a participation
in the general congestion of the small intestine, and 115, in which, although, according to
the testimony of Dr. Leidy, the ileum near the valve and the csecum beyond it were intensely
inflamed, the patches were healthy except that a few of the lower ones contained some
black pigment. The condition of the agminated glands was not stated in seven, 101-110,
of the twenty-four cases. Four of these may be set aside as presenting probalih^ lyi)hoid
lesions, but the remaining three cannot be so regarded. In 101 the ileum was Iml sliglitly
congested; in 105 it was extensively congested but not ulcerated; and in 108 (he mucous
membrane of the stomach was reported softened, of the lower part of the colon thickened
and softened, but no mention is made of the condition of the ileum or small intestine, and
it is hardly admissible to suppose that the characteristic lesion, in a case ailmittcd as fully
developed typhoid fever, would have been omittc(I from the record while details were given
of other and apparently less important lesions.
It is evident from these records that among the fatal cases reported as typho-nialiu'ial
were some which, while presenting the inHammatory conditions recognized as tla^ frequent
* Among llie forty-two coses entered as typlio-umlarial and tljc twenty-four wLicli, although showing in their clinical history a i>rolabIc malarial
complication, wito ni'veithi'less regarded as typhoid, arc to ho found those of wliith Hr. Woopw.\ni> spoke as follows in his reiiiarks on Tii]tliii-nmtmkd
Frrrr, h,/,n- the lulfnmlinwil MnlUal Comjivus, I'hila., 187i;, pamphlet, paces :!l-;i5 : "In the group of eases iu whieh the malarial pheiujuu-ua predominated
the disease tiegali ;uj a siujple iuterniittent or n-mittent fever, uf ijuotidian, tertian or <piartan type, the mo.st frc'<plent form lieing a Bim|>Ii' or double
tertian ; hut after a week or ti'U days the fi'ver assumed a more m- les.s lomph'tely eojitiiiued type, with many of the phenomena eharaeteristie cd' typhoid
fever, such as diarrho'a, alidomiiuil tendcrnesii, metcorisni, muttering didiriurn, sulisoltos tendinum, dry, brown tongue and the like. liut even when
the typhoid phenjiniena were nmst pronovineed some of the most charaeti'ristic of them were often wanting. Thus, soiuetinu'S tljere was no diavrhiea at
all, bnl rcinBli|«itiou instead. Tin' eharaeteristie taehe rouge, or rose-eolored eruption, was generally entirely absent ; gastric distin-baiK:e, hepatic ten-
derness and an iiteruid hue of the lonntenanee were much move generally present than in simple typhoid fever. Now, a largi' |iroportion of these eicsos
terniinateil favonibly, espi-cially, as I think, because (|ninine was so freely used in their treatment ; the occurrence of onlinary paro.vysms of iigue was a
fretinenl ar.ideni during tin' eonvalesei'iue. .\nd, ju.»t because of the frecpiency with which they recovered, I suppose, the uuTidier uf autopsies in cases
of this kin.l which I have been abh' to eolb'cl is nimli b-.-<s than in cases of the second gnmp, of which I shall presently spe-.ik. .•<till, 1 have .olli'ded a
nnndsT .d aut"psiea ofca-si'S of this kind, in which diarrlnea had been present during the fever anil in which, after it had a.isnnnd a continuous type, it
liiul strikingly reseuddiil typhoid fever, but in which dissection showed im other lesion in the alimentary canal than a smart intestinal catarrh. I'al.hes
of intlainmation, scattered irri'gnlarly throughout both snmll and large intotiues, and enlargement of the closed glamls, oft<ui ass.siated with pig nt
de|»i«il8, were the characteristic lesions. The solitary glamls of the small intestiiu- appesired iis little projecting tunnjrs the si/.e of piuheads, which olteli
had constricteil ni-cks, so that they resembled tiny pi>lyiii. The agminated glands of Peyer, slightly prominent, were often the seat of pigno'iit ileposit,
which gavi' them the so-called shaven-bearrl appearance. Sometimes the villi of the small iut.-stines were hypertrnphiisl ; sometimes they bad pigmi'iit
deposits at Iheir apices. In the large intestine the slightly swollen solitary glands were often the seat of pignu'nt deposits, seated either in the glands
alone or sometimes also in the surrounding nnieos;i, in which ease the central dot of pigment was sinronndeil liy a little pigmentary ring. When llio
fever had supervened, as often lia|.pemil, n|Kin a cbronii- tlnx, or w here dysentery had been developed during the course of the fever or of thi> conva-
lescence and had been the immediate cause of death, the characteristic follicular ulcerations of tlie colon or the iihenomemi of the iliphtheritic process
complicated the picttiro. Great enlargement of the spleen and congestion of the liver, w ith or w ithout fatty degeneration, were freipient com omitants."
360 POST-MORTEM RECORDS OF
attendant of acute malarial poisoning, did not have associated with them the morbid condi-
tion which daily experience shows to be the invariable accompaniment of typhoid fever.
Certain cases of the paroxysmal fevers, as for instance 58, 63, 81 and 82, indicated that a clin-
ical history suggestive of typhoid fever might be presented without the discovery of typhoid
lesions on 2^ost-mortem examination. This indication has been fully sustained by the records
just submitted. They demonstrate that there were sometimes developed in the progress of
a malarial fever, and in the absence of the local intestinal lesions characteristic of typhoid,
certain symptoms which are so generally the manifestations of typhoid fever that they are
technically known as typhoid symptoms. As these cases are too numerous and well autiien-
ticated to be disposed of by the assumption that they were exceptional cases of mistaken
diagnosis, it follows that our medical officers applied the term typho-malarial to cases which
Dr. Woodward did not have in view on its introduction. Adynamic malarial remittents
swelled tlie list of febrile cases reported as typho-malarial, and to a greater extent than would
be supposed from the small number o( jwst-nwrtem records that support this statement. Most
of the recorded cases presented the characteristic lesion of typhoid, or such ulcerative changes
in the mucous membrane of the small intestine as might be claimed to represent the typhoid
lesion, although malarial fevers are also productive of such changes. But it has already
been shown that malarial cases rarely reached the general hospitals in the rear, where facil-
ities existed for post-viortem observation and record. Such cases occurring at the front recov-
ered under the influence of quinine, or died, if the disease was pernicious, before reaching
the general hospitals. Hence the paucity of malarial changes as compared with the fre-
quency of typhoid lesions in the recorded cases. Had the post-mortem records of typho-
malarial fever been preserved in the field-books of the regimental surgeons as in the case-
books of the general hospitals, it is highly probable that the number of cases presenting
lesions not definitely typhoid would have been largely increased.
When anomalous febrile cases were first observed in the autumn of 1861 they were
viewed by our medical officers as remittent fevers which, owing to depressing influences
operating on the newly levied troops, tended to assume a continued type and adynamic
character. This is expressed in a large number of sanitary reports furnished at that early
period of the war, a few of which are herewith submitted :
Surgeon J. M. Cl'Yl.ER, IT. S. A., Fttrtress Monroe, Va., Amjust 17, 1861. — Continued fever of malarial orij^in, by
many here called "typhoid," is the most formidable disease we have to contend with; the number of fatal cases
has as yet been comparatively few, but patients are long in recovering their strength.
Surgeon Isaac J. Clark, 12th Pa. Seserres. — Our camp at Teunallytown, Md., in August, 1)^61, was on a hill-
side with a gravelly surface but a wet clayey subsoil, near a piece of low ground suitable for the generation of
malaria. The prevailing disease was remittent fever, which almost invariably in a few days changed to a mild
typhoid fever; most of the cases recovered, but convalesced quite slowly.
Surgeon A. P. Frick, W3d Pa. — During our sojourn at White Oak Swamp, June 1862, there was much and
serious sickness, principally typhoid fever, or we may more properly say remittent fever of a typhoid form. The
prolonged exposure, continued watching and great mental depression after the battle (Fair Oaks), united with the
malarial influences of the region in giving a low form to disease and in making cases alarmingly fatal. Stimu-
lants, quinine, chlorate of potash and opium were the remedies chiefly relied on.
Surgeon Samuel G. Laxe, oth Pa. Reserres. — Disease during the winter 1861-62 was of a decidedly typhoid
type, death being usually sudden and from local inflammatory complications. We had but few cases of enteric
fever; all others were purely miasmatic. The treatment was simple: Depletion, even local, was pernicious: (|uinine
in full and repeated doses, stimulants, nutritious diet and cleanliness constituted the general treatment, with oil of
turpentine, nitrate of silver, acetate of lead and opiates for diarrluea, which was a usual accompaniment, and dry
cupping, blistering and counter-irritants to subdue inflammatory action.
Surgeon S. N. Shermax, 3ith X. T., Seneca Milh, Md., Sept. 30, 1861.— The 34th X. Y. was mustered into service
June 15 at Albany, N. Y. It reached Washington July 6 and went into camp on Kalorama heights. There it remained
THE CONTINUED FEVERS. 361
until tho :?Otb, wheu tlio sick were ordered to the Oeorgotown hospital and tho regiment to Seneca Mills, Md., where
it arrived iin Ausiust 2. While eneaniped at Kalurania the diseases were almost exelusi vely diarrhiea aud rheumatism,
hut since it occupied its present location there have been superadded intermittent and remittent levers, which in a
few cases have assumed a typhoid typo. 1 was detained at Washington and did not rejoin my regiment until August
11, when I found it encamped in tho .Seneca hottom, half a inilo from tho Potomac. Immediately tho camp was
removed to an elevation half a mile from and one hundred and fifty feet above the creek and about the same distance
from and height above the Potomac. All possible attention has been paid to police regulations. The location is airy
aud descends in all directions. The water from a spring adjacent is both pure and abundant. Tho rations furnished
are sutlicietit in (|uantity and of unexce))tionable ([uality. Ardent spirits are excluded. Among the duties assigned
tho regiment is that of guarding the river for four miles above and below the camp; this has reijuired tho constant
services of two companies, with generally four on picket on the banks of the river or the tinv-path of the canal.
Chills and fever have resulted, but only among those doing guard duty on the river; and of those attacked few fail
of a rapid reeovery when ([uinine is liberally used and strict conlinement to camp enjoined. As the frosts of ant uinn
approach the number of attacks decrease and the recoveries are more speedy.
.laa'l Surg. S. COMPTON SMirii, Mli Ifia. Car., IkUiii //oh.vc, Md., Sept. 30, l»;i. — We had been in our present
encampment hut a few days when fevers of a remittent aiul typhoid tyi'e supervened, three jiatients having died of
the hist-named disease. Until the present time these fevers, accompanied with the various forms of interiuittent,
have been attendant upon us, latterly, however, assuming nujre the forms of remittent and tcntian. They are gen-
erally controlled by the sulphate of nuinia administered early in from ton to twenty-grain doses at intervals of two
or three hours and preceded by the usual cathartiis. At this date our hospital wards are tilled with jialients
laboring under tho two last-named forms of fever with a few cases of dyseutiM'y.
Siinjeon D. Wadsworth Wain-wkight, ith X. Y., Havre de Grace, Md.,Se}>t. 30, 1861.— On August 13 the reginumt
was ordered to guard the bridges on the Philadelphia, Wilmington and Baltimore Railroad: Company H at Hack river,
I! and 1 at Uunpowder river, E and 1) at ISush river, K at Pcrrymanvillc, A, C and G at Havre de Grace and F at Perry-
ville. We have had many eases of malarial fever, mostly from Hack, Gunpowder and Bush rivers; some of these
were intermittent, others remit tent, ami all had a tendency to a typhoid state. Most of them yielded readily to treat-
ment, ten grains of calomel with castor oil followed by (|uinine, twenty-four grains in twenty-four hours.
.isa't Siiri/. Hi-:n1{Y S. Sciieli., U. S. A., on the condition of the Liyht Batteries of Fit z- John I'orter's Vieision, Hall's
Hill, l'u.,Sej)t. 30, 1861. — Fort Corcoran is situated about ono-fonrth of a mile from the Potonuie river on the Virginia
side, opposite Georgetown, D. C. It is upon the brow of the first hill from the river, and is a recently constructed
earthwork exposing a large amount of freshly upturned and nmist soil to the action of tho sun. Besides this, tho
woods which at one time intervened between its site and the marsh below were felled during the summer in the con-
struction of abatis. Hence miasmatic diseases are pre valiant and characterized to sonm extent by a typhoid tendency.
.Sitrijeon N. F. Marsh, llh I'a. Car., Washington, II. C, Dec. 30, 18G1. — During the jiast two months the tendency
of every disease has been to assume a typhoid character; a simple attack of diarrhoea would in twenty four hours
render a vigorous man perfectly prostrate, and he would then present all the incipient symptoms of typhoid fever.
Surgeon Joseph 1'. Colgan, 59//i N. 1'., Camp Sherman, Fort (load Hope, D. V.,Januarii, 18G2. — Tho weather for tho
season of the year has been favorable, yet the temperature is variable and the transitions ijuick, which is productive
perhaps of UH)ro respiratory disease than a colder and less vari.able season might bo. Coughs and catarrhal atlections
have ])revailed to a considerable extent in consecjuence. Another cause of the prevalence of such complaints is found
in the fact that the Sibley tents in which the men sleep are furnished with small sheet-iron stoves of poor quality,
e:i.sily and quickly heated and as quickly cooled again, and unless they are eonstantly supplied with fuel the tem-
perature speedily falls to a low point, so that it is all the lime too hot or too eold. Previous to day-break, when
the nu'rcury orilijiarily falls lower than at any other hour and the men are all asleep, the fires die out, aud as the toi>
of the tent is open to the atnu>sj)here, dew, frost, snow or rain, as the case nuiy be, causes surgeon's call to be well
attended with invalids complaining of pains, coughs, colds, fevers, etc. Some of the stoves have pipes reacliiug
out at the top, hut others, and these the majority, have pipes reaching but half way up, so that tho smoke ascending
deposits soot on the slope of the canvas from which at every blast of the wind it is shaken oif, covering tho faces
and hands of the men, adhering to their clothes and giving them, previous to ablution in the morning, a dirty and
unbecoming appearance. This is, however, unavoidable wheu troops have to take up winter quarters in tents,
sleeping on tho ground. I nuiy as well say here that men so situated are too scantily su|iplied with covering, each
man being provided with but a single blanket for covering and i)rotcction from the cohl and damp ground. This
scanty eovering compels them always to sleep in their clothes, the ovcreoat being the only garment removed, and
this only to be converted into a beilcover or quilt. It must not be forgotten that when they retire to their eanvas
quarters their clothes are often wet. There can be no ([uestion as to the eouse(|ueure of men sleeping in garuu'.uts
aiul in such (piarters. huddled together in crowds of twenty to a tent; that it teiuls to demoralize them to a certain
extent I entertain no doubt, and think it should be practiced only whc'U unavoidal)le. As a consequence of these
eonditions our prevailing diseases are affections of the respiratory organs and fevers. Intermittents are .seldom
well marked, but remittents are frecjuent and various in their character from the most simple to the nujst compli-
cated, some soon assuming the typhoid type; for which reason they have been by many surgeons named "typhoid
fevers,"' so that nearly all have been compelled to adopt the nomenclature, while many arc of tho opinion that the
disease is "bilious remittent," which sometimes, of course, runs into continued and congestive fevers. The patho-
Med. Hist., Pt. Ill— 46
362 PO?T-MOKTEXr EECORIVS OF
logical euuditions are so various that no organ esrajtes l>eing involved in all cases. Qaiuine and stimnlauts ate
necessary and in verv large doses: in a few instances the disease refused to yield to these remedies until the system
was brought slighUy Jinder the intlueace of calomel.
Act. Ass't S»rg. Edward T. Whittixgh.vm, on tie camditiOH of tt« Artilltrg Brigade of EearMg'g Dirhioit. near Har-
riifouf LaHdiHii. Pn., June 30, l^tJ. — I joined the command Slay 17. at Cumberland Lauding on the Pamunkey
river. Since that time we have l>een constantly exj>ose<l to the fatigue of marching and the em:uiations from swamps
lying on our ronte. We have also V>e?n obliged to use water so muddy and impure as to l>e unfit for drinking. These
causes, in conjunction with the previous exposure of the troops in the marshes alwul Yorktown. produce*! a general
tendency to malarial fevers and dysenteric aftections severe in their tyi>c and escee<lingly unmanageable. Quinine in
very large doses and opium have l>een the reme<lies emiilovcil. Though the mortality has not been large, yet the
average dutxttion of sickness has be«n extremely long.
«?«rj»rt>ii J. M. BoiSXOT, r". S. P., Gaiars' Mill i/<>«jiijiii, Ktar M^i-ianic^rilU. Fii.. June. 18d2. — The seven cases of
typhoid fever which we report were of unusual severity, four of them original and three setjueuces of remiiieni fever.
All diseases in the army, of the class of fevers particularly, have a typhoid tendency. I Wlieve that circumstances
producing fre<incut and njpid changes in the temperature of the l>ody. as a rapid march and then a halt, a hot and
quickly eaten meal of soup and colfee, etc.. thet\ lying down on the cool ground, have maiuly to do in bringins alniut
this condition. My plan of treatment in the seven cases treated in this hospital was to give str«ng but digestible
food and stimulants in suutU quantities, administered nearly every hour; sis recovered and one died.
SiirtiroH D.vviD Mekkitt, 55** Pa.. Edifto Iflamd, S. C. June 30, 1^62. — Edisto Island, upon which this regiment
is stationed. alKinnds in swamps or salt-water marshes. The climate is warm and generally sultry, but modified by
a cool sea^bre<Pie in the altemotm from Xorth Edisto river. The prevalent diseases arv bilious remitteut lever, which
tends to assume a typhoid character, and dysentery, bilious in character and mild, easily managetl by the prompt
useof mercurials followed by full doses of s;»line cathartics. The duties of the trooj>s are light: they are quartered in
tents and the sick in hospitiU tents. The diet, clothing and general habits of the men as to cleanliness, tcmjierance,
etc., at* good. The water, however, is bj»d. being generally sulphurous.
SwrgitiHi A. B. Sxow, A". T. £iijr«iiorrSj HiUot> Head, S. C, Jtmte 30, ISliG. — ^During the winter the fevers were of an
interuiitteut character, but since the warm weather has set in they have assumed moi« of a bilious typhoid lyin-.
Smr^tw AlJix.\N"nKR M. SrEKR, 7J* Pa. Car.. Beinfe/oim, Aj»., Feb. S. 1S»J2. — ^The diseases to which the men were
most susceptible were a r«>mittent form of fever with a strong tendency to assume a typhoid chaRu-ter. diarrhipas
arisiug frtnu change of food and water, and mild bronchial affections, which have been, however, with a few excep-
tious. amenable to tn^atiuent.
Surgeon W. J. CnKXOwmi, 3.~><A III., near Kolla. ilo., Drc. 1, XS61. — Heiv also [Otterville, Mo.] was our largest
list of iuterniitients and rvniittents, and to add to our trouble we had uo quiuiue nor could we procure :tny. Frequent
requisitions were made on St. Louis, and in the space of two we<eks as many as five messengers wer»? disp;ttched for it :
but as the mediciue had l>een forwarded to us by the purveyor it was supjKised we would receive it. This supply.
however, was lost, and we wenft comi>elled to resort to ars*nite of potash and other antiperio<lics, but our sick-lisi
steadily increaswl from fifty a day up to one hundred and fifty. Many cases assumed a tyjthoid type, and two meu
died. A marked case, showing the efficacy of qniuiue in the arrest of the disease, was exhibited in the person of
Lowery, Co. E: One of our officers on rejoining the regiment brought with him a solution of qnii\ine. This we con-
cluded to give to any of the graver cases that still showed a rviuissiou. Lowery had a dr>- cracke»l tongue, fiv«inent
pulse, and his fever manifested every indication of falling, as in other cases, into the coutiuuetl form. We gave him
twenty grains of quinine and rvi>eatetl the dose during the next remission, with the i*suli of arresting the disease.
Snr^om James L. Kikrxax, 6tli Mo. Car.. June 30, 1SS3. — ^The prevailing disieases iu the Southwest at* bronchial
and thoracic affections, typhoid fever in the low alluvial districts, and in the army, amongst tbos« who have seen
service, that peculiar train of symptoms, induced by malaria. ejkiH>snre and privations and characterize*! by lassi-
tude, emaciation and a low irritative fever, which can scarcely be classifie*!. I olvserved the same phenomena amongst
the troops comprising the Army of the Potomac last year, but not to the same extent.
Fvphoid undoubted character broke out iu snau}' of the regiments soon aftf r
their orgitnizatioii, and it is highh" probable that many aises of this disease were mistaken
for adynamic developments in malarial cases where remittents and intermittents were- the
prevailing fevers. It is equally pmbable that during these regimental epidemics adynamic
remittents were occasionally classed with the prevailing fever. After the presentation of
so many cases of undoubted typhoid from the case-books of the Seminary hospititl and tho
post-mortem records of various general hospitals it is needless to occupy space with a selec-
tion of reports indicating the presence of this fever. Some extracts showing its prevalence
will be embraced in the section discussing the etiology of the continued fevers.* Brigade
Burgeon David Pkisce, under the impression that the Arrav Medical Board of which Surgeon
THE CONTINUED FEVERS. 363
McLarex was president had concluded, as the result of its investigations, that there was
no typhoid fever in the army,* filed, in protest at the oflSce of the Surgeon General, a detailed
account of cases of this fever that had been treated in his comnaand.
But although typhoid fever was recognized by so many regimental medical officers, it was
not held by them to constitute the prevailing army fever. Surgeon Zenas E. Bliss, U. S.
v., ajipears to have been the only officer whose recorded experience was opposed to the
general view. AVhile on duty with the 3d Mich, at Yorktown, in 1862, he had a few cases
of intermittent and remittent fever and about forty cases of typhoid. These were treated
at a hospital where were also many fever cases from other regiments, and nearly all were
regarded l>y Dr. Bliss as cases of typhoid, although some of them might easily have been
classed as ](t\v remittents. Death was caused by hemorrhage in many instances, and in six
cases in wliicli post-mortem observations were made the glands of Peyer were ulcerated.f
Even at this early date, however, cases of true typho-malarial fever were observed
and reported in general terms. When the troops had been exposed — using the language
of the accejited theory of a distinct pathogenesis for the typhoid and remittent fevers — to
tiie causes of both these morbid conditions the resulting epidemic presented such a com-
plexity and variability of symptoms that an accurate diagnosis could not be expressed by
a term in which but one of the etiological factors was represented. Surgeon J.\mes King,
1st Brigade Pa. Reserves, in a published article, J dated Dec. 23, 1861, on the sanitary
condition of the troops in his command, says that it was impossible to classify either as pure
malarial oi- pure typhoid all the cases of fever that occurred. He regarded them as. mixed
affections, combining in varying degrees the characteristics of both the diseases named : In
some the diagnostic symptoms of malarial fever predominated, in others those of the typhoid
affection, while in others again there was such a blending of symptoms that it was difficult
to say which was the prominent disease.
Similar views had already been expressed by some regimental medical officers in their
sanitarv reports.
Siiii/ion Ja.mks CoLi.i.ns, 'Sd I'a. HesiTies, Camp Ttnually, I'a., Dec. 31, 1S61. — Durinf: the iiiontli of Uctobei' the
bealth of the n-ftinieut con tinned tolerably good. 'J'here was, however, a slight and general increase of sickness, and
the tyjie of disease seemed to indicate a malarial origin. Early in November diseases of an un<loubted malarial nature
Itegan to a.ssiimc a more malignant tyjie than bad been noticed since the regiment had been organized. The preva-
lent <liseases were remittent and tyi)hoid fever, catarrh and acnte bronchitis. Cases of typlioid fever have without
doubt many if not all the symptoms of the same disea.se as seen in New England and Pennsylvania; yet, as seen
in this camp, malarial intliience exercises a modifying tendency npon the disease. In some cases the line between
intermittent and lyjilioid could not be sharjily drawn. In all cases (juiuia has been given with advantage; it has
seemed to produce jieculiarly haj)py etiects even in those of a marked typhoid type.
Siirgioii W. H. TilOH.VE, VJth Pa. Ileaerves, Camp PUrpoint, Va., Sor. 1, 18G1. — The camp of this regiment is located
on the slope of a hill well adapted for surface drainage; a streamlet drains the bottom of all snpcrll nous water and
carries off the refuse matter of the camp. The soil is clay mixed with pebbles and does not retain moisture to any
great extent. The iirevailing diseases are remittent and typhoid fevers, with some dysentery, but almost no diarrhcea.
The former fever scarcely ever occurs as pure remittent, being rather of the asthenic type and not so amenable to
antipcriodics.
Siirijeoii Wm. Kaii.knkk, Kid Pa.. HaH's JJill, I'a.. Die. 31, IStil.— It was during the first days of November that
typhoid anil remittent fevers began to show themselves, and indicated a most important change in the ty]ie and
character of disease. The worst cases were complicaleil with extensive disease of the mucous membrane, which called
for I he early and free use of quinine andalcoludic stimulants. They weredoubtleSsof a malarial origin and contracted
perhaps when in cam]) near the river in the latter part of September.
Surgeon David Mi.vis, iSth I'a., Camp ll'infuld, X. C, Dec. 31, 1861. — The 1st of October, 1861, found us encamped
at Camp Hamilton, near Fortress Monroe. and laboring under the usual epidemic of diarrhoea and dysenterj- to which
• For report of this Board. s*e iii/ra, |jiige 3li5.
t S«' his report, p. 80 of the Appenilix to the first part of this ToUime.
t Medical and Sargkal BrporUr, Philadelphia, Pa., VoL Wl, p. 306.
364 POST-MOKTEM RECORDS OF
new troops are liable. These diseases -(vere at this time almost imiversal but manageable, no case terminating fatally.
After their subsidence the health of the troops was excellent and continued so until the last week in October, when
an epidemic of catarrh set in, having its origin iu the exposure incident to the service during inclement weather.
This disease, although very general in its manifestations and exceedingly painful in its symptoms, yielded readily to
treatment. During the first week of November typhoid fevermade its appearance, following immediately in the foot-
steps of the epidemic catarrh, many cases of the latter appearing to glide by almost imperceptible gradations into a
typhoid condition with all the physical signs of the specific fever. On the lltli the regiment left Camp Hamilton and
next day encamped at Fort Clark, near Hatteras Inlet. Immediately after our arrival numerous cases of typhoid fever,
which had been in their incipient stage on leaving Camp Hamilton, became fully developed, and being modified by the
miasm of the island assumed a malignant and unmanageable aspect such as I had never witnessed in any cases of the
disease previously falling under my observation. In fact in these cases typhoid fever, epidemic catarrh, remittent
and intermittent fevers were so conmiingled and mutually complicated one another as to render the diagnosis obscure,
the treatment unsatisfactory and the prognosis unfavorable. The most striking characteristic of this epidemic has
been, in the graver cases, the almost total absence of tongue-symptoms. In some, and tho.se terminating fatally in a
few days after the access of the disease, there was no abnormal appearance of the tongue during the whole progress
of the attack ; while those cases in which the tongue became heavily coated, dry and red, made good recoveries. Hotwcen
the 1st and 20th of December the regiment was removed from Fort Clark to this station. Camp Winfield, about four
miles north of Fort Clark. The general health of the regiment is good at present. Either from the prevalence of cool
weather for the last two weeks or because the troops are becoming acclimated, disea.ses having a malarious origin
have almost disappeared. We have but few cases of severe aspect now under treatment.
No doubt the opinion that the fevers then prevailing in the army were adynamic remit-
tents was based primarily on etiological and clinical considerations, — the absence of a special
typhoid infection and of symptoms indicative of a typhoid lesion, the presence of malarial
influences, the sequence of the adynamic or so-called typhoid symptoms to an intermittent
or remittent attack and in many instances the notable efficacy of quinine. But since deaths
were unfortunately of frequent occurrence it must be concluded that the general opinion did
not continue long without supjiort from post-morte7ii observations.
The only official investigation into the nature of the fevers which prevailed in our
camps was made when the Seminary hospital was receiving and treating the typhoid cases
that have been presented in a previous section, i. <?., at a time when tyj^hoid fever was unusu-
ally prevalent among the troops. A Board specially instituted to ascertain whether the
existing fever was to be considered "an intermittent or bilious remittent fever in its incep-
tion assuming in its course a typhoid type, or a typhoid fever primarily," proceeded to the
field, and as the result of personal observation and inquiry concluded that, although a cer-
tain number of cases of ordinary tvphoid'existed in the army, the large majority of the cases
were bilious remittent fevers which "had assumed that adynamic type which is present in
enteric fever."
The report of this Board is as follows:*
*Sonio official ducumonts bearing on the nature of tlie fevei"s that prevailed in the Hooghly District during the years 1870-73 have been pul>liRhed
iu the Intiiini Med. Gazette, Vol. IX, 1874, p. 74 et mj. The.se arc of interest, as the question at issue was similar to that submitted to the lloanl men-
tioned in the text. Whole families, we are told, were prostrated at the same time by the Hooghly fever; from twelve to eighteen or more members of
joint families would he laid up at the same time, though uot all suflering from the sjiuie type of fever. For instance, of eighteen cases three would
present the symptoms of typhoid, four or five of remittent, five or six of intermittent and the remainder of common continued fever. J.\mes A. Gree.ve,
Civil Medical Officer, Serampore, having seen and treated at least 2,000 cases during the epidemic in the town and suburbs under his care, arrived at the
conclusion that "the fever we have to deal with is typhoid, complicated, no doubt, with malaria, but the first outburst in any place is typhoid, and this
is the formidable fever which kills or leaves its victims so prostrated that they suffer thereafter for mouths and ye4ii-s from relapses of malarious fever
ending in enlargement of the spleen, liver, etc." Unfortunately in Dr. Greene's practice post-mortem examination was never allowed owing to caste
prejudice. His reports on these fevers were sent to Surgeon-Major Norman Ciievers, with a request for his opinion on the subject. In reply this officer
refers to the want of precision involved in the use of the word typhoid. *' Having paid considerable attention to the recent discussion upon typhoid
fever ill India, it has ajipeared clear that much confusion and vain dispute would be avoidi^il if we strictly confined ourselves to the designations 'paludal
fever' and 'enteric fever,' never again using the word 'typhoid.' Kvery pmctitioner is aware that, in Bengal, cases of cholem and renuttent fever fre-
quently take on a condition so 'typhoid' or typhus-like in its character that no physician, seeing a case for the first time, could immediately deternune,
by the symptoms alone, whether it was one of true typhus or (when, as frequently happens in the congestive, paludal, remittent of the cold season, there
is bowel complication) one of the true enteric fever as described by Jenner." Dr. Chevers then discusses the typical eases given in the reports, showing
that the "patients may have been the subjects of 'typhoid' — that is, true enteric fever, but Dr. Greene has not at all proved that they were." He
acknowledges that enteric fever has taken a defined position among the diseases of Bengal, but claims that this malady has never during the last eleven
years become at all extremely prevalent in Calcutta, although a typhus-like fever (often attended with diarrhn?.a), demonstrably of paludal origin and
amenable to the antidotal action of quinine in nearly all but the moribund cases, has been almost daily among the chief subjects of his clinical practice.
"Dr. Greene has shown that cases somewhat resembling enteric fever occur in these districts [Burdwan, Hooghly and Sei-ampore], but such cases also
occur in Calcutta, where these causative elements are nearly equally rife. Still, when thoroughly sifted, very few of the multitude of grave Calcutta fever
Special Oudeks, }
No. 323. f
THE CONTTNURB FKVRKS. 365
IlKAlHilAlM'KUS (II- llIK Ak.MY, AllJUTANT UeNKKAL's OKI'ICK,
Wanhinyton, Dec. Gth, 1861.
6. A Hoard to consist of Surgeon A. N. McLakk.n, V. S. A.. Hiiuiide Suifn^oii G. II. Ly.man, U. S. Viiliintccr
service aud Ass't Surg. M. J. A.scit, U. S, .\rniy, is hereby in.stiliih<l lor the following object: To visit :is niiiny
of the camps in the vicinity of WiisUingtou as they may consider necessary to obtain suflicient data to iii;iKc a
report to the Surgeon General on the character of the di.seaso termed by the Medical (Jtlicers of the lirigadi's and
Kegimenls "Tyiihoid Fever," and as far as practicable the causes of its adyiianiie type and wlu'ther it is to lie
considered an intermittent or bilious n-iMilleiit lever in its inci'iilion, assuming in its course the t.vphoiclal l\pi' or
a ly(ihiiid fever inimarily.
The Hoard will be regulated in its .sessions :unl nuivcnients by its President so as least to interfere with llie
other operations of the service. The. junior member will act as recorder.
*»t* ^ ' -**####
JJV lll.MMANH (If Ma.I. (iKN'l. M( ( ' l.l'.I.I..vN.
(Signed) L. THOMAS,
Adjuldtit Cciirrnl.
In obedience to the aliove order the Hoard convened on Monday the Kitli day of |)ceinilici-, ISIU, at 1 lie (|iiarleis
of Hrigade Surgeon hvMAN and proceeded to examine the brigade and regimental hospitals of the division com-
manded liy Hrigadier General Kitz-.Iohu I'orter with a view to the observation of smdi eases as might exist, and
to the eoni)iarison of such sym])tonis ami tcnchmcies of the disease as at present prevailing with :i similar all'ection
that had already occurred and had Ikm^ii reported as typhoid fever.
The regimental hospitals of the ITtli and 2.")th New York, the 83d Pennsylvania,, the IXth .Massachusetts and
till- '.'d Maine regiments were observed, together with th(^ brigade hospital (■(iniiectcd with General Morell's brigade;
but few cases were discovered which could be designated correctly as of a typhoid character. Of the cas(\s so marked
the majority had been received into hospital as snlfering from bilious remittent fever which in its ]irogr(>,ss assnnu'd
the typhoid type so well known to those whose experien(re in malarial fevers has been gleaned in the Soulli. No
case of enteric fever was ob.served. The disease was evidently of malarial origin and was so considered liy the
medical otticers. Asa general rule in this division, quinine given in large doses in the remission, with mercurials as
re(iuired, had the effect of cheeking the fevers. The typhoid state only appeared as a result of a continuous neglect
of hygienic precautions when in health or in those persons who had been expo.sed to unusually severe and prolonged
duty. In the cases assuming the ty|ili(iid tyjie which the Board examined, although symptoms of prostration and
sinking were present, together with the dry glazed tongue, collection of sordes on the teeth and gums and subsultus
tendinum which characterize the state, still the absence of any enteric symptoms and of the taches rouges, which are
the almost invariably constant symptoms in trne tyidioid fever, as well as of any imlinonary complication, was siifli-
cient to warrant the Hoard in concluding that the cas(!s before them were not of the enteric fever so comiimn in the
Northern States and generally known as typhoid fever, while the previous location of the regiments in regions
notoriously malarious justified them in attributing malarial origin in the febrile cases brought to their notice. The
eaii.ps and hos]iitals of this division with one excejition were remarkably neat and clean and are deserving of the
highest encomium. It must be noticed as .a medical curiosity, which it would be scarcely safe to take as a pre(;edent
for any similar rule of action, that the cam)) in which police regulations had not been enforced and which, in con-
seiiucnce, was in an eminently filthy condition, was in the most satisfactory sanitary state and, at the period of the
visit of the Hoard, had not a .seriously ill patient in its hospital. It is but just to the surgeon of this reginn^nt to
state that he had already instituted uu>asures which in a very brief period would cause his camii to compare favor-
ably with any other in the division. There was observed in one of the regimental hospitals a numlMU- of cases of
superficial gangrene of th(^ toes resulting in some cases from fever, although present in others where no snch jirimary
cause existed but where the patient was in an adynamic condition.
Ou the 18th of December the Hoard again convened and visited the divisions commanded by (ien'ls MeCall and
Smith. Here were found some cases of typhoid fever with thi^ enteric and pulmonary sym])toms which distinguish
it in the North, but by far the majority of the cases were of bilious remittent fever resulting from the encampment
rai*cR turn uut tu be instances of tnie enteric fever. Tlie true nature of many of tlie cases wlii(!li occur in tbe Seraniporo district may t)e infernKl from tlie
fiiit mentioncl tjy Dr. Greene lliat, when iiatients stmpple tliroiif^ti tlie tirst violence of tlie malady, they ultimately fall victims to debility, enlar{;ement
of (lie »]ileen and liver, ana-niia and drojisy. These are not the jiropiT seiiuela- of enteric or of relapsing fever, and they dearly point to a iiiilndal cause.
Hence, I submit, our first course is to ascertain, t)y at least some half dozen carefully iwrfurmiid post-morlem examinations in welNdioscn cases, whether
the disease is, in reality, true enteric fever or a typhus-like fever of paludal origin, complicated in some cases with diarrlicea, which symptom, I neeil
scarcely say, is very common in the true marsh fevers of India whenever, as in very cold weather, the state of the skin does not allow of free critical
sweating." Here Dr. Chevers attaches the following note : "Since I wrote this a very characteristic case of this type of malarious fever \it\s tiM'ininated
fatally in luy ward. A khansamah, of Toltolah, was attended on the 4th instant, complaining that he had suffered from intermittent fever for about 15
days. Tongue moist and clean, tenipenitunt KJ.'jo, sjilenic fulness, a little cough and bronchitic riiles. On the next day there was jaundice with consti-
[ntitin. On the day after that pleuro-pneunionia of the right lung set in. .Some might considi-r this a primary feature in the case, I recognized it ;is a
secoudarj- lesion common in the severe malarious fever of this cold weather. The daily evening tempei-ature was 105 ; Wi ; tod ; 102 ; '.111 ; lot ; KKI, sordes
on tongue and lips ; 98 m., 99 e ; 101 ; 102 ; 102 ; I(X) ; 101, nither consti|)ated ; 99 m., 100.8 e. ; 101 m., 100 e., tongue, lijis and teetli dry, loose yellow stools ;
102 m. and e., tongue moist and clean, three stools of the consistence and appearance of thick dal, no gurgling in the iliac fossa ; 102 ; three stools ; 98 m.,
IttI e.; 97.8 m., tongue moist and clean, three diarrhceal stools, 101 e., frequent diarjha-al stools, incoherence, death. Here the stools had vi-ry iiiuch the
apjieamnce of those in enteric fever, tnit they did not contain blood or mucus. The character of the moderate head symptoms, the ninge of the tem-
IK-ntture and the state of the tongue, except for a time, did not indicate enteric fever ; and yet I could not feet quite satisfied on this point until I had
ascertained that the small intestine was iM-rfectly healthy."
366 POST-MORTEM EECOKDS OF
of the regiments dnring the aniunrn montUs in a malarious district. In Gen'l Smith's division nearly all diseases
assumed a typhoid type, which was attributed by the surgeons to ochlesis or crowd-poisoning jiroduced by the over-
crowding of men in their ijuarters. and also to the fatigue induced by excessive drilling and the unnecessary length
of time which the men are occasionally required to pass on duty, as well as the depressing inlJuence of camp life on
persons not habituated to it. In Gen"l Hancock's brigade a number of cases of typhoid fever had occurred which
Brisade Surseon Havex attributed to causes belonging to the men themselves and not to the condition of the camp.
This brispide is composed of Vermont troops, who are the most thoroughly provincial of any in the service, and who,
accustomed to their native mountains, feel acutely the depressing influence of nostalgia and malaria when absent
from them and on this account, probably, are more liable to disease of an adynamic type than those from other loeal-
ities. The same fact is noticed among those Pennsylvania troops coming from the mountainous region of the Alle-
ghanies. In the division commanded by Gen"l McCall a uumlier of cases of typhoid fever were reported, but. as in
Gen"l .Smith's division, the majority of the patients were laboring under bilious remittent fever: some cases of gastro-
enteric fever were found. As want of time precluded the Board from examining thoroughly all the hospitals of this
division, the following interrogations were propounded to the various medical officers, the answers to which will be
found appended, viz:
1. What number of cases of bilious remittent and of typhoid fever have occurred in your regiment ?
2. Is the so-called typhoid fever the typhoid fever of the North or is it of malarial origin ?
3. What do yon consider to be its cause ?
4. Describe the symptoms of the fever occurring under your care?
5. The treatment adopted f
6. The locality of the regiment before the appearance of the disease ?
7. The percentage of the disease?
S. Have any cases of gangrene of the toes bfen observed as the result of /ever or otherwise?
From the information aftbrded by the answers to these questions the Board found nothing to justify an opinion
that typhoid fever existed as an epidemic or otherwise than in a very small proportion in this part of the army. The
majority of cases of fever were clearly of malarial origin and in some cases from the causes above enumerated they
assumetl a typhoid type. The gangrene of the toes which had been observed in other divisions was found here also
from the same supposed cause and in but small ratio. In Heintzleman's division the brigades of Sedgwick and
Jamison were examined: In the former no c.-jse of enteric fever was found and but few of bilious remittent: in
the latter there wen? a few cases presenting the appearance of tyi>hoid fever in which were the taches rouges and
intestinal symptoms, pathognomonic of the disease, accompanied with pulmonary and cerebral disturbances, but the
cases were convalescing and no new ones were appearing.
From the data furnished by the investigations stated above the Board feel justified in concluding:
First. That the large majority of febrile diseases which have been reported as '-typhoid fever" are not cases
of that fever which is characterized by the eruption of rose-colored spots about the seventh day and has for its jiecu-
liar lesion inflammation and ulceration of the glands of Peyer and is known in the Xorthern .States as typhoid or
gastro-enteric fever, but they are bilious remittent fevers, which jiot having been controlled in their primary stage
have assumed that adynamic type which is present in enteric fever, on which account they have been erroneously
termed ••typhoid." whereas in reality those lesions which invariably accompany trne •■typhoid fever" have been
w;iuting. There is nudonbtetUy present in some patients low delirium, subsultus tendiuum. sordes on the teeth and
gums with occaiiionally a black, dry and glazed tongue, but the tender and tympanitic abdomen, the taches rouges
and the diarrhoea, which are almost constant symptoms in enteric/ever, are absent. Cases of typhoid fever certainly
exist in the army, but it is so far from being epidemic that the ratio of its occurrence is less than it would be in civil
life amongst the same numiier of individuals.
Secontlly. The cause of the bilious remittent fever that exists in the Arnnr of the Potomac is undoubtedly the
malaria generated in the vicinity of the river to which it has been exposed during the late summer and autumn
months, but the causes of the typhoid condition that it takes on are different and probably within our reach to be
guarded against. The hygienic measures instituted by the Medical Director of the Army of the Potomac are proving
eBVctual in lessening the number of cases of malarial fever, and it is possible tjiat measures may be adopted which
will lessen the tendency of diseases to take on the low forms that they have lately assumed. This tendency may
originate from blood-poisoning induced by the crowding together of men in close and illy ventilated quarters, from
fatigue occasioned by excessive drilling, from over-exertion resulting from a too protracted tour of duty, from nos-
talgia and from a want of attention to personal cleanliness. If it occur from these causes, and in the opinion of the
Board it does, the prevention is in the hands of the proper authorities. Suflicient space should be given for quarters;
a proper discretion exercised in the allotment of time for drill: consideration should be shown for those engaged in
laborious and fatiguing duty: cleanliness should be rigidly enforced and nostalgia avoided by diversion of mind
brought about by proper gymnastic and other sports, and it may be that the depressing influences now operating
■will be obviated and as a necessary result the adynamic type of disease will be changed.
The Board takes this occasion to remark that the sanitary condition of the army generally is eminently satis-
factory as far as it has come under observation, the number of cases of disease being proportionally few and of these
but a small ratio are of a serious character.
Papers appended to the Report of the Board.
Brigade SnrgeoH Jajiks Kisg, U. S. Toh. — 1st. The last three monthly reports of the surgeons show in the
four regiments of the brigade 539 cases of remittent fever and 37 of typhoid fever, the mean strength of the brigade
being about 3,200, officeis and men. 2d. The surgeons represent two forms of fever as prevailing — one, bilious
TIIK CONTINURT) FF.VERS.
367
remittent, a lever of malm i a I oiifjiii, the other typhoiil, " the lypliuid i>f tlie Xorth." In my opinion it is impossible
to draw sueh u line of distinrtion respecting these fevers as to divide the cases into two wclldelincd classes, one
exhiliitinj; in its group of symptoms the ordinary diagnostic nnirks of ty]>lioid and the other of remittent fever.
On the contrary, there is a certain tout iimrmblv or general form lielonging to all by which we recognize one allection,
though varying in its features in difterent oases, just as we know the physiognomy of man iu all its diversified
modes of exjiression. I have observed the following charaotors or so-called diagnostic signs of the two diseases
apparently expressed and variously coexisting in the san\e subject. It would lie easy to arrange the facts observed
in a tabular statement sluiwiiig in one column the distinguishing mm ks of the "malaria!" and in thi' other of the
"typhoid" disease, but the facts are so commingled and unitc<l in many cases that if rec|iiired to classify them with
one or the other disea.se it would he ditlienit to say to which they belong. The following facts, for example, I have
observed as variously coexisting in many cases:
AVWciiccd 0/ niiiiltcitt J'cecr or dimiisc of " miihirial iiiii/iii."
1st. The disesise maile its appearance in aiilinnn and on
the rotoMUic (malarial region).
I'll. Many of the subjects have the disease ilex clopid
suddenly.
;{||. Karn oases begin with ejiistaxis.
4th. Nospeeial tendency todianlnra nianifi'sted.at least
I have not (dis<rviMl this.
otli. We very seldom see miu'h tyiii))anites, often none.
(itli. The fever has distinct remissions and is fiinnd in
company with true intermittents.
7th. In the first stagi's the tongue is furred white or
yellow, enlarged and indente.l at the edges.
>ith. Numerous cases of other malarial disease oci'urring,
as neuralgia and ,jaMndi(u% fever patients showing jaun-
diced urine.
9tli. Certain marked ell'ecls of ijuininc in relieving head-
ache, 8tui>or and delirium in the early stages, in cutting
some cases short and occasionally in att'ording speedy ben-
efit when the cases are eharacteri/e<l by dry tongue, ro.se-
spots and other signs of tlu' ty|>lioiil condition
10th. Certain iiDxt-mnrltiii ap])earances, as loss of color
in the liver and <listention of the gall-bladder; the liver
was very jiale in two cases examined.
lllli. Exposure to night-air before the attack in locali-
ties where intermittents arise, as on night marches, ])icket
dntv. etc.
I'fidniccK of ti/phoid, lh<; " li/iilioid f<rif of the Xoilh."
1st. It continues to prevail after the heavy frosts and
in winter.
LM. Most cases have a protracted convalescence though
they have not been attacked with ])arliciilar viol(^n('e.
3d. Many show rose-coloreil s|)ots.
Ith. Few cas<'s, noni' that I have known, have shown
much nausea ami bilious vomiting.
."ith. Many of the cases havi^ sutlusion of the eyes, dusky
countenance and mental hebetuile.
fitli. 'I'he (huatiou of the disi'ase, when fully m;irked
mostly I'uns on to the third or i'ourth week.
7th. In the last stagi's the tongue is dry and glazed,
often crackeil and covered with sordes.
Kth. The occurrence of inuiblesome suppurations, as
abscess about the jiarotid glands, following th(^ fm'iM' in a
number of cases.
iltli. Certain good etti'cts of turpentine in cases with
glazed tongue and tympanitic abdonuMi, the decided ad-
vantage of nutritions stimulants, as brandy-]iunch, in all
cases, and the apparent necessity ol'suppoiting nutans to
relieve the adynamic stateand resist the temh iir\ hi death
by asthenia.
10th. (Jertain jio'it-morlfm apjiearances, as thickening,
inflanmuition and ulceration of Peyer's glands in three
ca.s(rs examined, and atlection of mesenteric glands. Ulcer-
ation of the elliptical plates was noticed where there was
no gaseous distention of the bowels.
nth. Previous crowding of men in badly ventilated
tents in filthy camps, for as yet it has been impossible to
enforce proper police regulations.
I cannot pursue this analysis further in the present report, liut I will ask, ari^ wi^ juslilicd in regarding all the
facts above noted as entitled to weight, as I think we are, and in determining from the combination in the same cases
of many of these characteristics of two diseases that we have a mixed atlection i Or. if not, shall we take the "rose-
colored eruption" and atlection of Peyer's glands as pathognomonic of the disease and say it is typhoid fever, or take
the intluence of i|uinine in the treatment as S|)ecilic for the malarial poison or some such chara<.tcristic and say the
fever is a "bilious remittent f" In my judgnu>nt it is only by carefully collecting tlu^ facts noti'd by reginusntal and
hospital surgeons who have made diligent observation of their cases that we cau arrive at just conclusions on this
subject, the investigation of which, by a competent ollicer detailed for the purpo.se, would not be without its uses
to the public service. 3«l. As to treatment, I have observed most .satisfactory results from the >ise of nuinine, begin-
ning with a dose of sixteen or t wi'uty grains in the morning and the remedy continued in snuiller doses for several
successive mornings in the early stages of the disease, tlii' occasional use of blue mass, febrifuge mixtures when indi-
cated, the early resort to nutritious stimulants and tluiil nourishment with nitrate of silver, sugar of lead and spirit
of tnrpentine administered for certain enteric symptoms when particularly indicated. The inllammatory and con-
gestive complications are treated successfully iu the usual way by sinapisms and cupping. 4Ui and 5tll, As to the
symiitoms and cause of the fever, I have uo other report than that given above to indicate its character. Olli- As
to the localities of regiments, I have to refer to the reports of the reginu'ntal siirgeons. 7tll. As to percentage of sick,
I suppose that is sullicieutly answered with the Ist point. 8tll. As to gangrene of the toes: This I observed in one
ca.se; in another great jiain was complained of, but I ob.served no discoloration or sloughing of the skin. In both
the fever was protracted, but as I had not the oj)portunity of watching-the progress of the disease iu the first case
I hiive uo further remarks on the subject.
Siirijeon H. K. Nki-k, Hlh Pa. — 1st. This reginunt has at the present time ten or twelve cases of liilious remit-
tent and typhoid fever under treatment. ii«l. The so-called tyiihoid fever here is not the same in all jiarticulars
368 POST-MORTKM RECORDS OF
as that of the North. I consider it emphatically of malarial origin. 3d. Treatment has been in all cases anti-
periotUc, tonic and stimnlant. Large doses of qninine are given at the outset and followed by decreased doses
throughout the course of the attack. Blue mass is also freijiiently given in combination with the quinine when
indicated. Ordinarily after the first dose, which is usually from fifteen to twenty grains, the patient gets the quinine
in divided doses so as to receive from ten to twelve grains in 24 hours. In addition to this he gets tonics such as the
tincture of iron and, when indicated, diuretics, febrifuges, etc. The usual plan of treatment is that j>ursued in the
North in like cases except the quinine and stimulants during the early stages. 4:tll. The symptoms are similar to
those of ordinary fevers. The tongue, however, is flabby, watery and pale, remaining so, except in the most malig-
nant cases, throughout the whole cour.se of the disease; when the fever is of the malignant type the tongue is dark,
dry and in some cases fissured. The pulse is generally feeble from the .start. In many cases for several days after its
onset the disease assumes a decided remittent and in some ca.ses intermittent form; but in most instances it after-
wards becomes continued. 5tll. The sui)po.sed cause is malaria. Exciting causes: Exposure, irregularities iu diet,
diink, etc., and an indifference to the established rules of hygiene generally. Gtll. Last locality: A northern slope
near the Potomac on the Virginia side, Fairfax Co. Present locality: Southern slope of opposite hill facing former
location. 7tll. Percentage of sick: 11. 8th. Gangrene of toes: no remarks.
Ass't Surg. D. McKinney, 10th Pa. — 1st, The number of cases of bilious remiMent fever treated in our hospital
has been 38, of which 13 occurred at Camp Tenn.ally .and 25 at Pierpont; we had three cases of typhoid fever. 2(1.
From my observation I am led to believe that the army typhoid is of malarious origin. Our first case had just
recovered from an attack of bilious remittent fever and the two other cases showed decided remissions at first. Quite
a number of our bilious remittent fevers exhibited for a time a typhoid character, although yielding readily to large
iloses of qninine. 3d. In the treatment of typhoid fever quinine, solution of the acetate of lead, mucilage of tur-
pentine, wine and brandy were used. 4tll. The early symptoms were those of rennttent fever, but after a few days
decided symptoms of typhoid fever were displayed. The disease yields much earlier to treatment than tlu' typhoid
fever of the North. 5tll. Malaria is the supi)osed cause, aided by the entire change of h.ibits of the volunteer from
the comforts of home to excitement, exposure, badly prepared food and crowded tents incident to camp life. Gtll.
Camp Tennally, two cases; Camp Pierpont, one case. 7th. Four per cent, for the past thirty days.
Surgeon S. G. L.\>'E, 5th Pa. — 1 st. We have had from December 1 to date 24 cases of remittent and one of typhoid
fever. 2d. The typhoid reported is properly so called, and is the typhoid or enteric fever of the North. 3d. Our
tireatment consists of quinine, gentle purgatives when needed, alteratives, turpentine, nourishment, stimulants and
cleanliness; local complications are treated as their character dem.ands. The large and repeated doses of quinine,
so highly lauded by many authorities, have failed in our hands to eftect the promised good results, and, I believe,
when given thus heroically, it is apt to oppress the nervous powers, mask the symptoms and aggravate local conges-
tions into inflammations. 4th. The symptoms vary as the case may be remittent or enteric fever. In the remittent
the disease usually makes its appearance suddenly with a chill, followed by fever and perspiration; sometimes the
patient has a sallow, sickly appearance, with impaired appetite, nansea, diarrhoea and the tongue covered with yel-
lowish or whitish fur. This diseased condition intensifies and breaks into a distinct remittent, or an intermittent may
pass into a remittent. When the fever is fully formed the patient has slight remissions, quick pulse, hot skin, head-
ache, tenderness of abdomen and more or less delirium ; the tongue soon becomes dry and cracked, the bowels relaxed
and the stools various. Many cases pass early into a low or typhoid condition with the usual symptoms. The local
aft'ections are numerous, occurring in the head, chest and abdomen. Usually the enteric cases begin insidiously:
Nervous derangement is an early symptom ; fever, sometimes at fir.st remittent; epistaxis; pulse quick and feeble;
headache, confusion of mind and duluess of hearing; stools characteristic; dry glazed tongue; sordes on teeth;
appetite often not aft'ected; hemorrhage from bowels; rose-colored eruption on abdomen; tympanites not always
present; slow and tedious recovery; patients generally young men; deaths sudden; ulcerations of glands of intes-
tines discovered on post-mortem examination; strong tendency to local inflammations. 5th. The supposed causes of
remittent fever are miasmata, but as our cases tend so rapidly to the typhoid condition I believe them also influenced
by the causes which develop enteric fever. Our camp is located on a narrow tongue of land until within a short
time densely wooded and surrounded by woods. A slow, boggy spring, iii which four regiments wash, runs along one
side, and at the point of the strip upon which we are encamped it meets another purer stream running along our
otherside. The tents are crowded together, preventing proper drainage. Six men sleep in one A tent. They have no
straw, insufficient blankets, sleep in their clothes, which they can seldom change, disregard cleanliness, cook badl.v,
take no gymnastic exercise and are discouraged. Log houses are being built by the men, but they are close and
crow ded. Here is a process of impairing the vital forces which mvist make our diseases adynamic. Gtll, These dis-
eases have prevailed in this regiment since September (when I joined), but are now more severe, 7th. Percentage
of sick of aggregate force to-day 13.11. 8th. Have had no gangrene of toes.
Surgeon L. W. Rb,vi), 1st iV.— 1st. Number of fever cases from August to December inclusive: Remittent 526,
typhoid 7. 2d. Many of the cases treated were well defined remittent fever, but the majority presented various
grades of complication, manifested by a sense of great weakness, exhaustion or prostration indicating the presence
of some depressing or epidemic influence; and as they did not present the characteristics of genuine typhoid they
were regarded and treated as remittent fever. Only seven eases, two of which died, gave evidence of pure typhoid
fever. 3d. The great change in the habits of the men, such as exposure to rain and night-air in the performance
of picket and guard duty, lying on the ground, sleeping in wet clothes, etc. 4th. Many of (he cases were ushered
in without any premonition, but the majority were preceded for one or two days by a feeling of great fatigue or dis-
inclination to exertion, with pain in the head and back; tongue coated and the circulation accelerated; about the
TlIK COJJTIJSUED FEVERS. 369
tliiiil (lay there was a diciili'd rliill ami trver with an a,c;gi'iiv'atioii of all the symptoms. There was generally a coni-
liiiiatiim of tlieso eonditions in tlio niorniiif;. .\ nnniber of the cases yieldetl readily to treatment and were conva-
lescent in five or six days. Those that persisted were characterized by a feeling of exhanstion or prostration, heavily
coated or dry tongue, pain in the head anil hack, loss of appetite, occasionally nausea and diarrlnea with slight
tyiu|)anites. The urine was turbid or highly colored, with a strong aninioniacal oilor. «)tll. When the case was seen
during the remission quinine was freely given, and during the day lilue-iiill followed liy castor or croton oil was
administered. When seen during the presence of fever, (luinine was preceded by purgatives: as a febrifuge neutral
mixture or muriate of ammonia was given; when the tongue was dry turpentine was used, and when there was
luucb depression an emulsion of carbonate of ammonia, brandy-i)unch and beef-tea; restlessness was treated with
anodynes. 6Hi. The locality of the regiment before the breaking out of the disease was Camp Wayne, West
Chester. Ta. 7th. Percentage: Kemittout fever 526, typhoid 7. 8tll. I have had no case of gangrene of the toes
but have treated a number of oases iu which there was great pain and acute sensibility of the toes, several of
which have persisted for more than three mouths.
lintjaiU- Sttrff. W. (i. Lowman, V. S. V. — l.st. I am of opinion that all the cases of fever in my brigade are bilious
remittents. 2d. The typhoid fever here is not the typhoid of the North. Although there are nuiny of the symptoms,
as slight diarrlnea and tymiianites, rose-spots, delirium, etc., the disease comes on too rapidly for typhoiil and there is
not that hebetude of body and mind, tendi'rness or tympanites of the bowels, nor the red pointed tongue that we
have iu the North. The <liscase assuuu!s a typhoid type iu cases that run on for ten days or two weeks, and in consti-
tutions that have been broken down by jirevious <lisease, in drunkards, etc. I am of opinion that if the use of qui-
nine be commenced early the disease will bo broken u]) iu from three days to a week, at least in the majority of
eases. Those of my surgeons who nse quinine early and freely have few cases of the so-called typhoid, — it is almost
always cut short. Hence 1 look upon the disease as remittent iu character and caused by malaria. ludeed all
diseases hero are, I think, influenced more or less by malaria. If a man takes a bad cold, sufficient to produce a
little fever, icterus shows itself and he will iu all probability have remittent fever. 3d. The treatment is blue-pill
and quinine: and those who give these freely have the best success. When the disease runs on for ten days or two
weeks and the tongue becomes red, dry and chapped, the treatment consists of stimulants and alteratives, as turpen-
tine, brivndy, wine-whey, punch, etc. The turpentine acts admirably on the dry, cliai)i)ed tongue. 4tll. The symp-
toms generally come on rapidly with chilliness or rigors followed by heat, full pulse, dry tongue, slightly furred and
soon becoming brown, constipated bowels, tenderness iu epigastric region, freijueut vomiting, .jaundiced skin often
preceding the attack, (lushed eyes and face and congested surface; and in all these cases the patient is ijuite delir-
ious. The remission is well marked in some cases, but in others it is not — in either event (ininine generally acts
well : but if the disease be not arrested in the course of a week, typhoid symptoms make their appearance. 1 suppose
the cause of the disease to be malaria. 6th. The location of the brigade at the breaking out of the disease was
Camp Tenually. 8th. I have not seen any gangrenous toes iu my brigade. Permit me further to state that the
prevailing disease at present is a catarrh of a peculiar character. There is seldom any coryza or lachryination. It
commences with a dry, tickling cough with little expectoration, no fever or loss of apjjctite except in a few cases
which run into brouchitis. The patient feels well generally, but coughs almost incessantly. The disease began about
a month ago after a few foggy nights followed by hard frosts. Since the frost our remittent fever (or so-called
typhoid) has decreased very much. There has not been a new case in my brigade for about three weeks, which is
additional evidence to my mind that it is caused by malaria and is not typhoid.
Surijcon W. II. TlluK.NK, Vlth I'li. — 1st. Of bilious fever we have had but one case in our rcgimcul : of lyiilioiil
we have had four, iu all of which there was more or less tendency to inflammatiou of the lungs. 3d. This typhoid
is the same as that of tlie North; it is uot malarial and does not yield to antiperiodics. A spurious typhoid, which
prevailed during the summer and fall, presented many of the symptoms of true tyjihoid, but there was a marked
remission generally iu the forenoon, and although the tongue indicated more or less intestinal irritation iu some of
the cases, the bowels were mostly constipated. This disease was of malarial origin and yielded readily to alteratives
and antiperiodics — blue mass and ([.uiniiie; none of the cases were fatal. 3(1. The treatment of typhoid has been
alterative, sujiporting and stimulant: turpentine was given iu nearly every case and with marked benelit. 4:tli.
Symptoms: More or less nervous derangement, headache, furred tongue and diarrhcea; in some cases epistaxis, tynipa-
iiites, sordes on the teeth and delirium; the taches rouges were mostly present. Stll. Cause: Impure and conlined
air, cold and damp, and irregularities in diet added to an improper location. Gth. Locality: Near the bottom of a
hill with a marsh on one side aud low, damp ground ou the other. 7th. Now sick, 10 per cent, of the commaud,
the majority being catarrhal aft'ections. Sth. We have had several cases of wounds of toes, but uo gangrene.
Surijeon J. A. Phillips, 9t/i Pa. Ilistrres. — 1st. During the last three mouths I have treated 56 cases of remittent
and 14 of typhoid fever. 2d. The majority of the idiopathic fevers which have come under my observation were of
the remittent type aud ditVered from the enteric or typhoid fever of the North iu these particulars: The disease was
not often preceded by headache, dulness or feelings of malaise, but began abruptly, nor was it preceded by ejiistaxis
or diarrlnea : the bowels were generally constipated during the course of the attack; in most cases rose-colored sjjots
and sudamina were not developed; there were distinct remissions though not at any particular time in the day;
lastly, the fever could often be cliecked iu a few days by the free use of quinine. Patients were generally conva-
lescent in ten or twelve days; but if the disease was uot subdued within two weeks, it often ran into an adynamic
form resembling typhoid iu some respects. 3d. A mercurial cathartic was tirst administered followed iu a few hours
by fifteen, twenty or thirty grains of quiuia. Kefrigerant diaphoretics were freely given during the fever. I was
not deterred fnmi the liberal exhibition of quinine by the absence of a distinct remission nor by symptoms of gastric
.\li:i). ilisT., Pr. Ill— 17
370 POST-MORTEM RECORDS OF
or cerebral ilisturliance. If the disease assumed a low form quinine, ammonia, milk-pnnch and the most nutritious
diet, bi!et-tea and beef-esseuce, "nere given. It may he proper to add that I have often seen a dry, brown ton^'ue
become clean and moist in twenty-four hours after the administration of what would be called in the Northern States
a heroic dose of quinine. 4:tli. In a few instances the attack was preceded by languor, loss of appetite, etc., but in
most cases it began with a chill and jiain in the head, back and limbs, followed by smart febrile excitement. There was
generally a remission of the fever daily, sometimes twice a day; the tongue covered with a pasty fur such as I have
seen accompanying yellow fever; bowels constipated; skin dry and pungent except duriug the remissions; conjunc-
tiva^ of a yellow tinge; pain in epigastric and hypochondriac regions; urine highly colored. Sth. The eU'ects of
miasmata. Three months ago the regiment for strategic reasons was encamped in its present position. The tents
were pitched on low ground with hills rising on either side. The camp, from the nature of its site, cannot be prop-
erly drained and policed. 6tll. Tennallytown, D. C. 7th. The monthly reports show an average of 2+ per cent.
8tll. I have not seen a case of gangrene of the toes; convalescents from remittent fever have complained occasion-
ally of stillness and soreness of the toes, but these symptoms yielded promptly to emollient applications.
BrUjade Surg. A. E. Stocker, U. S. V. — 1st. In answer to the first query, as the cases I have seen, although
numerous, have been only in consultation with the regimental surgeons, I can give no additional information.
2(1, Such of the cases as I have examined and designated as typhoid fever were clearly cases of the true typhoid
fever of the North, characterized by all the usual symptoms and phenomena of that disease as it there exists.
There have, however, been a great number of cases which in their commencement and progress were true bilious
remittent fevers, although they subsequentlj' put on a low or typhoid type; these were undoubtedly due to malarious
influences. 3d. I have advised quinine and iron, the former in doses of two or three grains every two hours, with
milk-punch and strong essence of beef; when the tongue became dry, brown and cracked, turpentine was used with
excellent eftect. 4th. The cases I have designated as typhoid have had, in addition to the usual symptoms of febrile
disease, the low compressible pulse, extinguishable by pressure, so characteristic of this fever, with epistaxis, deaf-
ness, flushed and besotted appearance, diarrhoea and taches rouges. If I should say one symptom of typhoid was
less marked than those usually found in this disease it would be the want of special tenderness and gurgling in the
right iliac fossa, while in many cases the tenderness on pressure seemed to be equally dift'u.sed over the abdominal
cavity. 5th. The cause of the disease is yet undetermined. I am not prepared to say that there is even a greater
number of cases of this disease in the camps of this division than would exist were the same number of men placed
under the care of one or two physicians in any city of the North. 6th. As the manifestation of the disease does not
seem to have been sudden at any time in my experience here, it would be impossible for me to designate the locality
of the regiments when it broke out. 7th. As no time has been sjiecified for the calculation of the number of cases
the regimental reports cannot be expected to approach uniformity in their calculation of the percentage of typhoid
cases. Sth. I have seen two cases of gangrene of the toes in the regiments under my charge. They were conse-
quent upon attacks of typhoid fever; the issue of them I cannot tell as they were removed to general hospital before
entire convalescence had taken place.
Surgeon D. Stanton, 1st Pa. Cav. — 1st. We have now five cases of remittent fever, all mild and amenable to
quinine in five-grain doses three times daily; of typhoid fever we have one case now convalescent and one case in
division hospital. 3d. With perhaps one or two exceptions the typhoid cases we have had this fall have been
clearly of a malarious origin. 3d. A mild purgative and quinine in five-grain doses every three hours during the
remission; during the febrile paroxysm sweet spirit of nitre with acetate of ammonia. When about the eighth or
tenth day the remissions become less marked and typhoid symptoms appear, the ([uinine is continued in doses of two
or three grains every four hours, with brandy, beef-tea and wine-whey, and when the tongue becomes dry and parched
and the bowels tympanitic I give castor oil and turpentine every four hours. I have found blisters upon the abdomen
to be of great advantage in the second stage of the disease. 4:th. Nearly all of our cases have been of a rendtteut
character at first. About the sixth or eighth day the fever became of a more continued form, with more or less
delirium and subsultus, tympanites, hot skin, compressible pulse, tongue at first furred and afterwards smooth or
cracked and dry, and on the ninth or tenth day the characteristic eruption of rose-spots would appear on the body.
About the end of the second week, in favorable cases, the tongue becomes moist and clean at the tip and edges; in
more protracted cases it cleans ofl" from the centre, becoming dry, parched and cracked. Diarrhoea occurred in most
of the cases, but was not attended with hemorrhage. The mortality of the cases treated in the regimental hospital
has been about twenty per cent. 5th and Gth may be conjoined, for the locality of our camp was certainly the cause
of two-thirds of our typhoid cases. We were located at first on damp, low ground, not susceptible of drainage.
Two weeks after this our sick-list was doubled, and ten or twelve of our typhoid cases originated. The camping
ground was certainly pregnant with causes of malarial and typhoid fevers. In addition to this cause there were also
those resulting from the mode of life in camp, and especially in the camps of recruits who have not yet learned and
practiced the most salutary police regulations. Bad cooking and want of cleanliness in their persons, clothes and
quarters, the change and irregularity of diet, exposure, etc., may be named amongst the causes of typhoid fever and
diseases in general. 7th. Sick 84, mean strength SW9, giving about 9.2.3 per cent., including about 25 who have been
recommended for discharge, and also those injured by horses, gunshot wounds, etc. Sth. But one case of gangrene
of the toes has occurred, — in a severe and tedious case of typhoid fever. The predisposing cause was, I think, the
low vital powers of the system and the exciting cause the pressure of bed-clothes. As this was the only case we were
not sufficiently on the alert; perhaps had more care been taken the gangrene might have been prevented. Bathing
in warm water or with hot whiskey and the application of artificial heat might prevent this trouble in a measure, if
not altogether.
THE CONTINUED FEVERS. 371
Surgeon J. CoLUNS, '3d I'u. — 1st. Cases of bilious remittent r>2, of typhoid fever 10, taken siek during the
mouth of November. 2d. There has been a striking similarity between the febrile eases observed in camp and those
I have seen in Pennsylvania and New England. A few cases have begun as well-marked remittents and ended as
typhoid fever of a malignant type. Moreover, the fact that (luinino is well borne iu all typhoid cases would sec-m to
iudieato that malarial inllnences oi)erated in them. 3<l. The treatment has iu)t been uniform. As a rule in a
case of remitlent fever a mercurial purge is given, followed by oil or a saline and afterwards by quinine and tincture
of iron. .Should the case prove persistent, alterative doses of blue-pill are given. During the paroxysm great relief
is allbrded by neutral mixture or acetate of ammonia. IIoffniann"s anodyne is valuable, anil in the later stages good
milk-punch plays an impoitant part. The Bei|uehe of the disease, debility, diarrhu-a and Jaundice, need partic-
ular attention. Typhoid cases reiiuire strict watching as the symptoms are iu many cases insidious and deceptive.
After the tirst stage these bear stimulants and <iuinia (juite well; in fact stimulants are absolutely necessary.
Carbonate of amnionia, milk-punch with generous diet of beef-tea and animal broths, an<l in certain ca.ses turpen-
tine emulsion, are given with great advantage. In the obstinate and debilitating diarrhtea of typhoid I have found
catechu most etlicient. 4tll. In remittent fever, besides the ordinary febrile symptoms, may be noted a peculiar
brown or bluish-black coating of the tongue. This peculiar shade I have never noticed before. Iu other cases the
conjuntivie are injected, often yellow and the tongue of a reddish tint. The paroxysm generally occurs towards
evening. In typhoid cases there is generally a greater tenderness or gurgling in the lino of the colon; the dis-
charges are dark or watery; the pulse has a hollow vanishing beat; the tongue is dry; the fever continued; rose-
colored spots, etc. otll. The supposed cause is concealed iu the two terms used with scientific llippancy, viz: pre-
disposition and malaria. Gth, The regiment has never beeu quite free from the disease. I think the violent and
malignant form assumed in November due to location in the swamp just in advance of our present encam]iment.
7tL. During the month 32 per cent, of the whole regiment were sick at oiu; pi^riod or another. 8tll. One case of
gangrene of the toes was sent to division hospital. Another, a ]>atient suti'eriug from a violent attack of typhoid
fever, occurred in the regimental hospital: On the morning of the tenth day ho complained of iutcuso pain iu the
toes. The feet were cold, the toes quite blue or bluish-black. I imnu'<liately ordered slimulation, aiul heat to be
applied externally, with large doses of tincture of iron, milk-i)unch and good diet. In a few days the patient ceased
to complain and the symptoms yielded.
Surijcon J. S. De Bkxxkvii.lf., IWi Pa. — 1st. Krom .\ugust to December inclusive we have had 20 cases of remit-
tent fever and lil of typhoid. 3cl. The cases of typhoid were similar to thu.se called typhoid or enteric fever at the
North. ;J(1. Treatment was by gentle purgatives when uecessary and diaphoretics of neutral mixture or acetate of
amni4>nia combined with sweet spirit of nitre, tartrate of antimony or ipecacuanha iu the first stage. Mecurials com-
bined with diaphoretics were used as the secretions diminished and the tongue became furred and dry; cold applica-
tions to the head, dry cups to the temples and back of the neck and blisters to the temples or scalp when fever and
delirium were present. In the advanced stages, when the tongue became dry and fissured and the abdomen tympa-
nitic, turpentine was employed with advantage. Dry cupping, mustard poultices and stimulating liniments to tho
chest were used in treating bronchitis and pulmonary complications. The diet was at first arrow-root gruel, farina
and barley, but as the disease advanced beef-tea, essence of beef, milk-punch and wine-whey were given with cinchona
or quinine. 4:th, The patieut usually suffered from a feeling of general uneasiness and discomfort, headache, alter-
nate sensations of heat and chilliness, diarrhoea, iu some cases epistaxis, furred tongue, etc. These symptoms became
aggravated with dry skin and tongue, pain in the iliac region, tympanites, bronchitis or pneumonia. Kose-colored
spots and sndamina were fouiul in nearly all cases; marked cerebral disorder with delirium occurred in mauy. Stll.
It is probably tho endemic fever of this region, its increase being favored by overcrowding in small tents and neglect
of cleanliness. 6th. The first case occurred while the troops were at Camp Tennally, .about a month after they had
removed from a camp one mile north of Washington. 7tb. The number of sick daily averaged 5.0 per cent, in .Inly
and August, 1.5 in September, 5.0 in October, 5.75 in November and G.75 in December. Stll. The only case of gan-
grene that came under my notice was at the division hospital. The patient had been sick in this regiment for sevi'n-
teen d.iy8 with a low form of remittent fever in which the prominent symptoms were cerebral; the lower limbs
became (Edematous and the gangrenous condition appeared soon after his entrance into hospital.
Surgeon S. D. Fkkkjian, 13*/i Pa. Reserves. — ^Ist. During the last three umnths we have had 91 cases of bilious
remittent and 9 cases of typhoid fever. 3d. The typhoid fever is not the typhoid of the North, but originates in
bilious remittent, attributed to malaria. 3d. Treatment is alterative, tonic and stimulating by blue mass, carlionate
of auunouia. turpentine, (luiniue and brandy. The disease does not yield to quiuine. •l-tli. Headache, with chills,
backache, general malaise, tongue coated, at first yellow then dark, crusting and cracking iu the centre — in short,
the usual symptoms, otll. The cause is supposed to be the change from a high and dry to a low and moist clim.ate,
as that portion of the regiment coining from the Alleghany mountains suffers most. Gth. The regiment was encamped
at llarrisburg, Pa.; Cumberland, Md.; New Creek, Va.; then again at Harrisburg, Sandy Hook, Buckeyestown and
Hyattstown, where fevers first made their appearance. 7th. The jiercentage of sick from all causes is at present
7.25. 8th. There is no gangrene of the toes.
Surgeon .V. W. Green, 7(/i Pa. Ix'escn-es. — tst. Six lases for the present mouth. 2d. I do not consider it tho
same as the typhoid fever of the North; it commences as a bilious remittent, ruuuing rapidly into a typhoid condi-
tion, and almost invariably with strongly marked cerebral symptoms. I think the heavy fogs overhanging us alnu)st
every night, the nature of the soil, vegetable mould with clay sul)soil, and the constant digging connected with
camp improvements serve to indicate a malarial origin. 3d. Quinine in doses of three to ten grains every two
lionrs generally succeeds in breaking up the fever; but at this time we have to be exceedingly careful, else the disease
^
372 POST-MOKTEM RECORDS OF
will assume tlie typhoid form. The treatment in this event consists of turpentine emulsion, opium or Dover's pow-
der beef-tea, milli-punch, brandy, carbonate of ammonia, etc. 4th. Chilliness, restlessness, fever, headache, pain in
back and bones, general uneasiness, torpor of the bowels, pain in bowels, tenderness on pressure, tympanites, diar-
rhcea, hemorrhage, dilated pupils, entire adynamic condition, death. 5th, The supposed causes are miasm and
exposure. 6th. Camp Tennally. 7th. Three and one-half per cent. 8th. Convalescents complain very much of
their feet, but I have not met with a case of gangrene.
Brigade Surg. S. K. Havex, V. S. V. — The report of sick and wounded shows in October 1,794 cases of disease
and in November 2,918 cases. Most of those included in the report for October have been of a distinctly malarial
tvpe: Remittent, intermittent and continued fevers; also a large number of cases of measles.
Camp Advance is situated on the bluft's forming the southwest bank of the Potonuic at Chain bridge. These
blulfs vary from 180 to 200 feet in height. The Potomac at this point and for a considerable distance above and below
flows over a rocky bed with steep banks on both shores, extending back in rolling hills with sharp gulches inter-
vening. The region is, therefore, apparently non-malarious. The intermittent and remittent fevers that have pre-
vailed here during the last month are attributable, I think, to the extensive felling of timber and clearing up of a new
country required by the military necessities of the camp. This division was moved to its present camp October 10.
Its topography is not unlike that of Camp Advance except that it is four miles distant from the Potomac. It wUl
be observed that the diseases reported iudicate a gradual deepening into more serious forms as the season advances.
These forms, I think, are not correctly designated typhoid, the condition being rather that of a low form of bilious
remittent incident to the depressing influence of camp life upon those wholly unaccustomed to it.
Brigade Surg. 3. H. Warren, U. S. V. — As far as I have visited the various camps in this division I have not
been able to find more than six or eight cases of true typhoid fever as I have been accustomed to see it at the North.
These cases were, I think, brought with the troops from the North here. We have a great many cases of bilious remit-
tent fever assuming the typhoid type. Quinine, opium and camphor seem to be the best agents for the treatment of
this form of fever. The surgeons unite in this statement, that all cases begin with the usual form of renuttent fever
and end with the typhoid type. The common diagnostic signs of typhoid fever as we see it farther North are wanting
in the incipient stage ot the disease.
In the face of this testimony acknowledging the existence of typhoid fever in our camps,
but pronouncing the prevailing camp-fever to be essentially a malarial fever of an advnamic
character, it is difficult to conceive that the insertion of the term typho-malarial in the
monthly sick reports, without a word of explanation as to its scope, could have so influenced
medical officers in the field as to cause them to change their views and regard these fevers as
typhoid modified by active malarial phenomena. As a matter of fact their opinions remained
unchanged. This is fully evidenced by the sanitary reports that were filed subsequent to
June 30, 1S62, the date of the introduction of the new term. Thus, Surgeon Jonathan
Letterman, U. S. a., Medical Director of the Army of the Potomac, in a report covering
the first six months after the date stated, referred the prevailing typhoid type of fevers to
the action of the deadly malarial poison.* His successor. Surgeon Thomas A. McParlin, U.
S. A., makes use of the new term, but does not explain the value attached to it when he savsf
that " during the advance from the Rapidan to Petersburg malarial and typho-malarial fevers
and diarrhoea were the prevailing diseases," and he is equally indefinite, s& far as the use of
the new term is concerned, when later in the same report he mentions "fevers of the inter-
mittent and typhoid type" among the diseases prevalent during the siege of Petersburg.
The. large number of cases, 23,346, reported as typho-malarial during the year following
the introduction of this term, shows how generally it was accejjted by medical officers in
the field; but it has no bearing on their views as to the essential nature of the fevers
thus repoi'ted.J The term, when used outside of the monthly reports of sick and wounded,'
• was seldom accompanied by any data indicating whether a modified typhoid or an adynamic
remittent was intended. There is on the files of the Surgeon General's Office but one report
which attaches to typho-malarial the value which Dr. Woodward had in view on its official
introduction. It reads as follows:
* p. 93, Appendix to the First Part of this volume. f Lo''- "'■< !>■ KJl-
t "As it was, the term went upon tlie sick report without any explanation or a word of comment. But even under these circumstances 2.3,.146 cases
were reported as typho-malarial fever during the following year, showing hew widely the opinions I had formed were shared by the medical ufticenj o(
the Army." — Dr. Woodward's paper on Ti/p/fj-nudttriat Fcvetj SedioH of MedicittCj httemalional JHeilical Coii'jrcss, Philadelphia, 16T0, p. 12.
THE CO^■TrNUEr) FEVERS. 373
Surgioii \Vm. O'MEAGnEU, o7//i X. V., lAluanVi) Ftrn/, Mtl., Sept. 30, 1862.— But notwithstauding all our ftioits,
aided bj- aljundauce of uouiishment aud stiiiiulauts, sovoral died of a mixed disease which is, to my mind, aecuialely
named in the new monthly reports of sick and wounded as typho-malarial fovor. The two cases of this nature recorded
in my report for Angust exhihitod very inaikcd evidence of typhoid fever and miasmatic poisoning, and the treatment
was adajited accordingly. In one case the delirinni was so violent as to approach the character of mania; cerebro-
spinal meningitis was the prominent condition, and to this the treatment was mainly directed, the remote and exciting
cause being, however, kept in view. Hut the patient died exhausted in a few days. The second case partook nu)re
of the tyjdioid condition and the delirium was of the usual character. He also died in an equally short space. A
third man recovered, but I am satisfied his constitution is permanently impaired. He is still in the regiment an<l
under observation, being on light duty only. I should have mentioned that the daily exacerbations in each case
varied considerably. In the lirst there was violent delirium, almost maniacal; in the second a mere shudder with
low muttering: and in the third a convulsive tremor, with gurgling in the throat and a hissing expiration accom-
panied by the expulsion of some frothy mucus between the teeth.
On the other hand Ass't Surg. J. T. Calhoun, U. S. A., believed the fevers of the
IVninsuIa to be not enteric but miasmatic, and appropriately denominated typho-mtvla-
rial* "The form of fever termed by the negroes swam[i fever, but which should be known,
perliitps, in scientific nosology as t3'pho-miil;u-ial fever, was verv frequent."f Dr. Cal-
houn bore testimony also to the absence of intestinal glandular lesions in certain adynamic
fcvers.J
Siiriiiofi ,1. M. Rice, 25th Mass., Xciv Berne, X. C, March 10, 18(38.— The intermittents, unless controlled by tlie
administration of cinchona or other antiperiodics, passed into remittent, aud the remittents frequently assumed
that type of disease now named in our reports typho-uuilarial. In the connnencement there was usually cephal-
algia; pain in the eyes; severe aching pain in the back ,ind limbs, very uoticeable even in the milder cases; some-
times nausea and vomiting: generally slight desire for food. The condition of the bowels was variable — diarrhcea
when present being readily controlled. During the remissions the debility was quite marked, with indisposition to
t!io slightest exertion. In a number of cases I had the most satisfactory evidence that the production of cinchonism
lit short the disease' in its early stages, and, .as it appeared to me, without causing any unsatisfactory result when
this was not accomplished. In some cases there was a tendency to the congestive form, and this, when occurring
in tho.se debilitated by frequent attacks of intermittent or by recent remittents, was always dangerous and in some
instances fatal. Nearly all were remarkable for the long and unsatislactory period of convalescence. Treatment
cousi-sted of nu'rcurials combined with other cathartics; sometimes emetics; counter-irritation when required; the
exhibition of quinine in full doses in the early remissions; diaphoretics during the febrile paroxysms, accompanied
with a dry skin, aud later in the disease quinine in small doses, with stimulants when needed.
But perhaps the strongest evidence of the undetermined value attached to the term
typho-malarial by our medical officers is afforded by a report of Surgeon George A. Otis,
afterwards for many years the colleague of Dr. Woodward in the preparation of this histoiy.
Hemarkx on the Monthli/ Hejwrt of Surgeon Georoe A. Otis, 21th Mass., Xew Berne, X. C.,June, 1863. — There were
three cases of typho-malarial fever (so-called) — cases in which it was impracticable for me to decide whether the
disease should be pronounced remittent or typhoid fever. One (Hall) entered on the 21st instant with high fever,
delirium, excessive prostration. He had been reported at surgeon's call for ten or twelve days previously with diar-
rho-a, but his bowels were confined when he was admitted. There was abdominal tenderness, especially near the
Ciccum. There was no remission in his fever, and the administration of quinine was not ventured upon, for signs of
rapid sinking were speedily noticed. He died three days after admission. It was not practicable to make an autopsy,
file other fatal case was similar in many respects, save that the cerebral complications were less iiromiueut. Although
a renii.-ision was anxiously looked for, none could be detected. At last tentative doses of quinine were given. They
did not apparently aggravate the .symptoms, but they failed to relieve any of them appreciably. In the third case,
the only ouc of recovery, (juinine was administered before an absolute remission was observed. The next day there
was a fair remission, aud the antiperiodic was given immediately in full doses with the happiest eliect.
This able officer made use of the term one year after its introduction, not as embodying
Lis views of the pathology of the febrile cases, but as indicating his inability to discriminate
between a typhoid modified by malarial manifestations and a remittent with typhoid symptoms.
Tlie general acceptance of the term typho-malarial fever, as indicated by the large number
of cases reported under it, shows manifestly that it filled a nosonomial want which had been
sorely felt. It may be fairly claimed that it was made use of in all febrile cases not purely
• In liis ro|M.rt, r- 91, ApiKudix, Part 1st. f Op. cU., p. 92.
X In Uio .lf<-(/. ami Siinj. lit-jiorU-r, Vol. X, Pliiln., 18G3, p. 97, bf Says that besides cases of pure enteric fever wliicli (iiffored in no manner from tliose
Bwn in nvil life, ttiere fn'rjnently orcuiTi-d ciises of an Hilynamic f<;vi'r in whicli tliere were no enteric symiitoms, no rose-colored spots aud no epistu.\is;
KOd in tl)e(M> jMMf-iHurtem examination failed to reveal any ulceration or change of stnicturo in tlio glands of Peyer.
374 POST-MORTEM EECOEDS OF
enteric, which presented the so-called typhoid symptoms, by those who regarded such symp-
toms as indicative of enteric fever, by those who regarded them as developed during the
persistence of a malarial fever irrespective of the presence of typhoid, and lastly, by those
who, in the absence of post-mortem, investigation in individual cases, were ready, like Dr.
Otis, to confess their inability to determine whether a specific typhoid element was or was
not present.
From the frequency with which ulceration of Pe3'er's patches was found in the post-
mortem researches conducted at the genei'al hospitals, the oflficers forming the staff of these
institutions very generally concluded that the prevailing fevers of the Array were essentially
typhoid. The cases whicli occasionally presented an unaltered intestinal mucous membrane,
or one changed only by an apparently unspecific congestion, were accepted as showing that
death had resulted from the malarial influences to which our troops were almost constantly
exposed. But these cases, as has already been explained, seldom lived to reach the gen-
eral hospitals, or if they did so died subsequently, not from the primary fever, but from
secondary pneumonic or intestinal complications, the latter of which offered to view exten-
sive ulcerations of the intestines simulating the appearances of typhoid fever. Typho-raala-
rial fever, therefore, to the medical officers of these hospitals generally, implied an enteric
lesion. Positive results were obtained at the necropsies, and specimens were forwarded to
the Army Medical Museum in such numbers as seemed to the pathological anatomist to
leave no doubt of the character of the pi'evailing fever.
But fatality and prevalence are not synonymous. Fevers j^resenting ulceration of the
small intestine, and particularly of its closed glands, certainly occasioned more deaths than
those unassociated with such anatomical changes, but the universal testimony of tlie medical
men who treated the fever cases that recovered or died at an early period after the onset of
the disease, is to the effect that the prevailing fevers were essentially paroxj^smal. The
hospital pathologists did not give due weight to these assertions. They found that the field
surgeons reported large numbers of typho-malarial cases, and assuming that these cases were
characterized by pathological conditions similar to those with which their experience had
made them familiar, they conceived their view of the enteric nature of the fevers reported
as typho-malarial to be correct because based upon post-mortem research instead of on symp-
tomatology and therapeusis.
But, as has been indicated by certain of the jDos^mo?'^?/!, records of typho-malarial cases,
this term was applied by the field surgeons to fevers which in its absence would have been
returned as malarial remittents. Inasmuch as no instructions had been issued limiting the
applicability of the term to enteric fever with malarial complications, these oflicers were
fully justified in including under it those malarial cases which had typhoid, i. e., adynamic
tendencies, particular!)' as there was nothing in the first part of the compound term to limit
its significance to one specific cause of typhoidal symptoms. Undoubtedly, also, the new
term was accepted by many as enabling them to dispose of their anomalous cases without
committing themselves to certain etiological and pathological doctrines.
The pathologists were therefore in error in supposing that enteric fever was present in
all the cases reported as typho-malarial by our medical officers. Tliis view is sustained by
a study of the monthly changes in the curve of prevalence; and on it only can the sin-
gular death-rate of typho-malarial fever be understood. It has been shown by the records
of the Seminary hospital that the fatality of typhoid cases which were complicated with
THK COXTINTKn FF.VERS. ST-'j
active nuiuit'ostalioiis of the malarial iutiueiicc was inucli greater than that of uncompli-
cated cases: and such a result is consistent with our general experience of the action of
inorhific agencies on the system, especially when these agencies have similar destructive
: iiidoncies. But the statistics of the white troops show that although the mortality caused liv
tvphoid subsequent to the introduction of the new term was 40 per cent, of tlie cases, the
fittalitv of the cases reported as typho-malarial was only 8 per cent. This is convincing
proof that the medical otiBcers who placed these cases on the monthly reports did not
restrict the term to cases in which there was a coincidence of both fevers. Had they
done so an antagonism between the action of the typhoid and malarial poisons on tlie human
svstem would have been immediately established. But there was no evidence of an antag-
i.iiif;m of this character. On the contrary, typhoid fever was deadly in proportion to its
modification by other deteriorating agencies, chief among which was the malarial iiiHuonce.*
In true typho-malarial fever at least 41.4 per cent, of cases among the white troops
should have terminated fatally, since typhoid gave 40 per cent, of fatality and remittents
1.4 per cent, froin June 30, 1862, to the end of the period covered by the statistics. But
as the cases reported under the term typho-malarial were fatal at the rate of only 8 per cent.,
it may be inferred that for one case thus reported which was really characterized by the
specific typhoid element, there were 4.85 cases which could not have been typhoid as the}'
lacked its gravity and were so amenable to specific treatment that they furnished only the
mortality which would have occurred among an equal number of malarial remittents. In
other words, 83 per cent, of the cases reported among the white troops as typho-malarial
were remittents or febrile attacks attended with no greater mortality than the remittents.
Speaking approximatively, of the 49,871 cases thus reported more than 41,393 were remit-
tent and less than 8,478 were true typho-malarial cases.
A similar calculation on corresponding data furnished by the statistics of the colored
troops — to wit: Percentage of typhoid cases which ended fatally 55.69, of remittents 3.27,
of cases reported as typho-malarial 17.27 — shows that 73 per cent, of the cases entered on
the reports under the new term were remittents or febrile attacks which had no larger
mortality than the malarial remittents.
Typhoid fever, including typhus, occasioned during the war 181 cases of sickness and
59.6 deaths among every thousand of our white soldiers. The remittent-malarial fevers
caused 664 cases and 8.2 deaths. There were also 115 cases and 8.6 deaths attributed to
typho-malarial fever. But the cases last mentioned have been seen to consist of one truly
typho-malarial case to 4.85 malarial remittents. Were the typho-malarial figures duly dis-
tributed among the typhoid and the remittent fevers the former would number 200 per thou-
sand of strength with 67.16 deaths, and the latter 759 per thousand with 9.24 deaths.
Theru were thus more than seven deaths attributable to typhoid fever for every death caused
by adynamic remittent or other low fevers not specifically typhoid or enteric. In other
words, seven cases of fever with typhoid symptoms presented typhoid ulcerations for one
case of fever with typhoid symptoms which had no ulceration of the closed glands. Hence
the opinion of the pathologists that a specific typhoid was the prevalent fever. The rela-
tive prevalence of these fevers was, however, 3.7 of malarial remittent to one of true
typhoid; most of the former were treated in camp, of the latter in general hospitals. Hence
• Dr. Ja8. J. Le\'I(tk is the only olt!?*rver wlio, while denying any antagonism between the poison of typhoid and that of malarial fever, eonsidcni
lut the malarial complication did iiut ,idd to the cnivity of the typhoid affection; hut, on the contniry, it, or the remedies employed to control it, seemed
tomider Ihe disease more tractable and less fatal.— /liiiericuii J„iirmil Mvil. iki., 1804, Vol. XLVII, p. 407.
376 POST-MOKTEM KECOKDS OF
tlie opinion of the field surgeons that the prevailing fever was a malarial remittent. These
figures include the vast number of typhoid fever cases that occurred after the organization
of the volunteer armies. Had they been excluded by making use of the statistics of the
third vear of the war, that ending June 30, 1864, the remittents would have been found to
have outnumbered the enteric cases in the proportion of 6.5 : 1, although the chances of
finding typhoid ulcerations in a fatal case of low fever would yet have remained as high
as 5.4 : 1.
It is to be regretted that the applicability of the new term was not fully explained and
limited on its introduction. Had this been done, the attention of our medical oflicers would
have been directed to the differentiation of typhoid fever with malarial complications and
remittents with advnamic symptoms, and our knowledge of this clinically obscure subject
would have been materially improved. As it was, the new term was productive of unde-
sirable results. It dissociated cases of typhoid and malarial fevers from their etiological,
pathological and therapeutic associates, thus injuring the totality of the statistics of both
the classes, and massed them in uncertain proportions in a separate group which could be
analysed only at the close of the war on the jiresentation of all the materials relating to it.
Instead of conducing to discrimination and simplification in the study of the camp fevers
its use tended to admixture and confusion. It appears, also, to have been responsible for
the lack of material illustrative of itself, as by afibrding a local habitation and a name to
obscure cases it relieved medical officers from the official necessity of maturely considering
them prior to formulating a diagnosis or of entering into the details of their peculiarities and
difficulties. Moreover, the term was carried by our medical men into civil practice at the
close of the war, where it has perpetuated the uncertainties attaching to the cases that have
been classed under it.*
But while the cases reported under the heading typho-malarial comprised so ^raall a
proportion of such as were really typho-malarial in the views of the originator of the term,
it by no means follows that true typho-malarial fever was a rare occurrence in our camps.
On the contrary, it may be said with certainty that it occurred with greater frequency than
unmodified typhoid ; and owing to its tedious and uncertain course, the typhoid affection
being often prolonged by preliminary malaiial attacks, and" the return to health interrupted
by relapses of the malarial essential or prevented by the development of diarrhoeal, dysen-
teric, pneumonic or other sequelae common to both its elements, it assumed prominence
among the fevere of our camps as being the most destructive to the army as well as to the
hfe of the individual, although by no means the most prevalent fever.
In the early months of the war typhoid fever was to be expected from the aggregation
of young and susceptible subjects under unhygienic conditions. But as the men at this
time had not become so thoroughly affected by the malarial poison as was the case at a later
date, their typhoid epidemics ought to have been of a comparatively unmodified character.
Nevertheless it has been shown bv the clinical records of the Seminary hospital that many
of the cases which then occurred were distinctly impressed by the malarial poison and on
that account entitled to be ranked as typho-malaiial fevers. Later in the war the frequency
of such cases undoubtedly increased, but as the typhoid element was recognized by some
symptom regarded as pathognomonic or by post-mortem observation in a sample case of
the series, the fever was reported as typhoid and not as typho-malarial. It is impossible to
* See pag« 509, infia.
THE CONTINUED FF.VERS. 377
say liow many of those so reported were modified by malarial influences, but the number
must have been verv great. Dr. Woodward was correct in assigning importance to the
true typlio-malarial lovers, but he erred in regarding the numbers reported under the typho-
malarial heading as giving expression to that importance. Tiie true typho-malarial cases
wore usually reported under the term tvphoid. The sanitary reports indicate that when
typhoid became epidemic among men on duty in a malarious section the disease did not.
present the characteristics common to it in the civil population of the Northern States.
Oulv in regiments newly levied and as yet unexposed to malarial influences was the typhoid
disease similar to that with which their medical officers had been familiar in civil life. In
the first-mentioned commands the disease was always of a gi'ave character; while in those
last referred to the mortality from typhoid was generally light, in some instances a hundred
cases having been reported with only a few deaths. Correspondingly the rate of fatality of
typhoid was only 18.8 per cent, among the white troops during the first eight months of the
war, while it rose later, as the disease became modified, to an average of 38.3 per cent. The
greater fatality during the later years may not be wholly attributed to the malarial influence,
but that it was due in part to this is obvious from the evidence already presented. These
considerations imply a relative paucity of cases of unmodified typhoid fever and a large
proportion of cases which, had the term typho-malarral been properly applied, would have
been dropped from the reports as typhoid and recorded as typho-malarial.
It has been shown that the cases reported as typho-malarial were chiefly composed of
malarial remittents with a comparatively small percentage of true typho-malarial cases. It
has been shown also that of the cases reported as typhoid the majority were really compli-
cated with malarial phenomena, and were thus in fact typho-malarial cases, while the minority
were cases of unmodified typhoid. But among those reported as typhoid was another group
in which typhoid symptoms were associated with no anatomical lesions other tftan those
attributable to the action of the malarial poison. In other words, adynamic remittents and
malarial fevers assuming a sub-continued form and typhoidal tendency, while forming the
mass of the cases reported as typho-malarial, constituted also a portion of those fevers reported
as typhoid. The following series of cases will amply sustain the latter part of this state-
ment. In most of these there is no clinical history to show what were the symptoms during
life, but the diagnosis presumes the existence of more or less of the so-called typhoid symp-
toms, while in a minority of the cases some of these typhoid symptoms are specified. A
certain number of these cases, so far as can be learned from the post-mortem records, were
instances of pure typhoid; others were instances of true typho-malarial fever; but a third
set, comprising no inconsiderable number, were cases which offered to view no other lesion
than those which have been construed as indicating the presence of malarial disease. Tliese
cases, like those which preceded them, have been arranged for convenience of study in
accordance with the character and situation of the changes in the intestinal canal :
C.VSES REPOnTED AS TyPIIOID FeVEK, THE CLIXICAI. HISTORY INSUFFICIENT OB ABSENT — 182 CASES.
(A.) Pi ijer's patches ulcerated and the ileum or small intestine only affected — 13 cases.
Casf. 117. — Private Levi t?chietz, Co. I, 47tli Pa., was admitted April 3, 18&1, with a hot and dry skin, biov.u,
dry and tracked tougiie and lips. ^sligIltIy dilated pupils, (|nick puKse, 112 to 120, and muttering delirium. Two days
thereafter, under the inHuenee of small doses of turpentine and lanilanum, the delirium subsided, the tongue liecanie
somewhat moist and the pulse fell to Ultl-112; but the improvement was only temporarj-, — iliarrlioea set in and the
skin over the sacrum became painful and reddened. He died on the 14th. Post-mortem examination fifteen hours
after death: "Slight ulceration but extensive iullamniatiou of Peyer's patches; also a slight degree of arachnitis."
— Irt. Ass't Surij. Charles Carter, Tnrner's Lane Hospital, Philadelphia, Pa.
Mf.d. Hist., Pt. 111—48
378 POST-MORTEM RECORDS OF
Case 118. — Private Henry H. Whitney, Co. D, 53(1 Mass., was admitted Aug. 16, 1863, having been sick a -sveek
witli diarrhtea, great jirostration, dry and furred tongue, sordea on teeth, sudaniina on abdomen and cliest, suffusion
of face and tympanites of abdomen. Gave beef-tea and sherry wine. 19th: Severe chill. 20th: Mumjis; pulse 110,
quick and feeble. 21st: Great prostration; rusty sputa; crepitant rales; death. Posf-mortfm examination ten hours
after death: Both lungs congested posteriorly and partly adherent to thoracic walls, with slight eft'usiou into each
pleural cavity; heart healthy; stomach much distended; bowels purple-sjiotted on their serous surface; Peyer's
patches in several instances proniiueut, much congested and slightly ulcerated. — Union Hospital, Memphis, Tmn.
Case 119. — Private John H. Beckwith, Co. C, 79th N. Y.; age 33; admitted June 6, 186.^1. Diagnosis — typluiid
fever. Died 26th. The only symptoms mentioned are delirium, almost constant, and much jactitation. I'osi-morlem
examination twelve hours after death : Lungs adherent to pleurse by fibrinous bands; spleen enlarged and softened;
Peyer's patches ulcerated. — Slough Hospital, Alexandria, Va.
Case 120. — Private Robert Booth, Co. A, 147th Pa.; age 21 ; was admitted Nov. 4, 1863, delirious, with dry tougue
and sordcs, and on the second day after admission involuntary discharges from the bowels. He died ou the 13th.
rost-mortvm examination showed "that condition of the intestinal glands usually found in typhoid eases." — Act.Ass't
Surg. James Ilohcrtson, 1st Division Hospital. Alexandria, Va.
Case 121. — Private Albert Graft', Co. D,4th N. Y., was admitted Nov. 30, 1864, with typhoid fever, much exhausted
by his journey from City Point, Va. His tongue was dry and brown, teeth covered with sordes, bowels tender; he
was aft'ected with low delirium and subsultus. He died December 3, having had involuntary ftecal passages and
retention of urine for twenty-four hours before death. Post-mortem examinatifui : Extensive ulceration of Peyer's
patches. — Third Division Hospital, Alexandria, Va.
Ca.se 122.— Private Aaron T. Ward, Co. B, 20th Me.; age 25 ; was admitted Oct. 29, 1862, with diarrluea following
typhoid fever. He was feeble and emaciated; the stools were generally natural in color, but liquid and occasi(uially
streaked with blood. On November 11, the diarrhcea still continuing, he was attacked with diphtheria characterized
liy suft'ocative jiaroxysms; he died next day. rnsl-mortem examination eighteen hours after death: The larynx was
(edematous and lined with pseudo-membrane. The lungs were congested. The heart was normal, its right ventricle
filled with a large firm clot. The stomach, liver and kidneys were normal. The glands of Briinner were enlarged;
Peyer's glands thickened and in the lower portion of the ileum ulcerated. — Third Division Hospital, Alexandria, Va.
Case 123.— Private William Martin, Co. M, 17th Pa.; age 23; was admitted July 19, 1863, delirious and with a
hot and dry skin, fre(iueut and feeble pulse, dry and brown tongue, tender bowels and some diarrh(ra. He died on
the 21st. Post-mortem examination twenty-four hours after death: Mucous membrane of the small intestiue iuflaiMod :
glands of Peyer ulcerated; mesenteric glands enlarged; lower lobes of both lungs congested; heart and liver normal.
— .let. Ass't Surg. S. Upson, Third Division Hospital, Alexandria, Va.
Case 124.— Corp'l Charles S. Benedict, Co. B, 144th N. Y , was admitted April 14, 1863, moribund: Pulse 1.30.
very feeble; respiration 28; tongue dry, brown, cracked; bowels relaxed; skin moist; extremities cold, clammy.
He died next day. Post-mortem examination twenty-four hours after death: Mucous membrane of larger bronchi
abnormally red ; liver and spleen enlarged and softened; stomach injected; mucous membrane of small intestine
much injected ; Peyer's patches enlarged, some deeply ulcerated. — Third Division Hospital, Alexandria, Va.
Case 125. — Private Anthony Duchey, Co. C, 195th Ohio; age 18; was admitted April 6, 1865, much emaciated
and very we.ak, his mind much impaired. A number of small abscesses on his thighs and legs, on being punctured,
discharged a ijuantity of thin milky pus. He had a large deep bedsore over the sacrum and (me over each trochanter,
great thirst, anorexia and a red, dry, transversely fissured tongue. He died on the 24th. Post-mortem examination
four hours after death: Large deposits of pus were found beneath the skin and between the muscles of the lower
extremities ; the right parotid gland was infiltrated with pus. The liver adhered to the diaphragm and the abdom-
inal parietes; its substance was softened; the gall-bladder was enormously distended with black bile; the spleen was
enlarged and softened. The stomach was contracted and its mucous membrane inflamed; the ileum Inflamed and
Peyer's patches ulcerated. — Act. Ass't Surg. S. B. West, Cumherland Hospital, Md.
Case 126.— Private John S. Hall, 17th Ind. Bat'y ; age 18 ; was admitted Nov. 10. 1862, with typhoid fever, and
died on the 20th. Post-mortem examination: The only lesion found was an extensive inflammation and ulceration of
Peyer's patches. — Ass't Surg. H. Pieree, 150th N. Y., Stewart's Mansion Hospital, Baltimore, Md.
Case 127.— Private William O'Brien, Co. D, 38th Mass.; age 19; was admitted Nov. 5, 1862, with typhoid
fever, and died on the 9th. Post-mortem examination: Heart, lungs, stomach, liver and kidneys normal; inflanmia-
tion of Peyer's glands: intussusception in the middle third of the ileum. — Act. Ass't Surg. T. F. Murdoch, Stewart's
Mansion Hospital, Baltimore, Md.
Case 128.— Private Patrick Farmer, Co. B, 38th Mass., was admitted Oct. 7, 1864, from City Point, Va., with
typhoid fever, and died next day. Post-mortem examination sixteen hours after death : Ulceration of Peyer's glands;
much pleuritic eft'nsion'. — Act.Ass't Surg. John T. Myers, Beverly Hospital, X. J.
Case 129.— Private William J. Roberts, 26th Ohio Bat'y; age 22; was admitted Nov. 29, 1864, with typiioid
fever. He died December 10. Post-mortem examination twenty hours after death: The spleen weighed thirty-four
ounces; Peyer's glands were inflamed and ulcerated throughout the ileum and for some distance up in the jejunum.
— Xatchez Hospital, Miss.
Case 130.— Private John Prall, Co. K, 160th Ohio; age 22; was admitted Aug. 29, 1864, greatly prostrated
and almost unconscious. He died next day. Post-mortem examination: Extensive ulceration of Peyer's patches and
an intussusception of one portion of the ileum.— Seminary Hospital, Columbus, Ohio.
THE CONTINUF.n FEVERS. B79
Case 131.— Private .Tonatliau Iliaiiiaii, Co. T[, r.TlIi Ta.; adniittiHl .Vinil 30, 18G4. Died May 10. Vonl-mortim
examination twenty hours at'tor death: Body niiii-h oniaciated. Lungs and spleen congested; I'eyev's glands ulcer-
ated.— Acl. Jsa't Surg. C. K. Fillmore, llarewood Ilosjiilal, IVashington, D. C.
C.vSE 132.— Private Joseph .1. Reed, Co. li, 8tli III. Cav.; admitted .\pril 10, IW)1. l'.\ phoid I'.v.-r. lii.d M:iy t;.
I'rtsl-miirliiii examination five hours after deatli: liody slightly emaciated. The lower lolie of the left lung ami llir
lower holder of the right lung were much congested anil sank in water. The heart was iionnal. The livii was
slightly enlarged ; the gall-liladder full: the sideeii iiiuch I'ougested, weigliing forty-one ounces; Peyer's patches wiie
eiil.iiged and many of them nlceraled; t hi' mesenteric glands were mucli enlarged. — Ul. . (»•<'/ .s'liiy/. ./. Ii. linlmi. Ihin-
wnoil Hospital, ll'ashingtott, I>. C.
C.VSE 133. — Private .Tno. ISenilcr, C'o.ti, (i7th Pa., was admitted May 10, ISti."), with typhoid fever, and died iiixl
day. i'l).•^^^«0)•/c«l examination twenty-eight hours after death: Lungs normal ; heart pale; liver jiale; spleen miiih
I nlai'ged ; Peyer's patches ulcerated ; kidneys normal. — Depot Fiild Ilospital, Sijrth Army Corpii, Army of J'otomar.
C.\.<E 131. — Private James McLoon, Co. E, 10th N. J., was :idniitted May 10, 1865, with typhoid fever, and died
on the 13th. I'ost-mortvm examination seventy-two hours after death: Lnnga, heart, liver, spleen and stomach nor-
mal ; mesenteric glauds enlarged : Peyer's [latches ulcerated. — Depot Field Ilonpitol, Sixth Army Corps, Army of I'otomiic.
C.\.«E 13.i.— Private William 1). Ehaugh, Co. F. 30th Ind.; age 18; was admitted Dec. 11, 18r>3, with typhoid fever,
and died March 2. 18111. I'ost-morleiii exaniiinition Iwenty-foiir hours after de:ith: Much emaciation; pleuritic, adhe-
sions on liotli sides; right lung heiiati/ed red and gray, left lung partly hepati/.ed; heart weighed ten ounces; liver
sixty-four ounces, fatty; spleen liftceu ounces and a half; right kidney six ounces, left six ounces and a half; mucous
memlirane of stomach somewhat congested; lower ileum showing a few large cicatrizing ulcers in Peyer's patches;
large intestine normal.— //ds^ji'/h? Xo. 1, Xaslerille, Tenn.
C.VSE 130. — Private Jaeoli Sjianglcs, Co. M, 1st Mich. Eng'rs, was admitted Dec. 3, 18(;3, with typhoid fever, and
died on the llth. I'ost-morlem examination fourteen hours after death: Pericardium containing six to eight ounces
of serum; heart tilled with large (cadaveric clots; lungs hepatized posteriorly, the right coutaiuing a few hard isolated
fuherdes; liver and kidneys normal : spleen weighing fourteen ounces: mesenteric glands enlarged; Peyer's patches
deeply nlcerated: stomach anil large intestine normal; anterior alidoniiual wall much contused iuferiorly and pie-
sintiiig some hlood-clots hcneath the peritoneum. — IJospital \o. 1, Xashrille, Tenn.
C.\SE 137.— Private W. IL Slingland, Co. H, lltli U. S. Inf., was admitted .June l."), 1803, and died on the ITtli.
I'oHt-mortrm examination twenty-one hours after deatli: Hody not emaciated. Brain healthy. ^Esophageal mucous
nicmhraue yellow-tinged and ])reseiitiiigsupcrlicial ulcers in its lower portion, the ulcers having their greatest diam-
eter parallel to the axis of the tube. Lymjihatic glands at liifurcation of trachea much softened and hiackish ; ii]i]ier
and middle lohes of right lung and ujipcr lohe of left lung slightly congested, lower lobes intensely congested. Heart
llahliy, containing no clots; pericardium everywhere tinnly attached to the heart, obliterating the sac. Liver very
llahby, dull greenish in color, evolving a peculiar chicken-coop odor and so soft that the linger could he inserted in
every direction; gall-bladder containing eight drachms of dark ochro-colored bile; spleen dark, soft, pultaceous,
weight seven ounces. Lower fifth of small intestine ulcerated, the ulcers confined to Peyer's patches and presenting
ragged surfaces, purplish walls and congestion of the surrounding mucous membrane — the patches higher up in the
intestine being pale and not elevated or congested. Kidneys congested. — Ass't Surg. Harrison Allen, U. S. A., Lincoln
Uiispital, Washington, D. C.
C.VSE 138.— Private .Stephen Cornwright. 18th N. Y.; age 23; was admitted Nov. 30, 18G4, with fever and feet
gangrenous from frost-bite. He died December 20. rost-mortem examination two hours after death: Body much
emaciated. The larynx, trachea, icsophagus and heart were normal. The right lung weighed twenty-two ounces
and the left thirty ounces; the lower and middle lobes of the right lung and the lower lobe and lower portion of the
upper lobe of the left lung were solidified and studded with small abscesses. The liver weighed seventy-one ounces
and a half and the spleen seven ounces and a half; Peyer's patches wore ulcerated; the kidneys ajiijcared to lie nor-
mal. [The attending pliysician remarks: "This man was admitted with both feet in a gangrenous condition.
According to his own statement ho had them frozen; hut my opinion is that their condition was a result of his
fever." This opinion is supported by the register of the hospital at Giesboro Point, Md., in which the patient appears
as admitted Xovemlier 2.") with tyi>hoid fever, and as sent to General hospital on the 29th. No reference is made to
frostbite.] — Lincoln Hospital, Washington, I). C.
Case 139.— Private Nathan Upton, Co. B, IstD. C. Cav.; age 32; was admitted Sept. 6, 1863, with typhoid fever,
and died on the 19th. Post-mortem examination eight hours after death: Rigor mortis well marked. The brain
substance was healthy; the pia mater slightly congested; half a drachm of tluid was found in the ventricles. The
right lung weighed twenty-four ounces, the left fifteen ounces; the lower lolies of both were mnch congested. The
Tight auricle of the heart contained a venous clot which extended into the ventricle; the left auricle contained :i
small fibrinous clot; the pericardium was everywhere firmly attached to the heart, so that its sejiaration was almost
impossible without tearing the muscular ti.ssne. The liver was healthy; the gall-bladder (umtained three ounces of
a thin straw-colored liciuid ; the 8])lccn was firm and dark purple on section, weight thirteen ounces and a half. The
mucous membrane of the stomach was congested. The small intestine was healthy in its upjier portion, but in its
lower part the solitary glands were enlarged and Peyer's ]iatchcs ulcerated. The large intestine was healthy. The
kidneys were congested; weight of right six ounces and a half, of left seven ounces. — .Iss't Surg. Uatrison Allen, U.
S. A., Lincoln Hospital, Washington, V. C.
380 POST-MOETEM EECOBDS OF
Case 140.— Private Charles B. Beams, Co. B, 14Gth N. Y.; age 2fi; admitted Nov. 23, 186.3; died 27t.h. Post-
mcn-tem exaniinatiou twelve hours after death: Rigor moi'tis extremely marked; body moderately emaciated. The
brain was unusually firm and weighed forty-nine ounces; its ventricles contained one drachm and a half of fluid.
The larynx, trachea and oesophagus were natural. The right lung weighed eleven ounces and a half and the left
twelve ounces; the lower lobes were engorged, softened, friable and charged with frothy bronchial secretion. The
heart was healthy and contained a large iil)rinous clot in its right cavities; the pericardial li(iuid was pale and meas-
ured fourteen drachms. The liver was healthy, weight sixty-eight ounces; the spleen firm, natural in size and of
normal color. The small intestine was much distended with air; within five feet of the ileo-ciecal valve its mucous
membrane was deeply congested, the solitary and agminated glands prominent, and the latter ulcerated in jiarts of
their surface. The kidneys were congested. — J-ss'i Surg. IT.AVrn, U. S. A., Lincoln Hosjiitiil, JVunhiiiiitnn, 1). C.
Cask 141.— Private Thomas Butler, Co. H, 137th N. Y., was admitted Jan. 11, 18G3, with typhoid fever, and
died during the night. He came from Fairfax Court House, Va., to Washington in an ambulance without covering,
80 that he was thoroughly chilled. Stimulants were employed without effect. Pofit-mortem examination: The tho-
racic viscera, the liver, spleen and kidneys were normal. The small intestine was inflamed; Peyer's patches were
thickened and ulcerated; the solitary glands were much swollen, especially in the jejunum, where they stood out
from the mucous membrane, attaining the size of medium-sized shot and having their apices pigmented or, in some
cases, ulcerated. — Lincoln Hospital, Washington, D. C.
Case 142.— Private Milton Striker, Co. C, 188th N. Y., was admitted Feb. 1, 1865, and died on the 3d. Lost-
mortcm examination: Upper lobe of right lung hepatized, middle lobe healthy, lower lobe congested, weight of lung
fifty-four ounces; upper lobe of left lung healthy, lower lobe congested, weight fourteen ounces. Heart normal.
Weight of liver seventy ounces; of spleen fourteen ounces. Stomach healthy; Peyer's patches and solitary follicles
ulcerated; mesenteric glands enlarged. Kidneys healthy. — Fifth Jnmj Corps Field SospHul, Aimy of I'otomuc.
Case 143. — Private James Loveland, Co. G, 4th Vt., was admitted Nov. 23, 1863, moribund, rost-mortem exami-
nation: Toes and anterior portion of metatarsus of both feet gangrenous. ISpecimens 79 and 80, Med. Sect., Army
Medical Museum, constitute the only record: 79, a portion of the upper part of the ileum, shows a single oblong and
thickened Peyer's patch ; 80, a portion of the lower part, presents two thickened and ulcerated patches and two small
ulcers, corresponding probably to solitary follicles.] — Ass't Surg. W. Thomson, U. S. A., Douglas i/«sj»7o7, Washington, I). V.
Case 144. — Private Michael Kennedy, Co. 1, 32d N. Y.; age 24; was admitted Aug. 10, 1862, and died on the llth.
rost-murtcm examination next day: The body presented a vigorous appearance, with but slight emaciation. Thoracic
organs healthy. Liver cirrhosed, much enlarged, of a yellowish-brown color and granular, the granules about the
size of pepper-corns; spleen enlarged, nine by five and a half by two and a half inches, but natural in color and con-
sistence. Mucous membrane of ileum reddened, the lower agminated glands thickened and ulcerated, the upper iniaf-
fected. Other organs apparently healthy. [^Specimens 60, 61 and 62, Med. Sect., Army Medical Museum, ulcerated
patches and enlarged spleen, are from this case.] — Act. Ass't Surg. Joseph Leidy, Satterlee Hospital, Philadelphia, I'a.
Case 145. — Private Joseph Terry, 1st N. J. Cav.; age 19: was admitted Jan. 14, 1864, in a state of low delirium
from typhoid fever. He died on the 19th. Po»i-»H«rtoH examination : Lungs congested; liver softened; Peyer's patches
ulcerated. — Third Division Hospital, Alexandria, Va.
Case 146. — Private N. G. Carey, Ist N. J. Cav.; age 18; adnutted Jan. 14, 1864. Diagnosis — continued fever.
Died 18th. rost-mortem examination : Lower lobe of left lung hepatized ; Pe}"er's patches ulcerated; one inch and a
half of ileum gangrenous. — Third Division Hospital, Alexandria, Ta.
Case 147. — H. Russell, citizen ; colored. Died June 24, 1865. Post-mortem examination : The lungs and heart
were normal. The spleen was large and hard; the mesenteric glands enlarged.- A series of elevated Peyer's patches
of all sizes, honey-combed and with constricted bases, extended from the iIeo-ca>cal valve along the ileum; the soli-
tary glands for eight or ten inches from the valve were elevated and had softened white centres. [Sjn-cimenrM'y, Med.
Sect., Army Medical Museum, taken from this case, shows also hypertrophied villi, giving the ileum a velvety appear-
ance, seen in plate facing this page.] — Act. Ass't Surg. W. C. Alinor, L'Ourerture Hospital, Alexandria, Va.
Cask 148. — Private William T. Barrett, Co. K, 39th Mass., was admitted Dec. 24, 1862, with typliiii<l fever.
Bronchitis set in about a week before his death, which occurred Jan. 29, 1863. Post-mortem examination twelve hours
after death : The brain was pale, firm and weighed forty-three ounces. There were pleuritic adhesions on both sides.
The lungs were marked by Idack pigment in the course of the ribs. The left lung weighed nineteen ounces and a
half; its lower lobe was much congested and friable and its bronchial tubes congested, especially in their finer
ramifications. The right lung weighed twenty-five onnces and three-quarters ; there was a mass of solidified tissue
in the posterior part of its lower lobe, the centre of which was occupied by fluid and opened into an inflamed l)rou-
chial tube of the third magnitude; several condensed pulmonary lobules were found also in the upper part of the
lung; the bronchial glands were mottled black and white and were quite firm. The heart was flabby and contained
clots. The liver, sevcnt}--fbur ounces, was firm and of a light brown color, its acini comparatively distinct; the
spleen, eleven ounces and a half, was soft and presented inferiorly a cyst containing half a drachm of fluid; the left
kidney, five ounces, was slightly flabby and full of blood; the right kidney, four ounces and a half, was normal.
The mucous membrane of the stomach was softened and free from folds. There were patches of intense congestion
in the small intestine; some of Peyer's patches were ulcerated in the centre, some were neither ulcerated nor thick-
ened and others near the valve contained black pigment and were ulcerated through to the peritoneum. The large
intestine was quite thin. — Lincoln Hospital, Washington, D. C.
THE CONTINUED FEVERS. 381
Case Mil. — Private George Kiulil, Co. F, 39th N. J.; a-je 3(!; was admitted Juno 28, ]8()5, delirious and inuch
exhausted. lie had lieeu sick teu days. The tympanites, whieh was present on admission, diminished, liut was suc-
ceeded by jirofuse involuntary stools, with extreme exhaustion. He died July 9. roni-morlmi examination twelve
hours after death: The solitary follicles of the lower ileum were enlarged, congested and in some oases ulcerale<l;
IVyer's patches were enlarged, pigmented and niecrated. The remaining viscera were normal. — Act. Jsii'l Surff. Otvryc
I'. lltiiiiiwuJI, Donijlux IIoKpilnl, Wanh'inijlon, I). C.
Cask loO. — Private David Cline, Co. U, ISllst Ohio; age 21; was admitted Juno 21, 1805, in a state of collapse,
having lieen sick about ten days with diarrluea. His mind was. obtuse; his pulse slow and almost imi)ercci)lil)li;
tiingiie dry and white: skin bathed in cold clammy sweat. .Stinuilanls were freely adminislcrcd and ho rallied some-
what, but nausc:i and hiccough supervened, and hedied on the 2;id. Pont-morUm cxaminjition : Heart pale and llabby;
blood uncoagulated and very thin; peritoneum over ileum covered with a deposit of coagulable lymph ; mucous mem-
brane of ileum inllamed: glands of Peycr ulcerated; corresponding mesenteric glands highly intlamed. — Act. Ass'l
.Snry. H. .1. IViesd, Cumbaland Uospitul, Mil.
C.vSK 151. — Private Andrew M. Hyland, Co. I), 38th Mass.; age 21 ; was admitted \ov. G. 18ii2, with typlii>id fever,
and died on the lOth. I'ost-nwrttin examination: Purulent cliiision within the sheath of the rectus abilominis; <xu-
ilation of lymph on the peritoneum, gluing the intestines together: ulceration of Peyer's patches; distention of gall-
bladder by about tour ounces of bile. — Asti't Surg. II. ricrtr, loOtli X. I'., Slewurt's Maimiuii llimpUitl, liaUimore, Md.
C.^.sK 152.— Private William N. Peake, Co. C, 19th Wis.; ago 18: was admitted from the .Vrmy of tho Potomac
Sept. 9, 18(il, having been sick two weeks with typhoid fever. On the 13th a pain, which had developed on the jire-
ceding day in the left iliac region, became diffused over the abdomen and was accompanied with much tympanites.
He ilied next day. Posl-Dioitcm examination two hours after death: The intestines were adherent; more than two
.[uarls of a yellowish-colored liquid, which had escajied in part from the intestinal tube, were found in the peritoneal
lavity. The glands of Poyer near the ileo-ca'cal valve were indurated at the edges and soft in thc^ centre; in one of
these patches the ulceration had perforated the peritoneum. [Specimen 810, iled. Sect., Army Medical Museum.] — Act.
.Uk'I *'«(•</. ./. //. liiitliT, If'ist's Building IIos})ititJ, liaUimore, Md.
Case 153. — Private S. Emmons, 2(3th Ohio Hat'y; ago 19; admitted Nov. 9, 1861, with tyi)lioid fever. Dii-d Dec.
11. I'osl-mortvm examination: Body much emaciated. Peyer's patches extensively ulcerated, in many places as far
as the peritoiieuu\. which in some places was perforated. — Act.Ass't Surg. J. T. Warner, Xatche: Hospital, Misn.
Cask 151.— Private J. C. Morrow, t\>. E, 110th Ohio: admitted Nov. 23, ISliS. Died 28th. I'oxt-morinn exam-
ination thirty-nine hours after death : The brain was healthy. The lungs were somewhat engorged posteriorly. The
heart was tiabby :ind contained a small clot in both sides, larger in the right than in the left. The liver was lirm and
somewhat congested, its surface of an intense bluish-.slate "color, which coloration extended two lines into the paren-
rliynia : the gall-bladder contained an ounce of dark-brown bile: the spleen was of a purple color with an admix-
ture of brown and was extremely firm; the pancreas was white and not very firm. Tho ileum, in its six lower feet,
was extensively ulcerated; about two feet above the ileo-ca'cal valve was a Peyer's patch of an irregular circular
shape, presenting three distinct ulcers with high blackish walls and stone-gray bases, in one of which was a small
perforation which had caused some exudation of lym]di on the peritoneal coat. The kidneys were healthy. — Jss't
Aiov;. //. Allen, C. S. A., Lincoln Hospital, Washington, D. C.
Case 155. — Sergeant James Geddis, Co. L, 6th Mich. Cav.; age 33: admitted Aug. 18, 181)3. Died 22d. I'lmt-
mortem examination nineteen hours after death : The brain was firm and healthy. The trachea was of a dark-purjile
color, tinged with ochre on the rings; the bronchial tubes contained a dark grumous secretion. The ojsopliagns
was yellowish throughout. The lungs were somewhat cedematous, tho right weighing twenty ounces and the left
twenty-one ounces. The heart was pushed upwards by the intestines; the right ventricle contained a fibrinous clot
which extended some distance into the pulmonary artery; the left cavities contained a soft venous clot; the aorta was
highly colored. The liver and stomach were concealed by the intestines; the liver was firm: the gall-ldailder con-
tained twelve drachms of dark-colored bile with a yellow fiocculent deposit : the spleen was comjiact anil of a dark-
purple color: the i>ancreas was dark-green externally, hard and white internally. The intestines were much dis-
lendeil, evidently from cadaveric changes: the lower third of the snrall intestine was ulcerated in several i>laees,
in one of which there was a circular perforation with pale white edges, and the peritoneum surrounding it blackened
to the extent of the Peyer's patch afiected and covered with tough yellowish lyniph for some distance beyond; the
large intestine was healthy except that its solitary glands were conspicuous. The kidneys were dark-purple in color.
— .Ifs't Surg. H. Allen, V. S. A., Lincoln Hospital, Washington, I). C.
Case 156.— Private W. S. Doyle, Co. H, 3d Mich. Cav.: admitted June U, 1863; died October 15. rost-mortrm
examination: Sudamina were observed, especially on the abdomen and arms. The brain-substance was very firm;
the lining membrane of the ventricles was roughened, especially over the corpora striata and tho descending crura
of the fornix, where the roughness seemed like an exudation of lymph, but it could not be detached without destroy-
ing the cerebral substance: there was no meningitis. The trachea, dark purplish-red in color, presented nuuurr-
ous minute whitish points of exudation on the surface of the mucous membrane at its upper part. The O'sopliagus
was of a pale purple color superiorly and of a brownish huo below; an abscess the size of a chestnut was found in
its walls. Both lungs were congested; tho right weighing sixteen ounces and one-quarter, the left twelve ounces
and a half. The heart contained fibrinous clots in both sides. The liver was firm, its capsule easily torn, its acini
distinct; the spleen was pultaceous. The stomach was mottled and filled with liquid greenish fa-cal-like matter.
The intestines were distended with air; patches of the peritoneal surface were of a bright crimson color and the coils
382 - POST-MOETEM RECORDS OF
of the small iutestine were glued together with recent lymph; the duodeuum was of a dark color, its villi softened
and readily detached ; the ileum was passively congested, its solitary glands enlarged, its agminated glands elevated
and whitish, those near the ileo-ca'cal valve forming elliptical ulcerated patches with high thickened walls and
smooth pale bases, in many instances covered Ijy a whitish adherent exudation, while iu one instance the j)erito-
neuiu formed the base and in another perforation had taken place; the large iutestine was healthy. The kidneys
were normal. — Ass't Suiuj. II. Alhn, U. S.J., Lincoln Hospital, Washington, D. C.
Case 157. — Corporal Cyrus B. Clark, Co. B, 15th Vt.; admitted Dec. 14, 1862, with continued fever; died Slst.
Vost-mortiiH examination: Peyer's glands were ulcerated and one of the ulcers had perforated. There was general
peritonitis and a large quautity of serum in the abdomiual cavity. The recti muscles, in their lower third, contained
much extravasated blood. — Third Division Ilospitul, Ahianilria, Va.
Case 158. — Private John Clark, Co. E, 16th Va.; age 21; was admitted Nov. 13, liiG2, presenting a hot skin,
frequent feeble i)ulse, dry, dark and furred tongue, diarrhoea, tymi)anitic and tender bowels and slight duluess on
l)ercussion over the lower lobes of the lungs; there were no rose-spots nor sudamina. The patient apparently did
well during the day and slept comfortably the greater part of the night, but towards morning he became delirious,
after which he sank rapidly, and died during the day. Posi-mortim examination: The middle and lower lobes of the
right lung were eugorged: the left lung was slightly congested. The heart was normal. The jteritoueal cavity con-
tained a large (piantity of serum luiugled with fiecal nuitter; the great omentum was eugorged and the mesenteric
glands enlaiged. The small intestine was greatly discolored, in some places nearly black; its mucous membraiie
was reddened and engorged with black T)l()od; the patches of Peyer were inflamed and ten of them ulcerated, two
of the ulcers having perforated. The liver and si)leen were enlarged but of normal consistence; the kidneys were
normal. — Third Division Hospiltil, Ahxandria, Va.
Case lo'J. — Private Martin Hogle, Co. B, 5th N. Y. Cav.; age 27 ; was admitted Aug. 12, 1864, with well-marked
symptoms of typhoid fever. He was delirious, the abdomen tympanitic and tender, the tongue furred and the pulso
accelerated. lie died on the 29th. There was no diarrhtea until within four days of death. Post-mortem examina-
tion on the day of death: Kigor mortis well marked; body moderately emaciated. The trachea was lined with
frothy sputa of a molasses color; the right lung normal externally, was studded internally with melauic spots
about the size of peas, it weighed twelve ounces; the left lung was healthy, it weighed seven ounces and a half.
The right side of the heart contained a large firm black clot. A considerable quantity of pus was observed on the
omentum; -the spleen, fdnirteen ounces and a half, was firm and of a bliiish-slate color; the liver, seventy-eight
ounces, appeared to be normal; the kidneys were healthy. Peyer's patches were extensively ulcerated and the ulcers
had perforated in five places; the large intestine was normal. [See Med. Sect., Army Medical Museum, 369 to 373,
and also plate facing this page.] — Act. Ass't Surg. H. M. Dean, Lincoln Hospital, Washington, D. C.
(B.) Pei/ir's patches ulcerated and the large intestine also implicated— i5 oases.
Case 16(1. — Private James Kilgore, Co. D, 150th Ind.; age 30; was admitted April 25, 1865. It was at first
sujjposed that this man was crazy, and his bed-card was marked accordingly: His manner was strange, his face
flushed, his breath exceedingly ofi'ensive and his habits filthy; when asked his age he answered ''about a hundred."
On May 1 bis pulse and respiration became frequent and he presented the physical signs of pneumonia. He died on
the 3d. Poxt-mortem examination four hours after death: Suggillation on the chest and posteriorly: sudamina on
the skin. There was some injection of the meninges and a moderate quantity of serum at the base of the brain.
The right lung was engorged with blood and adherent to the thoracic parietes. The transverse colon was much con.
stricted, not measuring more than eight lines in diameter; the mucous membrane of the ileum was intlamed and
the patches of Peyer ulcerated. The spleen was very soft and enlarged to three times its ordinary size. — Act. Ass't
Surg. H. J. Wiescl, Cumberland Hospital, Md.
Case 161. — Private Norman Boyd, Co. B, 1st Conn. Heavy Art., was admitted July 25, 1864, iu moribund con-
dition ; tongue dark biown, dry and cracked ; sordes on teeth ; involuntary passages from bowels. He died comatose
next day. Post-mortem examination five hours after death: Body not much emaciated. The lungs were engorge!
and the pleura> adherent. Peyer's glands were slightly ulcerated for the space of eight inches above the Oeo-cacal
valve, and extending for six inches below it were twenty or thirty ulcers, several of which nearly perforated the
intestine; the rest of the intestine was apjiarently healthy. — Fair/ax Seminary Hospital, Vu.
Case 162.— Private Patrick Lynch, Co. A, 65th 111.: age 17; was admitted July 20, 1865, with diarrh(r:i and
constant delirium ; he died on the 27th. Post-ntortem examination: There was about an ounce of clear serum in eich
lateral ventricle and two ounces in the sub-arachnoid space. The posterior portions of both lungs were congested.
Peyer's patches were greatly enlarged and ulcerated and the solitary glands enlarged. In the colon minute oval
pnrpura-like spots were observed. — Ass't Surg. Geo. M. 2IcGill, U. S. A., Hicks Hospital, Baltimore, Md.
Case 163.— Private O. J. Richardson, Co. C, 108th N. 'Y., was admitted Nov. 23, 1863, in a comatose condition:
pulse 120, just perceptible ; tongue dry and fissured ; breast and abdomen covered with sudamina and feet and legs
cold. Stimulants were freely given and warmth applied to the feet. He died on the 27th. Post-mortem examination
thirteen hours after death: Much emaciation; feet becoming gangrenous. Lungs, heart and spleen normal; Peyer's
glands enlarged and ulcerated : solitary glands of large iutestine enlarged and ulcerated; mesenteric glands enlarged.
—Act. As.i't Surg. W. H. Letterman, Douglas Hospital, Washington, D. C.
Case 164.— Private John Hutton, Co. D, 1st Vt. Cav., was admitted Nov. 23, 1863, delirions. He rolled from
side to side in bed and picked at the bedclothes; his tongue and skin were dry, his pulse small and his feet cold;
THE CONTINUED FEVKRS. 383
involuntary stools wpio |iasse<l fro(|Uontly. Stiinulauts were given ami wainitli and innstanl applied to his feet and
lens, lie died on the 27tli. I'o/it-mi>rl<m examination twelve hours after death: l)(jdy not (•niaeiale<l ; hoth feet jjan-
•{reuous. Heart and lun^s lieallhy. Spleen enlarged and of a dark-])urplo color: kidui^ys healthy; niosentoric glands
enlarged: I'eyer's ghmds enlarged and uleerated: solitary glands of large intestine uleerated. — .Id. Jsd't Siiri/. 71'. //.
[.(ilirmaii. Doiigtiin Ilospilal, JTashiiKiliiii, I). C.
Case U)5. — Sergeant Frank Donohuc, Co. A, 17th Pa. Cav., was admitted Feb. W, liStU!, having been siek for two
Mioutha with typhoid fever. He was completely deaf. On March 1 he had sore throat, severe hoadaehe and consti-
pation. On the 15th his stomach lieeanie irritalile and there was soreness in the bowels with diarrhcea. Later the
sioids became dark-looking but less fre<|ueut. He died ou the 25th. Poal-moilfin examination forty-eight hours after
death: Body well developed and not emaciated. The light lung weighed sixteen ounces ;ind a half and the left
twenty-one ounces and a quarter; posteriorly the lower lobe of the right lung was full of blackish-brown tluid, which
also tilled tlu' bronchi; similar appearances were found in spots in the left lung. The heart weighed nine ounces
and contained noelots: the aorta was somewhat contracted, deeply congested, and three inches beyond the semilunar
valves was a eieatrix-like puckering with intense surrounding congestion. The liver was pale and weighed (ifty-
eight ounces and a half; the spleen soft, reddened, weighed twelve ounces and a half; the pancreas natural, throe
ounces and three-iiuarters ; the stomach healthy. The mucous membrane of the upper part of the small intestiui' was
yellowish and presented several roundish ulcers with well-detincd edges in Peyer's patches and one patch, a half inch
in diameter, enlarged and indurated : lower ilown the ulcers were nu)re ragged and apjiarently did not involve Peyer's
patches: in the last tifteeu inches of the ileum the mucous membrano was of a reddish-slate color, the solitary glands
brownish, and there were ragged excoriating ulcers iu many of which was a thick yellowish exudation. The mucous
nu>nibrauc of the large intestine was of a dull slate color, presenting one ulcer on the ileo-Ciecal valve, one at tho
commencement of tho ca>eum and a third four inches beyond. The kidneys were llabby and much congested. — J»«'(
Siini. Harnnon .llleii, U. S. A., Lincoln ffoxpital, llashiniilon, D. C.
Ca.-^e 1G(>. — Private John F. Chapman, Co. I,32d 5Ie.: age 35; was admitted July 2, 18til, with sonu' irritability
iif the bowels, soreness of abdomen, slight tympanites, fever, great thirst, a dry furred tongue ajid a pulse of 11(1. lie
became alllicted with :i triuiblesonu" cough on thi^ 5th, which continued for some days, but ou the lltli he was reported
:is improving. Two days later the stouuich became irritable and the skin showed a tendency to slough. On the 1 Ith
lie refused food and medicine, and next day he died. Pust-morltm examination three hours after death: The right lung
weighed fourteen ounces, the left fourteen ounces and a half; both were healthy except that there were a few softeiie<l
tubercles iu the upper lobe of each. The heart weighed eight ounces; its right ventricle contained a small tibrinous
clot. The stomach was healthy. Peyer's patches were exteusivelj' ulcerated; the solitary glands showed many ulcers;
the ileo-ca>cal valve was much congested ; the ascending colon presented two ulcers — the ui)per one, about the size of a
pea, was siiperticial, the lower, five-eighths of an inch in diameter, penetrated to the peritoneum. The liver weighed
sixty-nine ounces and was slightly congested; tho gall-bladder contained five or six ounces of thin bile; the spleen
weighed thirteen ounces. — Act. Ass't Surg. James T. Logan, Lincoln Hospital, Washington, I). C.
Case 107.— Private F.verett H. Feltou, Co. G, 187th Pa.; age 28; was admitted Aug. 30, ISlil, with an apparently
uiild attack of typhoid fever; but on .September 20 a profuse diarrluea supervened, and he died Octobers. I'osl-morlcni
examination ten hours after death : Body much emaciated. Brain and thoracic viscera normal ; a fibrinous clot in each
side of the heart; spleen and kidneys normal; several Peyer's patches and solitary follicles ulcerated ; numerous
small ulcers in tho large intestine. — Act. Ass't Surg. H. M. Dean, Lincoln Hospital, Washington, I). C.
Case 1(>8.— Private Lewis AVeir, Co. A, 202d Pa.; age 18; admitted Nov. 2, 1861. Ty])hoid fever. Died on tho
"ill. I'ost-morlvm examination forty lioitrs after death: Kigor mortis well marked; snggillation posteriorly; no enuu'ia-
lion. On the ui>per surface of the cerebral hemispheres, anteriorly along the course of the large bloodvessels, there
was in several places a gelatinous subarachnoid <Ieposit; the subarachnoid space contained one ounce and a half of
>eruni. The right pleural cavity contained two ounces and the left four ounces of dark bloody serum; the posterior
part of the right lung was engorged and small jiortions of its upper and middle lobes were hepatized ; the left lung
was congested jiosteriorly. The intestines were distended with air; Pejer's patches in the lower part of the ileum
were ulcerated in several places; the solitary follicles of the ca-cuni and of the first six inches of the colon were
ulcerated; the remaindi'i of the large intestine was normal: the uuiscnteric glands adjai'cnt to the ulcerated intestinal
glaiuls were enlarged and dark-colored. The spleen was enlarged and softened. — Act. AssH Snrg. Thomas Boavn. Second
IHrision Hospital, Alexandria, Va.
Ca.se 1(59.— Private Jo.seph Uilly, Co. D, (ith Pa. Heavy Art.; age 17: was admitted Oct. 30, 1864, with typhoid
fever, and died Novembers. PosZ-iHoWeni examination nine hours after death: Marked rigor mortis; slight enuuia-
tion; snggillation posteriorly. Lungs very dark, filled with blood; bronchi slightly congested; bronchial glands
uoruuil: ventricles of heart dilated and containing small dark clots; liver enlarged, pale; spleen enlarged, dark-
ened, unich softeiuHl; mucous coat of stomach an<l Jejunum normal ; Peyer's patches in the lower two feet of ileum
anil solitary follicles of first six inches of colon thickened and ulcerated; mesenteric glands enlarged, filled with
dark matter, especially three near the ciecum; kidneys congested, — Second Division Hospital, Alexandria, Va.
Case 170. — Private John Verberson, Co. B, 35th Mass.; age 33; was admitted Nov. 30, 1864, convalescing from
typhoid fever. He was much debilitated and had a severe diarrhiea. He died December 16. I'ost-mortcm exami-
nation ten hours after death: Sndamina on legs and breast; slight snggillation posteriorly. Some jjleuritic adhe-
sions on the right side: emphysema of both lungs; puckering of middle lobe of right lung; three ounces of jialo
serom in pericardium: enlargement of liver; congestion and in some places ulceration of Peyer's patches; conges-
, tion of c.Tcum. — Third Division Hospital, Alexandria, Va.
384 POST-MOKTEM HECOKDS OF
Case 171. — Private George Wood, Co. B, 1st Bat'y, 2d Me. Light Art.; age 21; was admitted July 25, 1864,
ill very low condition. He died comatose on the following day. rogt-mortcm examination twenty-two hours after
death: Body extremely emaciated. Stomach and intestinal canal greatly inflamed; large intestine much ulcerated;
liver fatty; gall-bladder enormously distended; other organs healthy. ISpccimcn 420, Med. Sect., Army Medical
Museum, which is from this case, shows several large ulcers of Peyer's patches just ahove the ileo-ciccal valve,
penetrating in some jilaces to the transverse muscle and in others to the peritoneum, as also some enlarged and
ulcerated solitary loUieles.] — Surg. E. Benttet), U. S. V., Third Division Hospital, Alexandria, Va.
Case 172. — Private Joseph Swartz, Co. M, 2d U. S. Cav.; age 22; was admitted June 12, 1863, for a ccmtnsiun
of the chest. On July 5 he was placed on duty as nurse, hut on the 26th he became attacked with tyi)hoid fever
which i)roved fatal on August 10. Post-mortem examination seventeen hours after death: Slight emaciation; com-
mencing decomposition. Lungs slightly congested; heart healthy, a fibrinous clot in the left ventricle. Stomach
and liver healthy; spleen firm but nearly double its normal size. Peyer's patches in the lower part of the ileum
ulcerated, the surrounding mucous membrane much congested and the corresponding mesenteric glands enlarged.
CiBcum presenting one ulcer; the remainder of the large intestine healthy. — Aot. Ass't Surg. J. H. Hutchinson, Sat-
tcrlee Hospital, Philadelphia, Pa.
Case 173. — Private John Flowers, Co. M, uth Pa. Cav., was admitted June 9, 1862, with rheumatism, and died
July 29 of typhoid fever. Post-mortem examination on the day of death: Effusion of serum into the pericardium,
amounting to about one-third of a pint or more; no evidence of pericarditis except a more than usual redness of the
surface of the left ventricle; indications of a recent pleurisy, with the formation of pseudo-membrane on the right
side, the corresponding i>leural cavity filled with serous effusion. The mucous membrane of the large intestine pre-
sented patches of inflammation but no ulceration ; that of the ileum was more intensely inflamed and all the agiui-
nated glands were ulcerated, in most instances as far as the muscular coat and in two instances to the peritoneum,
though the latter was not inflamed. — Act. J.ss't Surg. Joseph Leidy, Satterlee Hospital, Philadelphia, Pa.
C.iSE 174. — Private George Young, Co. and Reg't not recorded, was admitted Aug. 10, 1862, and died on the 13th.
He was delirious from the time of his admission. Post-mortem examination same day: Age apparently between 3.5 and
40; body much emaciated; about a dozen scattered rose-colored spots on thorax and abdomen. The organs of the
chest, the stomach, liver, spleen, pancreas and kidneys appeared natural. The small intestine was inflamed through-
out; its agminated glands were ulcerated, the ulceration exposing the muscular coat; the mucous membrane of the
lower part of the ileum was of a livid purple; the agmiuated glands, together with a portion of the surrounding
mucous and sub-mucous tissue, were completely destroyed, leaving patches of exposed transverse muscular fibre
inclosed by thickened ridges of the mucous membrane. [Specimen 239, Med. Sect., Army Medical Museum.] The lining
membrane of the colon was slightly inflamed and of a slate-color. The solitary glands of the small and large intes-
tines were not conspicuously diseased. — Act. Ass't Surg. Joseph Leidy, Satterlee Hospital, Philadelphia, Pa.
Case 175. — Private Benjamin Allen, Co. H, 1st Ohio, was admitted Dec. 23, 1862, with typhoid fever and erysip-
elas of head and face; he died on the 26th. Post-mortem examination next day: Body fat; left side of head and neck
discolored by erysipelas. Brain healthy but pia mater somewhat injected on left side and slight ett'usion in sub-
arachnoid space. Lungs and heart, liver, stomach, pancreas and kidneys healthy. Spleen enlarged, seven by five
by two and a half inches, very flabby, bluish on the surface and marked with dark reticular lines; mucous mem-
brane of ileum and colon moderately inflamed; intestinal glands healthy except in the lower three feet of the ileum,
where the agmiuated glands were much enlarged and ulcerated. lS2)ecimens 112-114. Med. Sect., Army Medical Museum,
are from this case.] — Act. Ass't Surg. Joseph Leidy, Satterlee Hospital, Philadelphia, Pa.
Case 176. — Private Sidney Church, Co. A, 189th X. Y.; admitted Jan. 17, 1865; died 21st. Post-mortem exam-
ination: Lungs normal : heart flabby: liver healthy; spleen fourteen ounces, softened : duodenum and jejunum healthy:
Peyer's patches of ileum ulcerated, the ulcers cup-shaped and round; ileo-c:ecal valve much thickeued; colon for
eighteen inches filled with clotted blood, below which the solitary follicles were not enlarged. — Ass't Surg. H. Loetc-
enthal, XJ. S. V., Fifth Army Corps Field Hospital, Army of Potomac.
Case 177. — Private Silas N. Peterson, Co. D, 38th Mass.; age 25; was admitted Nov. 5, 1862, with typhoid
fever, and died on the 10th. Post-ntortem examination: Inflammation and ulceration of Peyer's patches and of the
colon near the caput; much enlargement of the mesenteric glands. — Act. Ass't Surg. T. F. Murdoch, Stewart's Mau-
sion Hospital, Baltimore, Md.
Case 178. — Private C. M. Kelsey, Co. M, 14th N. Y. Heavy Art., was admitted July 24, 1864, having been sick
since the 7th with diarrhoea and fever. He died on the 28th. Post-mortem examination on day of death: Lungs ami
heart healthy. Peyer's patches were inflamed and slightly ulcerated; several ulcers were found in the largo intes-
tine; the mesenteric glands were much enlarged and softened. The spleen was five inches long by three broad and
rather soft; the kidneys were large and "fatty. — Fairfax Seminary Hospital, Ta.
Case 179.— Private H. Richardson, Co. C, 13th E. Tenn. Cav., was admitted Jan. 22, 1864, with typhoid fever;
and died February 6. Post-mortem examination forty-eight hours after death: Body emaciated; rigor well marked.
The brain, lungs, heart and solid abdomhuil viscera were healthy. The stomach was injected; Peyer's patches ulcer-
ated throughout the entire length of the ileum; the mucous membrane of the large intestine inflamed and thickeued;
the mesenteric glands enlarged. — Act. Ass't Surg. G. TT. Eoberts, Hospital Xo. 19, Xashrille, Tenu.
Case 180.— Private Robert Traut, Co. A, 10th E. Tenn. Cav., was admitted Jan. 29, 1864, with typhoid fever.
He died Feljruary 6. Post-mortem examination twentj' hours after death: Body emaciated; rigor slight. The mem-
branes of the brain were slightly iujected. The lungs weighed sixty ounces and the pleural cavities contained
THE CONTINUKD FEVERS. 385
two ounces of liquid; tlic liciiit was healthy. The liver wa.s iiule but seemiugly healthy; the spleen congested,
wri"liing fifteen oiinees; tlie kiiliieys, especially the left, congested. The mucous nienibrano of the stomach was
inllained and softened, as was that of the .small intestine and colon : I'eyei's j;lauds were ulcerated and the mesenteric
ulauds, ill some instances, as large as a chestnut. — Act. Ami'l Surij. 0. W, lioberls, Hospital No. 19, XunhvilU; Tain.
C'a.kk 181.— Private Ira A. Sperry, Co.,D, 117th N. Y.; age 24 ; was admitted ,Inne 15, 18G3, with typhoid fever,
ami died on the '22A. Pout- mm l< in examination twenty-tive hours after death: Hody not enuiciatcd. Hrain healthy.
Mucous niemlirane of trachea nnicli congested; ujjpcr lobe of right lung somewhat congested, middle lob<^ more
natural, lower lidie extremely congesti-d, weight of lung sixteen ounces; np|)er lobe of left lung congested, weight
,.f lung fifteen onnecs ami a half. KIght cavities of heart contained fibrinous clots; left mixed clots. Liver, sixty-
live ounces, llabby, mottled cineritious and deep purple; about the middle of the anterior surface of the right lobe
\as a large white spot coated with lymph, indicative i)robably of pritvious inllanimation. (Esophagus iiunual;
-iKiiiach of a dull gray color: siileen firm, dark mahogany colored, weight eleven ounces and a ([uarter, an opac|ue
spot covered with recent lymiili on its ujiper surface: pancreas liriu and white, weight two ounces and a half. Duo-
deniiiii somewhat congested; jejunum and upper part of ileum normal; niucons membrane of lower part of ileum
; !iin, pale and easUy torn; Peycr's patches elevated, dark slate-colored; solitary glands prominent; ulceration pres-
iiit hut nowhere extensive. Large intestine dull greenish in color hut not ulcerated. Left kidney flabby, slightly
injected, somewhat friable and with many ecehymosed blotches on pelvis; bladder much distended with urine. — Ass't
Sur(j. Uiirr'mm Allen, U. S. A., Lincoln J[ospital, Wushbujion, D. C.
t'.\SE 182. — Private William Gibbings, Co. F, 5th Mich.; age 35; was admitted April 21, 181)1, with typhoid
fever, and died May 12. I'ost-morltm examination twenty-three hours after death: The brain weighed fifty ounces.
The mucous membrane of the larynx and trachea was somewhat congested. The right lung weighed thirty-two
ounces, its lower lobe hepatized red, its upper lobe gray and the pleural surfaces adherent; the left lung weighed
nineteen ounces. The heart was flabby: there were three drachms of light-red fluid in the pericardium. The
icsophagus was healthy; the cardiac end of the stomach reddish-brown and much softened; the mucous niembrano
of the duodenum much congested; the solitary follicles of the ileum and Peyer's patches ulcerated, some of the
ulcers penetrating to the iieritoncum; a small triangular piece of bone was found in the appendix vermiformis; the
mucous nu'iiibrane of the large intestine was much congested and softened. The liver, fifty-nine ounces and a half,
was fiabby and ana'mic; there were six drachms of gamboge-colored liciuid in the gall-l>ladder; tlu^ spleen eleven
ounces and a half, was pulpy, its c:ipsule easily separated and presenting on its superior surface a "round white
body resembling bone." The right kidney weighed five ounces, the left five ounces and a half; both v.'ere soft and
fiabby. — Act. Ass't Surg. A. Ansvll, Lincoln Hospital, Washington, D.C.
C.vSE 183.— Private Peter W. 15ackoven, Co. G, 8th N. Y. Cav.; age about 21: admitted Aug. 18, 1863; died
■.'6th. Post-mortem examination: Body not much emaciated; rigor mortis great. The brain weighed fifty-one ounces
and a half: the surface of the cerebellum was slightly red and the vessels of the pia mater filled with a purplish
lliiid: the interior of the brain was normal. The larynx and trachea were ytaXe, the portions between the rings of a
light purple hue. The (esophageal mucous membrane was pale gray in the upper part, becoming tawny or purplish
further down, and cousideraldy corrugated hoth longitudinally and transversely. The right lung weighed eleven
ounces and a half, the left twelve ounces and a half; both were scunewhat congested in their lower lobes. The heart
■was healthy, its right ventricle contained a fibrinous clot; the li(iuid of the pericardium was decidedly reddish
in color and measured six drachms. The liver weighed fifty-seven ounces, its surface purple with a few scattered
yellowish macuhe, its section paler than usual but firm; the mucous membrane of the stomach near the pylorus was
somewhat marbled; the spleen, nineteen ounces and a half, was firm and of a chocolate color: the pancreas was
normal. Peyer"s patches in the lower part of the ileum were elevated, white and covered with small ulcerations,
a few of the patches were congested; the large intestine was purple in its upper Jiart, becoming jialer towards the
rectum. The kidneys were firm; on section a small quautily of venous blood flowed from the cut edges of the pyra-
mids: the right supra-renal capsule was yellowish-white internally and did not contain the usual brown fluid; the
left capsule was darker in color and contained a small quautity of brownish fluid. — Ass't Surg. Harrison Alhn, U. S. A.,
l.inciihi lluspital, IVashinglun, J). C.
Case l>a.— Private Abiaiii I'.eeker, Co. H, 11th V. S. Inf.; age 39; was admitted Jlay 11, 18(M, with a gunshot
flesh wound of the left heel, lie contracted tyjihoid fever while in hospital, but had apparently convalesced; his
app.lite iiiii)roved, and he gained strength during the last two days of his life; he was walking about w ithin ten
minutes of his death on .liily 30. J'osl-iiiorlim exaiiiiiiatioii seventeen hours after death: ISody well nourished. The
lungs contained much frothy, bloody fluid; the right weigli<-d nineteen ounces and thrcoiiuarters, the left nineteen
ounces. The heart was flabby and contained a small soft fibrinous clot in the right ventricle. The liver was flabby
and dark-colored; the spleen weighed thirteen ounces and threc-(|uarters. In the ileum I'cyer's patches were con-
gested, near the ileo-ca'cal valve ulcerated: some of the solitary glands also were ulcerated. The large intestine
was somewhat congested in its upper portion. — Act. Ass't Surg. E. M. Dean, Lincoln Hospital, Washington, D. C.
C.v.sK 185.— Private Jos. 8. Nelson, Gth Me. Bat'y; age 45; was admitted Oct. 19, 18G3, with typhoid fever, and
died Nov. 24. Post-mortem examination next day: Body greatly emaciated. The brain was healthy. The epiglottis
was lined on the posterior surface with an exudation and ulcerated on either side of the free border, the ulceration
being confined to the nincous membrane, which was of a jialish pink color and thickened around the edges of the
ulcers: an irregular ulcer, with pinkish ■nails, was seen on the li'ft side of the larynx immediately lielow the vocal
cord and a smaller ulceration of similar appearance in the angle of the thyroid cartilage. The posterior portion of
Mi;i.. Hist.. Pr. 111—49
386 POST-MORTEM RECORDS OF
tlie iiliiiryiix opposite the epiglottis was the seat of a sn]>eificial ulcer; the tesophagus was pale and filled with a
whitish curd-like mass, at first supposed to be a retaiued portion of ingesta, but on careful examination found to be
a true exudation. The right lung weighed twenty-seven ounces; the posterior part of its upper lobe was quite
cedematous, its bronchi prominent, feeling like millet-seed under the fingers, and their mucous lining everywhere
of a dark-purple color; the posterior surface of the lobe was coated to the extent of an inch and a half with a thick
whitish membrane; the lower lobe posteriorly was ranch compressed by a circumscribed pleuritic effusion measuring
fourteen ounces. The weight of the left lung was thirty-two ounces; its upper lobe presented the same general
appearance as that of the right side; the bronchial tul>es were everywhere prominent, in some parts giving the feel
of a cirrbosed liver; the lower portion of the hing was of a dark-purple flesh-color, friable and heavier tlian water.
The heart contained but little clot in its right side and none in its left. The liver was dark and tolerably firm,
weighing fifty -seven ounces; the gall-bladder was very prominent and contained twenty <lraohms of thin brown
bile; the spleen weighed seven ounces and was of a dark mahogany color and i|uite firm. Peyer's patches and the
lower portion of the small intestine were ulcerated; the large intestine was also ulcerated and of a stone-gray hue
alternating with patches of a dull lardaceous appearance; the ulceration was of the punctated form. A large
gangrenous abscess was found on the right of the anus extending dee|)ly into the right buttock; its external opening
was small. Just before death a severe hemorrhage had taken place from this aljscess; several very large, firm, black-
ish clots were found in its cavity. It was supposed from the examination that this communicated with the rectum,
but the passage to that gut was obtained with some difiiculty, and it is not improbable that the force used in manip-
ulation prodnoed the communication. No flatus or excrementitious matter had escai>ed during life. — Ans't Surg. Har-
rison Allen, V. S. A., Lincoln Hospital, Washington, D. C.
Cask 186. — Private Martin Stevens, Co. D, 7th N. C; age 33; was admitted May 20, 18ti4, witli typhoid fever,
and died on the 24tli. Post-mortem examination sixteen hours after death: Body rather spare. Lungs congested
throughout; left ventricle of heart dilated; suuill intestine mncli infiauied; solitary follicles and Peyer's patches
ulcerated; large intestine inflamed; mesenteric glands enlarged and softened; liver and kidneys normal; spleen
much enlarged and congested. — Lincoln Hospital, Washington, I>. C.
Ca.se 187. — Sergeant John Link, Co. A, 107f h Ohio, was admitted Juue 15, 1863, delirious, and died on the 17tli.
Post-mortem examination ten hours after death: The brain was normal. The trachea was purple; its mucous mem-
brane firm ; the bronchial glands at its bifurcation large. The lower part of the (esophagus was of a pale yellowish
color and presented ulcers of the same hue; its mucous membrane was not softened. The right lung weighed nine-
teen ounces and a half and was congested in its lower an<l in part of its upper lobe; the lower lolie of the left lung
was somewhat engorged. The heart was normal and contained a fibrinous clot in its right side. The liver was large
and dark-colored, extending entirely a(rross the body; the gall-liladder contained three onnces and six drachms of
bile. The stomach was immenselj' distended and occupied the greater portion of the abdomen in an oblicine posi-
tion; its mucous membrane was softened and presented several n\iuute black spots towards the pylorus; between its
superior curvature and the gall-bladder was a small (|uantity of recent lymph. The small intestine was contracted;
its mucous membrane was softened and varied in color from light pink to deep purple; the .jejunum was filled with a
glairy tenacious mass; the last two feet of the ileum presented well defined ulceration of Peyer's patches, the ulcers
being mostly circular with ragged walls and an irregular base, which was generally stained of a dull-ochre color by
the intestinal contents; near the ileo-csecal valve several of the ulcers ran together, forming a large ulcerated area,
which, with its black indurated walls and yellowish base, stood out in strong relief against the jiurple, livid and
congested nnicous membrane. The large intestine was also much contracted, its rug;e elevated and coated with a
tenacious mucoid secretion; no ulcers were found in it. The right kidney was congested, and several suuiU spots of
transuded blood were noticed on its external surface ; the pelvis of the left kidney Was similarly discolored. — Aas't
Surg. H. Allen, U. S. A., Lincoln Hospital, Washington, I). C.
Case 188. — Private John Walford, Co. V, 2d U. S. Colored troops, was admitted .Jan. 17, 1866, in a moribund
condition; tongue parched; teeth and lips covered with sordes. Stinmlants were freely used, but he died next day.
There is no detailed record of the autopsy, but the whole intestinal canal was received at the Museum. The ileum
showed hypertrophied villi and progressive thickening and ulceration of the solitary follicles and Peyer's patches;
many solitary glands in the colon were enlarged to the size of peas and ulcerated on their summits. [See Med. Sect.,
Army Medical Museum, 707 and 708.] — Snry. li. li. Bontecou, V. S. }'., Harewood Hospital, Washington, D. C.
Case 189. — Corporal Walter Angel, Co. K, 10th N. Y. Cav.; admitted Aug. 17, 1803, with tyi)hoid fever. Died
20th. Post-mortem examination : Body slightly emaciated. The lungs, heart an<l i>ericardium were normal. The liver
was congested; the gall-bladder somewhat distended; the spleen enlarged and congested, weight eleven ounces.
The mesenteric and meso-colic glands were much enlarged and there w.as considerable venous congestion of the intes-
tinal peritoneum. The mucous membrane of the lower jejunum and ileum was congested in patches, the congestion
increasing progressively downwards, the last two feet being much congested, with, in the last six inches, several
deep circular ulcers having yellow bases and raised edges; Peyer's patches were not elsewhere ulcerated. The colon
was of a deep mahogany color, especially in the ascending portion. The pyramids of the kidneys were congested,
the cortical suljstance pale. — Harewood Hospital, Washington, D. C.
Case 190.— Private H. G. W. Stoner, Co. A, 14th U. S. Inf.; admitted Oct. 10, 1863, with typhoid fever. Died 13th.
Post-nwrtem examination : The lungs were normal excepting a slight adhesion to the pericardium on the left side.
The right cavities of the heart were dilated and filled with fluid blood ; their walls were thinned. The liver weighed
sixty-four ounces; the spleen twelve ounces. The stomach aud the upper part of the duodenum were much congested.
The jjeum was congested, especially in its lower part, which was thickened and inflamed and in Peyer's patchea
THE CONTINUED FEVERS. 387
iilcpraUnl; the ili>o-eiiH';il valvr \v:i.s imioli thiokeiicMl ami iilii'iatcd. The imicous iiienibrailo of the colon was coti-
HfsliMl ami softeiuMl ami Immlivds olits solitary follicles were ulcerated; the rectum also was congested aud softened.
The kidneys were congested. — Hurneoud Hospital, ll'iisliiniiliiii, D. V.
Case 191.— Private Martin Riley, Co. C, 122d I'a.: admitted April 21, 1863. Continued fever. Died May 21.
PihilniDrliiii examination twenty hours after death: The hody was much emaciated. The lun;js were healthy, liut the
lironehial tulies contained a purulent .secretion. The heart wn.s softened and ])ale; a small point of pus was found at
its apex; the mitral valve was thieki-ned and slifjlitly roughened. The stomach was nearly tilled with liile. The
liver was healthy: the gall-Madder nearly empty. The duodenum and jejuuum were normal; the ileum intlamcd
ami Peyer's patches uh'eratid; the ascending colon congested in sjHits. the transverse and <lescending i>ortions
healthy. The kidneys were normal. — ./c^ .l.-tn't Siirfi. .1. II. llunn, Ilarrwiidil IIiKpilal, WaxlihKjtiiti, />. ('.
Case 192. — Private John llause, Co. IF, IT.'ith I'a.: age:ir>: admitted .Inly t). IXliiJ. Died 12th. rnxt-iiiiirlim e\:\m-
in:itii>ii: Hody slightly enniciated. Liver healthy: gall-hhidiler distended with liili': spleen somewhat enlarged, much
congested and very soft: duodenum and jejunum healthy: ileum much inllauied and its agminaled and solitary glands
ulcerated, hut some of the ulcers a]>i)eared to lie healing: solitary follicles of ascending colon enlarged and ulcerated.
Kidneys healthy. — Act. Jss't Suni. LIujid Durm-y, Harcwood Huxjiital, ll'dshiiintoii, I). C.
Cask 193.— Private Frederick Wolfanger, Co. C, 93d N. Y.: age 13; was admitted Oct. 21, 181)3, and died
Novenilier 18. roxl-mortem examination thirty hours after death: Hody much emaciated. Hrain healthy. The left
parotid gland was the seat ot supjiurative inflammation; the pus had discharged from two openings, one in the
niiinth, Iietwcen the tongue and the inferior maxilla, the other externally, between the mastoid process and clavicle.
The left lolie of the thyroid gland containi'd a calcareous mass as large as a walnut, and in its upper portion a cyst
the size of a jiea, tilled with a dark-lirown tluid; tli<^ right lobe contained a cyst the size of a small <rhestniit, and in
its lower portion an apojilectii- extravasat ion one inch and a half long by one inch in width. The right lung weighed
forty-seven ounces and a half: its lobes were iiiteradherent but not attached to the ribs; the lateral and ])osterior
parts were (rdematous. The left lung resembled the other, but contained a greater (luantity of blood in many places,
the parenchyma Ipcing of a darker hue. The bronchial tubes were thickened and their mucous membrane ri'ddish;
a yellow tenacious mucus was contained in the snniller tubes, giving a granular appearance to a section of the lung.
Hoth sides of the heart contained mi.xed librinons and dark clots; its muscular tissue was much softer than usual.
The liver was normal; the spleen soft, llabby and of a turlad purple color. The intestines were of a dark grayish
color; Peycr's patches were ulcerated in places but were not elevated. The kidneys were slightly congested. — Ass't
Siirii. H. Jlhii, U. S. A., Uiicolii Iloxpilal, Washington, A C.
V\SF. 194.— Private Walter Wisner,Jl'o. F, 6th Mich. Cav.; ago 28; was admitted July 31), 18(i3, with typhoid
fever, and died August 3. I'ost-morltin examination eighteen hours after death: The brain weighed lifty-three ounces;
both lobes of the cerebrum were highly congested, especially in their superior and anterior portions, which were in
part of a brilliant crimson color. The tracheal mucous membrane was of a deep dull-purplish red; the trachea and
bronchi contained a thin bloody liiiuid instead of the normal secretion; the veins under the mucous membrane of
the larynx were distended; the lymphatic glands at the bifurcation of the trachea were large, soft and engorged
with black blood. The lungs were of a delicate pink color; the external and lateral portions of the upper lobes
and the whole of the lower lobes were doughy, seini-soliditied and engorged with dark blood mixed with a frothy
bronchial secretion; the right lung weighed twenty-five ounces, the left twenty-four ■ounces. 'ITie cavities of the
heart were free from clots, exce)>t a very thin wafer-like formation on the tricuspid valve. The liver was flabby and
somewhat congested; the sideen, sixteen ounces, was gr.ayish-purple in color and unusually firm. The intestines were
diseased throughout: the mucous membrane of the upper portion w,as flaccid, softened and easily torn, the viUvulae
eonniventes of an orange-ochre color; Peyer's patches were enlarged, elevati'd above the surrounding mucous mem-
brane, whitish in color and ulcerated, none of the ulcerated points being larger than the head of a ](in: the solitary
glands were also affected and, in the neighborhood of the valve, the mucous membrane was completely nodulated
with shot-like eminences; the inuc<ms membrane of the last six feet of th<^ iieiini, which was the part chielly inv()lve<l,
was of a dark-red color and its veins were very prominent. The kidneys were slightly congested, soft and flaccid. —
Aat't Surg. Harrinon Allen, U. S. A., Lincoln Hospital, Washington, D. C.
Ca.'se 19."). — Private Vincent Hogle, Co. E, 5th Mich.; age 33; was admitted March 21, ixijl, and dieil on the
2t!tli. rtist-morlcm examination: Lungs and pleura" inflamed; much effusion in right cavity. Intestines inflamed
nearly throughout; Peyer"s i)atches ulcerated. — Third Division Hospital, Alirundria, I'a.
Ca.se 196. — Private John Sullivan, Co. B, 1st Mass. Cav., was admitted July 2, IStW, and died on the 11th. Post-
mnrtim examination: Much emaciation. Lungs extensively inflamed; heart, liver and spleen healthy; stomach and
intestines much intlamcd; I'eyer's patches slightly ulcerated. — Third Dirision Hospital, Ahxandria, Va.
Case 197.— Private James Foster, Co. I, 83d Pa.; age 19 ; admitted April 19, 1864 ; died 22d. Post-mortem exam-
ination twenty-four honrs after death: The lungs, liver and spleen were normal. The glands of the intestines were
enlarged, tdcerated aud almost disintegrated. — Third DiviMon Hospital, Alexandria, Va.
Case 198.— Private Alonzo Wilkinson, Co. A, 20th Me., was admitted .\ug. 21, 1864. having about five or six
ah-inc evacuations daily, with some pain in the right side and slight dyspncea; pulse 120: tongue dry and covered
with a brown fur. The patient continued with but little change in his symptoms other than a temporary abatement
of the diarrho'a and aggravation of the lung trouble, together with increasing pro.stration, until delirium came on,
and death occurred on the 27th. rost-mortem examination six hours after death: Bod,y not emaciated; rigor mortis
388 POST-MORTEM RECORDS OF
great. The right luiig was generally congested and its middle lobe heiiatized; the k-lt lung was congested poste-
lioily. The pericardium contained two ounces ofli(juid; the right cavities of the heart were filled with a large par-
tially washed clot. The liver was enlarged and pale; the gall-bladder distended with viscid bile; the spleen enlarged
and soft. The stomach was inflated with gas, dilated and flabby, and its mucous membrane was reddened near the
pylorus. In the lower half of tlic ileum the agminated glands were congested, enlarged and prominent, and those
near the ileo-caecal valve showed small ulcers; the mucous membrane around the glands was more or less congested
according to its proximity or distance from the valve; the solitary follicles were enlarged and prominent. No ulcers
were found in the large intestine, which, however, was congested throughout and dotted with black pigment, par-
ticularly in the descending colon, where an occasional large black spotappeared. [.S/xcimo/sSOSaud liiiil, Med. Seet.,
Army Medical Museum, were taken from this case.] — Act. Ass't Siiry. 0. P. Swctt, Curvtr Sosjiital, irushington, D. C.
Cask 199. — Private Wm. S. Armstrong^ Co. B, 7th Me.; age 21 ; was admitted June 14, 1863, with high fever and
delirium, a furred and fissured tongue, sordes on the teeth, frequent retching and diarrhoea, the stools numbering
about twenty daily. He was much emaciated and so weak as to be unable to sit up. During the next few days his
stools liecame less frequent, but on the 19th the passages were involuntary, the delirium continued, the pulse, which
had fallen from 120 to 80, was very weak, the countenance pinched, the extremities cool, the perspiration cold. He
died on the 20th. rosl-murtfin examination fourteen hours after death: The brain was healthy. The nmcous mem-
brane of the oesophagus was of a bright-ochre color and rather softened; the trachea was of a dark-i)uri)le color, its
mucous membrane slightly softened. The lower lobe of the right lung and the whole of the left lung were congested.
The endocardium was somewhat darkened; the right ventricle contained a fibrinous clot; the aorta was reddish.
The surface of the liver was generally of a grayish-blue color, but anteriorly the right lobe presented a more healthy
appearance; minute collections of air were disseniLnated throughout the parenchyma of this organ, which was soft-
ened, of the color of sanious jius and possessed of a disagreeable odor; the air-cavities and the transverse section of
the portal veins gave a honey-combed appearance to the interior; Glisson's capsule was smooth and easily torn. The
mucous lining of the stomach was of a dark-slate color bnt healthy. The spleen, fifteen ounces and a half, was unusu-
ally firm and of a deep mulberry color; the pancreas was healthy. The intestines were distended with air; the
mucous membrane of the ujmer portion of the small intestine was of a light-yellow color; in the lower third Peyer's
patches were ulcerated and the mucous membrane, in some places very pale, was in others intensely injected; at the
ileo-Ciecal valve it was indurated, thickened and blackened and in the large intestine pale and irregularly dotted
with blackish spots. A cavity containing about four drachms of pus was found between the peritoneum and the
cellular tissue on the right side of the abdomen, about two inches below the diaphragm; the omentum was healthy.
The kidneys resembled the liver in having air-cavities disseminated through their jiarenchyma; the distinction
between the cortical and i)yramidal portions was almost obliterated, the latter being purplish; the organs generally
were tumid and flabby. Two large bed-sores were noted, one o\er the sacrum, the other over the great trochanter
of the right femur. — Ass't Sury. Harrison AlJni, U. S. A., Lincoln Hos})itaI, Washington, D. C.
Case 200.— Private R. L. Tyler, Co. E, 17th U. S. Inf.; age 23; was admitted Aug. 10, 1862, and Qied on the 16tu.
Post-mortem examination: The mucous membrane of the ileum was not generally inflamed, being of a pinkish-cream
color; there were twenty-two agminated glands, varj'ing in size from half an inch to one which was four inches in
length; the twelve upper i)atches were healthy, the thirteenth ulcerated, the fourteenth healthy and the remainder
ulcerated, some even through to the peritoneum; the last of the series, near the ileo-ca;cal valve, formed a blackish-
brown, irregular eschar about an inch and a quarter square and the fourth of an inch thick [see plate facing this
page]; in the vicinity of the ulcerated glands the mucous membrane was inflamed. The colon was inflamed in
patches, and its solitary glands were prominent and contained a deposit of black pigment, which was observed also in
the agminated and solitary glands of the ileum. [Sjiccinicns 240 and 241, Med. Sect., Army Medical Museum, are from
this case.] — Act. Ass't Surg. Joseph Leidy, Satterlee Hospital, Philadelphia, Pa.
Case 201.— Private Lorenzo H. Cox, Co. C, 6th Vt.; admitted August 10, 1862. Typhoid fever. Died Sept. 7.
PosJ-mo)'(6TO examination next day: Age about 25 years ; emaciation extreme; dift'use eeehymoses on skin of body.
Lungs healthy; heart natural, containing some liquid blood and a soft black clot in the right ventricle. Spleen small,
lake-red on section; liver dull-brown above, slate-color l)elow and uniformly brown on section. Stomach moder-
ately distended, its mucous membrane dirty gray with some vascular injection; ileum and colon inflamed in patches;
agminated glands containing black deposit, but otherwise healthy, except two near the colon, which were slightly
ulcerated; solitary glands everywhere pigmented. — Act. Ass't Surg. J. Leidy, Satterlee Hospital, Philadelphia, Pa.
Case 202.— Sergeant Samuel Kelley, Co. E, 23d N. Y., was admitted Dec. 23, 1862, with a gunshot wound, and
died Jan. 1.5, 1863. I'ost-mortem examination next day: Age about 30 years ; no emaciation ; a few faint reddish spots
on the abdomen. Vessels of brain distended with blood. Lungs and heart healthy. Liver pale Indian-red on surface
and on section: spleen enlarged, six by four l)y two and a half inches, rather soft and on section like black currant-
jelly. Colon pale gray with slate-colored streaks and reddi.sh spots, its solitary glands containing black matter;
ileum generally pale, but with streaks and iiatches of moderate inflammation, its solitary glands enlarged, some to
the size of pepper grains, and its agminated glands enlarged, several ulcerated and with ochre-yellow adherent gran-
ulations.—Jc(. A.w't Surg. Joseph Leidy, Satterlee Hosj)itul, Philadelphia, Pa.
Case 203.— Private Moses Burkett, Co. A, 12th U. S. Inf.; admitted Aug. 10, 1862. Typhoid fever. Died Sept. 9.
Post-mortem examination same day: Age about 20 years; emaciation ; slight petechial marks on breast and abdomen.
Right lung with old pleuritic adhesions throughout; left with adhesions at apex of upper lobe; small tubercles, few
in number, from the size of hempseed to that of a pea, deposited in the pleura pulmonalis, i)leura costalis and superficial
tissue of both lungs. Heart flabby, with a large, transparent, fibrinous clot in the left ventricle but none in the right.
THK CONTINUED FEVERS. f^SO
Peritoneum everrwhere strewed with small tnliercles from the size of miistarcl-sepd to that of hempseed. in K'f^iti'st
aluiiidami' in tlio |Klvi.s, wheri^ tliey were aeeompanied willi peritunitis, the bowels adhering by recent pseiido ineiu-
braniius matter; mesenteric glands and, indeed, all the abdominal lymphatic glands, enlarged but not tuberonlur.
l.iver fatty, the aeini in section ap]iearing huge, dull yellowisli with brown centres; spleen natural. Stomach moder-
ately contracted and not inllanied. Ileum witli several small patches of moderate inllammation and one ei'cdiymosi'd
patch; agminateil glands slightly thickened and the lower ones snperlieially uleeraled; solitary glanils enlarged.
Moilerate inllannnation in the eacum and sigmoid llexure of the eohm, the mucous membrane of tin- latter with a
blackish blush, apparently from deposits of line black pignu-nt in the epithelial cells; solitary glands Iiealthy and
not blackened. — Act. Asti't Surg. Joseph Lcidij, Satlerlec Hospital, PhiladHphia, Pa.
C.vsE 204. — Thomas James, a nurse of ward 7, died Oct. 30, 18G3, of peritonitis. Pont-nwrlcm examination eight
hours after death: .\ge abmit lifty years; body well nourished; thyroid body enlarged on one side to the size of a
hen's egg. Heart and lungs healthy; capacity of chest diminished by pressure of abdominal contents. Peritoneal
surface everywhere redili^ned by turgid vessels and covered by thin, recent, cream-colored pseudo-membrane, with
interstitial sero-purnlcnt li(iuid; alxhuuinal lymiihatic glands not paljiably diseased. Liver large, yellowish-brown,
soft and somewhat falty; gall-bla<lder small and i)artially collapsed; spleen flabby, on the surface bluish-white and
with an old white eicatri.\-like mark, which, together with the snb-serous tissue, was spotted with black macube, on
section light Indian-red, remarkably blooiUess and lor half a line from the surface black from pigment (leposited in
molecnhir grannies and round nuisses the size of blood corpu.scles. Stouiach, pancreas and kidneys healthy. Ileum
and colon slightly more pink than normal; upper agminated glands healthy; glands of lower three feet of ileum
ulcerated, the ulcers occupying only part of the surface, but extending to the muscular and serous coats and in one
instance perforating the latter, the hole being circular and about a line in diameter. The blood contained, if any-
thing, fewer white corpuscles than u.sual. ISpiciiiieiiH 231 to 23G, Med. Sect. , Army Medical Museum, are from this case.]
— Act. Ass't Siinj. Jo^tph Ltiily, Sutttrlie Ilospilal, Phila., Pa.
(C.) Condition of Pcyer's patclies not stated/ the ileum or the small intestine uleeraled — 22 eases.
Case 20.i. — Private Benjamin McCoy, Co. H, 4f)th Pa., was admitted Sept. 16, 1863, in low condition and cyan-
otic. Next day he became delirious, and soon afterwards ecchymoses appeared on the chest and al)domen. He died
on the 22d. Post-morlem examination: Heart sound; parenchymatous organs healthy; a portion of the ileum
ulcerated. — Aet. .Iss't Sury. 11'. f.eon Hammond, First Dirision Honpilal, Alexandria, f'u.
Case 206. — Private Kichard Boyer, Co. F, 149th Ohio N;itional Guard; age 43; delirious and with a feeble
intermitting pulse; <liarrho;i jirofuse. Pied .Vngiist 31, 1864. I'osl-mortem examination sixteen hours after de:ith:
Lungs somewhat empliysematous on their peripherj-; pericardium thickened and containing four ounces of yellow
liquid : heart enlarged but with no valvular derangement ; lower third of ileum ulcerated, some of the ulcers nearly
perforating, others almost cicatrized. — Seminari/ Hospital, Cohimlms, Ohio.
Case 207. — Private Levi Hentley, Co. E, 14th N. Y. Art.; age 18; was admitted .lunc 11, 1864, with typhoid
fever, and died on the 2oth. Post-mortem examination twenty-four hours after death: Miliary tubercles in Ipotli
luugs; ulceration of the ileo-ca-cal valve and of the whole of the ileum. Heart, liver, spleen and kidneys normal. —
.let. Ass't Surg. />'. B. Mihs, .Jurvis Ho«2>it<il, Baltimore, .Md.
Case 208.— Private William Park. Co. F, 14!Hh Ohio Natioiml (iiiards; age 37; was admitted May 30, 1864,
and died .June 26. Post-mortem examinat ion twenty-four hours after death : Adhesions of the membranes of the brain
ami slight etfusion of serum under the arachnoid. Lungs normal; heart natural, but the pericardium contained
some effusion; liver much mottled; spleen normal. The lower part of the ileum was much congested but showed
only one ulcer. — Act. Ass't Surg. B. B. Miles, ./arris Hospital, Baltimore, Md.
Ca.se 209.— Private .James M. Cammell, Co. G, 11th Va.; age 22; was admitted Aug. 31, 1861, witli typhoid
fever, and died September 10. Post-mortem examination twenty-four hours after death: Elfusion in the ventricles of
the brain. Twenty-five ulcers in the ileum, which, for two feet above the ileo-Ciecal valve, was intensely inflamed;
the valve was one mass of ulcers. — .Ic(. Ass't Surg. B. B. Miles, Jarvis Hospital, Baltimore, Md.
Case 210. — John Henry, contraband; age 22; was admitted Aug. 27, 1864, with typhoid fever, and died on the
30th. Po»/-Hior!(TO exaniinati(m: Lungs congested; heart, liver and kidneys normal; spleen softened ; small intestine
congested and extensively ulcerated, esijccially near the ileo-caical valve. — Chattanooga Field Hospital, Tenn.
Case 211. — Sjieuccr .lonaijue, contraband; age 29; was admitted Aug. 18, 1864, with typhoid fever, and died
ou the 27th. Post-mortem examination: Luugs congested; heart, liver and kidneys normal; spleen softened; small
intestine congested, softened and showing many minute ulcers. — Chattanooga Field Hospital, Tenn.
Cask 212. — Private James Lock, Co. K, 22d Mich.; age 19; was admitted Ang. 10, 1864, with typhoid fever,
and died on the 19th. Post-mortem examination on day of death: Lungs congested and lower lobe of left lung liep-
atized: heart llabby; liver and kidneys normal: spleen large and softened; mucous membrane of ileum softened
and showing many ulcers of various sizes. — Chattanooga Field Hospital, Tenn.
Case 213.— Private David Cantwell, Co. A, 42dU. S. Colored troops; age37; admitted Aug. 17, 1864; died 29th.
Post-mortem examination on the day of death: Lungs universally and lirndy adherent; heart, liver and kidneys nor-
mal; spleen oue and a half ounces: mucous nu-mbrane of small intestine thickened, softened and showing several
ulcers one-fourth to one-half inch in diameter. — Chattanooga Field Hospital, Tenn.
Case 214.— Private Fielding Childers, Co. D, 16th U. S. Colored troops; age 22; was admitted Sept. 2, 1864,
-and died on the 8th. Poat-mortem examination on the day of death: The lower lobe of the right lung and part of
390 POST-MOETEM RECORDS OF
the upper lobe were hepatized; the lower lobe of the left iung was congested; the heart was flabby. The liver
was softened; the spleeu, eighteen ounces, was softened and had two large cjsts on its surface. The mucous mem-
brane of the small intestine was softened, congested and studded with numerous small ulcers. The kidneys were
normal. — Field Sospital, Cltattnnooga, Tenn.
Case 21.5. — Private Henry W. Shedron, Co. E, regiment not stated, was admitted Oct. 14, 1864, as a conva-
lescent from typhoid fever. He was greatly emaciated and had sliglit chills every day followed by high fever and
night-sweats. On the 16th he complained of pain in the chest; diarrhcea set in next day, and he died on the 22d.
i*os(-JMoW(>m examination eight hours after death: Eight lung hepatized throughout; ulcers and an old cicatrix iu
the small intestine. — Hi»i2)ital Ko. 8, Xasln-iUe, Temi.
Case 216.— Private Simeon M. Van Horn, Co. F,14l8t Pa.; admitted Oct. 14, 1862 ; died 24th. Pos(-morie»» exam-
ination: The mucous membrane of the small intestine was much softened and presented many ulcerated patches.
The mesentery was highly congested ; the mesenteric glands enlarged ; the spleen twice the usual size, nmch engorged
and easily broken down; the liver enlarged and friable. — Third Division Hospital, Alexandria, Va.
Case 217. — Recruit John H. Skillington, 49th Pa.; age 25; was admitted Sei)t. 9, 1864, with typhoid fever.
He fell into an unconscious state, and died on the 14th. Post-mortem examination one hour and a half after death:
Slight eft'usiou beneath arachnoid at apex; three small, flat, strong deposits in anterior part of posterior commis-
sure in front of pineal gland; a dirty looking clot in the heart; gray hepatization of posterior i>art of upper lobe of
right lung and minute red-l>rown interlobular infiltrations in posterior part of lower lobe; liver large; spleen large,
dark and hard; kidneys pale; ileum, near ileo-ciecal valve, showing patches of congestion and ulcers with thickened
and reddened borders; colon normal. — Third Division Hospital, Alexandria, Va.
Case 218.— Private Benedict Gehrich, Co. 1), 67th Pa.; admitted April 24, 1865. Tyi)hoid fever. Died 29tb.
Post-mortem examination: Rigor mortis well marked; integuments excoriated; patches of denuded muscle here and
there. Lungs, heart and stomach healthy. Spleen enlarged to three times the usual size, congested; small intestine
slightly ulcerated at several points. — Depot Field Hospital, Sixth Army Corj>s, City Point, I'a.
Case 219. — Private Frederick Wombeyer, Co. F, 41st X. Y., was admitted March 15, 1865, and died on the same
day. Post-mortem examination twenty-four hours after death : The lungs were tilled with blood and frothy serum;
there were adhesions on the right side, and eight ounces of serum in each pleural sac: the heart was pale and con-
tained a small clot. The liver was normal; the lower portion of the ileum was entirely denuded; the kidneys were
inflamed and contained pus. — Depot Field Hosj)ital, Sixth Army Corps, City Point, J'a.
C.vSE 220. — Private .Tohn Fitzsimmons, Co. D, 102d Pa.; admitted March 15, 1865. Diagnosi-s— typhoid fever.
Died 28th. Post-mortem examination forty-eight hours after death : The lungs were healthy, but there were ])leuritic
adhesions on the left side: the heart contained large fibrinous clots in all its cavities. The liver was pale, almost
fatty; the spleen normal. The intestines were normal except the last two feet of the ileum ; near the ileo-c*cal valve
the gut was entirely denuded of membrane and covered with greenish slime. The left kidney was jiale : the right
contained a large abscess. — Depot Field Hospital, Sixth Army Corps, City Point, T'a.
Case 221. — Private Robert K. Shaw, Co. K, 111th N. Y.; age 23; was admitted ,lune 26, 1863, with typhoid
fever, and died Augu.st 10. Post-mortem examination twenty-five hours after deat h : Body rigid, not euuioiated. Lungs
normal excepting cadaveric changes, right weighing eighteen ounces, left seventeen ounces: right cavities of heart
containing a large clot, fibrinous with a bloody admixture, extending a long distance into the pulmonary artery.
Liver pale and flabby; spleen soft and decomposing; small intestine healthy to withiu four feet of the ileo-ca'cal
valve, below this point extensive typhoid ulceration existed, the ulcers being superficial and situated for the most
part in the centre of large congested patches; large intestine healthy; kidneys very soft and flabby, congested in
their cortical substance. — Ass't Surg. H. Allen, U. S. A., Lincoln Hospital, Washington, D. C.
Case 222.— Private H. Mortenson, Co. G, 27th Wis.; age 32; was admitted May 10, 1863, with parotitis, a
sequel of fever. An infusion of fiostwort ( Helianthemiini Canadense) was given and the att'eeted parts painted with
tincture of iodine. The patient would not permit any jioultices or other applications to be used. An ichorish mat-
ter was discharged from both ears until death on the 18th. "Autopsy revealed softening of kidneys and a cavity
containing fluid in right kidney: intussusception and ulceration of snuUl intestine." — Aef. Ass't Surg. W. A. McMitr-
ray, City General Hospital, St. Louis, Mo.
Case 223.— Private Wendiliu Griesbaum, Co. F, 16th 111. Cav.; age 43; was admitted Sept. 12, 1863, having
had fever for ten days. As he was unable to speak English and was rather dull withal, but little account of his
case could be obtained. Simple febrifuge remedies with (luinine were ordered. Castor oil was administered on the
15th, as the bowels were constijiated, painful, somewhat distended and hard. The abdominal symptoms were aggra-
vated on the 16th, although the bowels had been moved iu the meantime; the pulse was lOU and feeble. He died on
the evening of this day. Dr. F. K. B.vli.EV, attending surgeon, reports that "on in(iuiry. among his comrades 1 learu
that this man had been kicked, some six or eight months ago, in the abdomen by a fellow soldier, and that he has
been sick ever since." Post-mortem examination fourteen hours after death: Body emaciated; abdomen hard and
very much distended; large quantities of bloody liquid oozing from mouth; skin in dependent regions livid. The
thoracic viscera were normal. The peritoneal cavity contained a large quantity of bloody serum, pus and f;eces; the
omentum was livid and so tendej as to scarcely hold together; the liver was twice the usual size and could be easily
broken down by the finger; the spleen was discolored but not enlarged. The stomach was distended to double the
normal size; the ileum perforated near its union with the large intestine. The kidneys were healthy. — Hospital,
Quincy, III.
tHE continUkd fevers. 391
Case 224.— Private Eli W. Whitinj;, otli Mo. B.at'y, was adinittcd Sept. 1, 1862, with a ■;iiii.slii)t wduiuI received
at the l)attle of liull Kuu. He was sent to liis home ou furloii{;h November 12. and was there taken very sicli. Ho
returned to lio.si)ital February (>, 1803, in a debilitated condition. On March 18 lie was attacked by fever and a
severe [lain in the pra'cordial region. On the morning of the 21th he had a chill, and the seat of the pain changed
to the umbilical and hypogastric regions; he lay on his back witli his knees drawn up and the abdominal walls
motionless in respiration; his faco was pale and contracted, showing great distress and anxiety; pulse frcimcnt and
small: tongue red at the tip and edges and furred with yellow in the centre; thirst extreme; bowels constipated;
ho had nmeh nausea and vomited a greenish otVensive nuitter. He was conscious until within an hour of his death,
whidi took place ou the evening of the 2.^th. Pont-mortim examination: A large (luantity of serum and pus was
found in tlu> peritoneal cavity; the peritoneum was thickened and congested: it presented a brilliant red appearance
over some parts of the small iutestiue and a deep-red, abnost black, appoarauoo over other parts. The ileum for
about five feet from the ca'cum was more or less ulcerated; it was perforated by a large ulcer at a point eighteen
inches fr<un the ileo-c.ecal valve. [See spichiiin 117. Med. Sect., Army Medical Muscmmi. .ind plate facing this page.]
— J/((/. Cddrt .thnir Tliarj), U. S A., Columbian Hospital, IVashinyton, I). C.
Case 22."i. — Private Joseph Fair, Co. L, 14th Pa. Cav.; ago n2; was admitted .luly 25, 18G3, with delirium,
tremors and diarrhoea. He died August 3. Post-mortem examination ten hours after death: Lower lobe of right
lung liepatized; liver hypertrophied; gall-bladder enormously enlarged, six to eight inches long; ileum ulcerated
and perforated. [Ciall-bladder forms spitimcn 37, Med. Sect., Army Medical Museum.] — .(««'( Surg. DelVitl C. Peters,
U. S. A., Jarris Hospital, Baltimore, ^fd.
Case 221). — Corp'l Paul Ciranvet, Co. D, 1st N. J., was admitted Aug. 9, 1862, having sullered from diarrbtea
and fever at Harrison's Laniling. After his admission he did well, recovered his appetite, increased in flesh and
strength, and apjicared in fact entirely convalescent; but during the afternoon of the 31st ho was suddenly seized
with violent pain in the abdomen, cpiick jiulse, prostr:ition and vomiting. Under the use of opiates and restoratives
he was relieved from pain, but the .ibdouun became tumid. He continued to sink, .'ind died during the night. On
the day of this attack the patient took an unusually large meal of meat, which he did not chew sutliciently, and
which he vomited in pieces as large as a shellbark. "The autopsij revealed three large patches of ulceration, two of
which h,id perforated the small intestine, producing intense peritonitis." — Satterlee Hospital, Philadelphia, Pa.
( l>.) Condition of Peytr's j>atches not stated; the ilettm or the small intestine nleerated and the larije intestine also affected —
19 cases.
Case 227. — Private Albert Turner, Co. A, 42d U. S. Colored troops; age 48; was admitted Aug. 31, 1864,
with typhoid fever, and died September 2. Post-mortem examination on day of death: Right lung congested and at
points liepatized; left lung normal; heart pale and flabby. Liver congested and somewhat softened; spleen enlarged
and softened; kidneys enlarged bnt firm, weight of each nine ounces. I^ower ileum ulcerated in patches; mucous
iiicmbrane of ascending and transverse colon thickened and softened. — Chattanooya Field Hospital, Tenn.
Ca.sk 228. — Charles Lancaster, contraband; age 28; was admitted Sept. 2, 1861, with typhoid fever, and died
on the 10th. Post-mortem examination next day: Left lung partly he|iatized; lower lobe of right lung congested;
heart normal. Liver congested and softened; spleeii weighing two ounces; left kidney presenting a small cyst filled
with jMis. Large intestine congested and softened; ileum ulcerate<l, the ulcers measuring two to three inches in
their long diameter. — Chattanooga Field Hospital, Tenn.
Case 229. — Private Ire Campbell, Co. K. 16tli U. S. Colored troops; age 20; was .admitted Aug. 27, 1864, with
typhoid fever, and died on the 30tli. Post-mortem examination on day of death: Lungs somewhat congested; heart
normal. Liver congested and softened : sjileen much softened: kidneys normal. Largi' and sukiII intestines ulcerated,
some of the ulcers being one-fourth inch in diametc^r. — Chattanooya Field Hospital, Tenn.
Case 230.— Private Richard Weatherford, Co. D, 42d U. S. Colored troops, was admitted Aug. 14, 1861, with
typhoid fever, and died ou the 17th. Post-mortem examinatiou : Lungs congested; heart flabby. Liver and kidneys
normal; spleen softened. Intestines congested and softened, ileum ulcerated. — Chattanooga Field Hospital, Tenn.
Case 231.— Private Frederick H. A. Sterl, Co. U, 1.5th Pa. Cav., was admitted Aug. 16, 1864, with typhoid fever,
and died on the 18th. Post-mortem examination next day: Lungs much congested; heart and liver normal; s)ileen
softened; right kidney somewhat congested, left kidney congested and fatty: mucous membrane of intestines soft-
ened and congested, that of ileum presenting ulcers, some small and others with a long diameter of twondnches and a
half. — Chattanooga Field Hospital, Tenn.
Case 232.— Private Samuel Hurto, Co. H, 10th U. S. Inf.; age 21; was admitted July 2, 1864, from City Point.
Diagnosis — typhoid fever. Died 11th. Post-murtetn examination eleven hours after ileath : F.xtreme emaciation.
The intestinal canal w;is inflamed ;ind presented several indurated ulcers in the ca'CUm, colon, rectum and ileum.
The other organs were in a normal condition. [Specimen 421, Med. Sect., Army Medical Museum, is from this case, j—
Surg. E. Bcntleg, XJ. S. V., Third Division Hospital, Alexandria, Va.
Case 2.33. — Private George Martin, Co. B, 110th Ohio, was admitted Aug. 10, 1864, unconscious, and died next
day. Post-mortem examination : Much emaciation. Considerable thickening of the infest inal mucous membrane and
extensive ulceration of the ileum, ciecnm and colon. — Third Dirision Hospital, Alexandria, Ik.
Case 234.— Corporal William Powell. Co. K, 10th N. Y. Cav.; age 43; admitted July 13, 1864. Diagnosis-
typhoid fever. Died 24th. Post-mortem examination: (ireat emaciation. Slight adhesions of right pleura and exten-
Bive iutlamination of lower lobe of right lung. Numerous and large ulcers in the intestines, extending from about
392 - POST-MOETEM KECORDS OP
two feet above the caecum to tlie anus, aucl two intussusceptious of the ileuui, recent in appearance. Liver enlarged
and fatty; spleen very much enlarged and congested. — Third Difiaion EosiriUil, Alexandria, I'a.
Case 235.— Private George Fox, Co. K, 2d N. Y. Mounted Rifles; admitted July 23, 1864; typhoid fever. This
patient was delirious on admission, and continued so until he died comatose on the 29th ; vihiccs appeared On the chest
on the 27th and became darker and more extensive during the following day. rost-mortr-m examination twenty
luiurs after death: Much emaciation. Inflammation and ulceration of the mucous coat of the ileum and colon, in
some places nearly i)erforating; other organs not seriously diseased. — Third Division Sospital, Alexandria, Va.
Case 236.— Private Frederick Bingal, Co. I, 5th U. S. Cav.; age 24; was admitted June 26, 1863, in the last
stage of typhoid fever — pulse 110 to 140; muttering delirium, with subsultus. Post-mortem examination twenty-four
hours after death showed "considerable hepatization of the lungs, with extensive softening of the mesenteric glands
and ulceration of the intestines." — Act.Ass't Surg. A. P. Crafts, Third Division Hospital, Alexandria, Va.
Ca.se 237. — Private Isaac F. Blasdale, Co. C, 156th Ind.; age 18; was admitted June 16. 1865, in an extremely
weak and exhausted condition, having been sick in camp for ten days before admission. His tongue and lips were
pale and dry, the former covered with a white fur; he had great thirst; his imlse was very quick, small and feeble;
his respii'iition hurried, and his dejections small, licjuid aud frequent. He died on the 20th. Post-mortnn exann'ua-
tion sixteen hours after death: The spleen was large, soft and very dark; the mucous membrane of the ileum and
ciecum was inflamed and ulcerated. — Act. Ass't Surg. S. B. West, Cmnberland Hospital, Md.
Case 238.— Private William Fowler, Co. D, 91st Ohio; age 21; was admitted Aug. 21, 1864, with typhoid fever,
and died September 22. Post-mortem examination twenty-four hoius after death: Hypostatic congestion of both
lungs; a quantity of serum in the left pleural cavity, two ounces in the pericardium, four ounces in the peritoneum.
The liver was large and light-brown in color and the spleen large and congested. The whole of the large intestine
was much thickened aud its mucous surface covered with large elevated, hard aud ragged ulcers; the ileum was
softened, thinned and, for two feet from the ileo-ca>cal valve, intenselj" congested, showing traces of numerous ulcers,
some of which were healed. — Act. Ass't Surg. B. B. Miles, .Tarvis Hospital, Baltimore, Md.
Ca.se 239.— Private Alson Breedlove, Co. D, 13th E. Tenn. Cav., was admitted Jan. 22, 1864, with typhoid
fever, and died February 4. Post-mortem examination twelve hours after death: Body much emaciated; cadaveric
rigidity marked. The brain was healthy. The lungs weighed forty-one ounces; their apices were emphysematous
and thin ; bronchial tubes inflamed; heart healthy. The stomach contained two ounces of matter like coft'ee-grounds;
its mucous membrane was inflamed aud softened. The upper part of the small intestine was softened aud ulcerated
in small ])atches aud contained two lumbricoid worms; the mucous membrane of the large intestine was thickened
and softened in patches; the mesenteric glands were much enlarged. The liver was somewhat fatty; the spleen
congested, weighing tifteen ounces; the kidneys normal; the prostate enlarged aud containing one drachm of pus.
— Act. Ass't Surg, G. TV. Boberts, Hospital No. 19, Kashville, Tenn.
Case 240.— Serg't H. C. Rogers, Co. C, 16th Pa. Cav.; age 28; was admitted Aug. 18, 1863, with typhoid fever,
and died on the 20th. Post-mortem examination fourteen hours after death: Body but little emaciated. Trachea
slightly congested, purplish between the rings; right lung weighing seventeen ounces, its upper lobe greatly con-
gested and its lower lobe almost solidified but lighter than water; left lung, eighteen ounces and a half, congested
generally, emphysematous in lower part of upper lobe: right ventricle containing a tibrinous clot which extended
into the iiulmonary artery. Liver dark colored, its parenchyma stained around the portal veins; spleen firm, purple
and conspicuously mottled on its surface with a darker hue. Ileum congested and extensively ulcerated, the upper
ulcers being small, blackish and with depressed centres, while those near the ileo-c;ecal valve had a long diameter
of one and a half inches, in one of which the ulceration had penetrated to the luuscular coat; ciccum aud ascend-
ing colon, especially between the longitudinal bauds, studded with superticial ulcers having dark-blue borders aud
an elliptic form, their long diameter, one to five lines, at right angles to the axis of the bowel. Eight kidney anaemic
and firm; left somewhat congested. — Ass't Surg. H. Allen, U. S. A., Lincoln Hospital, Washington, D. C.
Case 241. — Private David C. Hollenbeck, Co. E, 188th N. Y.; age 37; was admitted Jan. 30, 1865, having been
under treatment for fever with his conlmand for seven days before admission. He died February 5. Post-mortem
examination: The lower lobe of each lung was congested; the right weighed twenty-two ounces, the left fourteen
ounces. The liver, spleen and kidneys were healthy. The mesenteric glands were enlarged and congested. The
stomach was congested and contracted; the duodenum aud jejunum healthy, except that there was an intussuscep-
tion, two iiJ^-hes long, about seven feet and a half from the stonuich; there was a good deal of ulceration in the
neighborhood of the ileo-ca'cal valve; a few ulcers were scattered through the colon. — Ass't Surg. M. L. Lord, 140/A
N. r., Depot Field Hospital, Fifth Army Corps, City Point, Va.
Case 242. — Private Charles Brown, Co. H, 9th Pa., was admitted Sept. 28, 1862, convalescing from typhoid
fever. The patient was greatly debilitated with diarrhoea, but under a tonic treatment he improved slowly until
within three or four days of his death, when he began to complain occasionally of faiutness. On October 17, after
visiting the water-closet, he lay down on bed and expired almost immediately. Post-ninrteni examination: Brain,
lungs and stomach normal; walls of right ventricle of heart very thin and soft; intestines ulcerated to a moderate
extent and showing signs of former ulceration.— Wro-d Hospital, Xorark, N. J.
Case 243.— Private Jeremiah Thorndyke, Co. C, 12th Mass., was admitted Nov. 4, 1863, having been sick for
some time. On admission his bowels were loose and he had pain in the chest and abdomen. Pills of tannin and
opium were given, with opiate enemata, but on the 10th nausea and vomiting came on and continued with failing
pulse, dyspntea and hiccough until death on the 15th. Post-mortem examination: The right lung was congested,
THE CONTINUED PF.VERS. 39o
the left liepatized; the walls of tlie right ventriclo of the heart were as thin as jilove-leather. The right lohe of
the liver, posteriorly, was softened, and the contiguous liepatic llexure of tlie eolon was gangrenous. Tlio nineous
ineiiihraue of the stoniaeh and of tlio duodenum, fioui tlio ]>yloric orifice to the valvnhn connivcntes, was jiiilla-
eeous* the ileum was uleerated; the lower end of the sigmoid llexuro constricted. The left kidney was normal;
the ri>'ht kidnev and suprarenal capsule showeil traces of inllammation; the fundus of the liladder was very niuili
thickened. Act. Ain't Siirg. V. Leun Hammond, First Divinioii Iluxintat, Ahxundria, I'a.
Case 244.— CorpT P. S. Nottingham, Co. D, 149th N. Y.; age 32; was admitted April 22, 1863, with a jirofuso
diarrhu'a which resisted renu-dies, intense pain and swelling in the hypogastric region and ditliculfy of miclurition;
Le was in low conilition, pulse 130. As the distention of the ahdomen did not dejieud on accumulated uiinii hot
fomentations were applied, and on the 2.")tli, llnctuatiiui heing apparent, an ahdominal aliscess was opened, giving
is.^ue to a sero-purulent discharge which c<uitinued for five days. He died Msy 1 with symptoms of peritonitis.
rnnliiiortim examination: Ulceration of a large portion of the intestines and perforation iu several places; fatty
degeneration of the kidneys. — .l^fmorii Square Uiisjiilut, IVaxhinf/lon, B.C.
Case 245. — Private Simon Fogg, Co. C, 2()th Me., was admitted Jan. 3, 1865, and died on the SOtli. J'ukI-
viintim examination : Lungs collapsed and pale ; left adherent to pericardium, weight ten ounces and a half; hronehi
filled with ]ius; right sixteen ounces, middle lohe inflamed; heart ten ounces, clot iu right ventricle'. Liver, sixty-
one ounces, healthy: gall-ldaddcr filled with hile; spleen five ounces, healthy. Stomach and jejunum normal; ileniu
ulcerated, jierforated iu eight i)laces, its walls surrounded with pus and interadherent ; colon slightly iullanied at
its upper end; nu'senteric glands enlarged, filled with cheesy matter. Kidneys four ounces each; suprarenal cajisulcs
much softened. — Fifth Armi/ Corjix Fiihl lluspital, Army of Potomac.
(E.) Condition of Pei/cr's patches not stated; the intestines congested or inflamed but not ulcerated — 11 eases.
Cask 246. — Private Daniel McCloud, Co. C, 17tli U. S. Inf., was admitted Aug. 14, 1863, with typhoid fever.
rou"He dry and cracked: sordes on teeth ; muttering delirium; pulse weak and tre<jucnt; extreme emaciation. Ho
died on the Uith. Post-mortem examination : Lower portion of ileum highly congested and contracted, its sulnnucous
coat thickened and its mucous coat softened. — 7'/iii-(7 Dirision Hospital, Alexandria, Va.
Case 247. — Private Mark E. Rohinson, Co. E, 13th AV. Va.; ago 21; wa.s admitted Feb. 16, 1865, complaining
of severe pain in the left side and iu the back of the head. His skin was hot, pulse 110, frciinent, small and coni-
pi-essihle, face darkly flushed, tougue dry, red and cracked; his dejections were frequent, copious and liquid, his
ahdonu'u tympanitic and tender on pressure. A diaphoretic mixture was ordered, with tepid sponging of the body,
cold to the head and nnistard to the ankles aud nape of the neck. He became delirious during the night, his pulse
increased, aud his teeth, gums and lips became covered with sordes. Quinine, oil of turpentine and carbonate of
ammonia were given, with chlorate of jjotash as a mouth-w.ash. He died on the 20tli. Post-mortem examination
twenty-four hours after death: Body slightly emaciated. The vessels of the pia rnater were filled with dark blood ;
the cerebrum and cerebellum were cougested posteriorly. The lungs were congested; the lower lobe of the left lung
was hepatized. The stomach and intestines were distended with gas; extensive patches of inflannnali<ui were
I'liund in the jejunum and ileuiu. The spleen was very large. — .Ie(. Ass't Surg. S. B. TTest, Cumberland Hospital, Md.
Case 248. — Private Theophilus Gillespie, Co. A, 13th W. Va.; age 23; was admitted Feb. 3, 1865, with ty]dioid
fever. He was very feeble and aphonic, his tongue dry, skin hot, pulse 100, bowels loose and abdomen swollen and
painful. (Quinine, oil of turpentine, lead, opium and whi.skey were given. Vomiting set iu on the 7th aud he died
next day. Post-mortem examin:ition two hours after death: Slight emaciation; good muscular development. The
epiglottis was thickened and ulcerated; the lining membrane of the larynx and of the trachea as far as the bifur-
cation was similarly aftected: the vocal cords were almost obliterated. The lungs and heart were healthy. The
spleen was very large, weighing nineteen ounces; the liver enlarged and cougested; the gall-bladder eiiornmusly
distended with bile. There was no intestinal ulceration, but scattered jjatches of infianinuition were found in the
ileimi. A large unantity of coagulated blood was extravasated iu the lower portion of the abdominal recti muscles
and iu the intermnscnlar septa. — .let. Ass't Surg. Sam2)lc Ford, Cumberland Hospital, Md.
Case 24H. — Philij) Fisher, recruit, 9th Ohio; age 18; was admitted Nov. 30, 1864, with typhoid fever. There
was nmch fel)rile action, dusky countenance, parched tougue, cough, diarrluea ami tenderness over the abdomen. A
grain of quinine was given every four hours, and on December 5 half au ounce of brandy three times daily was
ordered, with glycerine to moisten the tongue and morphine to allay abdominal pain, which had become severe.
After a few days the cough became more annoying and there was dulness on jiercussiou over the left side of the
chest; the pulse became rai)id and feeble and the diarrh<e;i troublesome. Acetate of lead with opium was added to the
treatment. On the 12th the tougue, lips aud mouth were very dry, the countenance livid, and bronchi.il jales were
heard over the left lung: but on the lltli an improvement took place, the tongue becoming moist and the diarrhoea
quieting; pulse 120 and feeble. Next day he was apparently much better than at any time since his admission ; but iu
the afternoon he was seized with intense pain in the back which caused him to make loud outcries. Hot cloths were
applied and morphine administered. In au hour he seemed relieved, and remained <omfortable until midnight,
when his breathing became hurried. He died comatose two hours thereafter. Post-mortem examination thirty-six
hours after death : The pericardium contained four ounces of serum. The right lung was healthy; the left was firmly
adherent to the costal pleura and diaphragm; the bronchial mucous membrane was inflamed throughout on the left
and in the larger tnlies on the right. The under surface of the diaphragm, the abdominal walls, the stomach, intes-
tines and left lobe of the liver were coated with a thick layer of straw-colored lymph. The spleen was of normal
size but contained several cavities filled with a soft, white, cheesy substance; two of these had ruptured into the
Med. Hist., Pt. 111—50
394 POPT-MORTEM RECORDS OF
peritoneal cavity. The mucons memhraue of the ileum was slightly inflamed; the colon was largely distended with
gas.— ^ss'( Surg. H. C. May, U5th N. Y., Hospital No. 8, Nashville, Tenn.
Case 250. — Private George Lubenk, Co. K, 4th Mich. Cav.; age 34; admitted Feb. 1, 1864. Typhoid fever.
Died 17th. Post-mortem examination: Body moderately emaciated. Lungs, heart, stomach, liver, spleen and large
intestine liealthy; the small intestine and kidneys highly congested. — Hospital No. 1, Nasliville, Tenn.
Case 2.51. — Theodore Jeter, 4th Ind.; age 22; was admitted March 21, 1863. He became sick January 16, at
Vicksburg, Miss., with typhoid fever, mild iii form, but with a tendency to diarrhoea. Suppuration occurred in the
parotid gland, and he died April 12. Post-mortem examination: Pleuritic adhesions on right side; heart fatty, right
ventricle thinned. Ileum congested; colon congested and softened. Eight parotid gland entirely broken down by
suppuration, leaving the external carotid bare but intact. — City Hospital, St. Louis, Mo.
Case 252. — Thomas J. Slaton, private of an Alabama regiment, admitted Oct. 29, 1864, with typhoid fever.
Bowels tender and somewhat loose; tongue narrow, tremulous, dry, slightly furred and red; pulse 110, weak; he
was dull and drowsy and became gradually weaker until death took place Decembers. Post-mortem examination:
Great emaciation. Abscess in left lung; atrophy of heart; congestion of bowels and enlargement of mesenteric and
solitary glands ; fatty degeneration of the liver ; spleen small. — Act. Ass't Surg. H. C. Neivkirk, Bock Island Hospital, III.
Case 253. — Private William Brown, Co. 1, 1st Ark.; died March 16, 1865. Post-mortem examination : The spleen
was mucli enlarged; the bowels distended and in many places disorganized; the mesenteric glands enlarged. An
abscess of the arm and shoulder had discharged a large amount of pus for some days before death; on incision great
disorganization of the muscles was revealed. — Act. Ass't Surg. H. H. Itussell, Sock Island Hospital, III.
Case 254.— Private Milton L. Coon, Co. I, 85th N. Y.; age 23; was admitted Aug. 19, 1862, with typhoid fever.
Died suddenly November 18. Post-mortem examination : Extensive inflammation of the lower part of the ileum and
ciecum, witli pin-head enlargement of the solitary follicles, ISjtecimen 153, Med. Sect., Army Medical Museum]; mes-
enteric glands enlarged; liver and kidneys liitty. — Surg, A. C. lioitrnonville, U. S. V., Hospital Fifth and Biitlomvood
streets, PhiladeJpliia, Pa.
Case 255.— Private Lewell Cates, Co. A, 12th Ky.; admitted April 24, 1865. Died May 7. The course of the
disease was that of typhoid fever; shortness of breath was the only pneumonic symptom observed. Post-mortem
examination thirty-six hours after death: No emaciation. Both lungs were congested, the lei't partially hepatized;
the heart normal. The liver was enlarged, frialjle and resembled that of yellow fever; the spleen and kidneys were
normal. The intestines were immemsely distended with gas, and the mucous membrane of the ileum and colon was
congested. — Act. Ass't Surg. E. Holdcn, Ward Hospital, Newark, N. J.
Case 2.56.— Private Patrick Cady, Co. B, 3.5th 111.; admitted July 23, 1864. Typhoid fever. Died September '22.
Post-mm-tem- examination : Body mucli emaciated. The intestinal nnicous membrane was congested and inflamed, liut
not ulcerated, in the lower tliird of the ileum and in the colon. An abscess holding two ounces of light-colored pus
was found in the right lobe of the liver. The other organs were normal. — Hospital No. 8, Nashville, Tenn.
(F.) Condilion of Pi'yer's patches stated varioiishj, hnt nut ulcerated, and generally without ulceration of the intestines— i2 cases.
(a.) Peyer's patches normal or healthy.
Case 257. — Private Edwin A. Maxfield, Co. G, 7th Me.; ago 27; was admitted Aug. 14, 1864, with remittent
fever. On admission the patient had a weak, frecjnent pulse, a dry, coated tongue and loose passages of a light color.
Next day he had fever and headaclie. On the 16th he became delirious and somewhat drowsy, and on the 18tli he
died comatose. He was treated with citrate of potash and nitre, cold lotions to the head, and afterwards with calo-
mel, ipecacuanha, camphor and blisters to the back of the neck. Post-mortem examination nine hours and a half
after death: Body not much emaciated; rigor mortis well marked. The base of the brain was covered with a thin
layer of lymph, the pia mater was injected, the liquid in the ventricles opaque. The trachea contained a consider-
able quantity of whitish frothy sputa streaked with the color of prune-juice; the right lung weighed twenty-tive
ounces, its posterior portion much congested, its anterior margin normal; the left lung weighed twenty-three
ounces and a half, its posterior and lower part in the state of red hepatization, the rest of the lung healthy. The
pericardium contained two ounces of straw-colored serum; the right side of the heart a small fibrinous clot. The
stomach, liver and spleen were normal in appearance; the last weighed nine ounces and a quarter. The kidneys
were somewhat injected. The mucous memljrane of nearly the whole of the small and large intestines was congested,
but Peyer's patclies and the solitary glands were normal. — Act. Ass't Surg. H. M. Dean, Lincoln Hospital, Wash'n, D. G.
Case 258. — Private James H. Morrison, Co. B, 151st Pa.; age 26; was admitted June 17, 1863, with typhoid
fever. [He entered Kalorania hospital, AVa.shington, D. C, Dec. 1, 1862, with snuill-pox, and was returned to duty
"Feb. 17, 1863; Douglas hospital, Washington, D. C, June 14, with diarrhcea, and was transferred to Philadelphia
next day.] He was much del>ilitated and had severe diarrho-a which continued throughout the case. On July
4 there was swelling of the riglit parotid gland and on the 6th constant vomiting. He died on the 14th. Astrin-
gents, quinine and iron, turpentine, beef-tea, wine and milk-punch were prescribed. Post-mortem exiimination:
Body much emaciated; skin marked with variolous scars. The bronchial mucous membrane was inflamed; the left
lung was covered with a thin pseudo-membrane stained with bhiod, the surface laterally, posteriorly and at the base
was darkly ecchymosed and there was a large clot with a quart of bloody serum in the pleura, but no rupture of the
lung. There were four ounces of liquid in the pericardium and white fibrinous clots in the cavities of the heart.
The spleen contained three soft tubercular masses the size of hickory nuts. The mesenteric glands were somewhat
THE CONTINUED FEVEKS. 395
enlarfifd and many of tliem lilaokencd. Four iiitiissiisceptioiis were found in the ilenm, the mucous mcmhrano of
which showed incguUuly diti'used intiauunation witli hlack deposits; the solitary glands were somewhat congested;
Foyer's patches were healthy. — Sattcrlee Hospital, Philadelphia, I'a.
Case 259. — Private Cieorgo Stone, Co. F, 73d Ohio; ago 20; admitted June 15, 1863, with phthisis and typhoid
fever. Died .July 2.5. Puxt-mortvm oxaniinatioii eleven hours after death: Emaciation. Urain forty-eiglit ounces,
soft; latcVal ventricles tilled with eflusion. JIucous membrane of trachea easily torn, slightly discolored, delicate
purple at its lower portion; tulie containing tough, tenacious sputa; lymphatic glands at bifurcation healthy. Mucous
lining of tesojihagus pale and extensively eroded, especially below. Right lung eight ounces, uniformly pale, lower
lobe .slightly injected: left lung seven ounces and a half, lower lobe slightly injected and containing a consolidation
about the size of a horse-chestnut, with a central cavity as large as a hazel-nut; walls of cavity well defined and
enclosing a secretion similar to that found in the trachea. Pericardium large and containing twelve drachms of i>ale,
limpid, straw-colored liijuid ; a small tibrinous clot in the right ventricle. Liver firm, of a dark-purple color externally
and showing portal engorgement on section ; 8i)leen four ounces and a half, tirm and of a dark mulberry color; <nnen-
tum crowded up under lower edge of liver, well supi>lied with adijiose tissue. Ujiper part of the small intestine con-
gested, lower ])oi'tion empty and much congested ; Peyer's patches perfectly healthy; large intestine normal and filled
with healthy fa'ces. Kidneys firm and congested internally, a blackish blood exuding on section. — Ass't Surg. II. Allen,
U. S. A., Lincoln Ilospiiul, JVashimjton, D. C.
Case 260. — Private George H. Grover, Co. C, 7th Me.; admitted Aug. 10, 1863; typhoid fever. Died 21st. Poiit-
nioWcm examination : Body much enuiciated ; apparently about 20 years of age; skin of trunk minut(!ly ecchymosed.
The lungs, heart, stonuuli and spleen were healthy; the liver was liright colored and exhibiti^d distinctly the outlines
of its acini. The mucous membrane of the lower part of the jejunum and of the ileum was lullamiul, the inllanuna-
tion being most intense in the lower part of the latter; the solitary and agminated glands appeared healthy and con-
tained no deposit of black pigment : the ascending and descending portions of the <!olon were moderately inflamed
but not ulcerated. — Ael. Axs'l Surij. J. Leidij, Sutterlce Hospital, Philudilphia, Pa.
Case 261.— Private W. C. Swails, Co. I, 49th Pa.; admitted Aug.- 10, 1862; typhoid fever. Died September 8.
Pofil-mortcm examination next day: Age about 40 years; body extremely emaciated; skin ecchymosed. Lungs filled
with bloody liquid ; heart presenting an opa<iue-white membranous spot on the surface of the right ventricle and
containing a large white clot in the right and a soft black clot with li(iuid l)loi>d in the left ventricle. Stouuich pre-
senting three large inflamed jiatches; its cul-de-sac softened. Liver dull-brown in color but otherwise natural:
kidneys healthy. Ileum intlauu^d in patches; its glands not diseased; mesenteric glands opaijue, cream-colored and
sonu'what enlarged: large intestine diffusely inlhnued in the colon, particularly in the ca'cum and sigmoid flexure,
and extending into the rectum along its rugie. — Act. Ass't Siiry. J. Lcidij, Scitlerlec Hospital, PhHadili>hiu, I'a.
(h.) Pei/er's patches not ulcerated.
Case 262.— Private Thomas Ward, Co. D, 42d N. Y.: age .W; was admitted Sept. 20, 1862, with ,i sliell wound of
the right cheek and typhoid fever. He died November 17. Post-mortem examination ten hours after death: Great
euuiciation. Lungs and pleura- healthy: pericardium distended with serum ; heart paler than u.itural. Liver, spleen
and kidneys lu'althy. Mucous nu'Uibrane of stouuich pale, softened and with spots of extravasated blood; of ileum
injected but not softened and i'eyer's patches not ulcerated; of colon and rectum greatly injected, thickened-, but
neither softened nor ulcerated. — Ass't Surg. C. //. Andrus, Vl>ithN. T., Stewart's Mansion Hospital, Baltimnn, Md.
Ca.se 2l!3.— Corp'l Daniel Landis, Co. C, 212th Pa.; age 22; admitted Oct. 21, 1861. Diagnoses— typhoid fever.
Died Noveml>er 2. Post-mortem examination twenty hours after death: Marked rigor mortis; .souu^ emaciation ; bed-
sores; two very large abscesses under each ear. Lower lobe of right lung hepatized i)osterlorly. Heart, liver, pancreas
and kidneys normal : gall-bladder containing two ounces of bile ; si)leen enlarged, black, softened ; nnicous coat of
small and large intestines much congested but no thickening or ulceration of Peyer's patches or the solitary follicles.
The reporter, Dr. Thomas Howex, says that, in view of the diagnosis being typhoid fever, a very careful examination
of the small intestine was nuide. — Second Division Hospital, Alexandria, Va.
(c.) Peyer's })atches prominent, conspicuous, enlarged, thickened, etc.
Case 264. — Private Henry Clay, Co. I, 179th N. Y., was adniitted May 11, 1865, much emaenated, very weak and
unable to speak : his teeth and gums covered with sordes ; pulse thready and irregular ; respiration labored. He was
washed with tepid water and whiskey, and treated with stimulauls and nutritives, turpentine, ijuinine and oi)iate
enenuita. He died on the 19th. Post-mortem examination: Emaciation extreme. Meml)ranes of brain ana-mic.
Lower lobe of left lung congested ; heart containing a few .snuill coagula; blood generally diffluent. Liver of normal
size, showing fat-cells under the microscope; spleen large, soft. Henm and c;ecum much congested and inflamed, in
a few i)laees ulcerated; Peyer's patches quite prominent by a soft, friable deposit; mesenteric glands large, filled
with similar deposits. Kidneys congested, somewhat fatty; urine albuminous. — Augur Hospital, Alexandria, )'«.
Case 265.— Private William Plomb, Co. I, 4th N. J.; admitted Aug. 9, 1862; typhoid fever. Died 10th. Post-
mortem examination next day. Uody well formed and robust. The lungs were healthy; the heart flabby but other-
wise normal. The liver, stomach, pancreas, spleen and kidneys were healthy. The ileum was deeply reddened, and
the agminated and solitary glands more than ordinarily conspicuous, but without apparent disease; the colon was
slate-colored, with patches of redness, and presented a numl)er of scattered ulcers about the size of peas. — Act. Ass't
Surg. J. Leidij, Satterlee Hospital, Philadelphia, Pa.
Cas^e 266.— Private Eugene Mason, Co. G, lii'th N. Y.: age 16; adniitted Sept. 19, 1864; typhoid fever. Died
Octobers. jPo»/-moW(«i examination eighteen hours after death: Slight rigor mortis; much emaciation. Brain fifty-
396 POST-MORTEM RECORDS OF
8ix ounces. Eight lung nine ounces, somewliat compressed and adhering firmly to the thoracic wall; left lunc
seven ounces; heart six ounces and a half, containing iilirinous clots in right and Ijlack clots in left cavities. Liver
forty ounces, normal; spleen three ounces and a half, firm. Small intestine congested, some of its solitary follicles
ulcerated and Peyer's patches thickened; large intestine studded with small ulcers a quarter of an inch in diameter.
Kidneys normal. — Act. Ass't Suri/. H. M. Dean, Lincoln Hospital, Washington, D. C.
Case 267. — Serg't K. A. Babcock, Co. H, 27th Mich., was admitted Aug. 12, 1863, having been suffering for six
weeks from fever and di.arrh(ca. Under opium, camphor, blue-pill and sub.sequently quinine, aromatic sulphuric acid
and morphine, he improved until the 20th, when the diarrhnea became profuse, and was followed by prostration and
delirium which terminated in death on the 2oth. Post-mortem examination: Heart flabby, pale; spleen enlarged,
softened; mesenteric glands enlarged; elliptical patches near the ileo-cseoal valve hypertrophied but not ulcerated.
— Act. Ass't Surgs. C. T. Simpson and J. F. White, West End Hospital, Cincinnati, Ohio.
Case 268. — Private Jacob Walder, Co. E, 2d Mass. Cav., was admitted Sept. 27, 1864, in a semi-conscious con-
dition; pulse 90 and feeble, tongue brown and slightly cracked, bowels constipated, right iliac region tender and
urine retained. Three pints of urine were withdrawn by catheter, and oil of turpentine and milk-punch were ordered.
On the 29th his urine passed involuntarily, his condition otherwise remaining the same. On October 5 the tympa-
nites had subsided and the tongue was cleaning. The turpentine was omitted, and as the bowels continued consti-
pated an enema was given. On the 12th the patient fell into a state of almost complete stupor. As there was much
difficulty in swallowing, beef-essence and whiskey were administered per rectum. He died on the 17th. Post-mortem
examination twelve hours after death; Body much emaciated. A tumor about the size of an orange was found
between the posterior portions of the cerebral hemispheres; it was quite firm and cut like soft cartilage. [Sjiecimen
535, Med. Sect., Army Medical Museum.] The lungs were congested; the heart, liver and kidneys healthy; the
spleen and glands of Peyer enlarged. — Act. Ass't Surg. W. S. Adams, Hospital, Frederick, Md.
Case 269. — Musician John Hummel, 4th N. Y. Cav.; age 29; was admitted June 28, 1863, having suttered for an
unknown time with typhoid fever. He appeared to be doing well until July 7, when he began to sink, and died next
day. Post-mortem examination nine hours after death : Spleen greatly enlarged ; glands of Briiuner, Peyer and of the
mesentery enlarged; mucous and muscular coats of small intestine ulcerated throughout their whole length. — Act.
Ass't Surg. A. F. Crafts, Third Division Hospital, Alexandria, Va.
Case 270.— Private Leonard Snell, Co. C, 2d N. Y. Cav.; age 27; was admitted Nov. 29, 1862, with enteric fever;
Hot skin, frequent feeble pulse, dry tongue, coated with dark fur, dry cough and severe dyspntea, delirium, slight
diarrha-a, tympanitic distention of bowels and dulness on percussion over the lower lobe of the right lung. He died
December 1. Post-mortem examination ; The lower lobe of the left lung was hepatized ; the upper portion of the left
lung and the lower lobe of the right lung were congested; the heart, liver and spleen were normal. The small intes-
tine was injected and the glands of Peyer enlarged. — Third Division Hospital, Alexandria, Va.
Case 271. — Private Jefterson Perkins, Co. F, 3d Ky. Cav.; age 21; was admitted Feb. 22, 1864, with typhoid
fever. His case progressed favorably till one day, after sitting on the close-stool for a long time, he grew worse,
failed rapidly, and died March 6. Post-mortem examination twenty-three hours after death: Lungs healthy; right
cavities of heart containing a large clot which extended into the great vessels; liver somewhat pale ; Peyer's patches
enlarged. — Hospital Ko. 8, Nashville, Tenn.
Case 272. — Private Benjamin Ostrander, Co. H, 91st N. Y.; admitted May 6, 1865. Diagnosis — typhoid fever.
Died 11th. Post-mortem examination fourteen hours after death: Lungs and heart normal; liver enlarged and softened;
ileum congested ; Peyer's patches much enlarged. — Sixth Army Corps Field Hospital, Army of Potomac.
Case 273.— Private James Roberts, Co. B, 67th Ohio ; admitted Oct. 27, 1862 ; typhoid fever. Died Jau . 27, 1863.
Post-mortem examination: Age about 22; no emaciation; a purplish color from gravitation of blood into the skin of
the occiput ; a number of reddish spots on the front of the abdomen and chest. Lungs and heart healthy. Spleen
enlarged and flabby; liver healthy. Ileum presenting diffused redness with a few ecchymosed spots; lower agmi-
nated glands moderately enlarged, upper glands healthy; lowest solitary glands enlarged and in a few instances
slightly ulcerated on the summit; large intestine with a grayish aspect of the mucous membrane accomi)anied with
a few inflamed streaks. [Sj)eeimens 102-5, Med. Sect., Army Medical Museum, from this case, show various degrees
of enlargement and ulceration of the agminated glands, 105 being specially noteworthy as exhibiting an extensive
sloughing patch.] — Act. Ass't Surg. J. Leidy, Satterlee Hospital, Philadelphia, Pa.
(d.) Peyer's patches reddeyted, congested or inflamed.
Case 274.— Private William Eckard, Co. E, 149th N. Y.; admitted Jan. 18, 1863; typhoid fever. About a week
before his death, February 21, pneumonic symptoms were observed. Post-mortem examination: Body slightly
emaciated; ajiparent age 20 years. The brain weighed fifty ounces and a half; it was light colored and of normal
consistence. The right lung weighed nineteen ounces and three-quarters, the left seventeen ounces and three-quar-
ters; on both melanic matter was conspicuously arranged in lines corresponding to the course of the ril)S. The left
lung contained a deposit of tubercle and there were several consolidated lobules in its ujiper lobe; similar lobules
were observed scattered through tlie right lung; a few cretefied tubercles were found in both; the bronchial tubes
of the left lung were intensely congested and contained purulent matter; several of the bronchial glands contained
calcareous deposits. There was a white fibrinous clot in tlie right side of the heart extending into the pulmonary
artery; in the left side a black clot from which a white fibrinous branch extended into the aorta. The liver weighed
sixty-seven ounces; its acini were distinctly marked; the gall-bladder was empty. The spleen weighed six ounces
THE CONTINUED FEVEES. 397
and ;< iiuaiter; it was of a light biiok-rod color and very soft. Tho pancreas weighed throe ounces and a iiuaiter; it
was lirni and of a light pinkish color. The kidneys and snpraroual capsules were natural. The mucous nienibrano
of the stoiniich was very soft; that of the small intestine was generally softened, especially in the jejunum, where
it had ii velvety appearance; the ileum was thin, dilated in places and somewhat congested; Peyer's patches warts
reddened; the largo intestine was slate-colored except in the rectum, whore it was congested; the niescntoric! and
nicsocoUc glands were nornuil. — Jss'l Siiry. Giorgc il. McGill, C. S. A., Linculn Uospital, IVashinijlon, D. C.
Case 275. — Private George P. Thomas, Co. G, 43d Ohio; age 2G; was admitted Fob. 4, 1865, with the eni)itioii
of measles well developed. In a few days the eruption had almost entirely disap])eared; but symptoms of tyjilioid
fever were manifested, and ho died on the 12th. I'oiit-mortcm examination: The bniin was normal. The lungs were
congested posteriorly and presented nodulated infhinnnation, the substance of which was heavier than water; great
numbers of miliary tubercles filled the posterior and inferior portions of the lungs; the right lung weighed thirty-
seven ounces. Clots were found in both sides of tho heart. The liver and paiicn^as were normal; the spleen,
MX ounces, contained miliary tubercles; the kidneys wero somewhat enlarged and lobnlated, each weighing eight
ounces. The stomach was contracted and its nuicous membrane somewhat congested. In the il< iini small raised
IKiints wero observed, which were hard to the feel , Peyer's ))atches were generally tumid and dark ; aliout the middle
of the ileum its mucous f<dds were deeply congested, and above these a long Peyer's patch, enlarged and reddeuid,
was situated in the midst of another congested region; among the valvuhe connivoutes, surrounded by congestion,
was a patch a foot in length resembling a Peyer's patch in structure and enlarged, as were such patches in tho ileum.
The transverse and descending portions of the colon were reddened; the rectum congested. — Ass't Surij. Geo. M.
McGill, U.S. J., Xational Hospital, BaUimore, Mil.
Case 276. — Private Phincas Wooster, Co. E, 137th N. Y.; age 35; admitted Jan. 11, 1863. Diagnosis — typhoid
fever. The clinical history is meagre, consisting of only one entry dated February 4: Pulse frennent, easily com-
pressed; tongue dry, edges white; skin dry and harsh; night-sweats; bowels loose, stools thin and offensive. Trcati^d
by wine and porter with opiates at bedtime, lie died on the 10th. I'oiit-mortcm examination twenty-eight hours
after death: Body much emaciated. The brain was anicmic. The right lung weighed seventeen ounces and a (juar-
ter, its upper lobe congested posteriorly and its lower hepatized and containing small abscesses which conimuuicatcd
with the bronchial tubes; the left lung weighed eleven ounces. The pericardium adhered to the surface of the heart,
on which were dark spots and exuded lymph: the heart was flabby and contained librinous clots in both ventricles.
The liver, forty-four ounces and a (luarter, was llabby and light colored : the gall-bladder contained two ounces of.
thin green bile; the spleen was small aiul tough. The duodenum was much congested in its upi)er i)art, its serous
coat was slate-colored; the jejunum in its upper ]>art was slate-colored without and highly congested within, and
lower down the color of the serous membrane was darker; Peyer's patches were congested, the valvuhe softeiu'd and
the coats of the ileum generally thinned and reddened; tho ascending colon was slate-colored. The left kidney was
slightly congested. — Lincoln Hoapital, Washington, D. C.
Case 277. — Private M. W. Reese, Co. H, 42d Miss.; rebel ; age 28 ; admitted Aug. 3, 1803 ; typhoid fever. Died
11th. Post-mortem examination: Body rigid, not emaciated. Brain forty-seven ounces, healthy: lateral ventricles
distended. Trachea pale above, purple and congested towards the bronchi; ffisophagus ))ale, with light purplish
patches in its upper third and ochre-colored below. Right lung eighteen ounces, much congested, several of the
lobules of the upper lobe surrounded by a dark-reddish material resembling clotted blood; left lung seventeen
ounces and a half, engorged with semi-soliditied blood in the posterior part of its lower lobe. Heart nine oun<!e8,
no clot. Liver sixty-four ounces, mottled light and dark purple externally, slightly pale internally; gall-bladder
containing an ounce of bile; spleen fourteen ounces, dark but firm; pancreas four ounces, healthy. Intestiu(^s
healihy except near the ileo-ca'cal valve, where Peyer's patches seemed to be congested, but they were not swollen
nor ulcerated. Both kidneys were ana-mic, with the pelves pale and the pyramidal bodies of a dark-purple color. —
Jss't Hiirg. Harrison Allen, U.S. A., Lincoln Hos2>ital, Washinf/ton, 1>.C.
Case 278. — Serg't Alexander Beatty, Co. I, 15th N. J.; age 22; was admitted Jan. 2, 1863, with gangrene of
I he toes following typhoid fever. The gangrenous condition was attributed to frost-bite while sick in cam]). Both
feet were amputated through the metatarso-ijhalangeal articulation. On February 3, the day after the operation,
delirium set ill and continued, with occasi<mal lucid intervals, until death on the 10th. Post-mortem examination an
hour and a half after death: No rigor mortis; skin sallow; in the sole of the right foot was an abscess with olicn-
sive grayish contents, and over the external malleolus of the left foot was another which eonimunicated with tlu^
wound of operation; the cartilages exposed by the amputation were much eroded, and those of the cuboid aiui
internal cuneiform bones were nearly destroyed. The subarachnoid space and the ventricles of the brain contained
an unusual quantity of serum. The right lung weighed eleven ounces, the left nine and a quarter; in the upper
lobe of the left lung were two small round masses of cheesy tubercle and an abscess the size of a chestnut, which
contained offensive jius; a similar, rather smaller, abscess was found in tho middle lobe of the right lung; the bron-
cliial tubes contained a w liitish exudation ; the bronchial glands were dark-colored externally and contained a white
calcareous deposit. The heart was flabby. Tho liver was of firm consistence and .somewhat congested; the s))leen,
sixteen ounces, was dark-colored, firm and congested; the pancreas was of a light-red color and firm. Both kidneys
were of firm consistence; in the lower part of the right kidney was a small cavity containing whitish cheesy pus.
The stomach was healthy; the jejunum darkly congested; the lower part of the ileum intensely congested, its soli-
tary glands enlarged and inflamed and Peyer's patches congested and somewhat |>r(uninent; there was a region of
congestion in the ascending colon.— 4«»'« Surg. Ocorije il. MvGill, U. S. A., Lincoln Uospital, irashimjton, D. C,
398 POST-MORTEM RECORDS OF
Case 279. — Corp'l John ScUafFncr, Co. li, 14th Vet. Kes. Corps: admitted March 28, 1864 : typhoid fever. Died
April 3. Post-mortenn examination eigliteen hours after death : Body much emaciated. The duodenum was congested ;
the jejunum slightly congested in patches; the ileum congested throughout; Pcyer's patches congested but not
ulcerated; there was one congested spot in the lower colon, which was otherwise healthy. — Act. AssH Surg. C. T.
Trautman, Harewood JSoitjriUil , Washiiiyton, D. C.
Case 280. — Private Conrad Hold, Co. D, 52d X. Y., was admitted Fell. 13, 1863, with fever and persistent
vomiting. Epi-staxis occurred on the 17th, and with the vomiting continued to the end, the lilet-ding usually recur-
ring at night. The patient liecame stupid on the 21st, and there was some diarrha>a, which did not last tieyond the
28th. Creasote, acetate of moiphia and blisters had no efl'ect on the vomiting. Medicine was discarded towards
the end, stimulants and nourishment only being used. He lingered until March 7. rost-mortem examination: The
glaud.s of I'eyer were congested and swollen and there were some signs of recent pericarditis. The spleen, liver,
kidneys and lungs were normal. — Act. Ans't Snry.John E. Smith, Douglas Hospital, Washington, D. C.
Case 281. — Private Henry G. Howell, Co. I, 27th K. J., was admitted Feb. 15, 1863, in a prostrate and ililirious
condition. Me had frequent fits of coughing and expectorated a viscid, transparent, frothy mucus. During the
following night his face became purplish, his delirium increased, and a clammy jierspiration bedewed his skin. He
died next day. Post-mortem examination four hours after death: Body robust; apparent age 25 years. The brain
Heighed forty-six ounces and was soft and congested to redness. There were pleuritic adhesions on both sides;
the right lung weighed forty ounces and a half, the left thirty-three ounces; the lower lobes of both lungs and
portions of the upper lobes were in a state of red hepatization, ajiproaching gray; the bronchial tubes were con-
gested and in some instances plugged with a fibrinous deposit. The heart contained large fibrinous clots on both
sides. The liver weighed twenty-eight ounces and a half, its acini were distinct; the spleen, four ounces and threi-
quarters, was light-colored and soft, with distinct trabecuhe; the right kidney weighed five ounces and a half, tli«
left five and a quarter; the suprarenal capsules were small, dark and tough. The stomach was large and its fundus
congested; the glands of the duodenum were slightly enlarged; the upper third of the jejunum was irregnhirly con-
gested; the ileum was i-ongested, its solitary glands enlarged and reddened and the iialches of Peyer irregularly
indamed and thickened. The large intestine was distended with gas, the solitary glands swollen and reddened —
twelve of these enlarged glands were counted in a square inch selected at random: the mesenteric glands were
enlarged and inflamed. — AssU Surg. George M. McGill, U. S. A., Lincoln Hospital, Jl'ushinyton, I>. ('.
Case 282. — Private Henry Campbell, Co. H, 20th Mich., was admitted Jan. 24, 1863, with typlniid fever, anil
died February 2. Post-mortem examination sixty-eight hours after death: Body well developed and fat. Tlie brain,
forty ounces and a half, was of light color and firm consistence. The heart contained clots. The lungs were con-
gested hypostatically; the left lung weighed eighteen ounces, the right twenty-four ounces. The liver weighed
forty-five ounces; the spleen ten ounces; the kidneys seven ounces each; the pancreas two ounces and three-quar-
ters; the gall-bladder was empty. The mucous membrane of the stomach was congested; a luinbricoid worm wa.s
found in the jejunum, which was irregularly congested; its lower part and the upper part of the ileum were mnili
thinned; Peyer's i>atche8 were enlarged and inflamed, especially near the ileo-ca-cal valve: the coats of the large
Intestine were very thin and the mucous membrane congested, especially in the upper portion of the colon. — Ass't
Surg. George M. McGill, XJ. S. A., Lincoln Hospital, Washington, 1). C.
Case 283. — Private Martin Dusenbery, recruit, 9th Ohio Cav.: age 20; was admitted Oct. 14, 1863, with tyjihoid
fever. He had been sick four or five days. His fever was slight, but there was some delirium and cough with
mucous sputa; his bowels were open, and there was slight tenderness in the epigastric and right iliac regions.
Xext day the delirium had disappeared and he was otherwise better. On the 18th his tongue was more coated,
bowels open, abdomen tender, cough aggravated and respiration hurried. During the night of the 19th he was
actively delirious, requiring restraint; and next day there was severe pain in the right lung, with dulness and
crepitant rales. He died on this day. Posf-mortcm examination three hours after death: Left lung congested; lower
two-thirds of right lung hepatized, with pleuritic adhesions especially of the diaphragm, and twelve ounces of seriun
in the pleural cavity. Intestines congested ; Peyer's patches enlarged and inflamed but not ulcerated. — Dennison
Hospital, Ohio.
Case 284. — Private George W. Harvey, Co. H, 24th Maine; age 31; was admitted July 24, 1863. This patient
was a deserter, and although rational on admission his mind was much exercised on the subject of his capture and
prol)able punishment. This had an evident inllueuce on the progress of his disease. Low delirium followed and con-
tinued until death on the 30th. Post-mortem examination: Heart, lungs and liver healthy; mesenteric glands and
those of Briiuner and Peyer extensively enlarged and inflamed; mucous coat of small intestine softened and ulcer-
ated throughout its entire length. — Act. Ass't Surg. A. P. Craft, Tliird Pyivision Hospital, Alexandria, Va.
Case 285.— CorpT William H. Glattz, Co. K, 4th Del.: age 23; was admitted July 23, 1863, in an advanced
stage of typhoid fever. He died on the 26th. Post-mortem examination : Lower lobe of right lung congested : Peyer's
■patches inflamed and elevated; mucous follicles of the colon much enlarged; spleen congested; liver and kidneys
normal. — Act. Ass't Surg. T. Turner, Third JJieision Hospital, Alexandria, I'a.
Case 286.— Private Peter A. Wayman, Co. B, 91st N. Y.; admitted May 6, 1865. Diagnosis- tyjihoid fever.
Died on the 11th. Post-mortem examination sixty hours after death: Upper lobe of right lung hepatized and adherent:
left lung and heart normal; spleen double the usual size; stomach healthy; Peyer's patches swollen and intlaineil :
colon normal. — Sixth Army Corps Field Hospital, Army of Potomac.
(e.) Peyer's patches pigmented.
Case 287.— Private William Sibley, Co. A, 2d Mass. Heavy Art.; age 25; was admitted Sept. 10, 1865, liaving,
THK CONTINUKP FKVKES. 399
from liis own siutonioiit, liccn sick for ;i imig tiino with fever and diarrhoDa. Jlr had a lio( skin, dry and coated
tongue and feehle inturniittent jmlse; ho heeanio delirious during the night, and died next day. J'osl-mortrm exam-
ination ten hours after death : Not much emaciation ; no rigor mortis. The subarachnoid space contained about two
ounces of serunr, and a small ([uantity was found in the veut^^e^es ; the jiia mater was congested ; ecehymosed spots
were observed on the summit of the riglit cerebral hemisphere and on the right side ofthe floor of the fourth ventricle;
the section of the hemispheres showed numerous puncta vasculosa. A large portion of the lower lobe of the loft
lung was in the first stage of pneumonia; the right lung was congested posteriorly and weighed twenty-two
ounces, tlu' left thirty-two ounces. The heart weighed twelve ounces; the auricular siptum was jierforated; there
was a mixed clot in the right si<le, a little lluid blood in the left. The liver was lirm, dark-colored and weighed
lifty-eight and a (juarter ounces: the gall-bladder cimlained a small ijuantity of thin brown bile; the spleen was soft
and weighed six ounces. The stomach was thin anil iliscolored: the ileum congested in regions, its siditary glands
enlarged and I'eyer's patches prominent and speckled with blood; the large intestim^ flaccid and in part discolored.
The kidneys were large and soft. — Ass'l Siinj. tltorge M. McG^ill, U. S. J., Hick's HospituI, liaUimorr, Mil.
Ca.si'; 288.— Private Henry II. Joyce, Co. B, f.tli Va. (rebel') Inf.; admitted Aug. H, 18r>:!: typhoid fever. Died
7tli. I'osl-moilnii examination sixteen hours after death: Hody not enuiciated: rigor mortis slight : ajipareut age 23.
The brain was lirm jind weighed forty-eight ounces; the pia mater was congested over the posterior portion of
both liemis]dieri's. The mucous nieuilirane of the trachea was congested, the congestion extending into the bron-
chial tubes; the lymphatic glauils at the bifurc:iti(in of the trachea were linn and black. There were pleuritic, adhe-
sions on both sides; the right lung weighed nineteen ounce.s, its upper lobe slightly congested and a frothy secre-
tiiui exuding on pressure, its middle lobe congested hypostalically and having on its surface numerous si)ols of
transuded blood ; the left lung weighed twenty ounces, its upper lobe normal, but the low or ecehymosed and greatly
congested. The right auricle of the heart contained a thin librinons clot which extended into the ventricle and
thence into the pulmonary artery and its branches for a distance of three or four inches ; the endocardium in the right
auricle was )>urplish. The liver was somewhat congested and rather flabby; the gall-bladder contained half a drachm
of thick bile; the spleen, nineteen ounces, was firm and of a rich mahogany color; both kidneys were moderately
tiriu, the surface somewhat greenish, the cortical substance pale except at the superior extremities ofthe organs,
where it was congested, the pyramidal bodies purplish; the pancreas, three ounces, was purplish and of normal
finmiess. The mucous membrane of the fundus ofthe stomach was dark-colored, in the rest ofthe organ it was ])ale.
The small intestine presented nothing remarkable except a dark-purplish congestion in the lower third of the ileum ;
I'eyer's patches were pale with conspicuous black sijots in their follicles, but nowhere were they thickened or ulcer-
ated. The large intestine was healthy. — Jsn't Surg. Harrinon Allen, V. S. A., Lincoln Hospital, Washington, IK C.
Case 28it.— Private .Jacob llenson, Co. (J, Kith Pa. Cav.; age 18; was admitted March 25, 18M, very weak
and much emaciated, with a fre(iuent and feeble pulso and hurried resjiiraticm. He was quite deaf; ho had a bed-
siue two inches sipuire, with highly inflamed margins, over the lower part of the sacrum; his riglit knee-joint was
acutely iullamed, ipiite red over the internal condyle, very hot and exquisitely painful. From the testimony of a
comrade it was learned that the patient had been alfected with erysipelas and typhoid fever, and that the inflamma-
tion ofthe knee-joint occurred as a sequel to these diseases. Cold water was applied to the knee and extension ke|it
up by (Jurdon Buck's ajqiiiratus with a three-pound weight. Opium and whiskey were administered. Next day
the condition ofthe knee-joint was improved; but the patient's eyes were yellow, his skin jiurpuric and dry and his
lace flushed; he had jiain in the left side with some dulness, bronchial resiiiiation and increased vocal resonance, a
hacking cough but no expectoration ; he had also some dianhcea. On the 28th he had a severe chill, which recurred
next day and was followed by profuse perspiration. After this, although there was manifest improvement in the
condition ofthe knee-joint and lung, his strength failed gradually, and he died on April 7. Post-mortem examination
fourteen hours after death: Body much emaciated; skin dingy with many purpuric spots; rigor mortis well marked.
The brain was healthy. The right lung was healthy but firmly adherent on all sides; the left pleural cavity con-
tained two pints of serum ; the lower lobe of the left lung was covered with fibrin, at one point nearly half an inch
thick, and in its lower and iiosterior jiart was an abscess the size of a large walnut surrounded by much solidified
tissue. The ]iericardiuiii contained two ounces of seium. The liver, seventy-one ounces, was firm and waxy and
lia<l |iale spots scattered over its surface; the gall-bladder was empty; the pancreas, spleen and kidneys were
healthy. The solitary and agminatcd glands of the intestines were prominent and dotted with dark jioinls. The
knee-joint contained two ounces of ])U8 mixed with librinons flakes, one of which was over an inch and a half in
diameter; the cartilage on the lateral aspects ofthe femoral articulating surface was destroyed, laying bare tlu^ can-
cellous structure of the bone; the synovial membrane was vascular, especially above the patella, where also it was
covered with shreds of fibrin; the bursa beneath the extensor tendon ofthe thigh communicated with the joint by
several orifices and was filled with pus and \ym\th .—Lincoln Hospital, Washington, D. C.
Cask 290.— Private Daniel Cruni, Co. C, Gist N. Y.; admitted July 26, 1862; typhoid fever. Died August 21.
Pott-mortem examination next day: Organs generally healthy except that the agminated and solitary glands were
thickened and of a most remarkable black color, resembling the bluish-black marks of tatooing; the surrounding
parts of the mucous membrane were pale and devoid of anything like congestion. — Act. Ass't Surg. ./. Lridg, Salterhr
Hoxpital, Philadelphia, Pa.
Case 291.— Private Thomas J. Crumb, Co. D, 4-tth N. Y.; admitted Aug. 10, 1862; typhoid fever. The patient
had diarrho-a on admission, and during the last few days of life was delirious. Died 27th. Post-mortem cxam-
ination next day: Body much emaciated; age about 25 years. Brain natural in apjiearance except that the pia
mster was unusually bloodless, opaque and w rinkltd. Heart small, contracted, without a vestige of adipose tissue,
400 roST-MORTEM RECORDS OK
liquid blood in its liglit siilo, tlie left empty except a small coagiiluin of fibrin attached to the chordie tendineae.
Lungs healthy. Liver small, dusky-purple above and slate-colored below; spleen small, in section dull-brown.
Stomach and intestines distended with air and presenting no evideuco of inllammation; agminated glands heaUliy
except that they contained a deposit of black matter; solitary glands unusually prominent and containing black
matter; mucous membrane of the colon cream-colored, remarkably bloodless, solitary glands barely perceptible. —
Act. AssH Surg. J. Lcidy, Sattcrlce HospUal, I'hiladclphia, Pa.
Case 292.— Private Thomas Rose, Co. A, 49th Pa.; admitted Aug. 10, 1862; typhoid fever. Died September
.23d. Pus(-?HO)toft examination: Age about 20; body considerably emaciated and everywhere ecchymosed. Lungs
and heart healthy, the latter containing a white clot in the right ventricle extending into the pulmonary artery,
another in the left auricle and a third in the commencement of the aorta. Spleen, liver, kidneys, suprarenal bodicis
and pancreas natural. Mucous membrane of stomach inflamed more or less dilFusely and with occasional small
patches of greater intensity. Ileum inflamed in i)atches, increasing in intensity towards the lower end; solitary
glands enlarged, inflamed and containing black matter; agminated glands with black deposit but otherwise ajipa-
rently healthy. Colon distended with air, except descending portion, which w-as narrowly contracted but not
inflamed; ca'cum, ascending and transverse colon inflamed; solitary glands conspicuous and containing black J)ig-
meut. — Act. Ass't Surg. J. Lcidy, Satterlee Hospital, PhiladeljiMa, Pa.
Case 293.— Private A. W. Parris, Co. H, 2d Vt.; admitted Aug. 10, 1862; typhoid fever. Died 26tli. I'ust-
mortem examination next day: Body large, somewhat wasted, aged about 30 years; skin bronzed and upon the trunk
somewhat ecchymosed. Heart normal, containing a fibrinous clot and much liquid blood. Lungs, liver and spleen
healthy. Stomach distended with air and liquid, its mucous membrane dusky-gray and with an inflamed jiatch near
the pylorus. Ileum highly inflamed in patches; agminated glands, thirty-six in number, all dotted with black pig-
ment but otherwise natural; solitary glands inconspicuous. Colon contracted, gray, with a few small red patches,
and with black pigment in the solitary glands. — Act. As.iH Surg. J. Lcidy, Sattcrlce HoxpituI, PhiltuMpliia, Pa.
Case 294.— Private James B. Hendricks, Co. F, 49th Pa.; admitted Aug. 10, 1862; typhoid fever. Died 14th.
Post-mortem examination: The organs of the chest and abdomen appeared to be healthy except the ileum and colon,
in both of which the mucous membrane was inflamed. The agminated and solitary glands contained points of black
pigment, but otherwise seemed natural. — Act. Ass't Surg. J. Lcidy, Satterlee Hospital, PhiladelpMa, Pa.
Case 29.5.— Private Joseph Kobbins, Co. H, 49th Pa.; admitted Aug. 10, 1862 ; typhoid fever. Died 14th. Post-
viortcyn examination next day: The body was much emaciated; the skin of the trunk in some places appeared as if
ecchymosed. The heart, lungs, liver, stomach, spleen, jiancreas and kidneys were healthy. The mucous membrauo
of the ileum was inflamed throughout, but near the lower end, for about ten inches, the inflammation was most
aggravated and had attached small but numerous shreds of opaque-white j)Seudo-membrauous matter, which under
the microscope was found to consist of a fibro-granular matrix and granular corpuscles resembling ordinary pus
corpuscles; the solitary glands were invisible or absent, excejjt a few scattered here and there in thejejunum;
the agminated glands were conspicuous, dotted with black pigment, but not perceptibly diseased. The colon was
exceedingly contracted; within the caecum and ascending colon the mucous membrane was red and the solitary
glands large and conspicuous by the presence of black pigment; the lower two-thirds of the colon presented a
mingled red and slate-color, with many small ulcers apparently resulting from the destruction of the solitary
glands. — Act. Ass't Surg. J. Lcidy, Satterlee Hospital, Philadelphia, Pa.
Case 296.— Private Thomas Elder, Co. D, 14th U. S. Inf.; age 18; was admitted Aug. 10, 1862, with typlioiil fever,
and died on the 18th. Post-mortem, examination next day: Body not much wasted. Heart and inner surface of iieri-
eardial sac roughened with old p.seudo-membranes ; right lung engorged. Liver large; gall-lihidder nearly empty;
mucous men\brane of stomach preseutiug a large reddened jiatch on the lower part of its cardiac extremity; spleen
showing an inflamed condensation of its tissue about the size of a nutmeg at its upper end, with the omentum in
contact also inflamed. The mucous membrane of the ileum was inflamed in regions, one of which was two feet long
and stojiped about six inches from the ileo-colic valve. There were thirty-two agminated glands ranging from half
an inch to three inches in length; a large patch on each fold of the ileo-colic valve was dotted with black pigment,
but appeared otherwise healthy; the next gland above also appeared healthy; the others, except the first two,
were much thickened, opaque and white, or tluckened and reddened by inflammation, but none were ulcerated: the
Bolitiiry glands generally were invisible in thejejunum and were few in the ileum, but where obvious in the latter,
they were quite i)rominent and red. The colon was much contracted; its mucous membrane was of a shite-color
mingled Avith small patches of inflammation, and the solitary glands were black. [Specimens 228 to 231, Med. Sect.,
Army Medical Museum, are from this case.] — Act. Ass't Surg. Joseph Lcidy, Satterlee Hospital, Philadelphia, Pa.
Case297.— Private Daniel Eaton, Co. H, 3d N.J. Cav.; age 20; was admitted April 29, 186.5 : Pulse 150; tongue
dry, brown and glazed; teeth and lips covered with sordes; i>upils considerably dilated; mouth, nose, cheeks and
hands stained with blood; respiration fre(i«ient and deglutition difficult. He moaned constantly and lay in a state of
low nrattering delirium, from which ho could be partly aroused, but was unable to articulate; there were freiiuent
slight convulsive movements of the body somewhat like those produced by moderate shocks of an electric battery;
his urine was passed involuntarily and there was a very offensi\e anunoniacal odor about his person. He died Jlay 1.
Post-mortem examination five hours after death: Body but little emaciated. The vessels of the pia mater were
engorged. The upper lobe of the left lung was hepatized, and hepatized patches were found here and there tluougli
both lungs; the rest of the lung-tissue was congested. The pericardium contained about an ounce and a half of
serum. The spleen was enlarged. Peyer's glands were enlarged but not ulcerated; slate-colored patches, having a
peculiar punctated appearance, wore scattered hero and there in the lower portion of the ileum and in the coloa Ja
the vicinity of the ileo-ccucal vahc— Jc<, Ass't Surg. G. Ellis Porter, Cumberland Hospital, Md,
THE COKTINrKB FEVERS. -101
(f.) Pei/er's pnlrhea cicatrized.
Case 298. — Ri-cniit Joseiih Hughes, 7th N. Y. C'av.; ago Ki; was uduiitted Jan. 31, lfi(iri, with phthisis tousccu-
tive to cauip fcvei. He hail been siek live mouths. He coniphiined of palpitatiou of tlie heart and pain iu the left
hieast just below the nipple, with cough and slight expeetoiatiou. Siuapisuis were applied to the chest and brown
mixture prescribed, with Dover's powder at night. Stimulants seemed to aggravate the chest symptoms. He died
February 8. Pust-nwrttm examination : The brain was quite firm. The right lung was small and had a few tubercles
at the apex: in the left there were numerous vomica'. The abdominal cavity contained a quantity of serum ren-
dered turbid with curdy flakes of lymph; the viscera were coated with soft white lymph. The mucous membrane
of the ileum was of a grayish-slate color, its villi were hypertrophied and at the apex of each was a deposit of black
pigment; Peyer's patihes, which had been ulcerated away, were in every stage of cicatrization, the ulcers lieing
smooth and the gut around them puckered. [See njucimtiix 489-191, Med. Sect., Aruiy Medical Museum, and the plate
facing this page.] The colon was cream-colored, its solitary follicles black and with niiinile cciitial depressions.
Act. Ass't 6'hi(/. n*. C. Minor, Third Dirinion Hospital, Ahxandria, Va.
Overlookiiio; for the present the eighty-eight cases lu wliicli the patches of Peyer were
saitl to have been ulcerated as indicating the presence of the typhoid poison, and the I'orty-
onc cases of ulceration of the ileum or small intestine as failing to exclude the possihility of
tvphoid from a want of precision in the language used, attention is invited to a brief consid-
eration of the intestinal lesions in the remaining fifty-three cases: In eleven of these, 24(>-
256, the condition of Peyer's patches was not stated, and the intestine is said to have been
congested or inflamed but not ulcerated, and in forty-two, cases 257—298, various conditions
of the patches, not, however, including ulceration, were reported, and the intestines also were
found to be generally free from ulceration.
Case 253, one of the eleven, may be set aside as iinj^lying iu the disorganization of the
intestine a possibility of typhoid sloughing of the closed glands. Tin- histury in seven of
the cases, 219-252 and 254— 25G, shows that the patients lived lung enough for notable
changes to have taken place in the agminated glands had typhoid fever been really pirsent;
liut the records refer oidy to a congestion of the intestines; in 252 the solitary glands witc
enlarged and iu 254 their apices were ulcerated, but the agminated glands were unaffected;
in 249 there was no typhoid lesion, but whether the changes in the spleen, which caused
the fatal peritonitis, were malarial or not is uncertain. In one other case, 248, time was
aflbrded before death for the development of typhoid uleeration of the glands had the typhoid
poison been the primary cause of the fatal sickness, for the patient liveil lung enough to
present extensive ulcerations of the larynx and trachea. In two cases the duration of the
sickness is unknown; but in one of these, 246, the condition of the ileum is expressed in
language that admits of no doubt of the absence of tvphoid, and iis in the other case, 247,
the post-mortem appearances indicated tvphus or a malarial fever, the inferenci; is that the
disease was malarial.
()( the forty-two cases pi-esentmg \ai'ious conditions ot the agminated glands, not, how-
ever, iiiehiding ulceration, the glands were normal, healllty or not diseaacd in Jive cases, 257-
261. In the first of these the patient was only five days in hospital when death occurred
witli syni|)t(ims ot cerebral implicatiiMi which, if not due to a malarial cause, was certaiiilv
not owing to typhoid fever. A tumefaction of the glands of Peyer has, since the time of
Louis, been regarded as the initial and essential lesion of this fever; but in the case in
.question these glands were healthy while the brain presented signs of inflammation. In the
four other cases there was ample time afforded before deatli for well-developed uleeration of
the patches, but a congestion of the lining membrane was the only morbid intestinal appear-
ance, and in 259 this was mainly found in the upper portion of the small intestine.
In tit'o ot th(j forty-two cases the patches were reported as tiot vJcerated, and in both
the patients were in lii>spital long enough to permit of the occurrence of well-marked changes
Meu. Hi.st., Tt. 111—51
402 POST-MORTEM RECORDS OF
if typhoid fever had been the cause of their sickness. In one of these, case 263, it is recorded
that, in view of the diagnosis, special attention had been j.niid to the post-ynoi-fem conihtion
of the small intestine.
In accordance with ]iathological doctrines which are generally accepted, the prominent
condition of the patches in the ten cases, 264-273, must be regarded as indicatiiiL;; the pres-
ence of enteric fever at the time of death. But since the fatal illness in most of these cases
lasted long enough for sloughing of the patches to have taken place had it been typhoid
fever from its inception, some morbid cause must have been in opei'ation before the inthience
of tlii.^ typhoid poisdii was manifested; and there is nothing m the po.sf-/H'ijicjii, lesions to
contraindicate, but on the contrary much to sustain the opimon, derived fiom clinical uliser-
vation in other and concurrent cases, that this antecedent disease was an active malarial
atTection. These cases may therefore be viewed as truly typho-malarial, the typhoid affec-
tion supervening on the malarial attack.
Of the thirteen cases, 274-286, in which the vascular supply of the patches had under-
gone notable changes, these were associated with tumefaction in seven cases, 275, 279, 281-
284 and 286, in most of which the short period elapsing before the fatal issue suggests death
from typhoid fever in advance of the period when sloughing usually takes place. It may
be remarked, however, that if tumefaction and congestion of the patches are overdeveloped,
in the absence of enteric fever, as a consequence of morbid vascular action affecting the
intestinal canal as a whole,* the claims of some of these cases, to wit: 275 and 279, as
illustrative of this condition might be entitled to consideration. Two of the thirteen cases,
280 and 285, may be regarded as truly typho-malarial, since they presented the glands
swollen but entire at a period when in pure typhoid the eliininative process would have
been in operation. In 277 there was no tumefaction of tlie agtyinated glands, although the
patient was eight days in hospital and sick for probably a longer time. In 274 and 276,
in which the fever lasted long enough for the establishment of the ulcerative process if a
typhoid element had Ijeen present, the- plaques were altered only in so far as they partici-
pated in a general and long continued congestion of the intestinal membrane. Lastly, in
278. which ended fatally at a late period, the patches were not ulcerated but only congested
and somewhat promment in an intestine which was darkly injected throughout.
In twelve of the forty-two cases, 287-298, the intestinal lining was pigmented, but the
agminated glands were not ulcerated. In the first of these there was neither ulceration
nor sloughing, although the patient was sick for a long time; the ileum was congested in
regions, its patches prominent and speckled with blood and its solitary follicles conspic-
uous.* In the eight cases, 288-295, the solitary and agminated glands were dotted with
black pigment, and in most of these there was ample time before deatli for ulceration ef
the patches to have taken place, for even in 295, which had been only five days in hospital,
the jiatient had lived long enough for the development of ulceration in the solitary follicles;
nevertheless the agminated glands were intact but for the pigmentary deposit. But in the
remaining three cases, 296—298, an enteri'c element was superadded to the pigmented con-
dition; in 296 certain of Beyer's glands were thickened, opaque and white or reddened by
congestion ; in 297 they were enlarged, and in 298 the ulcerated glands had become cicatrized.
In summing up the analytical results briefly enumerated in the above paragraphs it is
found that, of fifty-three cases characterized by so many of the so-called typhoid symptoms
* See iii/ra, page 456.
THK rONTlNUED FKVKKt;. 403
that the attending medical officers formed a diagnosis of typhoid fever, no less than thirty
failed to present at the post-mortem examination those aiiatomioal changes wliicli from the
time of Louis have been generally regarded as pathognomonic of the disease; but showed,
on the contrary, a series of lesions in perfect harmony witli our knowledge of the frequently
occurring but not essential incidence of the malarial poison on the intt'stinal canal. It is
submitted that these cases fully sustain the statement that amon^ those reported as typhoid
fever were many which were purely and simply malarial fevers; and since similar cases
have bcfn presented from the typho-malarial rei'ords, and e\-en from those of the paroxvsmal
fevers, the conclusion that'typhoid symptoms were not necessarily associated with a specific
enteric poison must be admitted.
The post-mortem records contain also a series of seventv-nine cases variously reported
at first, but from their later symptoms or necroscopic appearances afterwaixls regarded as
tvplioid fever. These are of interest as showing the relations of typhoid to various otlier
diseases. Tliree cases, 301, 347 and oiii>. adnntted liy the attending medical officers as mala-
rial fevers, should have been presented m a piv\ious part of tins section; but their al)sence
from the series of cases reported as typho-malarial does not alter the conclusions that have
been derived from an investigation of that scries, while in their present connection they
serve as delegates from the typlio-malarial cases, each illustrative or typical of its kind;
301 as instancing true typho-malarial ffver — typhoid modiiicd by malarial complications ;
347 as representing malarial fever with typhoid symptoms, the record of winch fails to show
whether the intestinal ulceration was due to the malarial or the typhoid element, — such cases
have in this report been set aside as probably typhoid; anil 366. as illustrating paroxysmal
fever Willi typhoid svinjitoms. but with no post-mortera lesion to indicate the presence of a
specific enteric poison.
These seventv-nihe cases have been arranged in accordance with the analotnical changes
in the intestinal canal.
(A.) PKYKK'S rATCIlKS CI.CKUATKn — IL' CASKS.
( a.) Xo dUiijnoxU.
I'a.sk 2U!1. — I'riviite tJfoij;!; II. KimiT, Co. I, L'llli .\. V. Cav.; ;ijl;i3 IiJ, wan adniiltuil .Jum^ 24, 1801, Willi a Ki'n-
shot tIeNh wuuiiil nf tlie left le^. On July 1 signs of cougeslion of tlio brain nuule their appearance; tlie pupils
were largely dilated, the right being larger than the left; the head was hot and with tlio chest was covered
with a copious perspiration; the fieces and urine were passed involuntarily; articulation was indistinct. He died
on the 3d. I'osl-morttm examination twelve hours after death: The body was somewhat emaciated. The brain
weighed sixty ounces; its bloodvessels were niucli injected, and thi> liquid in the ventricles and subarachnoid spaces
wa« increased in (juantity. The lungs were slightly adherent at their apices by recent lymph; the right weighed
eleven ounces and a half, the left thirteen ounces; the lobes of the left lung were iuleradherent and the posterior
part of the lower lobe was hepatizcd. The heart weighed seven ounces and a half, the liver fifty-nine ounius, ami
the spleen nine ounces and a half. The stomach was noiinal. JIauy of I'eyer's patches were extensively ulciM^iled,
the others thickened; the solitary glands were much enlarged ; the large intestine was congesteil and iu its lower
portion ulcerated. — .(c7. Jmi't Siiiy. IT. M. Dciiit, Liiirolti Uogpilal, ll'dnliiiii/hiii, I). C.
Cask :S00. — Private John Rice, Co. V, lOtli Vt.; age 23; wasadmillcd fiom llelil hospital at Sandy Hook, .Aug.
27, 18t>l, ill a low condition, lying dull and inattentive, comiilaining of < xi|uisite pain in the abdomen :ind having
frequent mucous <lischarg<s IVoin the bowels. llolVmaiin's ano<lyne was piesiriljed and a large poultice applied over
the abdomen. On the 3llth tlien> was much headache, which continued on the 31st ; on this day the discharges were
controlled by enema t a containing lead and opium. September 1 the symptoms werenuire favorable, the skin less liarsh
tod sometimes pers)iiriiig, the pulse less rapid and not so weak, but there wi'ie occasional reciirreiKres of febrile^ action.
Beef-tea, wine and citrate ot iron and i|uiiiine were given, with opiate enemata and woolen jiacking to the abdomen
iDStead of the pfoiltiee; turpentine was also ailminislered. Tlie palieiit's appetite was good, but he remained A'ery
weak and his tongue continued red and dry. Towanls the end of iSeptcmbc^r the febrile symptoms returned, assum-
ing the tertian ty]>e, and the diarrhira continued. On October 3 the patient became dull and was aroused with diffi-
' iilty; the dejections were pa.sscd involuntarily anil were mixed with blood and juis; beil-sores .appeared on the hips.
\\ ineaiid stimulants were freely given, but the patient grew worse ra|iidly,aiid died on the 14tli. I'ltximnrtem inves-
tigation showed the coats of the largo intestine extensively thickened, its calibre diminished and its mucous tissue
11
404 POST-MORTEM RECORDS OF
destroyed in jiatclies Tjy iilceratiou; these patches were most numerous iu the sifjnioid flexure, where perforation had
taken place, the orifice being two-thirds of an inch in diameter. The mucous coat of the ileum was eroded and the
agniinaled and solitary glands ulcerated; the jejunum was inflamed iu patches. [See spicimcna 459 and 4()0, Med.
Sect., Army Medical Museum, and plate facing this page. J — Ass't Siii-fj. C. Bacon, jr., U. H. A., Aniiiipolh HuspiUiI, Md.
(b.) Diagnosis: Remittent fever.
Cask 301. — Private Jesse Steiner, Co. D, 167th Pa.; age 30; was admitted July 12, 1863, with debility and remit-
tent fever, and died on the 21st. Post-mortem examination twelve hours after death: Body well developed; rigor
mortis well marked. The brain-substance was firm and slightly congested ; half a drachm of bloody fluid was found
in the lateral ventricles. The trachea was discolored and tilled with viscid, dark-brown sputa; its mucous mem-
brane was rather soft and the lymphatic glands at its bifurcation were enlarged, blackened and softened, except iu
the centre, where there was a calcareous degeneration. The a'SOj)hagus was pale and rather ct)Utracted; numerous
dark-colored spots were found at the lower portion, one of which was the seat of superticial ulceration. The right
lung weighed twenty ounces; its upjicr lobe was covered with fibrinous adhesions; this lobe and the lower lobe were
slightly congested, but the middle lobe was healthy; the bronchial tubes were filled with a secretion similar to that
found in the trachea. The left lung weighed twenty-three ounces and was somewhat cougested at its apex and of a
dark-purple color from venous engorgement in its lower lobe. The heart contained a very small clot iu the right
ventricle The liver was of a delicate purplish hue externally, its acini pale, capsule readily torn and parenchyma
firm; the spleen was mulberry -purple and moderately firm. The small intestine was perfectly healthy to within a
few inches of the ileo-ca'cal valve, where several Peyer's patches were ulcerated. Numerous ecchyuiosed spots were
found in the upper portion of the large intestine; the lower third contained an inmiense quantity of unripe black-
berry seeds, and its mucous membrane, purple in color and rather firm, was lined with an extensive black clot. — Aas't
Surff. H. Allen, U. S. A., Lincoln Uuspital, Washington , D. C.
(c.) Diagnosis: Gastritis.
Case 302. — Private Lorenzo Weakley, Co. C, 7th Va.; age 19; was admitted Aug. 21, 1864, his previous history
being unknown. He was emaciated and exhausted from epigastric pain and incessant vomiting, his food and drink
being almost instantly rejected; he had a slight diarrhoea; his pulse was feeble and his tongue covered with a gray
moist coating. The vomiting and diarrhoea continued until the 23d, when there was some abatement; but the sur-
face of the body became cold and clammy, and he died on the 25th. He was treated with brandy, morphine, mild
astringents and sinapisms. Post-mortem examination six hours after death: Abdomen tympanitic. The lungs were
eni|ihyseniatous and in their posterior parts congested; the right side of the heart contained a large fibrinous clot,
the left was empty; the jiericardium contained about six ounces of li(iuid. The liver was slightly enlari^ed and pale;
the gall-bladder nearly filled with dark viscid bile; the spleen nornuil iu size but dark-colored. The iierieardmm
and omentum were cougested; the mesenteric glands enlarged. The mucous membrane of the stonuxch was tliick-
ened and of a deep red color at its caroliac enil. The snuiU intestine was healthy to the middle of the ileum, below
which point it was congested and ulcerated, the ulcers being larger and more numerous at the lower end; the aper-
tures of the solitary follicles and tubuli were colored with lilack pigment, giving the mucous membrane the appear-
ance of being covered Avith small black spots; the lower portion of the descending colon was considerably tliickened
and softened. The kidneys had a large deposit of fat iibout the pelves and their medullary substance was abnor-
mally pale. [Specimens 407 and 408, Med. Sect., Army Medical Museum, are from this case.] — Act. Ass't Surg. 0. P.
Siveel, Carver Hosjrital, Washington, D. C.
(d.) Diagnosis: Cerehro-spinal vitningitis.
Case 303. '—Private Davis N. Hosmer, Co. F, 15th Mass.; age 18 ; was admitted Jan. 30, 1863. Two days before
admission he had a slight chill, which was succeeded by violent headache, slight eiJistaxis and pain in the back and
limbs. On admission he had severe occipital headache, fever and delirium; his head was thown back. Diarrhiea set
in, but was controlled by acetate of lead and opium; cough also was troublesome, and sibilant rales were heanl over
both sides of the chest. On February 4 the pulse declined to 100, the skin became cool and moist and the ability to
answer (juestions returned. Next day there was gurgling in the right iliac region. On the 6th the patient became
rather stupid and affected with low delirium, but there was no diarrhoea. Several spots appeared on the abdomen on
the 7th. He became comatose on the 8th and died on the 10th. Post-mortem examination fourteen hours after death:
The cerebral membranes were slightly injected; the la.teral ventricles were distended with turbid serum; a firm
deposit of lymph from a quarter to three-eighths of an inch in thickness covered the inferior aspect of the c;<rebel-
lum and medulla oblongata. The lungs were congested posteriorly. The heart, liver, stomach, spleen, pancreas,
kidneys and bladder were normal. The solitary glands of the intestines were enlarged and Peyer's patches thickeiied
and in one or two places ulcerated. — Ass't Surg. J. B. TreadwcU , i5th Mass., Stanley Hospital, Neiv Berne, X. C.
- (e.) Diagnosis: Diarrhcca.f
Case 304.— Private Milo Holmes, Co. G, 37th Mass.; age 38; was admitted July 28, 1863, having been suftering i
more or less from diarrhcea for the previous twelve mouths. He was much emaciated but was able to sit up and i
* This case was published by J. B. Upham, Boston Med. anil Surg. Journal, Vol. LXVIII, 186.3, p. 191, as one of ccrcbro-spinal meningitis. ^
tClUHLES H. Kawson, Surg. 5tli Iowa Vols., .imrrlmn Medical Times, Vol. IV, 1862, p. 129, briefly enumerates the symptoms of two fatal eases of
camp typhoid fever. These were at first reganli*ri as diarrha>as and treated as such in ipiarters witlmut any beneficial ri'sult. At the end of five days j
they were taken to hosi>ital, where soon after fever of a remittent type was develt'|HMl, presenting in its course a dry, red tongue ; subsultus ; delirium ,
forty -eight hours before death ; a pulse ranging from 120 to 160 and feeble, imiK'rceptible at the wrist for two days i>rei-eding the fatal termination. Tie'
abdomen was tender in the first case but not in the other. Both patients succumbed ten days after the attack. The treatment consisted of the adnun-
istration of stimulants and nourishment. The nmcous membrane of the alimentary tract from the cardiac extremity of the stomach to the aims was
THK CONTINUED FEVERS. 405
walk aroiiiiil a little, ili- liad no ai)i>ctiti' ; luul several thin nIikiI.s daily: his pulse was iiuiik ami weak, tongne
furred, teiiii>eratiire of liody low and breathin;^ slow and lahoied. There was no marked iliaiifje in these symptoms
until August (!, when the stools beeaine involuntary and he appeared to he sinking. Coma 8n)>ervened on the 8th,
anil he died next day. Posl. mortem examination twenty hours after death: The liody was very luiieh emaeiated.
The lirain weij;hed forty ounces and a (piarter; the posterior part of the eerehrum was hypostatically congested :
one drachm and a half of clear serum wa.s contained in the lateral ventricles: the hrain-suhstanee was rather linn.
The trachea \va.s pale and somewhat purplish between the rings: the lymphatic glands at its bifurcation were small
and not softened, but of a moderately blackish color; tUi« cpsophageal lining was tirm and of a yellowish-ochre color.
The upper lobe of the right lung was hypostatically congested posteriorly, but it{i anterior portion was healthy; the
middle lobe was of a dark-purple color and its central portion was si)lenitied posteriorly: the weiL'ht of this lung was
thirteen ounces and a half. The left lung weighed fourteen ounces and a half; it was of a dark-purple hue poste-
rio'ly and its lower lobe was considerably engorged with venous blood. The heart was normal; its cavities cop-
tuined a soft Jelly-like clot : a large tibrinous dot w:is found in the pulmonary artery, exfending a long distance
l>eyond its bifurcation, and lying on the posterior surfa<'e of the ves.sel surrounded by a thin venous tluiil. i'he liver
was sonu'what congested: Glisson's capsule was readily torn: the g;ill-bladiler contained six drachms of bile: the
spleen was (irni aiul of a mulberry color. The small intestine presented nothing remarkable except in the lU'ighbor-
hoiid of the ileo-ciccal valve, where were several ulcers of Peyer's patches, evidently of huig slanding, circular in
form and penetrating to the transverse muscular fibres. The kidneys were soft and anaemic but .snnicwhiit injected
on their external surface. — Ass't Surg. H. Alien, U. S. A., Lincoln Hospital, Jt'aahington, D. C.
Case 30.1. — Private Charles Jillson, Co. G, 146th Ind., was admitted Aug. 2, ISO,"), with clironie iliarrluea. lie
had pain in the hypogastric region and very freciuent stools. He <lie<l <ui the tith. roit-morlrm ex;iniinatiou: Mrain
normal. Lungs o'deniatous posteriorly, weight of each twenty-six ounces; heart normal, a black clot in the left ven-
tricle, a mixed one in the right. Liver sonu-wh;it dark-colored and ([Uite full of blood: si>leeii dark-colored, weight
six oum-es: pancreas and kidneys normal. The fundus of the stomach was congesteil. and there were huigitudinnl
streaks of congestion in the o^.sophagus. The ileum was congested and Peyer's patc'hes thickened aiul ulcerated,
espeiially near the ileo-cacal valve. The contents of the large intestine were semi-llnid and of a dark-green e<do>-
mixed with a yellowish granular nuittcr. — Asu'l Siiry. Giorgi M. MiGill, V. S. A., Ilickx Iloxpitnl, Ttaltimon', Mil.
Case 300.— Private Kichard Parker, Co. K, 133d Pa., was admitted Dec. 30, isr.2, having been sick three weeks.
When the first notes were taken, .Jan. 1, 1863, the diagnosis recorded was typhoid fever, hut this was afterwards
I'hangeil to chronic diarrhoea. The patient was sleepless, his mouth dry and his tongue smooth, glazed and red; his
eni:u'iation was progressive and ultimately Ix^came extreme. A loose cough set in on the 12th, and a few days Later
he becanu' jaundiced. lie died on the 17th, having vomited a good deal of yellow matter the day before his death.
Voxtmiirtem exaiuination twenty-three hours after death: There were strong pleuritic adhesions on the .anterior sur-
face of the upper lobe of the right lung: the parenchyma of the lung was congested and .a purulent secretion issued
from its lirouchi upon pressure. The left lung was less congested, but the purulent discharge from the smaller rami-
tieations of its tubes was of a thicker consistence than that found on the other side: cheesy tubercles were thickly
scattered throughout the parenchyma of this lung except in its upper portiim. The right cavities of the heart con-
t.iined fibrinous clots. The liver had a nutmeg appearance and weighed forty ounces : the spleen was of a dark cidor
and weighed three ounces and a half. The mucous membrane of the Ics.ser curvature of the stomach was injected
in p<iiuts; the jejunum exhibited irregular patches of congestion in its lower part; Peyer's patches were almost
destroyetl. The kidneys weighed five ounces and a half each. — Lincoln Hospital, Washington, D. C.
Case 307. — Private Matthias Koon. Co. E, 8th N. Y.; age .'lO; was admitted Dec. 1, 186-1, in a partially comatose
conditi(Ui. Diagnoses — diarrhoea and anasarca. He died on the 1.5th. I'ost mortim examination : Kigor mortis ni.irked;
!<udaiuina on left breast. Trachea congested; bronchi tilled with bloody Huid: lungs congested; the middle and
lower lobes of the right lung sank in water: the right lung and up])er lobe of the lung were adherent to the ]>.arietal
pleura. I'ericardium thickened and containing six ounces of straw-colored .serum. Peritoiu-nni thickened and con-
taining sixteen ounces of straw-colored serum. Liver mottled light brown, fatty: two ounces and a half inspissated
bile ill gall-bladder. Uriinner's glands and Peyer's patches ulcerated: ileum intlamed; mesenteric glands filled with
chalky ciuicretious. Kidneys large and fatty. — I'liitd I)iiision Hoxpilul, AUxanilria, Va.
Case 308. — Corp'l Joseph Cole, Co. 15, 2d N. Y. Mounted liifics, was admitted July 21, 1864, much emaciated
from chnmic diarrluea. Under treatment hy wine, opium, catechu and milk diet he improved, aiul his stools were
iiatnral, Angust 7-il, but on the 10th his throat became swollen and covered with false nienibrane. He died on the
12th. roxt-morttm examination eleven hours after death: Larynx thickly covered with false lucmbrane; glottis
o'dematons. Lungs, heart, liver, spleen and kidneys uoruuil ; Peyer's patches ulcerated, esjiecially near the ileo-ca'cal
valve; large intestine healthy. — Fairfax Semiuary Hospital, Va.
ntl .111'! tt)ii-k<-ne<1 ; Peyer's glunds were thickened tiut not ulcerated. In » tliird c.-ia- the piitc]ie.s were cxtc-n.-^ively ulcenited. TJie nature and exiriit
>'f tie iiiti-stiual nfTectiuii revealed by jwisZ-Hi/TMH examination K-il (o the aliandonnient ut' tin- .stiniiilaiit iniKle iif treatment in the thirty c;».-*<'.s which
"l*"»'J''.v followi-J. Cups and blisters to the atidomen, with turpentine elllul^iun containing tipiiim, anil, in the prewnci- of ilinrrhiea, cuj^tor oil, were
itiiccesjtfully emiiloyed. But one fatal case occurred after thip, and in it the intestinal niucouH meinbrune was red as in the previous cas<'S. "Every one of
Peyer's patches was ulcerate^l to its fullest size, enormously raised and spread out like a full-blown rosi-, if I may use the expression. They would ninf^e
fnttu a five-^-ent piece to the size of a dollar. Every mucous follicle and duct w:is thickened, mLsed and ulcerated from the size of a pin's heiid to a i«'a.
on |a.*Aiii^ through into the ca-cum, at the junction of the Ileum, was an ulcer as larpe as a teacup. The whole mucous meinbrane to the ri-ctum wil*. in
» frii:Iilful slate of disorptnizatioii." [The three cases brietly sketched by Dr. Raw.sos ap|tear on his 3Ionthly Heport of Sick and Wounded for Decem-
Ivr, Isi'.l. as cas«>s of gastro-enteritis. The thirty cases said to have terminated favon»bly canuitt W ideiitifieO on the ofhcial reiK)rts unless they arc
mcluded among seveDteen cases of typhoid fever, three of which were fatal, and forty-three casi-s of remittent fever, none of which were fatal, specified
on his moDlhly lepons for December, 1861, aud January, 18(K.)
406 POyT-MORTKM RECORDS OF
Case 309. — Private Smith Byerly, Co. C, 57tli Pa.; age 22; was admitted Fel>. i, 1865, with chronic diarrhoea,
and died on tlie 28th. I'osl-morlciii examiiiatioii : Right lung adlierciit for the upper two-thiril.s of its extent; eight
ounces of a sero-purulent liquid in the pleural Rac; pericardium inflamed and its cavity literally tilled with pus.
Liver, spleen and kidneys very nnicli softened. Ileum perforated at its junction with the colon, the aperture being
ahout the size of a Spanish half-dollar; small intestine much inflamed, with some degree of ulceration scattered
throughout and well-marked ulceration of the glands of Peyer. — Act. Aas't Surg. B. B. Miles, Jarvis Huxjrildl, Balii-
more, Md.
Case 310. — Private Ch.arles M. Delano, Co. I, 7th Me., was admitted Aug. 10, 1862, with diarrhoea, and died
on the 20th. Posl-iiiorttm examination next day; Body exceedingly emaciated; apparently ahout thirty-five years of
age. Lungs he;ilthy althougli adherent to the costal pleura throughout; heart, liver and spleen normal. The nmcous
memhrane of the stomach presented numerous injected points about the size of mustard-seed, and the ruga- along
the great curvature near the pylorus were inflamed. The ileum was inflamed in patches, some of them intensely;
the lower fifteen agminated glands were ulcerated, some completely, others with from one to three small ulcers;
the upper glands were inflamed but not ulcerated. The colon was inflamed, especially in its descending portion,
which i)re.sented many small black stellate ulcers in positions formerly occupied by solitary glands; a patch of
intense inflammation, extending from the sigmoid flexure into the rectum, was covered with an opaque-white mem-
branous matter which the microscope exhibited as a fibro-granular substance mingled with desquamated epithelium.
— Act. Asa't Surg. Joseph Leidy, Satterlee Hospital, Philadelphia, Pa.
Case 311. — Private J. R. Everts, Co. G, 2d E. Tenn.; age 22; was admitted from Richmond, Va. (a paroled
prisoner), April 18, 1864, with diarrhnea. He died May 3d. Post-mortem examination twenty -four hours after death:
Large vomica in left lung with two quarts of ett'usion in pleural cavity, pushing the heart to the right side; vomica
in middle lobe of right lung and tubercular deposit in upper lobe with adhesiou of pleural surfaces. Heart flabby
and pale; aortic valves thickened. Spleen soft and friable; gall-bladder empty. Peritoneum inflamed; omentum,
lower part of ileum and whole of rectum gangrenous. — [Specimens 307 and 308, Med. Sect., Army Medical Museum,
showing ulceration of the solitary follicles and Peyer's patches, with exuded lymph on the peritoneal surface, are
from this case.] — Act. Asa't Surg. B. B. Miles, Jarvis Hospital, Baltimore, Md.
Case :;12.— Private Gilbert F. Sherwood, Co. K, 144th N. Y., was admitted July 20, 1863, with chronic diar-
rho>a. Typhoid symptoms set in about August 1. The low delirium was conceived to have been favorably influenced
by a large blister over the epigastrium. He died on the 21st. Post-mortem examination twelve hours after death:
The whole of the intestines were inflamed, especially the caput coli and twenty inches of the ileum, the mucous
membrane i)resenting a deep-red, velvety appearance with many ulcerated patches. [Specimen 76, Med. Sect., Army
Medical Museum, shows the ulcerated ]patclies of the ileum and the follicular ulcers of the ciecum in this case.] — Act.
Ass'l Surg. F. Hinlle, Jarris Honpital, Baltimore, Md.
Case 313.— Private John Weiant, Co. !<>, 118th Pa.; age 23; was admitted Aug. 30, 1864, with diarrhoea. On
September 13 he became much prostrated by constant vomiting and diarrhoea. He died on the 20th. I'ost-morlem
examination eighteen hours after death': Some emaciation. The brain was normal. The larynx and trachea con-
tained a large (juantity of frothy rose-ccdored eiiuta. The right lung weighed thirty-one ounces and a half and
was much congested and hepatized posteriorly, exuding on section much frothy, rust-colored sputa; the left lung
weighed fourleen ounces and contained a similar frothy, reddish fluid. The heart inclosed a mi»dium-sized fibrinous
clot in its right side and a small one in the left. The liver weighed eighty-one ounces; the spleen sixteen ouni-es
The .stomach was normal: the solitary follicles of the lower ileum were enlarged and Peyer's (patches ulcerated,
there were a few small ulcers in the ca-cuni, hut the large intestine was otherwise normal: the left kidney was
much congested. — Act. Ass'i Surg. B. M. Dean, Lincoln Hospital, Washington, D. C.
Case 314. — Corji'l Andrew Richardson, Co. K, 189th N. Y., was admitted Jan. 17, 1865, with ihrouic diarrhoea,
and died on the 2Htli. /'osi-niur/fiH examination: The right lung weighed forty ounces and the left twenty ounces;
the right pleural sac contained pus, and tlie lung was adherent and hepatized; the heart weighed eight ounces, the
liver seventy-four ounces and the spleen eight ounces and a half. The stomach was injected at its cardia<' end ; the
jejunum much inflamed ; the ileum injected and Peyer's patches thickened and ulcerated ; there were some small ulcers
in the upper part of the colon. — Fifth Army Corps Field Hospital.
Ca.se 315. — Private Orlow Lawrence, Co. F, 140th N. Y., was admitted Jan. 17. 1865, with chronic diarrhoea,
having previously suffered from what was supposed to be remittent fever. He died on the 26th. Post-mortem exam-
ination: The right lung weighed eighteen ounces, the left thirteen ounces and a half; there was an abscess in the
lower lobe of the left lung, and the left pleura contained twenty-four ounces of serum with much plastic lymph. The
liver weighed seventy-two ounces and presented the nutmeg appearance; the spleen weighed six ounces. The ileum
was injected throughout ; Peyer's patches were thickened and ulcerated as was also the colon; the mesenteric glands
were much enlarged. — Fifth Army Corps Field Hospital.
Case 316.— Private John H. Benjamin, Co. H, 127th N. Y., was admitted July 29, 1863, with chronic diarrhwa of
three months' standing. A few days after admi.ssion it was discovered that he was also laboring under a tertian
ague; this was controlled by quinine, but the diarrhrca continued. He had a scorbutic appearance; his gums were
spongy and he was feeble and emaciated. He gradually sank, and died comatose August 27. Pont-mnrtcm examination;
Peyer's patches were extensively ulcerated and the solitary follicles enlarged. The mucous membrane of the rectum
was converted into a pulpy mass. — Act. Ass't Surg. W. H. Letterman, Douglas Hospital, Washington D. C.
THK CONTTNUKD FKVERS. • 407
Case 317.— I'livato J. W. Foreman, Co. M, 5tli C. S. Art.; adiiiiUfil ()<t. 10, 18ti3; chiouic iliaiilura. Dioil
17th. y'o(i/-»i(>r<(Hi examination : Hody somewliat emaciated. Lungs normal ; heart atropliied. Liver Hlifjlillv hyper-
trophied: gall-bladder distended; spleen enlarged. Stomach congested; duodenum congested and tliiikened; Jeju-
num normal; Peyer's patches enlarged, congested and in some instances ulcerated; colon congested, tliickcned and
ulcerateil in patches; rectum thickened. Kight kidney normal, left fatty. — Ilareu-ood Ilospitul, fVaKhiiuito)i, H. C.
Ca.sk :?1S.— Corp'l Charles M. Moslier, Co. A, IL'2d N. Y.; admitted April 21, 18fi.S. Chronic diarrluea. Died May 7.
I'osliiioilim e\an]Miation: Hody mudi emaciated. The right lung, heart and pericardium were lo'althy; the lower
loheof tlu- left lung was hepatized and a portion of its jdcura tliickened. The liverwas mottled and fatty; the s))leen
mottled and doulde the usual size. The stonmch was healthy; the duodenum injected in patches; the Jejunum slighly
injected and presenting small ulcers; the mucous nu-mhrane of the ileum was congested in patches, thiniuMl and soft-
ened, and I'eyer's glands were reddened and ulcerated. The ascending and descending portions of the colon presented
small |inrple spots with, in the former, several snuill distinct ulcers, some of which were healed ; there was one large
inflamed patch in the transverse colon and a purple spot three inches long in the rectum. Some cysts were observed
in the kidneys. — .Ic'. Ass't Sura. II. Ilirshfteld, Iltirewood Hosjiitat, Wiinhi>igto>i, D. C.
Case 319. — Private William Green, Co. H, (ith Mich. Cav., was admitted July 30, ltit!3, with chrouii'. diarrlm-a.
Under treatment he seemed to improve until August 10, when sudden prostration came on. Next day he felt better,
but in the evening the prostration recurred with slight delirium, lasting until death, on the 12th. ronl-morlim exam-
ination eighteen hours after death: Lungs somewhat congested. Solitary follicles of intestines ulcerated; Peyer's
glands enlarged, intlamed and ulcerated. — Third Difisioii Iloxpitiil, AUxandriu, X'li.
Cask 320. — Privati^ David Runibaley, Co. A, 32d Mass.; age 20 ; was admitted August 30, IXtil. having lieen .sick
for two weeks at City Point, Va., with diarrluea and occasional rigors. He was emaciated, had anorexia, pain in both
hypochondriac regions and severe diarrhcea with involuntary stools; his tongue was coated in the centre with a dark
fnr. On September 4 there was intense pain in the right side of the chest, with slight cough, accelerated pulse and
breathing and continuance of the anorexia, diarrlKea and progressive deliility. Delirium, with great prostration,
set in next day, and he died on the (ith. I'nulniorlim examination: The larynx and trachea were healthy; the
lungs were congested, the left markedly so, ami while both were in p.art closely and lirmly adherent to the jiarietes
the right had a coating of recent lymph lui its pleura. The pericardium was firmly adherent to the costal cartihiges
and sternum; the right side of the heart contained a large tihrinous clot, but the left w;is nearly empty. The liver
was enlarged and .soft and conlu^cted by recent lymph to the abdominal wall and the diaphragm; the sjileen was
enlarged, soft, of a <l;irk-brown color, coated w ith recent lyui])!! and adherent to the abdominal wall. The stomach
was red and congested towards the c;irdia, thickened and softened at the pylorus. The small intestiiu^, disten(le<l
with llatus, was healthy in its upper part, but tow;ird the ileum the agminated glands and the mucous MK^mbrano
around them were congested; lower down these glands and the solitary follicles wer<! enlarged and prominent, oc<^a-
sioually presenting dee]) ulcers with red areohe, which became more numerous and stained with yellow i)igment near
the ileo-ca'cal valve. [Spicimcns 121 and 12."), Med. Sect., Army Medical Museum.] The large intestine was distended
with air; the ascending colon congested and presenting a few small ulcers; the transverse and descending imrtions
slightly congested and the orifices of their solitary follicles covered v.ith black pigment; the mesenteric glands
enlarged. The kidneys were normal. — Act. Ass't Surg. O. P. Hweet, Carver Uospital, U'ashinfiton, I). C.
(f.) Diagnosis: DysentiTy.
Case 321. — Private Thomas Jones, Co. A, 1st U. S. Art., was admitted March lt>, Ihii'i, with dysentery, and died
on the 23d. /'o»/-iH<)r(nM examination: Kigor mortis well marked. Kight lung completely hepatized; left lung, he:irt
and pericardium normal. Stomach inflamed along its lower border and pyloric orifice; lower jiart of ileum slightly
infhtmed and Peyer's glands ulcerated, the ulcers surrounded by a red areola. — Furt Strong, In.
Cask 322.— Private William II. Morse, Co. H, 117th N. Y.; age 33; was admitted Aug. 20, IXtil, with <ly,sentery
of four weeks' standing, lie had about twelve passages daily, with tormina and tenesmus. The disease did iu)t yield
to treatment. He died on the 30th. Post-mortem examination: Peyer's patches were much nlcerated, soiiu> to the
muscular coat and one perforating the intestine, [Sjucimciis 374 and .37."), Med. Sect., Army Medical Museum,) Irat
there was no li(|uid in the abdominal cavity; a small cul-de-sac existed in the ileum. — Act. Ass't Surg. I>. I,. Ilnight,
Douglas Hospital, Washington, I). C.
Case 323.— Private Addison (Jrillin, Co. (i, 11 Ith N. Y., was admitted July 29, 18G3, witii typhoid dysentery.
He was much prostrated for two hours after his entry, but he rallied and seemed in fair ciuidition; pulse 88 but
feeble; much tormina and tenesmus; abdomen ti'uder upon pressure, especially over the ileo-ca'cal valve; tongue
smooth, glossy and red in front and coaled white with a greenish-yellow tinge liehind. On the day of admission the
discharges consisted of glairy mucus specked in a few places with blood. Pills of lead acetate, oi>ium :ind blue
mass, with an opiate enema, gave him a rather quiet night, with only four passages, so that next nmrning his con-
dition was encouraging; but at 4 P. M. he pa8se<l a large <|uantity of blood from his bowels and died w itliin an hour.
Poslniortrm examination fifteen hours after death: The mucous coat of the small intestine was softened in its whole
course and in many places not able to bear its own weight; the glands of Peyer were softened and ulcerated, some
com|detely disorganizeil ; the mesenteric ghinds were enlarged to the size of a pigeon's egg. The large intestine in
its w hole length was softened and <li.sorganized. — .let. Ass't Surg. W. U. I.ttlrrmnn, Douglas finapilal. Washington, I). C.
Case 321.- Private Custavus l-'rank, Co. H, 20tli N. Y., was .admitted July 20, 1802, with chronic dy.sentery, and
died August t». Post-mortem examination the same day: The body was much emaciated. The heart was pale and
4y8 PORT-MOKTEM ]IEC0KT>S OF
flabby, with opaque, white patches on tlie lifjht ventricle about the size of a dime and siniihar but quite small patches
on both auricles, together with some roughness of the corresponding i)ortions of the pericardium. The lungs, liver,
stomach, pancreas and spleen were healthy. The mucous membrane of the ileum was inflamed and the agminated
glands, with the exception of the upper ones. Avere thickened and inflamed and in several instances presented small
ulcerations, [Sjicchiiviis 242 and 243, Med. Sect., Army Medical Museum:] the mesenteric glands were tumefied. The
mucous membrane of the colon was inflamed, especially towards its extremities. — Act. Ass't Surg. Joseph Leidy, Sat-
tcrJee Hospitul, rhiladelph'm, I'a.
(g.) Viugnoxis: Typjiuiil ili-hUiti/. i
C.\SE 325.— Private Howard Rice, Co. H. 20r,th Pa.; age 27; was admitted Oct. 14, 1864, with debility, and
died on the 30th from gastric and intestinal hemorrhage. J'i>st-morlfm examination forty-two hours after death:
Muscles well developed. The spleen was dark-colored, enlarged an^ softened. Peyer's patches in the lower part of
the ileum and a few solitary follicles in the c:ecum and in the first six inches of the colon were thickened and ulcer-
ated, but beyond this the large intestine was nornuil. The lungs, heart, liver .and kidneys were normal; the
stomach was healthy but contained four ounces of grumous lii|\iid. — Acl. Asx'l Siirii. Thomux Boirni, Second Division
Hospital, AUxandria, Va.
Case 326. — Private Jeremiah Blair. Co. C, 21i2d Pa.; age 38; was admitted Nov. 4, 1884, with debility, and
died on the Ctli. Post-mortem examination: Peyer's patches near the ileo-ciecal valve were thickened and ulcerated
in two or three places; the mesenteric glands were enlarged; the liver dark-colored; the spleen enlarged; the other
organs healthy. — Second Division Hospital, Alexandria. Va.
Case 327. — Private Isaac H. Cole, Co. M, Cth Pa. Art.; age 40; admitted Oct. 17, 1864; died November 7.
I'dst-iiiortem examination twenty-six hours after death: Marked rigor mortis; no emaciation ; extensive suggillatiou
posteriorly. The left lung was congested posteriorly and a small portion of its upper lobe was hepatized; there
was an ounce of sernm in the right pleural cavity and two ounces in the left. The pericardium, which was slightly
reddened, C(mtained four ounces of serum. The great omentum was inflamed and adherent to the small intestine,
the coils of which were interadherent ; there were extensive deposits of lymph on the peritoneum, and thc> cavity
contained two pints of a thick straw-colored liquid having a ficeal odor and some floating shreds and snuill masses,
apjiareutly IWcal, about the size of barley-grains. The liver was enlarged; the coats of the gall-bladder were disor-
ganized from extension of the peritonitis; the pancreas normal; the spleen enlarged and softened. Several uf
I'eyer's patches in the lower ileum were thickened and ulcerated, one ulcer about two feet from the ileo-c:pcal valve
li:i\ ing i)erforated; the mticous coat of the o;ecum and of the first few inches of the colon was infiauu'd and thick-
ened: the mesenteric glands were much enlarged and quite dark. — Second JHrision Hospital, Alexandria. I'a.
Case 328.— Private William DePr.aley, Co. I, 118th Pa.; admitted Oct. 10, 1863. Del>ility. Synqiloms of jieri-
tonitis were <ibserved on the evening of the 28th. Died 29th. Post-mortem examination: P>ody much em.aciated.
The lungs and heart were normal; the pericardium contained four ounces of liquid. The abdominal cavity con-
tained a large i|uantity of serum; the liver was adherent to the adjoining viscera; the gall-bladdi'r. spleen, stomach,
dnodenum, jejunum and kidneys were normal. The ileum was inflamed and Peyer's glands ulcerated; one of the
ulcers just above the ileo-e:eeal valve had- perforated the peritoneum: the colon and rectum were much inflamed.
— Harewoiid Hospital, Washinijton, D. C.
(h.) Diai/nvsis: Bronchitis.
Case 320. — Private John Connor, Co. B, 28th Mass.; age 22; was admitted Oct. 18, 1863, with acute bronchitis,
and died November 8. Post-mortem examination twenty-two hours after death: The brain was natural. The larynx
anil trachea were inflamed; the mucous membrane al)Ove the chorda' voeales was greenish-brown in color and much
pulled out and thickened, ]>articularly on the right side; a slight exudation was observed on the cords and under
surface of the epiglottis; the sub-epiglottidean follicles were enlarged, softened and blackened: the mucous mem-
lirane below w.as of a paler color but still greenish, becoming grayish in the bronchi. The O'sophagus was inflamed,
its lower p:irt dark purplish-red and presenting numerous purpura-like spots which invaded the sub-mucous tissue,
its upper part greenish-brown and very much softened and thickened. The right lung weighed fifteen ounces,
contained much pigmentary matter, was well filled with air and on section exuded little or no bronchial secretion;
the left lung weighed twelve ounces and was healthy, excepting the slate-color of the bronchial membrane; the
pleural cavities contained three pints of serum. The heart was firm and almost free from clots; three ounces of fluid
were found in the pericardium. The liver was perfectly healthy: the spleen was firm and weighed three ounces
and three-(inarters; the pancreas four ounces. The small intestine was thin and the valvula; conniventes almost
obliterated; the solitary follicles were not enlarged; Peyer's patches were of a deep-brown color and but little ele-
v:ited — such as were ulcerated were surrounded by a light-red areola, but the ulcerations were in no place deep
and had everywhere the appearance of undergoing the healing process. The large intestine was of a darkish gray
color, its solitary glands nonual. Both kidneys were somewhat congested. — Ass't Snrg. Harrison Allen, U.S.A., Lin-
coln Hospital, Wasliington, D. C.
Case 330. — Private E. B. Dolph, Co. B, 27th Conn., was admitted March 9, 1863, having been suff'ering for six
weeks from a rather severe attack of bronchitis, for which he had been treated in quarters. On admission his pulse
was 108, tongue clean and moist; he had considerable cough with white frothy sputa and some substernal soreness;
his stools were rather infreijuent (not daily) but loose aud watery. Next day he seemed better; pulse 84. On the
11th his pulse was 108, respiration 20, tongue furred and a little tinged with brown, and he had one watery passage
in the preceding twenty-four hours. He continued in this condition until the 14th, when he had three loose passages
TTTK cONTINUF.ll FKVKRS. 409
ami comphiiueil uf sonic teudcrness over Iho wliolr luursi' ul' llie loKiii. Xo^lI day the i)ulse and lospiration became
slifllitly aceelerated and the tongne dry; he had two loose passa';es. On the lOtli the pulse was 120, the respiiatiou
28, the lips dark in patches, the tou;;ne dry and dark; he did nut answer ijuestions sensibly; the abdomen was tender
all over; his couf;h was loud, dry and very annoying; the respiratory mnrmur was absent and there was dulness on
percussion from the lower extremity of the scapula downwards on the rifjlit side, but elsewhere the niurniur was loud
and dry. Tubular breathing was lieani on Ihc 17th bdow tlio fifth ribou the right side anteriorly and laterally. He
died on the 20th. The cough ceased during the last three days of life. The abdomen was at no lime tympanitic nor
were any ro.se-colorcd spots observed. I'oi^l-iiitiiltiit examination: [The condition of the thoracic viscera is not rci'onleil.J
There were about twenty-tive indnrated Peyer's patclies in the ileum, six of which were ulcerated; the ileo-c;ccal
valve was thickened anil presented an indunitcd. slightly ulcerated patch on its ciecal surface; the neighboring parts
of the ileum and colon were mncli congested; the mesenteric glands were enlarged. [Sinciiiini l.'JO, Med. .Sect., Army
Medical Museum, is from this ease.] — Siini. 1)'. <). McDonald, llonjiitiil, 27//i Conn. f'oh.
(i.) Diagnosis: Pninnioniii or Ijnihoid pni Hninnio.
Cask :i;il. — Private Orlando Stevens, Co. A, oth Vt., was admitted .Jan. 2, 18(33, with pneumonia. As marked
typhoid symptoms were present a su)iporting tieatment was adopted. He imjiroved to within a day or two before
his death, when imistration set in. He com)>laincil at one time of a dull pain in the left breast and of souu' dillienltv
in breathing: he had also a slight diarrhiea. He died on thi^ lUth. I'ust-niortcni examination six hours after death:
Kody much emaciated: skin sallow and tightly stretched. The lower part of the upper lobe of the left lung contained
a few small masses of hepatized tissue; the lower lobe was hepatized, its small bronchi filled with false mem-
brane and its whole surface covered with a thin layer of exuded lymph. The spleen was small but of normal
consistence and color: the kidnfys and liver were natural. The stomach was contracted, its greater curvature having
strongly marked rugn> in front and towards the pyloric orifice; the fundus was injected, particularly at the lowest
point and near the cardiac orifice; the mucous membrnne to the right of the cardiac and towards the pyloric orilice
was niammillated. The small intestine was healthy to the upper end of the ileum; below that jioiiit it wascongesled
ill patches which occujiied about half the surface for two feet and a half in length, thence it w;is uniformly congested
to the ileo-ca'cal valve. Pcyer"s patches were punctated — .some were reddish; they wen' slightly swollen and nnich
softened; w ithin :i foot of the ileociecal valve were eight or ten over which the mucous mcmbr.ine was eroded, while
the luu.scular tissue beneath was much congested; the ulcers as a rule did not occupy the wh<ile of these patihes, but
in the middle thinl of the ileum there were several in which this was the case; the mesenti^ric glands were normal.
The )ieritoneal surface of the cacuiu was congested; the mucous membrane of the desceiuling colon was slightly con-
gested ne:ir its commencement, then slaty in color to the sigmoid flexure; in the lower two-thirds of the gut the
solitary glands were distinctly marked and filled with a dark-blue deposit; in the sigmoid flexure were several
small ulcerations not exceeding a line in diameter, but thcmucous membrane was of normal consistence. — Ad. .Iss't
Snrg. T. !>'. DuniiHson, Lincoln Hospilal, Washington, D. C.
V\^v. 332.— Private M. W. Knowles, Co. D, 67th Pa., was admitted Feb. 3, ISfiJ, with iiiieiiinoni.i, and died on
the Stii. I'osl-morliin examination : The right lung, excepting a part of its anterior margin, was hejiatized : tlii^ left
was congested. The liver was slightly granular and fatty; the spleen large, soft and id" a dull piirjile color inter-
nally: the kidneys congested. Peyer's patches in the lower part of the ileum were ulcerated but the surrounding
villi were not affected. [SjHCimcn 201, Med. .Sect., Army Medical Museum.] The large intestine presented isolated
ulcers mostly conlineil to the ciecnm : the mucous membrane was of a dull whitish-blue color. — Jst'l Sun/. Iluirisun
AlUn, V. S. A., Lincoln Hospital, JTashington, I). C.
Case 333 —Private L. M. Cole, Co. E, 16th Me.; age 20; was admitted March 26, 186i, with pneumoni.i, and <lii(l
on the 28th. /'oxZ-moifcm examination twenty-three hoars after death : Body much emaciated. Hrain hialthy. I'rachea
much conge.sted ; right lung twenty-six ounces, left twenty ounces — both congested: bronchi tilled with bloody
iniiims and each jileural sac containing a Hinall (luantity of bloody serum. Heart pale. Liver aniemic, weighing
fifty ounces: spleen healthy, nine ounces. CE-sophagus and stomach normal; small intestine much congested,
especially towards the ileo-ea-cal valve, where the mucous membrane was of a bluish-slate color; Peyer's ])atclies
and the .solitary follicles prominent, several showing points of ulceration; large intestine congested near the caput
coli. Mucous membrane of bladder around orifices of ureters dark-bluish colored in spots, varying in size from a pea
to a large cent. — Act. Ass't Surg. LI. M. Dean, Lincoln Hospital, Washington, L). C.
, Case 334. — Private Henry Shrnm, Co. F, 2d Md.; age 55; was admitted Sept. 6, 1865, with pneumonia. Two
weeks before his entry he had a chill lasting for half an honr, followed by oppression in the chest, with complete
anorexia for five days. On admission he had diarrhoea, a suffocative feeling on taking a deep breath, a purple pus-
tular eruption on his body and coldness of the hands and feet. He died on the 8th. I'lisi-mortim examination : Left
lung adherent and colla|i.sed posteriorly; right lung congested generally and solidified posteriorly. Sjileeii enlarged
and softened. Peyer's patches of ileum elevated, enlarged and in some instances ulcerated; siditary glanils of colon
and rectum enlarged and presenting the shaven-beard appearance. Kidneys with many superficial cysts containing
a transparent light-brown fluid. — Act. Ass't Surg. Carlos Carrullu, Douglas Hospital, Washington, D. C.
Case 335.— Private ,Tohn Strickland, Co. E, 103d 111.; age 34 ; was admitted June 21, 1863, with typhoid pneu-
monia. He was delirious on admission, but it was learned that he had been seriously ill for two or three weeks. His
pulse was small, tongue dry , thirst excessive ; he had not much diarrluea, but expectorated large ((uantities of iinrulent
matter. His condition lemained unchanged until the morning of the2.Sd, when a large jiool of bright-red blood,
which had flowed from his bowels, was discovered under the bed. Ten drops of solution of perchloride of iron were
Mki>. Hist., Pt. Ill— 52
410 POST-MOKTEM KECORDS OF
or(lere<l to lie taken tn-ery thirty minutes, and the patient was placed on anotlier bed; Ijut he continued to bleed so
freely tliat tliis also became speedily soaked. By the time the third dose of the iron was given the blecdiui; had
ceased, but the patient was extremely exhansted and almost pulseless. He rallied, however, and seenu'd to be doiu"-
well until the evening of the 26th, when be s)iddenly l>ecame restless and his pulse accelerated. He died next niorniii".
I'oxt-moylfiii examination ten hours after death: The nie.senteric glands were enlarged, softened and in soine cases
nearly broken down. Only two nlcerated Peyer's patches were found: these were large and ragged, situated a chort
distance from the ileo-c;ecal valve; there was no blood in the intestines. — Tmhsou Hospital, St. Louis, Mo.
Case o3(i. — Private Morris Hyatt, Co. A, U2d Ohio National Gnard; age 21; was admitted July 28, 18(!4, with
typhoid pneumonia. He was delirious and had a slight coiigh, without expectoration, and an iufre(|uent diarrhcea.
In the progress of the ca.se the pulse became rapid and weak, the breatliing hurried and the conntenance dusky. He
died August 1. Post-mortem examination si.x hours after death: Kigor mortis nuaked. The lungs were engorged pos-
teriorly and son\e of the ]ol)ules hepatized. The liver was engorged, enlarged and softened; the spleen softened.
The mucous membrane of the stonuich in the region of the greater curvature was much softened and easily torn.
Peyer's i)atches and the solitary glands of the small intestine were extensively diseased, this condition becoming nujre
nuirked toward the lower end of the ileum ; for three or four feet above the ilco-ca-cal valve the morbid patches were
circular, from the size of a pinhead to that of a two-cent piece,, or oval, some of the latter having the greater axis
over two incdies long with a thickness in some cases of three-sixteenths of an inch ; they were firm, the edges smooth
and regular, the surfaces in those most advanced slightly excavated and in all more or less covered with a yellowish-
green, easily detached coating or deposit. [See S})icimcns 37(>-3S0, Med. Sect., Army Medical Museum, and plates
facing pages 410, 412 and 436, iti/ra.] The mesentery was greatly thickened and the glands enlarged, some to the
size of a large peach-stone, [Specimrn 381, Army Medical Museum.] The large intestine was generally healthy.
The kidneys were normal. — Donglus Hospital, Washinriton, D. C.
Case 337. — Private Frederick Brand, Co. E, 11th Pa.; admitted J;in. 7, 1865; typlioid pneumonia. Died Feb-
ruary 1. Po.^t-mortem examination ten hours after death: Both lungs were hepatized (gray) and closely ;idherent to
the costal pleura. Slight adhesions existed between the liver, diaphragm, ascending colon and suuill intestine: tlic
intestines were covered with plastic lymph; the abdominal cavity contained twelve ounces of a colorless li(|uid:
the mesentery was thickened and congested throughout and contained large, soft, white deposits which resenililed
tubercle. The duodenum was healthy; the upper part of the jeiunum was slightly congested in spots and its lower
part presented a large nicer; the ileum was congested throughout and Peyer"s patches ulcerated. Tlu^ ascend iiig
colon was healthy; the rest of the colon and the rectum much congested but not nlcerated. The nlhpr viscera were
normal. — Act. Jss't Surg. C. T. Trautman, Rarewood Hospital, Tfashington, D. C.
Case 338.— Serg't Alexander M. Elgin, Co. B, 1.39th Pa.; admitted April 21, 1863; typhoid pneumonia. Died
May 21. Post-mortim examination: The left parotid gland and surrouiuling cellular tissue fornu'd the site of an
ab.scess which penetrated to the lesopliagns. The lungs and heart were normal. The duodenum and jejunum were
dark-lead colored and contained fresh bile; the ileum was thin and dark colored, its mucous membrane nnich
injected; Peyer's patches and certain of the solitary glands were deeply colored, softened and in some instances
nlcerated. The largo intestine exhibited large black spots scattered over its surface. The liver was l)lack on its
under surface, its p.irenchyma fatty; the gall-bladder distended with bile ; the spleen and kidneys normal. — .ict. Ass'l
Siirij. Thus. H. Elliott, Harewood Hospital, JTasliington, D. C.
Cask. 339. — Private H. F. AVardwall, Co. D, 33d Mass., was admitted Feb. 9, 1863, with great dyspna>a and com-
plete aphonia. Death occurred from sufi'ocatiou on the 15th. There was no indication during life of any intestinal
lesion, nor was the patient emaciated as he would probably have been if just recovering from typhoid fever or chronic
diarrho'a. Post-mortem examination: The lungs were much congested, but there seemed to be enough of compara-
tively healthy tissue to have enabled respiration to go on. The trachea was highly inflamed, the larynx ulcerated ami
the glottis occluded by O'denui. The mucous membrane of the small intestine, and especially of the ileum, pi'esented
the softened and tumetied aspect usually fovind in cases of chronic diarrho^.i, and there were nuuu>rous ulcers, one
near the eacum being two inches in diameter. ISjucimiii 207, Med. Sect., Army Meiliial Museum, showing ulceration
of Peyer's glands, is derived from this case.] — Med. Cadtt E. Cnues, U. S. A., Mount Ple.asiiiit llospilal, Wiisliinijton, II. C.
(1'.) Diagnosis: Pleinisg.
Case 340. — Private Henry Mead. Co. D, 10th N. Y. Cav.; age 19; was admitted April 7, 1865, with jdeurisy. [lie
entered the cavalry corps hospital, City Point, Va., March 27, diagnosis chronic diarrhcea, and was transferred In
Lincoln hospital, Washington, D. C, April 1, where his c;ise was registered bronchitis.] He was pale and iimili
debilitated ; tongue white; bowels loose; appetite poor; pulse full, weak, not frequent, intermittent and sometimes
resembling the whir-r-r of an aneurism; breathing hurried and difficult; he was unable to lie on his right side.
Physical examination discovered dnlness over the left lung and inferiorly over the right lung, crepitation over the
right lung posteriorly, with a large moist rale over its middle lobe and a sibilant riile over its lower lobe and dis-
placement of the heart four inches towards the right, its apex seeming to be under the right niii]de. He died on the
12th. Post-mortem examination: There were two gallons of bloody Ii(juid iu the left thoracic cavity; the left lung
was compres.sed against the spinal column and so dense as to sink in w:iter; the right was ]ia.ssively congested,
especially in its lower lobe. The heart was displaced to the right and contained a soft coagulum iu its left cavities,
a fibrinous one in the right; there was slight etfnsion into the pericardium. I'he liver was somewhat congested.
The small intestine was congested and some of Peyer's i)atehes were ulcerated. — Satterlec Hospital, Philii(hlphiu,Pa.
THK conttnitb:p fevers. 411
(B.) CoxKiTiox OP Peyku's tatciiks xot statkd; the ii.ei'm or the small intestine saii> to have heen
ri.CEKATEIl — 21 cases.
(o.) I*itittnosh: Jnlvnnitltiit J'frcr.
I'ase ;-ill. — Private .Jncob l^hoiildors, Co. 15, 15tli Vii.; nsc 2r>: was admitted Au>;. .SI, ISIil, with iiitcnuittent
fever, and died Septenilier 13 with t.vplioid sym))toni8. I'ost-morlim examination: Hypostatie cmisestion of lioth
liin^. Liver large, weiu;hing live pound.'!; sidceii very large, twenty-six ounces; left kidney small, tliree ounces;
ileum for tliree feet aliove the ileo-ca-cal vahe intensely intlamed aud containing thirty ulcers, some of the size of a
silver dollar. — .l<7. Ans't Siirij. li. li. ^fH^•s, .7<irris Ilnxpitiil, lliillimoir, Md.
(b.) Diitfiiiosh: Ceirhral (Useasv.
Case 342. — Private Zeluilou K. Whittaker. Co. H. llith Me., was admitted Eel). 1, 18()5, as a convalescent from
.yphoid fever, lie was liypocliondriaral aud nostalgic, complaining ot severe headache, intense lumliar pain aud
constipation. HIisters were apjilied Iiehind the ears and dry and wet cups to the back with Imt temporary relief.
He vomited large iiuautitics of a greenish watery li(iuid, aud later had involuntary stools aiul jiaralysis of the bladder
necessitating catheterism. Ho became very restless and noisy, and on the 20th had to be fastened to his bed to
prevent his leaving it. He died on the 24th. Post-mortrm examination : Brain normal. Lungs congested, softened
anil friable. Stomach showing numerous eechymoses; ileum and ileo-ciccal valve presenting a few isol.'ited ulcers.
Bladder thick, small, ecchymosed. — lil. .isn't Siinj. Ctirlox Carrallo, Douglas riospitnl, JVushiinitdii, ]). ('.
(c.) Didgnosis : Diiinhda.
Case 343. — Private R. M. Hapman, Co. E, loOth N. Y.; ago 41; was admitted July 9, 1863, with chronic diar-
rhoea and general debility. He was doing well up to August 22, when meningitis supervened, and ho died on the
2.">th. roit-morlim examination: Close adhesion between the pia mater and the hemispheres of the cerebrum, with
ail unusual quantity of serum 'in the subarachnoid spaces; ossification of a Pacchionian granulation, [Sprvimfii 41,
Med. .Sect., .\riiiy Medii-al Mu.seum.] Lungs and heart healthy; liver and spleen softened and congested; ileum
iiillamed and ulcerated in )iatclies. — Act. Jss't Suri). B. B. Miles, Jnrris Hosjiitnl, Baltimnii', Mil.
Case 344.— Private Franklin SoUans, Co. E, 122d Ohio; age 22; was admitted Aug. 12, 1^04, with diarrlm-a,
and died on the 19th. Post-mortem examination: The vessels of the pia mater were amemic and seemed to contain
globules of air: there were two ounces of serous effusion at the ba.se of the brain; the third ventricle contained
one iMince of li<|uid; the brain-substance was natural. There was extensive interlobular eniphyseina of both lungs,
vvliicli were congested posteriorly; the areolar tissue of the anterior mediastinum was infiltrated with .air. The
heart aud kidneys were natural: the liver large; the spleen congested. There were three ulcers in the ileum; two
of which were one inch and the other eight inches above thp ileocecal valve; the mucous iiicinbraneto the extent
of a foot from the valve was very nuich congested. — .Ict.Ass't Surg. B. B. Miles, Jiirvit Iloxpitnl, lUiltimore, Md.
Case 34 ">.— Private Charles A. Taylor, Co. A, 9th Mich. Cav.; age 18; admitted dead, March 1, 18(>4, having
dieil in the ambulance on the way to hosiiital. Postmortem examination fonrteen hours after death: Body greatly
emaciated. The lungs were healthy; the heart small and llabby. The liver was largo liiit of normal consistence; the
left kidney engorged with blood, the right small and apparently fatty. The omcntiini had lost its fat ; the mesen-
teric glands were enlarged aud there were indications of former peritonitis. The stomach was healthy; the iiiiicoiis
membrane of the ileum was destroyed by ulceration in iii:iny j^laces and thickened in others. — Surff. tVm. ('. (titrr-
ton, P. S. r., Iloxiiiliil ,\o. S, S'lishrille, Teiin.
Case :t4r..— Private Martin O'Neil, Co. E, 14th N. J.; age 40; was admitted Nov. 5, 18(i4. He had been sick
for two weeks with diarrluea complicated with kidney disea.se aud <edema of the hands aud feet. He died .Jan. 30,
IM!."). J'nst-mortem examination nineteen hours after death: Mucous membrane of ileum and CiPcum ulcerated in
a dozen patches, two of which perforated the gut about two feet above the ileo-ciecal valve; abdominal cavity con-
taineil about six ounces of pus. Left kidney .somewhat enlarged, pale aud mottled; right normal in size but con-
gested.—Jcr Ass't Surg. S. P. White, Ifurd Hospital, Xeirark; X. J.
Case 347. — Private Rudolph Norman, Co. U, 28th Mass.; age 28 (a paroled prisoner); was adiiiillcd fnuii
Richnioud, Va., April 18, 18lU, with chronic diarrhcea. He died .June 4. Post-mortem examiiialion tweiity-lbur
hours after death: Lungs healthy; heart flabby and anH>mic, filled with white clots: liver adhering by its eiifiie
upper surface to diaphragm; spleen large; mncous coat of intestines much congested aud thickened; ileum perfo-
rated in ten or twelve places by nlcers; peritoneiini congested and adherent in many places. — Act. Ass't Surg. B. B.
.\file8, Jarris Hospital, Baltimore, Md.
Case 348. — Private .\lfred A. King, Co. F, 2d Pa. Cav.; age 16; admitted Aug. 9, 1864, from Army of Potomac;
chronic diarrho-a. l>ied next day. Post-mortem examination: Much emaciation; enlargement aud suppuratiou of
parotid glands. Ulceration of ileum, ca-eum and part of colon ; a half-irint of lumbricoid worms scattered through
the intestinal canal and quite a lot of them in the ca-cum. — Third lUrision Hospital, .Alexandria, Va.
(d.) Diagnosis: Debility.
Case 349.— Private Henry C. Davis, Co. C, 9th N. Y. Cav.; age 32 ; was admitted .July 23. 1863, with debility.
He was ajipoiuted an assistant nurse, but symptoms of meningitis came on, for which cups, blisters and eneniata
were employed. He dieil Angnst 3. Po«/-Hio)-(fi« examination fourteen hours after death: "On removing the cere-
brum slight adhesion was found on the left side with some effusion, the meninges of the brain being softer than
nsnal. The liver was congested and weighed four pounds and six ounces, and an ulcer was found in it near the gall-
412 POST-MORTEM KECORPS OF
lilailder; the spleen -n-eighed two poiiiirts and four onnc(\s. There was ulceration along the ilenni." — Act. Ass'i Surg.
U. II. Mih'fi, .Jiirvis Jfos2)ital, Baltimore, Mtl.
Case 350. — Private Lyman Avery, Co. I, i)th N. Y. Cav.; age 23; was admitted July 20, 1863, with debility, and
died August 14. 2'oxt-ninrlciii examination twenty hours after death: Brain, lungs, heart and liver healtliy; ileum
showing cicatrices of old nlcers in their diftereut stages. — Act. Ass't Surg. B. B. ililes, Jarris Ilospilul, Baltimore, Aid.
Case 351.— Private Henry Lott, Co. D, 173d N. Y.; age 22 ; was admitted Oct. 29, 18G3, suffering from cough and
tyjihoid debility. Next day it was noted that his abdomen was covered with purple spots, and on Novemlier 2 that
he hail dysentery but with little tenesmus. He was treated with carbonate of ammonia, whiskey, nourishment and
hot applications to his extremities. He died on the 3d. ront-mnrltm examination twenty-six hours after <leath:
Inflammation and ulceration of the intestines. — Act. Ass't Surg. TV. W. lioi/iil, Hospilal, Annapolis, Md.
(e.) Diagnosis: lilieninalisin.
Case 352. — Private Daniel Repplogel, Co. A, 61st Pa.; age 28; was admitted Aug. 23, 1864, with rheumatism,
and died Septemlier 22. I'ost-mortim examination twenty-four hours after death : The middle lobe of the right lung
was hepatized aud infiltrated with pus. The ileum was intensely congested in spots and presented four large ulcers
at a little distance from the ileo-caical valve. The bladder was very much thickened and contracted. — Jet. Ass't Surg.
B. B. Miles, Jarris JJospital, Baltimore, Md.
(f.) Diagnosis: Ptnuinonia or t!/j>hoitl jincumonia.
Case 353. — Private Richard Vaughn, Co. F, 146th Ind.; age 26; was admitted June 8, 1865, having been sick
for ten days with pneumonia. On admission his bowels were rather loose and he bad some cough with free exjiecto-
ration. He improved steadily until the 13th, when permission was given him to go to Cumberland to lie mustered
out; liut he became much exhausted by the way, was abandoned by his friends, and returned to the hospital on the
mil ill a prostrate condition. He died on the 17th. Post-morlcm examination eight h'ours after death: There were
pleuritic adhesions on both sides. The abdominal cavity contained a quantity of sernm and the intestines were coated
with coagulable lymph. The liver was large, intensely congested and softened; the spleen large, congested, soft-
ened and of a black cidor. The mucous membrane of the jejnnum, ileum and ca>cum was inflamed, softened and
ulcerated. — .-let. Ass't Surg. S. />'. West, Cumhirlund Hospital, Md.
Case 354.— Private Philip Dick, Co. A, 187th N. Y.; age 28; was admitted Feb. 20, 1865, with pneiimouia. He
diiMl March 4. rost-mortem. examination eight hours after death: Purpuric spots, the largest one-fourth of an inch
ill diameter, were scattered on the lower extremities. The lower lobe of each lung was deeply congested and on the
outside of the left was a sunken star-shaiied cicatrix, with beneath it a collection of tubercular matter about as large
as a butternut, connected at its inner side with one of the bronchial tubes. The heart was healthy and contained a
large white clot in the right ventricle and a smaller one in the left. The liver and kidneys were healthy. The spleen
wi'ighed twelve onnces and adhered strongly to the diaphragm; in its substance beneath the adhesiim was a ca\ ity,
]iartly divided by a partition extending to its bottom and containing about an ounce of viscid greenish fluid, [.^^kc-
imen 523, Med. Sect., Army Medical Muscuui.] The stomach was inflamed and exhibited one ulcer about the iiiiiliile
of its greater curvature; the duodenum was congested; the.jejunum injected in patches, its lower three feet healthy,
as was the first foot of the ileum; the rest of the ileum ulcerated; the mesenteric glands inflamed; the Large intes-
tine healthy. — Surg. W. L. Faxon, 32d Mass., Depot Hospital, Fifth .trnii/ Corps, Citg Point, Vu.
Case 355. — Private Charles Hackett, Co. D, 12!ltli Iiiil.: age 26; was admitted May 26, IStil, with i>nfUiiioiiia.
When hist seen by the reporter June 5, the patient was feeble, delirious and had diarrhiea with iiividuiitary stools.
He died June 10. Post-mortem examination : There were recent adhesions and a large serous eft'usion in the left ])leural
cavity; the upper lobe of the left lung was congested, the lower partially consolidated and coated with pseudo-mem-
brane; the right lung was comparatively healthy. The heart was flabby and soft. The spleen was enlarged, con-
gested and easily torn. The ileum was much inflamed and ulcerated in a number of places. The lelt kidney was
slightly inflamed. — Act. Ass't Surg. L. A. tl'alton, Hospital Xo. 8, Nashville, Tenn.
Case 356. — Private Edwin Preston, Co. D, 5th N. Y. Cav.; age 20; was admitted Oct. 13, 1861, with tyjihoid
pneuinouia, and died on the 24th. Post-mortem examination twenty-four hours after death: Adhesion and almost
cuuiplete consolidation of both lungs, which did not, however, sink in water; a band of lymph connecting the two
surfaces of the pericardium; twelve ulcers in the ileum penetrating to the serous coat. Other organs normal. — Act.
Ass't Surg. B. B. Miles, Jarris Hospital, Baltimore, Md.
Case 357. — Private Meredith P. Osborn, Co. I, 9th Tenn. Cav., was admitted with typhoid pneumonia, and died
Oct. 27, 1864. Post-mortem examination : The right lung was healthy; the left was in a state of gray liep.atization with
eit'usion of about one pint of serum in the pleural cavity. There was a large white clot in the right side of the heart.
The liver was much congested; the ileum ulcerated; the mesenteric glands enlarged. — Act. Ass't Surg. J. E. Brooke,
Bbcic Island Hospital, III.
Case 358. — Private William Walters, Co. 1, 17th Ohio; age 34; was admitted Aug. 27, 1864, with typhoid |uieu-
monia. He died September 4. Post-mortem examination on the day of death; The lower lobe of the left lung was in
the state of red hepatization. The heart, liver and kidneys were normal. The spleen was softened and enlarged;
the lower portion of the ileum ulcerated in patches. — Field Hospital, Chattanooga, lenn.
Case 3.59.— Private Ansel Fraley, Co. F, 33d Ohio ; age 16 ; was admitted Aug. 21, 1864, with typhoid pneumonia,
and died Septemlier 8. J'ost-mortem examination next day: Both lungs were congested and several lobules of the
lower lobe of the right lung were hepatized. The mitral valve was thickened. The liver was somew hat softened;
THE CONTINUED FEVER?. 11'.
the sjiU'en ami kidneys normal. The iiiucoiis memhraiie of the lower portion of the ileum wa.s deeply niii^i-,-,ii d,
softened and i)resented a number of ulcers. — Fitld Hot^pilnl, Chattanooija, Tciiii.
Case StiO. — Private r.liy Hall, Co. D, 3d Va. Cav.; age 17; was admitted Dec. 27, USiU, with pneumonia of the
left lung, and died Jau. (!. 181)5. Post-mortrm examination twenty-four hours after death : .-Vljout three ounces of liipiid
and some recent adhesions in each pleural cavity; lower lobe of each lung deeply congested aiul slightly hepatized.
Heart and liver normal ; spleen large and soft ; kidneys congested. I'eritoneal cavity containiug about two pints of a
turbid liiiuid; ileum above the ileo-cjecal valve presenting many deep and large ulcers, one of which had per furati'il
the gut; colon slightly ulcerated. — Jet. .Ii.t't f^uifi. ft. B. Mika, Jarris Eospitat, Baltimore, ild.
(if.) Diagnosis: Prntonitis.
C.\SK 3i;i. — Private William Iviley, alias Cohen, Co. C, 14th Conn., was admitted Feb. 13, 1865, with peritonitis.
Large doses of anodynes were given per rectum, the stouuich being too irritable to retain auytJiiug. He died
on the 17th. Post-mortem examiiiatiou li\e hours after death: Peritoneum thickened and intlamed, containiug twelve
ounces of pale serum : small intestine adherent by bands of lymph ; lower ileum showing many large, deep, irregular
ulcers and containing three living lumbricoid worms: large intestine intlamed and in the rectum presentiug ulcerated
hemorrhoidal tumors; liver normal; spleen enlarged: kidneys small. — Thinl Dirisioii Hospital, JItj-aiidriu, fa.
(C.) CoXlllTION OF PEYER's PATCHES NOT ST.\TED; THE INTESTINAI, MUCOUS .MEMliKASE KOT ULCER.VTED 1 CASES.
(a.) Diaijnosis: Pneumonia.
Case 31)2. — Private Garrison North, Co. E, 5th Mich. Cav.; admitted March 25, 1863. Diaguosis — pneumonia.
Died April it of typhoid fever. Post-mortem examination two hours after death: Brain forty-seven ounces. Kight lung
eighteen ounces, some pleuritic adhesions of upper lobe; left lung twenty-ounces, lower lobe much congested: bronchi
of both lungs, especially of upper lobes, thickened and indurated, feeling on section like nodules. Heart thirteen
ounces and a half. JLiver eighty ounces, dark-purple, adherent to diaphragm, acini not well marked, capsule easily
torn; two drachms and a half of pale Idle, with white liakes, in gall-bladder; spleen fourteen ounces and a half,
slate-colored exlerually, mulberry colored internally, softened. Stomach of a delicate i)ink color; duodenum anil
jejunum yellowish, mui'ous membrane tough ; ileum pink, much congested, .and solitary glands enlarged, especially in
the lower part. Large intestine greenish at the c;ecuni and rather pale in other parts, with hyperaiuic spots irregu-
larly distributed over the surface; solitary glands dotted with black pigment. — Ass't Siirij. Harrison Allen, V. S. J.,
Lincoln Hospital, IVashinijton, D. C.
Case 3i>3. — Elim Hess. Mo., guerilla; age 30: was admitted Nov. 2, 1864, with typhoid pneumonia: Tongue dry,
slightly furred and red, bowels regular, pulse 100; he had no cough or expectoration, nor did he complain of pain
or discomfort, but was so drowsy he could not be aroused, to give his history; the lower lobe of his right lung was
considered to be hepatized. During the last two or three days of life the bowels were tympanitic and tender. He
died December 2. Post-mortem examination two hours after death: Lower lobe of right lung hepatized; spleen
enlarged and softened; mesentery inllamed and glands much enlarged; solitary glands disorganized; bowels con-
gested.— Act. Ass't Sur<j. H. C. Xewkirk, llock Island Hospital, III.
(b.) Diagnosis: lihenmalism.
Ca.se 36^1. — Private Saletu Brocket, 1st Kans. Bat'y; age 16; admitted June 9, 18(>l. A liniment of fluid extract
of aconite, chloroform and tincture of camphor gave relief; but typhoid symploins supervened, with cough, pain in
the right side and expectoration of tenacious mucus; the stools were passed involuntarily. Pills of acetate of lead
and opium were given with carbonate of ammonia and brandy. He failed gradually, became delirious and died on
the 20th. Post-mortem examination: Lungs much congested, right partially adherent; pericardium containing two
ounces of serum; liver and spleen enlarged f lower ileum inflamed; kidneys nearly double the normal size. — Hospitiil
2fo. 8, Xashrille, Tenn.
Case 365. — Private Aaron Dudley, Co. E, 31st Me.; age 31; was admitted .lune 6, 1864, with rheumatism, and
died of ty]>hoid fevir .\ugust 8. Post-mortem examination twenty-four hours after death: Lungs congested poste-
riorly: liver nonnal : gall-bladder distended; kidneys much congested; spleen large and rather soft; intestines con-
gested in spots; ileum near the ileo-ca'cal valve much congested and preseuting many ecchymoses; mesenteric glands
very much enlarged. — Act. Ass't Surg. B. B. Miles, Jarvis Hospital, Baltimore, ild.
^D.) PeYER'S PATCHES VARIOUSLY STATED, BUT NOT ULCERATED — 12 CASES.
(a.) Pvyer's patches health;/.
Diagnosis: Intermittent.
Case 366. — Private Francis Bleakley, Co. E, 6th Pa. Heavy Art.; age 24; was admitted Oct. 10, 18(54, with inter-
mittent fever. He died November 14 of typhoid fever. Post-mortem examination thirty hours after death: Enuicia-
tion; bedsores and suggillation posteriorly. Kight lung normal anteriorly, congested ami indurated posteriorly,
spjenitied in a small portion of the lower lobe; left lung normal in its upper but congested in its lower lobe. Lower
ileum congested in patches, but Peyer's patches were healthy. Kidneys slightly congested; pancreas, liver and
spleen normal. — Act. Ass't Surg. Thomas Bowen, Second Division Hospital, Alexandria , t'a.
IHagnosis: Ptritonitis.
Case 367. — Private James Wynn, Co. D. 175tli P;i.; admitted .July 6, 1863, with fever and peritonitis. Died
7th. Post-mortem examination: Body not much em:iciated. Lungs and heart healthy. Liver large and mottled,
adherent to the diaphragm and intestines. The cavity of the abdomen contained much yellowish serum in which
414 POST-MOETEM RECORDS OF
flakes of yellowish lymph floated. The intestines were injected and interadherent by recent lymph ; the mesenteric
glands much enlarged aud the mesentery thickened; the ileum was slightly injected and presented in its lower
portion two perforating ulcers, one as large as a pea, the other the size of a ten-cent piece; Peyer's glands were
free from disease. — Act. Am't Surg. Lloyd Dorsey, Hartwood Hospital, Washington, D. C.
(b.) Peyer's patchen tliivkened and prominent.
Diaijnonis : Pericarditis.
Cask 3G8. — Hiram Bailey, colored; age 24; was admitted on the evening of Dec. 22, 1865, complaining of pain
in the stomach and bowels. He came to hospital on foot without apparent difficulty. A dose of opium, with ginger
and caijsicum, was administered and he rested well during the night. Next day cathartic pills were given, with castor
oil in the evening. On the 24th the patient had a copious stool, but in the meantime he had fallen into a lethargic con-
dition: eyes open and staring: pulse 80, weak: skin natural; head cool: mucous laUs heard over the large brouehi :
chest resonant; no swelling or teuderness of the abdomen. Quinine was given freely aud at short iuter\als, with
mustard to the spine, feet aud chest, but death took place on the morning of the 25tl^. Posl-mvrtcm examination
six hours after death: The brain was normal. The right pleural sac contained ten ounces of serum; the luugs were
nornuil but for the presence of a few scattered tubercles. The pericardiuui and heart were firuily adherent except
at a small space where was an ouuce of serum ; the heart substance was normal. The liver and spleen were somewhat
enlarged. In Ihi' ileum several of Peyer's patches were slightly elevated and (xuite dark, nearly black in color. The
other abdominal \ iscera were normal. — L'diirirliirc Eospital, Alexandria. Va.
Diaynosis: Pleurisy ,
C'a.se 309. — Private Charles A. Hoadley, Co. I, 3d Vt., was admitted Jan. 2, 1863, with pleurisy, aud died on the
8th. Post-mortem examination thirty -six hours after death: The brain weighed forty-seven ounces. The right lung
weighed fifty ounces ; between its lobes was a deposit of yellowish semi-organized fibrinous lymph ; posteriorly it was
consolidated aud in jiart hepatized, the consolidated portions being readily reduced to a pulp and exuding a reddish-
gray puruloid matter. The left lung weighed fifty-two ounces; its lower lobe and the lower and posterior portions
of its upper lobe were infiltrated with puruloid matter. The right auricle of the heart contained a fibrinous clot
which extended thmngh the ventricle into the pulmonary artery; the left cavities contained a black clot; about
the middle of the thoracic aorta were some transverse yellow bands which were supposed to l>e atheromatous. The
liver, sixty-nine ounces, was finely mottled aud of a light reddish-brown color; the spleen, nine ounces, was light-
colored, hardened iu small portions and softened near the hilus, whence a thick reddish puruloid matter was readily
pressed; the right kidney weighed seven ounces, the left six ounces aud a half. The stomach was softened and con-
gested; the jejunum was irregularly congested towards its termination; the ileum was very thin and there were
spots of intense congestimi in its middle third; Peyer's patches were enormously thickened, especially towards the
cieeum. — .IssH Siiri/. Georyc M. McGill. U. S. A., Lincoln Hospital, Washinyton, D. C.
Diiiynosis : Pneumonia.
Case 370. — Private John Mosner, Co. B, 149th N. Y., was admitted .Tan. 18, 1863, with typhoid pneumonia. The
patient was very deaf and almost unconscious; his skin was hot and dry, respiration hurried, tongue dry and pulse
95; there was dulness on percussion and line crepitation on the right side of the chest. He was ordered hlue-piJI,
ipecacuanha aiul tartaremetic in small doses with dry cups to the chest. On the 22d the tongue became dryer, the pulse
more rapid aud the expectoration bloody and of a dark color. Stimulauts and beef-essence were employed, witli a
blister to the right side, but they were unavailing; death took place on the 27tli. Post-mortem examination four hours
after death : Body finely developed. Tlie brain weighed forty-nine ounces and a half. The right lung weighed thirty-
two ounces aud a quarter, the left twenty-eight and a half; the right luug was much congested, the lower jiart of
its iqiiver lobe in the state of gray hepatization and parts of its lower lobe -in the state of red hepatization ;
the lobes of the left lung were interadherent, the lower congested and partly solidified; the broueliial glands were
large, soft ami black. The heart weighed nine ounces; there w;is much adipose tissue about the auriculo-ventricular
rings; the cavities on both sides contained small clots. The liver weighed eighty ounces, its acini were distinct;
the spleen weighed nine ounces aud a half; the right kidney eight ounces, the left seven and three-fiuarters. The
fundus of the stomach was extremely congested, as was the mucous membrane of the whole intestinal tract; in
the lower part of the large intestine the congestion was so inten.se as to resemble ecchymosis; the glands of Peyer
were large. — Ass't Siiry. George M. McGiU, U. S. A., Lincoln Hospital, ITasliington, D. C.
C'A.'iE 371. — Private John Beaton, Co. I), 1st Vt. Cav.; admitted Nov. 2, 1862, with typhoid pneuumuia: Hot dry
skin, pulse 85, comj>ressible, tougue coated with brown fur, moderate diarrhoea, sudamiua profusely distributed about
the neck and thorax, gurgling aud some tenderness iu the right iliac region, dry cough, severe dyspn(ea and almost
comjilete aphonia; dulness on })crcu,ssion and bronchial respiration over the lower portion of both lungs; no rose-
colored spots. Treatment: Sm;ill doses of calomel, ipecacuanha and opium; dry cups and turpentine stui>cs to the
chest; a mustard cataplasm to the abdomen. Died 5th. Post-mortem examination eighteen hours after death: The
lower portion of both lungs was hepatized. The heart, stomach, spleen, liver, kidneys aiul large intestine were nor-
mal. The glands of Peyer were enlarged aud iutlamed. — Third Dirision Hospital, Alexandria, Va.
Case 372.— Private Charles Whitten, Co. K, 20th Me.; age 16; was admitted Nov. 18, 1862, with typhoid pneu-
monia. He com])laincd of a dull pain below the right nipple ; his pulse was frequent and feeble ; his tongue covered
with a white fur; skin hot and dry; bowels constipated. There was dulness on percussion over the right side, and
crepitus was distinctly heard both anteriorly and posteriorly. Snuill doses of calomel, oiiiuni and ipecacuanlia were
given, with dry cups to the right side of the chest. Iu the progress of the case the cough became more troublesome
THE CONTINUED FEVERS. 415
and the rcspiratiiui huiiicd; diaiilma sHpiTvcncd. acouiiiiiaiiiiil by great tympanites of tlie abdonien: tlio ti)ii)j;ne
became dry and fissured and the lips and teeth covered with sordes. Stimulants were freely administered, but he
died on the 26th. Posl-miirlim e.\aniination: The surface of the liody was bluish from capillary coujiestion : the
abdomen tumid. The npjier lobes of both lungs were cou-jestedaud the lower lobes, with the middle lobe on the right
side, hepati/ed. The stomach and colon were innnensely distended with gas; the mucous nu>nibrane of the small
intestine was highly injected; the glands of Peyer enlarged. The liver, spleen and kidneys appeared to be normal.
— ThinI IHriniiiii Huspital, Alexandria, ('«.
(c.) I'tinr's pulilitx cunyented or iiijlamvd.
Diaynohin : Uluumathm.
Case 37:<.— Private .lames Makin, Co. H, 124th Pa.; age about 25: admitted Dec. 26, 1862. Died Kcl). 17, 1S63.
roal-miirUiii cNamination forly-dght minutes after death: Higor mortis marked; hypostasis general. Brain forty-
four ounces, light-colorcil, nujderately lirm. Pharynx purple, congested; tonsils yellow, enlarged to the size of an
almond. Higiil lung twenty ounces, left seventeen ami a half, congested; bronchial glands black. Heart eleven
ounies aud tlirce-i|uarlers; librinous clots in both sides extending into vessels. Liver sixty-eight ounces, light-col-
ored, linn; gall-blailder light-colored, containing seventeen drachms of watery bile; spleen seventeen ounces and a
ijuurter. soft, of a dark-purple color, intensely congested; pancreas three ounces and a half, dark-colored, slightly
ciuigested. Duodenum slightly congested, stained with bile, valvul;e thinned; jejunum light brownish-yellow,
thinned in lower two-thirds, solitary glands slightly enlarged in u])per third; ileum thinned, solitary glands some-
what enlarged and Peyer's patches in upper third slightly congcsti'd ; large intestine generally congested. Supra-
renal capsules light-colored, soft, decidedly fatty; right kidney six ounces and a quarter, left six and three-(|narter8,
somewhat congested. — Jss't Siiry. Ginrijr M. McCill. f. 5. .1.. Umiilii Hospital, IVashinijIoii, I). V.
Diatjnosis : Diarrhoea.
Cask 374. — Private Cyrus (;. t'liattcrton, Co. C, 24th N. Y. Cav., was admitted .July 24, 1864. lie was greatly
emaciated, having sulVcred from diarrhu'a for some time. The stools were frc(iuent, iiuitc watery, clay-coloreil and
at'companied with griping pains in the abdomen; he had no appetite; his tongues was red and hail marked eleva-
tions of the papiike; pulse UIO and very weak. In a few days the p:issages became less fre(iuenl aud of a dark-green
cidor, but although thus improving he continueii depressed in mind. On August ;i the right side of the face became
much swidleu and the gums swollen and red but not bleeding, the general appearanc-e of the patient being scorbutic.
Chlorate of potash was given internally and as a wash. Next day he had much difficulty in opening his mouth,
and complained of sore throat; the fauces becanu' much inflamed, the tonsils covered with ]iseudo-nu'mbrane, por-
tions of which were expectorated, and nnicous rales were developed in the chest. He died on the 6th. PoH-
iHorliiii examination: Hody very much emaciated. The larynx and fauces were covered with |)atches of false mem-
brane. The right lung was slightly adherent; the left lung and Iw.urt normal. The liver was normal: the spleen
measured five inches and a half by four inches; the right kidney was seven inches and a half long, its substanc<! lirm
aud healthy: the left kidney ami suprarenal capsule were absent, their place being occupied by a closed cyst, one
inch and a half long, in which no kidney structure could be detected. Peyer"s patches were much inllaiiiiMl: the
mesenteric glands healthy. — Act. Ans't Siiry. E. Dariil, Fairfax Si.minarij Hospital, Va.
Case 375.— Private Elias Zimmerman, Co. D, 48th Pa.; age 18; admitted July 24, 1861, fnim City Point hos-
pital, Va. Died August 5. Potil-mortrin examination: Body much emaciated. Peyer's patches inllamed: solitary
follicles extensively ulcerated. Other organs normal. — Act. Aas't Siinj. G. H'. Peer, Fairfax Siniinurij Hospital, J'a.
C.^.sB 376.— Private Franklin Dougherty, Co. D, 100th Pa.; age 18; admitted July 5, 1864, with chronic rheu-
matism and diarrhoea. He was considerably emaciated, had anorexia and severe diarrluca, with pulse weak and
frei|uent and tongue coated in the centre with a thick gray fur; the left parotid was painful and much swollen.
The parotid abscess was opened on the 15th and a snnill (luantity of dark fetid pus was obtained; meanwhile the
diarrhiea persisted and the patient seemed to be sinking gradually; he had a slight remission of fever in the fore-
noon of every day. In thi^ progress of the case the integuments covering the parotid sloughed, delirium set in, at
tirst chiclly at night, his face became more flushed and the daily remissions less marked. He died on the 22d. Posl-
morttm examination six hours after death: Body greatly enuiciated, rigor mortis well marked. Lungs nun-li con-
gested, heart pale and flabby. Liver slightly congested ; gall-bladder distended with bile ; spleen enlarged and pale;
kidneys healthy. Stomach reddened in patches, which were more numerous near the pylorus: duodenum and jeju-
nnin healthy; Peyer's glands congested slightly in the upper portion of the ileum and the solitary follicles in the
jower portion considerably enlarged, many having incipient ulcers on their sunmiits. Mucous membrane of the
large intestine i>uckered, softened and presenting several small ulcers in the cacum and in the lower portion of the
descending cidon. ri)i)er portion of left parotid gland expo-sed by sloughing of integument and siipcrlicial fascia;
dark fetiil pus had burrowed a short distance down the side of the neck. ISjxvimciis 385 to 390, Med. Sect., Army
Medical Museum, are from this case.] — Act. Aas't Surg. 0. P. Sweet, Carver Hospital, fVashington, JJ. C.
Xo diagnosis : Heath from heart-clot.
Case 377.— Private Nicholas Sassaman, Co. E, .')llth Pa., was admitted Oct. 11, 1861, at nixni. Mis i)ulse wa:i
weak and intermittent, breathing hurried, difficult and mainly abdominal; his extremities were cold and he ctr.ii-
plaincd of severe pain over the pra^cordia and epigastrium. In the evening two wet cups were applied over c :ch
lung, after which he arose from bed and walked to the chair to stool: he expired as ho sat down. PoHl-morlim
examination ten hours after death: Body well developed and not emaciated; rigor mortis strongly marked. There
were old pleuritic adhesions on the right side; the lower lobe of the lung was congested, the upper contained
416 POST-MORTEM KECOBDS OF
tubercles; tbe left luug was Uealthy. The heart weighed twelve ounces aud a half; fibrinous clots were found in
the rifht ventricle, the walls of which were hypertrophied ; the mitral valve was thickened and its right segment
studded on the margin with roundish fibrinous bodies, some about the size of a pin-head, others as large as a pea.
The liver was enlarged and fatty; the spleen was triple its normal size and mottled with spots surrounded by red-
dish areola', exuding on section a sero-purulent liquid; tbe kidneys were enlarged and fatty. Peyer's patches were
inflamed and the mesenteric glands enhuged.— Armory Sciuure HoapUal, Washington, D. C.
Of the above seventy-nine cases, forty-two in which Peyer's patches were ulcerated,
and twenty-one in which the ileum was ulcerated, may be set aside as being distinctly or
probably cases of typhoid fever. In four, 362-365, of the remaining sixteen the intes-
tinal lining was congested or inflamed. It is not stated that the membrane was not ulcer-
ated or that Peyer's patches were not affected; for these pos^-mor^em records seldom embody
neo-ative evidence in terms so positive. It must be inferred that if tlie membrane had been
ulcerated the inquirer who noted its ecchymosed condition would have observed its ulcer-
ation, and that had the agminated glands been implicated the anatomist who took note of
the enlarged, pigmented and disorganized condition of the solitary follicles would not have
overlooked the condition of the others, particularly in cases in which typhoid fever was iu
question. Now, as there was no post-rnortevi evidence of typhoid fever in these cases, the
change in the diagnosis must have been occasioned by the occurrence of typhoid symp-
toiiis, i. c, in these cases typhoid symptoms were present although typhoid fever was not.
Of the remaining twelve cases five, 368-372, presented appearances of the patches consistent
with the theory of death at an early period of the progress of typhoid fever; but in the
others the presence of that fever cannot be considered established ; In 366 and 367 Peyer's
glands were healthy. In 373-377 they are said to have been congested or inflamed, but
this condition alone may not be accepted as pathognomonic of typhoid, since in 376 the
ulceration of the solitary follicles, with whicli it was associated, while giving assurance that
had the patches been ulcerated their condition would liave been stated, indicates that the
patient had lived long enough for this change to have taken place; indeed tlie prolonged
duration of the fatal illness is sufficiently attested by the disorganization of the parotid
glands. But for the congestion of the agminated glands the case of death from heart-clot,
377, would have found place in the malarial series in company with its cases 95 and 96.
In the absence of clinical histories it is impossible in many cases of the above series
to say whether the change in the diagnosis was based on clinical or post-mortem consid-
erations. It is certain, however, that in sixty-eight of the seventy-nine cases the post-
mortem lesions authorized the change, while in eleven their testimony was less positive.
In some of the latter clinical observation must have suggested the presence of typhoid
fever, as the intestinal appearances were inadequate to sustain the diagnosis, but in others
the presence of typhoid seems to have been based on a mistaken view of the import of
these appearances.
A few cases illustrative of accidents in the course of typhoid fever or morbid condi-
tions following it complete tlie post-mortem records of cases reported under this heading;
but from the condition of the intestines in some of these cases it is doubtful if typlioid
was the antecedent fever.
Case 378. — Lanibricoid worm in larynx. — Private Joseph Shuman, Co. M, 1st N. J. Cav.; age 17; was admittpd
Jan. 16, 1864, with ty|iboid fever. The patient was doing very well under tonics and stimulants when, on the IStli.
he suddenly died asphyxiated. At the autopsy a lumbricoid worm nine Indies long was found extending from tlie
trachea into the right bronchus. — [See specimen 2!I0, Med. Sect., Army Medical Jlnscuiu.] — .lc(. Ais'l Sim/. .S. />'. IViird,
Third Dieinion HonpHat, Alcxtitidriu, I'a.
Case 379. — Snddcn dmlh during conralciiccncc ; heart-clot; cerehriil conrjcition. — Private James F. Wilson, Co. C,
16th Me.; age 21; was admitted Feb. 8, 1865, convalescing from typhoid fever. He had a slight cough, but was
THE CONTINUED FEVERS. 417
otherwiso well and contiiiucil to ;;aiii streufrtli until the 24tli. At 3 a. m. on this day the must', in iiassiii-; throujjh
tlu' ward, found him awakf. jiut tlic hhinketsovi r hiniand gavo him some water to drink. He was then well. Three
hours later he wa.s found dead, having apparently died without a struggle, rnxt-morlrm examination: No lividity
about the faee; pnpil.s dilated; rigor mortis well marked on the right side, slight on the left. A eonsiderahle quan-
tity of venous hlood eseaped on opening the cranium; some exudation was found on the arachnoid; the suhstanco
of the ccrehruni and cerebellum was highly engorged, and bright blood welled np in unn.sual quantities when sec-
tions were made; the lateral ventricles were distended with a sero-sauguineous liquid. The lower lolie of the right
lung was engorged. The right ventricle contained a large (ilmuous clot. There were no other unusual appear-
ances.— Act. Jss'f Surg. H'. iiempata; ratttmon Park Hospital, Baltimore, J/rf.
C.\SE 380. — DestructircinJIammation of lunijs. — Private Richard H. Nelsou, Co. A, 8th Mich., was admitted Dec.
30, 1862, with typhoid fever. On Jan. 24, 18(53, he appeared to be couvaleseeut and was walking about the ward, com-
plaining occasionally, however, of pain in the right side of the chest. On February IS he had headache, slight irrita-
tion of the fauces, constipation, difliculty of micturition and severe pain in the right side of the chest. He was ordered
to bed. a laxative administered and warm fouu'utations applied to the chest. Next day, feeling better, ho got nji and
went out of doors, after which the pain in the side returned and he began to cough and expectorate a muco-iiurulcnt
matter. His cheeks were llushed, pulse 120, respiration 22; a friction sound with sibilant rales was heard over the
lateral portion of the right lung; the resi)iratory murmur was absent in front.' On the22d beseemed much improved;
the pain was not so severe; his appetite was good and bowels regular, but the expectoration remained copious. Two
days later he had chills followed by fever and increasing prostration. He died March 8. roat-murtcm examination
twenty-eight hours after death: Body slightly rigid, not emaciated; apparent age 21 years. The brain was healthy.
There was a white fibrinous clot in the right side of the heart extending into the pulmonary artery, and a small white
clot with 8<uue dark blood iu the left side. The right lung weighed thirty-four ounces and a half; it was congested
generally and consolidated on the posterior and inner part of its lower lobe; its bronchial tubes, especially those
proceeding from the consolidated portions, were somewhat congested and contained a puruloid nuitter; its anterior
surface was co:ited with a thick layer of fibrinous lymph and the pleural sac contained sixteen ounces of pus. The
left lung weighed twenty -seven ounces; portions of it were carnified; its bronchial tubes were congested and con-
tained a purulent matter; the pleural cavity was sacculated and contained twenty-two ounces of straw-colored serum.
The liver was firm, coarsely mottled, of a light reddish-brown externally and covered with numerous blood-sj)ots ;
on section it was slate-eolored; the gall-bladder was empty. The spleen, twenty ounces and three-quarters, was of
firm consistence, dark-purple in color and with prominent trabecuhe; in its inferior border was a hard nodule about
the size of a hazel-nut. The pancreas was firm and of a light-straw color. The kidneys were of a purplish-slate
color; the suprarenal capsules firm, large and of a reddish-ash color. The mesenteric glands were much enlarged.
The stomach was softened and congested along the longitudinal' folds and in the lesser curvature; the duodenum
and jejunum were irregularly congested; the ileum decidedly congested; Peyer's patches Apparently healthy; the
solitary glands slightly enlarged and congested. The ascending colon and ciecum were dilated, their nmeous mem-
brane thin and soft; the transverse colon was somewhat contracted and covered with black specks; the sigmoid
llexure congested; the rectum normal. — Jss'i Surg. George M. McOiU, U. S. A., Lincoln Hospital, Washington, D. C.
C.VSE 381. — Inflammation of the parotid; paralysis and hypera'sthesia of the limbs. — Private John Parker, Co. B, 3d
Ohio Cav., was admitted March 4, 18(U, as a convalescent from typhoid fever. His tongue was very much coated
and the parotid gland was slightly swollen. In a few days the swelling had almost disappeared but he continued
feeble, lost the use of his arms and legs and complained when they were touched; this sensitiveness was especially
marked in the right arm and left leg. Diarrhiea set in on the 11th, when his tongue became dry and pulse snudl;
death took jdace on the 13th. I'ost-mortem examination eighteen hours after death: Body not much emaciated. The
lungs, heart, stomach and intestines appeared to be healthy. The liver was pale, much enlarged, and showed evi.
denee of a local peritonitis; its right lobe was congested; the galf-bladder was empty. Both kidneys were much
cougestetL — .let. Ass't Surg. L. A. Walton, Hospital Xo. 8, Xashiille, Tenn.
C.\SE 382. — Psoas abscess. — Private S. E. Robinson, Co. A, 3d Md.; ago 26; was admitted from Patterson Park
hospital Sept. 21, 1864, as a convalescent from typhoid fever. On the 28th he had a chill and two days later there
was pain iu the upper part of the right thigh, where redness, swelling and fluctuation were observed. On October 1
llatus and fa-eal matter were brought away by an exi)loring needle, and the case was regarded as one of typhlitis
with perforation and adhesion of the bowel to the abdominal walls. A free incision was made and a considerable
quantity of pus escaped mixed with fu'cal matter. The patient became delirious on the 4th and had obstinate hic-
cough. He died on the 6th, after having been unconscious for thirty-six hours. Post-mortem examination: A largo
psoas abscess had dissected the muscles of the thigh as far as the middle third. "No perforation of the bowel was
iliscovered, so that what was supposed to have been f;ccal matter must have been altered pus. It is but right, how-
ever, to state that several medical men present at the time concurred iu the opinion then formed." [The condition of
the nmeous membrane of the intestine was not recorded.] — Mower Hospital, Philadelphia, Pa.
Case 383. — Purulent collections. — Private J. W. Cunningham, Co. 1, 170th Ohio; age 26; was admitted from hos-
pital, Frederick, Md., Aug. 7, 1864; diarrhea following typhoid fever. He died September 8. Post-mortem examina-
tion twenty-four hours after death: Abscesses were found under the right arm, on the anterior aspect of the right
forearm and on the dorsum of the left foot. Both lungs contained abscesses; the lower lobe of the left lung was one
immense cavity which had opened into the pleural sac, filling its lower half with pus, but adhesions of the parietal
and pulmonary pleune around the upper part of the lobe separated this purulent collection from the ui>per half
of the pleura; on the right side the abscess under the arm communicated freely with the pleural cavity, which
Med. His., Pt. Ill— 53
418 POST-MORTEM RECORDS OF
■was filled with pus. Tlie pericariliuni was ilistended -with serum. The liver was ijonual; the gall-blader distended.
— Act. Am't Surfi. B. B. Miles, Jarvis Hospital, Baltimore, Md.
Case 384, — ViiMluTia and inflammation of the suhmaxillar)/ tjland. — Private Charles Williams, Co. F, .52d Pa.;
age 21; was admitted Sept. 22, 1864, with typhoid pneumouia. He was recovering from au attack of typhoid fever
and was thin and broken down ; his skin presented a peculiar bronzed appearance in spots, from which the epider-
mis was easily peeled off, leaving an abnormally white surface beneath; he suffered considerably from diarrhoea.
There was duluess on percussion and an absence of the respiratory murmur over the base of the right Inug, with
slight nocturnal cough. His condition did not change much until the middle of November, when he had an attack
of diphtheria, followed, after a few days, by inflammation of the left submaxillary gland, ivhich sui>purated and was
opened about December 1. On the tith he complained of cough, difficult expectoration and constant pain through
the lower part of both lungs, with occasional i)aroxysms of pain of a more lancinating character. There was dulness
on percussion and bronchitic rales at the base of both lungs with friction sounds superadded ; these signs afterwards
gave place to blowing respiration with entire absence of the vesicular niurnuir, and finally to loose mucous and sub-
mucous r;"iles. He died December 24. Post-mortem examination: Both lungs were bound to the thoracic parietes by
extensive and firm adhesions ; the lower portion of each lung was in a state of gray hepatization. [There is no record
of the condition of the intestinal mucous membrane.] — ('iii/ler Hospital, I'liihidelpliia, Pa.
Of tlie fevers reported as typhus the recorcls furnish but five cases in which the post-
mortem appearances are described. In one of these, 385, extensive disease of the agmin-
ated glands sufficiently indicates its typhoid character. Case 386 appears to have been an
exatnple of pernicious malarial fever, for although the disease had lasted some time, most of
the patches were healthy, a few only being inflamed and somewhat thickened and none
ulcerated, while the large intestine was ecchymosed and ulcerated. Case 387, with its prom-
inent and pigmented solitary glands, was apparently of a similar nature. Many cases pre-
senting intestinal lesions of this character have already been noted as referable to the
malarial rather than to the typhoid influence. From the necroscopic appearances 388 seems
related to the suddenly fatal cases which were reported as cerebro-spinal meningitis.* Case
389 is the only instance in which the •post-mortem lesions, so far as determined, were con-
sistent with the diagnosis, and as the case occurred in the city of Philadelphia, it is proba-
ble that it is the representative of that veritable typhus which occurred among soldiers
exposed to circumscribed foci of infection during a temporary residence in the large cities.
Ca.sb 385. — Private Burton White, Co. E, 147th N. Y., was admitteil April 22, 1863, with an incised wound of
the right leg. He died May 26, of pueunujnia supervening on an obscure disease resembling typhus. Post-mortem
examination: Body plumji and full; depending parts dark-oolored. The adjoining halves of the lower and middle
lobes of the right Inng were infiltrated with pus. The lower part of the ileum was extensively ulcerated in patches,
in one of which was a small perforation closed by adhesion to the peritoneum covering the bladder ; there had
been no escape of intestinal contents and there was no indication of peritonitis. The sjileen and the mesenteric
glands were enlarged and softened. {^Specimens 180 to 183, Med. Sect., Army Medical Museum, are from this case:
see also plate facing this page.] — Sury. Thomas B. Crosby, U. S. V., Columhian Hospital, Washiuijton, D. C.
Case 386.— Private Charles B. Dorr, Co. B, 17th U. S. Inf.; admitted Aug. 10, 1862, from the Army of thc^ Potomac.
Typhus fcvor. Died 22d. Post-mortem examination: Age about 22 years; body moderately emaciated and with dif-
fn.sed ecchymoses on the skin of the trunk; the muscles were of their ordinary character, but the viscera of the
chest and abdomen were generally softer than usual. The lungs and heart were normal except that there were two
ecchymosed spots about a quarter of an inch in diameter near the base of the latter. The blood presented nothing
unusual. The liver and spleen were natural. The mucous membrane of the stomach was inflamed near the pylorus
and jiresented a number of small ulcers, about a line in diameter, along the lesser curvature. ISjiceimeii 272, Med. Sect.,
Army Medical Museum.] The ileum was inflamed in patches, some of which were intensely affected; the solitary
glands were enlarged and inflamed; most of the agniinated glands were healthy, some were inflamed and slightly
thickened, but none were ulcerated. [Specimens 273-276.] The mucous membrane of the colon was more or less slate-
colored, with patches of inflammation, a number of ecchymoses about half an inch in diameter, and in the descending
portion a number of stellate, blackened ulcers. — Act. Ass^t Surg. J. Ltidtj, Salterlcc Hospital, Philadelphia, Pa.
Case 387. — Private John Mills, Co. C, 43d N. Y.; vigorous looking, but somewhat emaciated; admitted Aug.
10, 1862. Died 14th. [Case supposed by Dr. Atlee, the attending physician, to be typhus.] Post-mortem examina-
tion next day: The skin of the front and sides of the chest and abdomen was slightly ecchymosed. The lower lobe
of the left lung was aftected with recent pleuropneumonia; the upper lolie was inflamed; the right lung was some-
what congested. The heart, stomach and spleen were natural, and the liver exhibited a healthy color and texture,
but presented an unusually lobular appearance (as in the rat). The mucous membrane of the small intestine was of
See infra, p. 552 et Beg.
TIIK (■O.NTlM.I-:it KKVKKS. 419
ii iiiiikish-croam color and tinijoil nitli liilc; the solitary ;;laiiils of lln> jcjniiniri wcri^ opai|iii'-wliit(i anil those of tllc^
ileum iinusiiall.v proniiin-nt and dotted with Maek lugnienl ; the ajjniinated j;land» were sli]ij;lilly thieker than nsnal
liiit iliil not ajipear positively diseased. The colon was much contracted and its mucous menilirane slifjlilly inflamed ;
the solitary glands wcro iar-jo and prominent, especially in the ca'cuni, and were niarkid liy a deposit of black pi;^-
nient. — Act. AssH Surg. J. LeUhj, Saltcrlec Hospital, ■rhila(kl}>hia , I'a.
Case 38X. — .JiTemiali Saulsluirg, a colored soldier, died of tyjihns Jan. 21, ISlil. ront-morlmii examination
ei);lit hours after death: liody stout and well developed. There were well-nuirked dejiosils of viscul pns lietwcien
the eoMV<dntions of (he frontal lolies and of the parietal lolies near the lon;;itn(lin.il lissure, as also over the ]>oiis
inednlla and crura ; a mass of pus overlaid the anterior corpora (luadrijjjeniina, and th(^ mcnilirane covering them was
finely injected ; tlu' suhslanco of the brain was gorged with blood, liut the choroid ple.xus was jiale anil the ventricles
not enlarged although containing some etiusion. The pericardium was full of serum and the right cavities of the
li<>art ciuilained tibrinons clots. The lower lobe of the left Iniig was congested by hypostasis, but thi're wore also
some sjMits of proper hepatization. The liver was darker than usual and full of blood. The colon and ileum were
inflated. (There had been strabismus during the last three or four days of this patient's life.)— .Jcf. JshH Surg. W. C.
Minor, Knight Gciurtil Jlonpital.
Ca.'sk 389.— Private William W.Fcnno, Co. K, l_l.">th I'a.: age lit; was admitted 1)<>(-. IM, 1802, with chronic rheii-
niati.sni and debility, and so far recovered as to be able for guard duty; but on Feb. 17, 18(1M, he was taken with diar-
rho'a and next day he had a high fever, (|uick breathing, tremulous voice and a dark furred tongue. lOth : Diag-
nosis-typhus fever; ilyspmea greatly increased; diarrlnea alnuist ceased; stupid, but could be aroused by a loud
voice; aliilomcn tympanitic: capillary circulation feeble; no eruption. 20lh: Suppression of urine. 1.30 r. M.,
vomited a large Innibricoiil worm and other matters; restless delirium alternating with connito.se quiet. Died at
1 V. M. ro.ft-mnrlim examination : Suggillation distinct ; no vibices; petechia" over epigastrium, stated by the nurse
to haveexisted during life. Urain not examined. Lungs congested posteriorly. Left ventricle of heart filled with
black fluid blood; right containing two fibrinous clots. Liver largo but lualthy; spleen much enlarged an<I lolm-
Inted; kidneys and intestines healthy.— Cuj/itr Hospital, riiilmMphiu, I'u.
v.— ON thp: pathological anatomy and pathology of the
CONTINUED FEYERS.
I.— THE CASES AND THEIR ANALYSIS.
Tlircc hundred and eighty-nine cases from the post-mortem record.s liavc been sub-
mitted. These were regarded by the medical officers in attendance as fatal instances of
continued fever. They have been presented as —
1st. Fifty cases, 1-.50, presumed from their symptoms to have been unmodified typhoid;
2d. Sixtji-xix cases, 51-llti, of an adynamic continued fever, which might from the syulptoms or diagnosis have
liecn individually either cases of modified typhoid or of adynamic malarial fever;
3d. Two hnndicd and xirlij-eight cases, 117-384, of fever which, although reported as typhoid, might individually
have been typhoid, tj-pho-malarial or adynauiic malarial, in view of the uncertainty attaching to thi^ diagnosis;
4th. I'ire cases, 38.5-389, reported as typhus, but which, in liko manner, might have been due to other perni-
cious caases than the typhus or the typhoid poison.
The study of the intestinal lesions, as conducted in the last section, has modified ante-
raortera views as to tlie relationship of these cases one to the other, and rendered a rear-
rangement advisable to facilitate further investigation into their pathological anatomy.
Tlie diagnosis of the fifty cases presumed to Ije unnuidifiod typhoid was confirmed by the
evidence of the agminated glands or by such conditions of the ileum as were suggestive of
a glandular involvement. The sixty-six continued febrile cases of an adynamic or tvphoid
type consisted oi forty -six in which the lesions of typhoid were associated with malarial
.symptoms and of twenty in which the absence of these lesions indicated the malarial influ-
ence as the sole cause of the morbid phenomena. The two hundred and sixty-eight cases
of reported typhoid comprised ^/"fee/i cases in which \\\e post-mortem appearances testified
that some febrile cause, which from its symptoms was of a malarial nature, had preceded
the onset of a typhoid attack, forty-one in which typhoid lesions were not discovered,
420 PATHOLOGICAL ANATOMY AND PATHOLOGY
and two hundred and tivelve in wliicli tliese lesions were present or sucli ulceration of the
small intestine as might be attributed to either typhoid fever alone or to typhoid as modi-
fied by the concurrence of malarial fever, thus constituting a mixed series of typhoid and
typho-malarial cases. The five cases reported as typhus were similarly found to consist of
one typlioid case, two malarial cases, one case related to cerebro-spinal fever and one of
probably true typhus.
Aggregating these in accordance with clinical history, diagnosis and intestinal lesions,
there appear —
Fiftjl cases of unmodified typhoid, cases 1-50;
Sixty-three cases of malarial fever with typhoid or adynamic symptoms but without typhoid lesions, cases
70-73, 70, 7«-81, 84, 87-91, 104, 105, 108, 113, 115, 246-252, 254-263, 274, 276-278, 287-295, 362-367, 373-377, 386 and 387;*
Sixiy-om: cases of true typho-malarial fever, cases 51-69, 74, 75, 77, 82, 83, 85, 86, 92-103, 106, 107, 109-112, 114,
116, 264-273, 280, 285 and 296-298 ;t
Two hundrecl and thirtcoi casesof a mixed class, consisting chiefly of typho-malarial fever, liut i>rolial)ly containing
some instances of typhoid alone and of malarial fever alone, cases 117-245, 253, 275, 279, 281-284, 286, 299-361, 368-
372, 378-384 and 385;
One case of cerebro-siiiual fever, (?) case 388;
One case of typhus, (?) case 389.
The results of an analysis of the post-inortem appearances in these cases is herewith
submitted; and, to admit of a comparison between the anatomical details of the tyjjhoid cases
of the war and those of civil life, a summary of the lesions in the cases so carefully observed
by Louis is given below. J
Analysis of the Post-moktkm Appearances.
The Saliv.vky Glands. — In but one of the continued febrile cases was mention made of an inflamed condition
of the submaxillary or sublingual glands, but a destructive inflammation occurred with some frequency in the parotid
region. It was present in sixteen of the recorded cases; in six the glands were swollen and indurated and in leu
destroyed by suppuration. In three cases the morbid action affected both sides, while in thirteen it was confined to
one side; the right gland was involved in five cases, the left in three; in five the record does not specify the side.
Parotid abscess occurred in but one case, 31, of the fifty typhoid cases ; one side only was affected. In 258 of the
malarial series the right parotid was swollen, and in three cases abscess was formed, — on the right side in 251, on the
left in 376 and on both sides in 263. Parotitis occurred in four of the typho-malarial series: In 53 on one side and in 65
and 97 on the right side ; suppuration was present on one side, in 103. In the mixed series of cases swelling existed in
two cases and suppuration in five: The swelling in 118 and 381 does not appear to have culmimited in abscess;
the right gland suppurated in 125; the left in 193 and 338, and both glands in 222 and 348. Suppuration occurred in
the submaxillary glands in case 384 of this series.
The condition of the phauynx and a;soriiAGUS appears to have been seldom observed by our medical officers.
The mucous meml)rane. was reported ]iale in case 23 of the typhoid series. It presented morbid appearances in six
of the malarial cases, — pnri)li8h coloration in 90 and 277, deep congestion in 373, erosion without accompanying con-
*To these might with propriety he added certain cases reported as typho-malarial fever by the attending officers, but submitted in the second
part of this work as cases of diarrhtra and dysentery. Thus, in case 313, entered as typlio-malarial fever, the small intestine was found healthy; in 3G3,
reported as typhoid-remittent fever, the duodenum was of a dark-purple color, but the remainder of the small intestine was healthy except near the
valve, where were many small circular superficial ulcere, the solitary glands being prominent and the patches of Peyer pale but neither ulcerated nor
elevated ; in 518, reported typho-malarial, the mucous membrane of the ileum was somewhat inflamed ; in 832, at first regarded as rc^mittent fever and
afterwards .a.s typhoid dysentery, the ileum w.is congested and studded with small ulcerations, whilo the large intestine w.as more extensively ulcerated
and almost gangrenous. Perliaits also case 783 should be added to these, as the patient had an adynamic fever from the time he entered the hospital,
yet posl-morrcm investigation showed the small intestine to be in a healthy condition. In fact many cases of the diarrhceal series, in which the typhoid
tesion was not found after death, presented more or less of a clinical resemblance to typhoid fever.
■f-To these might be added the case submitted in the second part of this work jis 825 of the diarrbccal series ; the diagnosis was typho-malarial
fever, and pi)st-morlt)ii examination revealed the ileum and colon studded with ulceration. Perhaps 430, presenting fever of an adynamic type, with
hemorrhage from tlie bowels, and showing at the autopsy the small intestine ulcerated in patches and the large intestine perforated, may also have been
a true typho-malarial case. For a discussion of the connection between the diarrhceal cases and the continued fevers, see itifni, p. 615 et seq.
J The following abstract of the post-mortcyn a]ipeiirances found by Lotus in his forty-six cases may be of interest in connection with the lesions
observed in the fifty typhoid cases of the te.xt :
The SALIVARY GI.ANDS. — The submaxillary and sublingual glands were not altered in any of the cases ; but in two there was suppuration in the
parotid region, due in one instance to inflammativu of the surrounding cellular tissue and in the other to inflammation of the glandular structure.
The PHARYNX was affected in eight cases ; ulcerated in six and covered with false membranes associated with purulent infiltration of the suli-
mucous cellular tissue in two. The ulcerations were few, three to eight lines in their greatest, the vertical, diameter and situated on tlie lower and
lateiul aspects of the sac. As no such ulceration was found in seventy cases of other acute diseases, Louis considered it an important lesion and one of
the seconiPary anatomical characteristics of the typhoid affection.
The onsopHAGUs was ulcerated in seven cases, only two of which were included among those having the pharynx affected. The ulcers, when few,
were situated near the cardia, when numerous they extended throughout the whole of the tube, hut were more frequent and larger towards the lower end.
Lot«s associated these ulcers with those of the pharynx as peculiar to typhoid fever.
OF THE CONTINUED FEVERS. 421
f
gestion in 259, softenins and deinulatiou in 71, and diphtheritic exudation in 371. In tlio lypho-malarUil series a
morbid condition is mentioned in but three instances: In 65 the mucous membrane was intlamed; in 54 inflamed and
ulcerated: In 67 abscesses were found on the left side in front of the hyoid bone. In the mixed series morbid appear-
ances were noted In twelve instances: The esophageal lining was of a pale color and ulcerated in its lower part in
l,i7 and 187, while in the same region in 301 it presented dark-colored spots, one of which was eroded; it was con-
gested in longitudinal streaks in 305; inllauu-d. ]iuri)lish. and in its lower part ecchymosed in 329; in 156 the mso-
phagiis was of a puqtle or broAvn color and its walls containeil an abscess as large as a chestnut, and in 185 there was
an ulceration on its posterior wall on a level with the larynx, while the tube below was filled with a whitish exuda-
tion; in 155, 199 and 304 the mucous membrane was yellowish iiud in 1S3 purple; in 338 the pharyngeal coats were
|ierforated by matter from the parotid region.
The STOMACU was normal in four of the typhoid cases, 11, 27. 35 and 36, and in one, 16, it was not examined,
of twelve cases in which a morbid change was reported its mucous membrane in 24, 26, 29, 41 and 47 was reddened
from congestion; in 9 the congestion was in circamsorilied patches; in 8 the fundus, which was of a dull-red color,
contained five lumbrieoid worms; in 21 the mucous nu'mbrane was pale and thickened; in 22 slaty and mottled; in
23 mottled, congested and blackened from pigmentary deposits near the pylorus: in 48 thickened and softened, and
in 31 thickened and congested, the viscns containing about a pint of an oflensive yellow li<iaid. Of the sixty-three
iiKifrtriti/ cases the condition of the stomach was not stated in tliirty-fonr, and in the remaining twenty-nine it wao
nonual in fourteen, congested in six, thickened ami softened in three, inflamed on its peritoneal surface in 249 and
along the great curvature in 91; ulcerated along the small curvature in 386; flaccid, thin and greatly discolored in
287: ecchymosed but nncongested in 262. and in 71 the organ contained a pint of dark-colored liquid in which floated
shreds of its disintegrated mucous membrane Of the I i/pho-malarial scrica the condition of the stomach was mentioned
in sixteen cases: It was normal in six, congested ui two, 103 and 296; softened in two, 98 and 112, in the former of
which the lining membrane was almost disintegrated; in 93 it was unusually corrugated; in ()5 and 116 inflamed; in
96 it presented black p;itches and was ulcerated near the pylorus ; in 62 it was filled with dark grumous blood, and in
106, in which death resulted from periionitis, it contained fa'cal matter. In the mixed series of cases the state of the
Stomach was mentioned" seventy-four tinu>s: In thirty-three it was normal, but in one of these, 325, it contained a
gmmons liquid: in four it was merely distended. Of the remaining thirty-seven cases its mucous nu»mbrane was
con<'ested and more or less softened in sixteen; softened in four, to pultaceousness in 213: injected in five; inflamed
in six, in one of which, 354, there was ulceration, and in another, 239, the viscns contained matter like coft'ee-grounds;
grayish, slate-colored or marbled in three: ecchymosed in one, 342; in 191 the stomach was filled with bile and in 156
with a liquid of a greenish color and fa>cal-like odor.
The DConEXUM was distended in case 5 of the typhoid series, normal in 26, filled with thick tenacious mncns
in 23 and undergoing putrefactive changes in 22; its mucous membrane was congested or inflamed in 17, 18, 29 and
50, softened and thickened in 48; in 41 its glands were enlarged ai»d in 9 congested Morbid changes were defined
in four of the malarial series: In 87 the glands of Briinner were enlarged; in 276 and 373 the lining nuMubraue was
congested and in 71 disintegrated ; but in other instances, as 81, 113 and 259, a congested or uiflanied condition of the
dnodenum may be inferred. Ten observations were recorded in precise terms or by inference in the typho-malni-ial
aeries: In four a normal condition was indicated: in 269 the glands were enlarged; in .53 there was follicular inflam-
mation with softening; in 86 the lining membrane was dark-colored and congested; in 65 and 116 inflamed and in 96
ulcerated. Twenty-six observations were noted in the mixed series of cases: In ten a healthy condition was stated;
in four the glands alone were mentioned, enlarged in 122 and 281, inflamed in 284 and ulcerated in 307; in nine, 181,
182, 190. 279. 317, 318, 354, 370 and 380 the mucous membrane was congested; in one, 243, pultaceous; and in two, 156
and 3;{8, dark-colored.
The JEJTNUM was distended in case 5 of the typhoid series; normal m 10 and 26 and probably also in 23.
In 17, 18, 29, 47 and 50 it was more or less congested; its mucous membrane was softened in 8 and 48 and white,
inelastic and easily torn in 22. Its condition was altered in seven of the malarial cases: In 90 its calibre was con-
tracted and its mucous membrane pale: in 247, 259, 260, 276 and 278 there was more or less of congestion or inflam-
mation, in some general, in others affecting the lower portion only; in 274 the mucous membrane was softened and
velvety. It was mentioned as normal in six cases. Eleven observations were made in the typho-malarial cases: In
five the jejunum was normal; it was congested in 86 and 95: softened in .53; inflamed in 65; ulcerated in 269 and
slate-colored in 112. In many of the mixed series a healthy condition of the jejunum may be inferred; in others, as
171, 174, 180, 195, 196, 210, etc., the inflammation which affected the ileum apjiears to have extended upward. But in
forty-two instances its condition is specified in precise terms; In seventeen of these it was normal; in fourteen, 141,
187. 189, 279, 281, 282, 300, 306. 314, 321, 354, 369, 370 and 380, congested ; in three, 191, 323 and 339, softened ; in seven.
IK, 239. 284, 309, 318, 337 and 353, ulcerated, and in one, 338, lead-colored. It was normal in 181, although the dno-
denamand ilenm were implicated, and in 241, notwithstanding the existence of an intussusception; in 3,54 its lower
part only was congested; in 239 and 282, respectively ulcerated and congested, there were lumbrieoid worms.
ISTUSSUSCEPTIOX OF TilE s.MALL INTESTINE was not recorded as having been observed in any of the typhoid or
Tile sTwMAcii was liealtby in thirteen eaees and in the others more or less altered by hypenemic conditions; in four there were small ulcerations
or erusious ; but similar changes, and in nearly the same proportion, were found in seventy -two jtatients who died of other diK(«ses.
The DVODESCM. — The notes ou the condition of this portion of the alimentary canal are restricted to twenty-two crises, in eight of which it was
healthy. Of the remaining fourteen the mucous membrane was red in four, the rwiness being diffused or circumscribed ; grayish in two ; soft in three,
in which it was also red ; Briinner's glands were much enlarged near the pyloric end in three, two of which had the mucous membrane softened and
in two there was slight ulceration near the valve. With the exception of the ulceration similar conditions were found in thirty -six cases of death from
KUte diseases other than typhoid.
InTUSSCSceftion of the small intestine was fotind in three cases.
422 PATHOLOGICAL ANATOMY AND PATHOLOGY
typho-malarial cases; but it was noted in 88 and 258 of tlie malarial series, and in five cases, 127, 130, 222 234 and
241, of the mixed series ot febrile cases.
LuMBRicoiD WOHMS were noted in cases 6 and 8 ol the typhoitl, in 239, 282, 348, 361 and 378 of the mixed series
and in the typhus case 389. Their presence was not observed or recorded in any ot the malarial or typho-malarial cases.
The PATCHES OF Peyer were ulcerated in tliirty-three of the fifty typhoid cases, wliile in seventeen their con-
dition was not stated; but, as will be seen m referring to the occurrence ot jjerforation, the ulceration of the intes-
tine in the latter cases was of the same circumscribed and penetrating character as that definitely stated in the
former as having its site in the patches. Since all febrile cases presenting adynamic symptoms have been in this
volume classified as typhoid -when post-mortem examination revealed in them a tumefied or ulcerated condition of the
patches, it necessarily follows that in the sixty-three cases submitted as examples of malarial fever the agminated
glands were not found to be thus aflccted. Their condition was not stated in twenty-six cases; they were healthy
in seven cases, 257-261, 366 and 367, and reported not ulcerated in 262 and 263; in the remaining twenty-eight cases
they were i)ale, white, reddened, congested or iiigmented. Their condition was not stated in ten of the sixty-one
tijpho-malarial cases; they were enlarged, congested, inflamed or pigmented in twenty-one cases and ulcerated in
thirty. Of the two hundred and thirteen mixed cases their condition was not reported in sixty-eight. Thev were
ulcerated in one hundred and thirty-one and tumid and infl.imed in twelve; they were healthy in one, 380, and indi-
rectly stated to have been so in one, 379, — in the former death occurred from pneumonia six weeks after the patient
had 80 far convalesced from his typhoid attack as to be able to walk about the ward; in the latter, as the object of
the 2>ost-mortem examination seems to have been an explanation of sudden and unexpected death during conva-
lescence, the appearances presented by the agminated glands were not referred to except in so far as they may he
included in the general statement that there were no other unusual appearances thau those recorded as having been
observed in the brain, heart and lungs.
The condition of the mucous membrane of the ileum, in tlie intervals between the ulcerated patches, was
not stated in twenty-two of the fifty typhoid cases. What may have been its condition in these instances is uncer-
tain. If credit he given to the records as well for what is not said as for what is stated, the mucous membrane pre-
sented no morbid ajipearauce ot note beyond its destruction over the site of the att'ected glands. But such negative
evidence is of doubtful value, and has not heretofore been admitted in these analytical observations. Nevertheless,
it seems probable that in at least some of these cases there was no general congestion of the membrane, for, as will
be seen immediately, congestion when present in other cases was coilfined to the vicinity of the aft'eeted i>iitclie8, and
in cases 23 and 48 the bases of the ulcers are said to have been of a reddish color, which distinction could not well
have been made had the general lining of the intestine, including the part surrounding the ulcers, been in a highly
injected condition. In twenty-five cases the ileum was reported congested, but in nine of these, 8, 9, 16, 26, 30, 34,
39, 40 and 46, the congestion was confined to the lower part of the intestine or to that part in which the destruction
of the patches was greatest, and in many of those in which a general congestion is intimated it was more intense at
this part than higher up, where the disease of the patches was less advanced. The raucous membrane was softened
in two cases, 15 and 29, and of a dull whitish color in one case, 22. In 5 the ileum was contracted and in 27 it con-
tained a Irothy semi-liquid sanguinoleut matter.
LuMBRicoiD WORMS Were notod in two cases ; but this does not express tlie frequency of their presence, for some instances of their passage from
the body during life and otberB of their detection after death were not recorded.
The PATCHES OF Pevek were altered in structure in the lower 2-8 feet of the small intestine in all the cases; iu the whole length of the canal
in one case only. Those nearest the caecum were most altered, those farthest from it least altered; whence it is inferred that the morbid process did in»t
commence simultaneously in all the patches, but was progressive in an upward direction, and that the changes to which an individual plaque is subject
may he appreciated by a study of the various patches from above downwards. They were at first slightly elevated and of a pale-rose color, the (devation
being due to a hyperplasia of the i)arts or an exaggeration of the normal structure, .\fterwards they became redder, thicker, larger, softer and adherent
to the submucous tissue, which was reddened and thickened beneath them. Then ulceration took place, or a process of absorption without ulceration.
The destruction of the mucous membrane covering a patch was due to the union of many ulcerative points or to the extension of one; hence the ulcer-
ations diffenal from each other considerably in appearance. Their outline wiis generally regular, oval or rounded, but sometimes angular; in some the
edges were ]ierpendicular, in others they sloped gradually into the central and deeper parts of the ulcer; the muscular coat was exposed in some,
and in a certain number the serous coat w.as perforated. On the estiiblishment of recuperative action the red color became: tinged with gray orblae,
and a thin cicatricial pellicle was developed j'rom the surrounding mucous surface. In those that had not undergone ulceration a similar change in color .
was accompanied by a diminution of the tumefaction and softness. Louis gave the name of soft patches (j>hujiies moUefi) to the agminated glands when
affected as has been described, ajiplying the term hard patches {pla^fues durm) to them when, superadded to the conditions present in the soft jiatchcs,
there was a transformation of the submucosa by an interstitial exudation of a homogeneous, unorganized and more or less friable substance of a faint
rose or yellowish color which attained a thickness of two or three lines. AVhen the mucous membrane over these plates was unbroken they had asmootlt
uniform appearance; hut when ulcerated their ajipearance was uneven, furrowed aud stained with bile. This sidjstance was also formed beneath some of
the irregular patches intervening between the patches of Peyer, and in some cases it appeared in the form of prominences two or three lines in diam-
eter and of equal height. These hard patches were found in thirteen of the forty-six cases, in ten of which they alone constituted the local lesinii,
while in three they wero associated with the plaques moUes. The solitarv glanus of the small intestine were affected in twelve cases, but generally only
within a few feet of the cajcum. They were flattened and white or rounded and of a grayish color. In one instance they had a grayish point in their
centres; in three others they were ulcerated. Locis considered it doubtful if all the small wdiite elevations present in some of the cases were realb'
enlarged crypts. Setting aside the condition of the jmtches of Peyer, these changes in the small intestine, the result of congestive or inflaiiniialory
processes in its mucous membrane, were found in other acute diseases and in nearly the same proportion as in typhoid fever. Kven the changes in tlio
solitary glands may not be excepted, as in five cases, three of which were cases of scarlet fever, those near the caecum were enlarged aud reddened.
Hence these morbid changes, like those affecting the stomach, were considered by Louis as the result of a continnance of febrile action on the system.
But as the affection of the agminated ghands was not found iu any other disease it was conceived to be the primary and pathognomonic lesion of
typhoid fever.
In seventeen cases the mucous membrane of the je.iunum and ileum preserved its natural color, white or yellow from a tinge of bile, throughout
nearly their whole length ; in sixteen it w.as red, and while in six of these the redness extended throughout the length of the tube, in ten it was con-
fined to tile lower half or third ; in thirteen iiatients in whom death took pl.ace late in the attaik the nnuubrane was of a grayish color. t)f furty-Hvo
cases the mucous lining wiis of normal consistence in nine, softened throughout in thirteen and in its lower uortiou only in twenty.
OK THE CONTINUED FEVERS. 423
Of the sixty-three maUiriaJ cases the coiulitimi of the mucous inembrano of the ileum was not stated in eight;
congested in patches in thirteen; generally injected or inflamed in thirty-two, and variously stated in ten. Of the
thirteen in which the injection was circumscribed in i)atches the lower part of the ileum was chielly atfected in three,
115, 2;i2 and iitili, the njiper part in one, 259, whili' in nine a general distribution of the patches thioughout the ileum
is imlicated: In 217 these localized congestions were extensive; in 24M scattered ; in 287, 29:iand3>«> intensely atfected,
and in !tl and S(!5 ecchymosed; in HI and 2(il the agminated glands were not diseased notwithstanding the existence
of these inflamed patches. Of the thirty-two cjises in which the congestion of the membrane was general throughout
the ileum it is expressly stated in some, as in 105, 2.50 and 2ti3, that no ulceration was present; in3li7the intestine was
perforated by ulceration, but the patches of Peyer were not involved. Of the ten cases in which the condition of the
membrane waa variously reported it was thinned in 373: thinned and reddened in 274 and 276; of a pinkish-cream
color in 387: softened in 78; thickened and softened in 87; gangrenous in 80; and free from congestion or other lesion
than pigmentary deposits in the closed glands in 90, 290 and 291. In the eight cases, 70, 108, 277, 289, 371-.377, in
which the condition of the mucous membrane was not stated, it is probable that there was no marked congestion, for
in several, as in the pya'uiic case, 289, the attention of the r)])erator was certainly directed to this part of the intes-
tinal cjinal, since the condition of its closed glands was observed and recorded. Moreover, as has been already shown,
the jHiKt-morIrm appearances in the paroxysmal fevers do not necessarily include congestion or intlammation of the
lining membrane of the small intestine.
Of the sixty-one tijiiho-malarial cases the condition of the ileum, exclusive of its glands, wms not stated in
thirty-three. It was more or less congested or inflamed in twenty-four; but in three of these, 63, 68 and ^M, the
morbid condition was confined to the neighborhood of the ileo-crecal valve; in (me, 102, it constituted only a border
to the inflamed or ulcerated patches of Peyer; in two, 116 and 296, it was arranged in circumscribed patches, and
in one, 273, darkened by spots of ecchymosis. In one, 53, of the renuiining four cases the mucous membrane of the
ileum was softened, in a second, 67, thinned, in a third, 297, pigmented in punctated slate-colored patches, and in
the last, 298, of*a grayish-slate color from deposits in the villi.
The condition of the mucous membrane of the ileuni was not stated in one hundnd and seven of the two
hundred and thirteen mixid febrile cases; it was more or less reddened, congested or inflamed in eighty-two and
variously afl'ected by inflammatory action in twenty-four. In some the injection was slight; thus in 201 it gave
only a faintly pink tinge to the membrane. In tlie .seven cases, 137, 172, 198, 200, 320, 321 and 329, the congestion
was confined to the vicinity of the inflamed and ulcerated patches of Peyer, around each of which it formed an
areola: in the last-mentioned case the mucous membrane of the upper part was thinned and its valvuUe almost
obliterated. In the nine cases, 140, 208, 217, 221, .302, 341, 344, 359 and 238, the congested or inflamed condition was
found only in the lower part of the ileum; in the last-mentioned case the membrane was thinned and softened in
the upper part of its track. In the five cases, 190, 209, 312, 331 and 333, the congestion, although affecting also the
upper i)art, was noted as especially inten.se towards the ileo-ca-cal junction. It was disposed in scattered patches
or streaks in the twelve cases, 148, 189, 199, 201, 203, 275, 310, 318, .343, 3.52 and 369, in one of which, 203, an ecchy-
inoseil patch was observed, while the congested spots in 369 were thinned and in 318 thinned and .softened. Thick-
ening was usually associated with the congestion, but in the four cases already mentioned and in 338 the membrane
was thinned. In the remaining forty-seven of the eighty two cases the congestion was general throughout the
ileum. Of the twenty-four cases in which various conditions of the mucous membrane were recorded it was said
to have been .softened in 1!M, 212, 213, 216, 239, 284, 323 and ,339; thickened in 233 and 345; thinned in 282; thin, i)ale
and easily torn in the lower part in 181, and of a dark-grayish color in 193. It was said to have been ulcerated,
apart from the ulcerations of the agminated glands, in 165, and the erosions in 300 appear also to have been in addi-
tion to the destruction of the membrane at the site of the ulcerated glands. The ileum is said to have been denuded
in its lower part in 219 and 220 and gangrenous in 311. In five cases, 139, 161, 301, 304 and 354, it was healthy in
its upper part, while in its lower part the condition of the glands only is stated; but in case 332 it is said that the
surrounding villi were not affected. From these last observations it seems probable that in many of the large num-
ber of cases in which the condition of the nnicous nu'uibrane was not recorded the failure to report its appearance
arose from the fact that it presented nothing of imjiortance apart from the condition of the glands.
The L.-vlHiK IXTKSTINE. — Of the fifty li/phoid eases the inflanmiatory processes afl:ected both the large and small
intestine in seventeen, and the small intestine alone, so far as can be learned from the records, in thirty-three,
but in two of these, IS and 41, it is stated that the large intestine was not examined. The large intestine was there-
fore congested, inflamed or ulcerated in seventeen of forty-eight cases, or in 35.4 per cent. In one of these cases, 27,
ulceration of the solitary glands was the only abnormity mentioned; but in six other cases the general appearance
of the mucous membrane was recorded in addition to the condition of the crypts, which will be considered here-
in the LARGK ISTESTIXE rlUtontion was otiscrrcd witli ninrh more freqneucy tlian in tlic uniall iutiwtine. It was present in twenty-two of Hiirty-
ninc cMi-s, an.l in sixteen of tile twentj-tivo it was considerable. Notwithstanding a great distention of the gut its coats were not thinned, but on the
contrary rather thickene<l, a result considerwl dne to the r«irtion of the membmnes on the distending gases. Its murons membrane was white in thir-
teen of fortj-threo cases and jellow-tingiHl from fafces in two ; its color was uniformly red in fifteen cases, in three of which the redn<«s was general and
iu twelve localiztil ; in four cases there were cin-uuiscril>e(l red patches; the membrane was grdj,-ish in color in nine cases, all of wliich were fatal at a
late dale. Tlie mucous liiiing was of nomiuU-onsistence in thirteen of the forty-three cases ; 8ofteue<! throughout its whole extent in sixteen ; throughout
its first nr seconil half in eight ; in the ca-cum and rectum in one ; in the caecum only in two, andat different points in the extent nf the intcstirn- in three
cases. Knlnrgement .rf the solit.vry GLA.\ns, usually not numerous and with no manifest cliange in the mucous membrane of the Im^alitj- occupied by
them, was found in eight casw ; in a ninth case the enlarged glands were numerous, scattered over the whole extent of the canal, ulcerated at their sum-
mits anil with the submucous ami ninscnlar coats near them considerably thickentnl. Four other cases pre-senttil bant [Bitches like those «x-curring in the
miall intestine, but only from three to four lines iu diameter, and ulcerateil only in one instance. Ulcerations were found in fourteen cases, but they
were rarely numerous— they variiil from four to thirty lines in length aud affected the caecum aloue, or, in conjunction with other iMrts of the intestine,
424 PATHOLOGICAL ANATOMY AND PATHOLOGY
after: Tims in 22 it was soft and of a grayish-slate color, in 24 mottled red and slate-colored, in 26 greenish, in 31
dark-colored, in 48 greatly congested and in 50 inllanied. In two cases, 25 and 28, the ciecuni was congested; in one,
47, dark slate-colored, and in four, 30, 32, 33 and 49, ulcerated; in the first mentioned of these four there was also an
inflamed condition of the rectum, in the second of the colon, while in the third tlie ca'cum had become perforated.
Ulceration was also found in 23, in the lower part of the intestine, where it was unconnected with the state of the
solitary glands. The mucous membrane of the colon was inflamed and thickened in 29. Lastly, in 21, the colon is
said to have contained a considerable quantity of blood.
Of the sixty-three malarial oases the large and small intestines were affected in thirty-eight, the large alone in
two, and the small alone, so far as is shown by the records, in nineteen. The intestines in the four cases not accounted
for in the preceding statement presented no lesion other than pigmentary deposits confined, in case 291, to the agminated
and solitary glands of the small intestine, but involving also the walls of the large intestine in cases 90, 289 and 290.
The large intestine was thus implicated in forty-three of sixty-three cases, or in 68 per cent. In thirteen of these
cases, 71, 73, 78, 81, 88, 252, 257, 261, 263, 862, 363, 365 and 373, tht; inucous membrane of the large intestine was generally
congested or infl.imed; in 87 softened; in 90 bluish; in 287 discolored, and in 80 diseased, while in 289 and 290 pig.
mentation of the solitary glands was the only abnornuil appearance recorded. The mucous membrane of the colon
was congested or inflamed in ten cases, 91, 251, 2.54-256, 260, 278, 292, 294 and 387, in the first of which the inflamed
membrane was also eccbymosed; it was thickened and softened in 108, slate-colored in 276, and gray with a few red
patches in 293. The rectum was affected in four cases: In 72 its lining was softened; in 70 inflamed and softened;
in 262 injected and thickened, the colon being similarly afl'ected; and in 274 congested, the large intestine generally
being slate-colored. Ulceration was mentioned in seven of the cases: In 386 the lining membrane of the intestine
was slate-colored, with patches of congestion, ecchymosis and ulceration ; it was inflamed and ulcerated throughout,
but particularly in the rectum, in 115; the lower part of the bowel was ulcerated in 84, ulcerated and gangrenous in
76; the colon was ulcerated in 89, slate-colored, injected and ulcerated in 295, and thickened, softened and ulcerated
at its commencement and termination in 376.
Of the sixty-one typho-malarUil cases the large intestine was affected in twenty -nine, the small intestine alone
in thirty-one, but in three of these, 52, 64 and 83, the large intestine was not examined. In one case, 69, nothing is
said concerning an intestinal lesion. The large intestine was thus involved in twenty-nine of fifty -seven cases, or iu
51 per cent. In three of these cases the glands only were mentioned: In 285 as enlarged, in 298 as pigmented and in
85 as ulcerated. The membranous lining of the intestine generally was congested or inflamed in the five cases, 66,
86, 92, 112 and 273; in 296 it was slate-colored and injected in patches; in 297 the dark coloration was confined to the
Ciccum and in 67 and 68 to the colon. The colon was congested or inflamed in 100, 102, 106 and 116, and strictnred
in 77. Ulceration was present in twelve cases; generally throughout the intestine in 74, 103 and 266; in the colon in
65, 99, 101, 109, 110, 264 and 265; in the colon and rectum in 75, and in the rectum alone in 98.
Of the two hundred and thirteen mxxecl cases the large intestine was more or less affected in one hundred and
six, the small alone, so far as can be learned from the records, in one hundred and one. In six cases, 378, 379, 381-384,
the record is silent concerning the condition of the intestinal tract. The large intestine was thus implicated in one
hundred and six of two hundred and seven cases, or in 51.2 per cent, of the cases. In fourteen of these cases, 163,
164, 168, 169, 188, 192, 193, 197, 199, 281, 319, 329, 334 and 338, the recorded statements as to the condition of the large
intestine refer only to enlargement or ulceration of its glands or pigmentation of its walls. The intestine was more
or less congested or inflamed in twenty-one cases, in one of which, 173, the congestion was disposed in patches; in
another, 282, it was particularly intense in the csecum, while in a third, 370, in the lower part of the bowel it resembled
ecchymosis. In addition to these twenty-one instances of congestion the lining membrane of the large intestine as a
whole was recorded as greenish in 181 ; thickened and softened in 239 ; thinned, softened, pigmented and slightly con-
gested in 380 ; soft and disorganized in 323 ; ecchymosed in 301 ; while in 187 its rugie were elevated and its calibre
contracted. The colon was constricted in two cases, 160 and 243 ; in 176 it contained coagulated blood ; in 227 and
302 its mucous membrane was thickened and softened; in 162 dotted with minute oval purpuric spots ; in twenty-
two cases it was congested or inflamed: In ten of these this condition appears to have been general, while in seven,
170, 184, 245, 312, 327, 330 and 333, it was more particularly observed at the commencement; in three, 279, 310 and
337, towards the lower end of the bowel, and in two, 203 and 324, at both of the extremities. Ulceration was present
in thirty-seven of the cases. It affected the intestine generally in the thirteen cases, 167, 171, 178, 185, 229, 232, 234,
236, 238, 242, 244, 300 and 351, but in 300 the action was especially manifested in the sigmoid flexure, where per-
foration had taken place; it affected the ciecum in the eleven cases, 161, 165, 172, 177, 237, 313, 314, 325, 332, 348 and
353; the colon in ten cases, 166, 233, 235, 240, 241, 315, 317, 318, 320 and 360, in one of which, 318, there were jmrpuric
spots; the rectum in one case, 299, but in addition to this the lower end of the bowel was gangrenous in one case,
311, and disorganized in another, 316.
The condition of the solitary glands was observed and stated in thirteen of the fifty typhoid cases. They
were inflamed in one ; ulcerated in six ; sloughing in two ; in most of the cases they were unusually prominent,
in ten cases. The ulcers were in some cases evidently au affection of the solitary glands, but in others their site was the mucous membrane in the inter-
vals between these crypts. In one of the cases an ulcer near the anus communicated with a sm.all submucous abscess. Excepting the hard plaques the
Tnorbid changes in the large intestine were the same in those who died of typhoid as in tliose who died of other acute affections, and the difTerenc c of
proportion was considerable only in the instances of meteorism and ulcei-ation of the mucous membiune. Thus, in forty-five cases of typhoid fever the
membrane was generally red in three, partially red in ten, grayish in nine, generally softened in sixteen and partially softened in fourteen, while in
sixty-nine cases of other acute maladies there was general redness in three, partial redness in twelve, a gray color in seven, general softening in twenty-
two and partial softening in twenty-flve cases. Meteorism was observed only in three cases and in none of them to the extent found in tyi>lioid fever;
while excluding one case of dysentery, in which the colon presented many ulcers, erosion of the memta'ane was discovered in three ca«es only, all of them
instances of lung inflammation.
OF THE CONTIXrEP FKVEKS. 425
ami in four this enlargement was the only aluiuniial luiiiiitioii reiiorted. In some instances it is uncertain from the
tcniis of the record whether the glands of the large intestine were involved in the morbid jirocesses: Thus, in 4, 6. 7
13. 14 and IT. the changes in the solitary glands were mentioned in connection with those of the patches of Peyer.
while nothing was specified with regard to the glands of the ca'cum or colon ; and in 28 and 31 the solitary glands of
the ileum were particularized, while those of the large intestine juid even the intestine itself were not mentioned.
On the other hand, in the three cases, 23, 24 and 27, the glands of the large intestine were aftected as well ,is those of
the ileum, although in one of these, 23, the appearances were not similar, the glands of the latter being prominent
only, while those of the former were blackened by pigmentary deposits. Again, in the two cases, 20 and 4X the
glands art'ected were confined to the large intestine. Hence, so far as the indefinite terms of t\\e post-mortem records
{>ermit of a kuowle<lge of the locality of the altered glands, those of the ileum -were affected in eleven case.s and those
of the large intestine in five.
The condition of the glands was observed in a larger proportion of the malarial than of the typhoid cases.
Twenty-nine observations were made, in four of which, 2.">7, 260, 261 and 263, the glands of both the large and small
intestines were normal. Of the remaining twenty-five the glands were reported congested in one, 258; inllamed in
two, 278 and 386: ulcerated in five, 84, 89, '295. 375 and 376: disorganized in three, 70, 73 and 363, and pigmented in
nine. In most of these there was coexisting enlargement, but in five cases, 87, 252, 2,t4, 287 and 373, prominence of
the glands was the only abnormal condition stated. In some instances the same difficulty is found in determining
the site of the aftected glands that was exi>erienced in certain of the typhoid cases. They were mentioned in "cneral
tenns. but in connection with the patches of Peyer in two cases: those of the ileum were reported altered in seven
cases, in which more or less uncertainty attaches to the condition of the large intestine: those of both intestines
were affected in thirteen, while in three the glands of the large intestine alone are mentioned. Hence, so far
as the terms of the record permit of a knowledge of the locality of the glands aftected, those of the ileum were impli-
cated in twenty-two cases and those of the large intestine m sixteen. In 290 and 291, of the nine in which the change
consisted in the deposit of pigmentary matter in the glands, with or without enlargement, congestion or ulceration,
the altered glands were those of the ileum; in 91, 289, 292, 294 and 387 all the solitary glands were thus affected ; in
one, 3ti2, those of the large intestine were pigmented, while those above the ileo-c:ecal valve were sinigtly enlarged,
and in 2;i3 the black deposit was reported present in the large intestine only. Usually the glands in the large and
the small intestine were similarly aftected, 362, already instanced, being exceptional in this regard, and also 84, in
which the glands of the large intestine were prominent while those of the small intestine were ulcerated.
Seventeen observations were recorded in the sixty-one ti/pho-malarial cases. Of these there was no unhealthy
condition in two, 54 and 102: simple enlargement in three, infiammation or ulceration in eight and pigmentation in
four. The glands of both the large and small intestines were aftected in three cases; of the large intestine alone in
three cases: and of the ileum in nine cases, in w hich more or less uncertainty exists as to the condition of the lar"e
intestine. Hence, the crypts of the ileum were altered in twelve cases; of the large intestine in six cases. In but
one instance, 116, were the glands of the ileum .said to have been pigmented, although in 297 the mucous membrane
was slate-colored and in 298 deposits in the villi darkened its color. The solitary glands of the colon were x>igmented
in five cases, — in 116 and 298, just mentioned, in 67, in which the crypts of the ileum were not mentioned, and in 68
and 296, in which they were intlamed or nlcerated.
The condition of the solitary glands was observed and noted in fifty -one of the two hundred and thirteen
■MJTfd febrile cases, and in one of these, 329, the crypts were normal throughout the whole of the intestinal canal. The
glands were enlarged in eighteen cases, ulcerated in twenty-three and pigmented in nine cases, in some of which
enlargement and ulceration were also present. The site of the aftected glands is uncertain in some instances and in
others definitely stated: In twelve cases the glands were mentioned in connection with the patches of Peyer. whence
it may be inferred that those of the small intestine were certainly aftected; the ileum appears indicated as the site
in eighteen cases, in the majority of which the condition of the glands of the large intestine is more or less uncer-
tain, as in only one, 203, are they stated to have been normal; both the ileum and large intestine were involved in
nine cases, while the large intestine alone was mentioned in eleven. Hence it may be said with certainty that the
solitar}- glands of the ileum were implicated in at least thirty-nine cases and those of the large intestine in at least
twenty cases. Pigmentation was found in the glands of the ileum in 141 and 302, in which no reference was made to
those of the large intestine, and in 200 and 201, in which the glands of the large intestine also contained the deposit;
in 203, 320 and 380, in which the crypts of the ileum were enlarged or congested, those of the large intestine were
pigmented: the latter glands were pigmented also in 331 and 334, in which those of the ileum were not mentioned.
Pekfor.\tiox ok the ixtestixe axi> PEiUTOXiTis.— In twelve of the fifty typhoid cases, or in 24 per cent., the
intestine was perforated by the ulcerative processes, the situation of the perforation being in Peyer's patches in the
six cases, 16-20 and 32: in the ileum and probably in the patches in the five cases, 43-46 and .50, and in the ciecum
in case 33. Peritoneal infiammation generally followed this accident, but in 32 it is said that there was no evidence
of infiammatory action. In 19 and 23 fa-ces had escaped into the peritoneal cavity. Peritonitis occurred in the
altsence of perforation in cases 31 and 49, apparently without any other immediate or determining cause than the
morbid condition of the glands of the mucons membrane and mesentery. In striking contrast with this record, there
was but one case of perforated intestine among the sixty-three malarial cases. In this instance, 367, the ileum had
given way, while Peyer's patches were reported fr.-e from di.sease. Peritonitis was present in 80, in which the intes-
tines were in a gangrenous condition, and in 249, in which it w;is apparently due to a rupture of splenic cysts. Per-
foration occurred in six of the sixty-one lyptio-malarial cases, or in 9.8 per cent.: In 107 the small intestine was
recorded as the site, in 82, 83 and 106 the ileum, and in 64 and 103 the nlcerated aggregated glands. Peritonitis
oeenrred without i>erforation in the five cases, 63, 93, 101, 296 and 298; in 63 it may have been connected with the
Meu. Hist., Pt. 111—54
426 . PATHOLOGICAL ANATOMY ANP PATHOLOGY
degenerated condition of tlie lecti muscles, and in 296 witb raorliid changes in the spleen. Perforation of the intes-
tine was observed in twenty-four of the two hundred and thirteen mired cases. Tlie accident is stated as having
taken place in the intestines in case 244; in the large intestine in 300; in the small intestine in 226; in the ileum
in nine cases, 223-225, 245, 309, 346, 347, 360 and 385, and in the patches of Peyer in twelve cases, 152-159, 204, 322,
327 and 328. Case 385 is exceptional as showing a possibility of recovery even after perforation; in it there was
neither escape of the intestinal contents nor peritonitis, on account of the occlusion of the aperture by adhesion to
the serous covering of the bladder. Peritonitis was reported as having occurred in seven cases in which no mention
was made of perforation; in 203 and 337 it was probably tubercular; in 151 connected with the condition of the
abdominal recti muscles; and in the others, 150, 311, 353 and 361, with the state of the interior tunics of the intes-
tinal canal.
Pigmentary deposits in the intestine are mentioned in only two of the fifty typhoid cases ; in 23 near the
pylorus and in the solitary glands of the large intestine, and in 26 in which the ulcerated glands near the ileo-ciecal
valve were of a dark-blue color. The colon, however, was slate-colored, greenish or dark-colored in cases 22, 24, 26,
31 and 47. Pigmentation was found in twenty of the sixty-three maJariul cases, or in 31.7 per cent, of the cases:
The patches of Peyer were dotted with dark-colored spots presenting what has been called the shaven-be.ard appear-
ance in the six cases, 87-90, 115 and 288, as also in the eight cases, 91 and 289-295, in which the solitary glands are
mentioned as involved in the pigmentation; the ileum and mesenteric glands were blackened in 258, although the
patches of Peyer were healthy; in 287 the patches were prominent and speckled with blood and the mucous mem-
brane of the colon discolored; the interior of the colon was slate-colored in 274 and 386, and its solitary crypts
blackened in 362 and 387. The intestines were blackened by deposited pigment in ten of the sixty-one tyj'ho-mularial
cases, or in 16.4 per cent.: Peyer's patches were atfected in 54, 86 and 96, and the solitary glands also in 116 and 296;
the ileum and colon in 297 and 298; the colon alone in 265, and its solitary glands in 67 and 68. Peyer's patches pre-
sented dark-colored ulcerations or deposits in the four cases 148, 149, 181 and 368 of the mixed series. The colon or
its glands are alone mentioned as pigmented in the twelve cases, 168, 169, 174, 198, 202, 203, 302, 310, 320, 329, 334 and
380, while Peyer's patches were also atfected according to the records of 200, 201, 331 and 338, and the ileum accord-
ing to that of 199. The solitary glands of the small intestine were pigmented in 141 and 165, and the ileum was of
a blue-slate color in 333, which also presented dark-blue spots in the bladder near the orifices of the ureters. The
intestines were of a dark-gray color in 193. These twenty-five instances of deposited pigment form 11 per cent, of
the total of two hundred and thirteen mixed febrile cases. But there should be mentioned in this connection the
ecchymoses or purpuric spots in the large intestine in cases 162, 183, 189, 301, 318 and 370.
The condition of the mesenteric glands is mentioned in but fourteen cases of the typhoid series, in all of
which there was notable enlargement. In the malarial series the glands are mentioned fourteen times; in twelve
cases they were enlarged and more or less altered in color, while in the two others, 274 and 374, they are said to have
been healthy although Peyer's i)atches were much affected ; in 70 the enlargement was so great and general that the
mesentery had the appearance of being one continuous gland. In the typlio-inalurial series their condition is recorded
seventeen times ; enlarged and more or less deeply colored or affected with yellow softening in sixteen cases, and ulcer-
ated in one case, 93. In the mixed series they were inflamed, enlarged and softened in all of forty-five cases except
two, 307, which contained chalky concretions, and 331, normal notwithstanding the affection of the agminated glands.
The appearance of the spleen is stated in thirty of the fifty typhoid cases, in only two of which was it nor-
mal. The alteration consisted of enlargement and softening, sometimes to pulpiness, frequently associated with
a darkened color. In case 37 the spleen was three times its usual size ; in 9 it weighed forty-one ounces ; in one case
only, 42, one of sequent consumption, was it small and hard. Its condition was reported in fifty-two of the malarial
cases. It was normal in eighteen and small in six cases, 90, 91, 252, 259, 276 and 291; it weighed only three ounces
and a quarter in one of these, and was tough and of a dark color in most of tliem. In the other instances it was
enlarged, congested, soft, flabby or friable; in 70 it was three times its usual size; in 87 it was similarly enlarged and
The l.TMPHATic GLANDS. — All of the mesentcrw glands corresponding to altered plaques suffered a modification of size, color or consistenre. Tliey
were enlarged and rose-colored, subsequently becoming softened, of a darker red and develoiring yellowish points or purulent foci in their tissueB;
.%nd even the glands corresponding to apparently healthy patches in ten of the forty-six cases were found to he enlarged and reddened. The niesiicolic
}>;lands were marked by iufiiinunatory changes in fourteen of nineteen cases in which they were examined, and although these changes were associated
with redness, softening or ulceriition of the membrane in most cases, in othei-s the membrane was healthy; nevertheless, these glands iu no case
contained purulent deposits. Enlargement and reddening of the glands of the stomach corresponded in three cases with inflammatory conditions of
the mucous lining of that viscus, but in a fourth case, in which the glands were affected, the lining was healthy, and in a fifth case this want of corres-
pondence was reversed. Louis considered that this latter condition was of frequent occurrence, although not recorded by him. He argued that while
the stouuieh was very frequently altered, he could scarcely in his post-iuurtem work have failed to notice corresponding enlargement of the glands liad such
a change been present. The lumbar glands were large and firm in two cases, in one of which the patient succumbed to a sequent erysipelas of the lower
extremities. In a similar case the itifftiinal glands were Large, red and contained white pus; in three others, in which the legs had been blistered, these
glands were inflamed but had not suppurated. The cerrkal glands were enlarged and reddened in nine of twelve cases in which they were examined. Six
of the nine had concurrent ulceration of the pharynx, but in the three others there was no marked lesion of the organ corresponding to the glands. In
patients who died of other acute maladies the mesenteric glands were large and red in six cases of small-pox, scarlet fever, pneumonia and erysipelas,
and somewhat softened in one case of small-pox, but in none of these was the change comparable with that suffered by the glands of the lower part of
the mesentery in typhoid fever. The cervical glands were affected in four cases, three of which were eruptive fevers, and in only two of these was there
a manifest alteration of the .air-passages. It is inferred from these facts that while the condition of the glands does not in all instances depend on that
of the organs with which they are connected, the typhoid affection sstabli-shes a marked predisposition to inflammatory changes in the mesenteric and
cervical glands.
The 8i>LEEN was unaltered in four only of the forty-six cases. It was more than three times its usual size in seventeen cases; more llian
double its usual size in nineteen, but slightly enlarged in nine and apparently small in one case. It was softened in thirty-four, and in seviai of
these, in which the softening was extreme, the organ was largely increased in vvdnme; but in no instance was pus found in its tissues. It was observed
that the tumefaction and softening specially chai-acterized those cases that were speedily fatal, while the organ was more frequently normal or bat
OF THE CONTINUED FKVRRS. 427
containeil aliscesses; in 377 its surface was mottloil with s|)ots siirrouiuled by rcilflisli areola' and its section cxnileit
a seici-]iiinileut li(iiii<l; in 258 it contained tiilierciilar masses and in 219 cysts, llie cheesy contents of whicli liad in
part escaped into the peritoneal cavity. Its condition was not stated or not observed in nineteen, normal in eif^hr
and altered in thiity-fonr of the sixty-one ti/plio-miildriiil cases. In case 206 it weijihed three ounces and a half ami
was tiriii: in ()7 it was small but extremely soft. With these exceptions it was cnhufjed, conjjcsted, softened and
often darkened in color. In ca.se 99 it is said to have been rotten : in '.'96 it had an intlamcd condensation of its ti.ssuo
about the size of a nntmcj; at its upper end and the contiguous omentum was also inlianicd. In the mixed series the
spleen was normal in thirty-six and variously changed in one hundred and seven cases. It was small in seven of
these, 201, 213. 228, 281, 306, 329 and 331, varying in weight from one ounce and a half iu 213 to four ounces and threc-
i|uarters in 281. It was discolored but not enlarged in a few instances. Generally the organ was large, congested,
dark-colored and more or less softened ; in 132 it weighed forty-one ounces, in 319 thirty-six ounces and in 129 thirty-
four ounces; in 137 and 221 the alteration of the tissue ai)proached decomposition, and in 137 it was pultaceous; in
369 it was light-colored and hardened in portions of its substance, but softened and suppurating near the hilus; in
354, uiulerlying a diai)liragmatic adhesion, was a cavity containing an ounce of viscid green licpiid; 148 and 214 also
contained cysts: in 204 the superlicial layer of the splenic parenchyma was colored slate-blue by nudocular de])osits.
The appearance of the liver was recorded in twenty-nine of the fifty ti/phoid cases: It was normal in eleven,
leaving only eighteen in which the attention wiis c:illed to diseased conditions. The liver was large in four of these,
soft in one, large and Habby in one, large and pale in two, large, pale and soft in two, large and fatty in one, pale
and fatty in one. large and congested in one, ccuigesteil in four and mottled in one. In the sixty-three malarial cases
the conditiim of the liver was recorded fifty-three times: in twenty -one it was normal and in thirty-two altered.
Knlargement is indicated in most of the cases ; but there was generally more than this, for enlargement alone is men-
tioned in but one of them. The organ was soft, flabby or friable in five cases: pale in four, iu one only of which
it was lirm: fatty iu four; waxy in (me; congested in five; dark-colored or bronzed in seven; in 249 it was covered
with exuded lymph; in 80 it adhered to the diaphragm and in 367 to the intestines also; in 87 it contained minute
abscesses and in 256 a single abscess of large size. In the sixty-one ti/pho-mahirial cases the liver was reported normal
in nineteen and variously changed in appearance in twenty-six cases; in sixteen its condition was not examined or
not stated. Enlargement was generally observed, and in four cases this was the only change mentioned. The organ
was pale in four ca.ses ; soft in four, in which this condition is stated alone or with enlargement ; tatty in four and of
the nutmeg appearance in one; dark or bronzed in three; congested in five and emphysematous in one. In the »ii«(/
series of febrile ca.ses the condition of the liver was not stated in seventy-one, normal in fifty-five and altered in
eighty-seven. Knlargement alone is mentioned in eighteen and iu conjunction with various changes in many of the
others. The organ was ))ale in twelve, iu two of which it was reported flabby anil in one firm. It was ana-mic in
one case, .333: granular in 144; fatty in nine; of the nutmeg appearance in two, 306 and 315; soft, flabby or friable
iu eleven, in one of which, 199, its substance was empliysenuitous, of the color of sanious pus and possessed of a dis-
agreeable odor, while iu another, 137, in which the parenchyma was of a greenish color, a chicken-coop odor was
instanced. It was soft also iu five of fifteen cases which were reported congested, and in two, 125 and 320, in which
there were adhesions; in three others, 328, 337 and 347, the serous coat adhered to contiguous organs. It was brown
or dark-colored in eight, mottled in 181 and 208, of a blue-slate color iu 154, ecchymosed on its surface and slate-col-
ored on section in 380, and small, weighing only twenty-eight ounces and a half, in 281.
The GAI.I.-ULADDER OK ITS CONTEXTS were observed in seven of the typhoid casiis; The viscus was small
in 29 and Large in 31,— in the former it was half filled with bile; it was completely filled with viscid bile iu 48;
it contained five drachms of yellow bile in 24; eleven drachms of dark-green bile in 47; twenty-six drachms in 23
ami ten ounces of brown bile in 26. Observations were made in sixteen of the malarial cases: The viscus was dis-
tended with dark-green or yellow-colored bile in the six cases, 70, 80, 104, 248, 365 and 376; one ounce was said
to have been present in 90 and 277, and about two ounces in 263, 276 and 373, the bile iu the last-mentioned case
having been watery; the gall-bladder iu 274 and 289 was empty, and in 287, 288 and 362 the quantity of its thick or
flaky contents was small. Among the typho-malarial cases fourteen observations were made: The gall-bladder was
normal in 103, simill in 112, empty or nearly so in 61 and 296; it contained six drachms of bile iu 62, three ounces in
100, and was distended in the seven cases, 67, 69, 75, 86, 92, 94 anil 96; generally the bile was of a dark or black
color and of some viscidity, but in the last-mentioned case it was descril)ed as watery. In 95 the walls of the gall-
sliglilly iiicn'asnl in vuliiinr iir <liiiiiiii8lR'<l iu consistence in those tliat ilieil at an .iJvanccd period ; whence it was concluded tliat these morbid chances
were «irl.v etTectcd ami tended to sulisidc as tlie duration of the attacli was lengtliened. Tlie spleen was darker than usual in one-half of the cases anil
lighter than usual in nine ou<es; but no constant relation existe<I between its color and its volume or consistence. Nor was any relationship detected
tietween its condition anil that of the mucous membrane of the stomach or intestine. In diseases other than typhoid this organ was enlargcHl in eleven
and BoftrtiMl in twenty-five of eighty-three cases ; but the softeuiiif; was more frecinently connected with a diminished than an incrcaaod volume. Kroiu
these facts it was infen'csl that enlargement and softening of the spleen are peculiar to and characteristic of the typhoid alfection.
The i.n-iR was seldom altered in size; it was larger than usual in five cases and smaller in two cases. It was not finncr than the normal in a
single rose, but it was sofleneil in twenty-two, in four of which the fingers penetrated its substance without resistance, and this softness was generally
assis'iatiil with a jiale color nither than w ith a congested state. The liver was of its natural color in twelve of the forty-si.t eases ; it was jialo in
tweiily-one c,-i»es, in fotirtmn of which there was a coexisting softni'ss ; in eight it was redder than usual ; iu one it was yellowish with purplish star-
shaiSHl bl(>lclu.s an inch in diameter ; in one the organ contained suppurating tumors, and in three its bloodvessels were penneatird by a greater or less
•luuiitity of air, but in no case was there any emphysema of its substJilice.
The nAij.-Bi.AnoER was evidently intlamcd iu three cases in which ltd contents wi-re purulent aud its lining membrane reddened ; in a fourth case
the membrane was of a faint rose-color mixed with gray aud the contents a turbid gniyish liiinid. The bile was reddish-yellow, sometimes with a greenish
tinge, and very liquid in twenty-five cji.ses and more copious than usual in ten of the twenty-five ; in others it was thick, viscid and blackish ; in two,
in which there was eoniprt.^ion of the cystic duct, the bile was replaced by a tnuisparent a.iueoiis liijiiid of the color of urine. But similar conditions
of the liver, gall-bladder aud bile were found iu other diseases, although not perhaps with as much frequency as iu typhoid.
428 PATHOLOGTOAL ANATOMY AND PATHOLOGY
blaiUTer were, disorganized and perforated, the bile in this instance having been of a light-green color. Thirty
observations were made in the mixed scries: The bladder was healthy in one case, 328, large in one, 225, small and
collapsed in one, 204, and empty or nearly so in 191, 282, 311, 380 and 381. It contained one fluid ounce or less of bile
in the four cases, 137, 1.54, 182 and 304, dark-brown in the second instance, and gamboge-colored in the third. In 1.55
it contained twelve drachms of dark bile, and in 185, 139, 187 and 166, respectively, two and a half, three, three and
three-quarters and five ounces of liquid. It was distended also in the twelve oases, 125, 132, 151, 171, 189, 192, 198,
245, 302, 317, 338 and 383. In 327 the walls of the gall-bladder were disorganized by their participation in a general
peritonitis.
Only two observations on the pancreas were recorded in the typhoid series: In case 29 the gland was said to
have been enlarged and somewhat hard; in 24 it was normal. Of thirteen observations in the malarial cases the pan-
creas was normal in eight, 84, 115, 263, 277, 289, 292, 295 and 366 ; it was soft in one case, 67, in which it was of a red-
dish color, and firm in three, 90, 274 and 278, in the first of which its color was white and in the others somewhat
reddene.d; in 288 it was of a purple-flesh color, and in 373 dark-colored and slightly congested; its weight varied
from two and a half to four and a quarter ounces. Nine ob.servations were recorded in the tij2)ho-tiialarial cases:
In 62, 68, 93, 110 and 265 it was normal; in 111 large; in 112 of a grayish color ; in 67 soft and of a dull-red color, and
in 86 reddened and increased in weight to seven ounces. Of seventeen observations in the mixed series the organ
was normal, so far as can be learned from the records, in thirteen cases, its weight ranging from two and a half to
four ounces; it was recorded as white in color in 154, 155, 181 and 380, not very firm in the first-mentioned case, hard
or firm iji the three others.
The KIDNEYS in thirteen of twenty-seven cases of typhoid were normal. In five of the remaining fourteen
they were congested, with concomitant enlargement in two instances; in three others they were enlarged and in
one of these granular; in five they were pale or fatty, and in one, 26, the right kidney was pigmented on its surface
and contained an abscess with ecchymosed walls, while the left was merely congested. In sixteen of thirty-seven
malarial cases the kidneys were normal; in thirteen they were congested, with softening superadded in one instance;
enlargement was noted in three, in one of which the organs were soft and in another fatty; they were pale in one,
flabby in one, fatty in one; in 278 the right kidney contained a small abscess, and in 374 the left was represented
by a closed cyst in which no glandular tissue could be detected. Of twenty-eight typho-mularial cases they were
normal in eighteen; congested in four, in one of which they were said to have been fatty; large in two; small in
one; small and pale in one; in one case, 110, the right kidney was small and transformed into a thin-walled cyst,
while the left contained large abscesses, and in 93 both were inflamed to suppuration. In sixty-two of one hun-
dred and eight cases of the mixed series in which the kidneys were examined they were pronounced normal. Of the
remaining forty-six cases the,}' were congested in twenty-two, in one of which, 187, there were eechymo.sed spots;
large in four, 227, 275, 369 and 370; pale in two, 217 and 302; fatty in five, 178,244, 307,317 and 345; soft or flabby in
six, 199, 181, 148, 182, 304 and 309, and in the first-mentioned of these they were tumid and emphysematous, like the
liver in the same case, while in the second the left kidney was ecchymosed ; in 243 traces of inflammation were said
to have been present in the right kidney, and in 219 and 220 suppuration had taken place; in 228, 222, 318 and 334
there were cysts which, in the first-mentioned case, contained purulent matter.
The SUPRARENAL CAPSULES Were mottled in case 23 of the typhoid series. They were reported healthy in
three malarial cases, 115, 274 and 292; soft and fatty in 373. Their condition was reported in five cases of the mixed
series: Yellow in 183, soft in 245, small, dark and tough in 281, firm, large and of a reddish-ash color in 380, and
showing traces of inflannnation in 243.
Urinary bladder. — The only observations of interest respecting the condition of this viscus occur in the
mixed cases: Its mucous membrane presented bluish spots in case 333 and was ecchymosed in 342; the prostate
in 239 was enlarged and contained jins.
The pericardium was seldom altered. It contained an unusual quantity of eft'used liquid in case 36 of
the typhoid series, a small quantity of bloody liquid in 26, and in 42 the sac was tuberculous. A manifest excess of
liquid was found in three of the malarial cases, coinciding with efi'usion into the pleura in 258, with bronchial
inflammation on the left side in 249 and with a healthy condition of the lungs and pleura; in 262. No indication of
inflammatory action was recorded in these cases of efi'usion ; but in 90, in which only six drachms had exuded,
the contained floccnli and the fibrinous coating over the serous surfaces testified to an intercurrent pericarditis;
in 276 there were adhesions and the surface of the heart was covered with dark spots and exuded lymph. In the
iyplio-mularial series three cases, 52, 61 and 75, presented an excess of serum, with some injection of the sac in the
first-menticmed instance; in 280 there were signs of recent pericarditis, and in 296 the serous surface was rough-
ened by exudation unconnected with the fatal illness. In the mixed series five cases presented evidence of a peri-
carditis which antedated the typhoid attack : In 324 the opposing pericardial surfaces showed some small roughened
patches; in 356 they were united by a fibrinous band; in 368 the adhesion was more intimate, leaving only a small
sac at the apex in which was an ounce of serum, while in 137 and 139 the sac was wholly obliterated. Moreover,
in 320 the pericardium was firmly united to the costal cartilages and sternum. On the other hand, in 182 and 183 the
effused liquid, although not large in quantity, was of a red color, and in 309 the sac is said to have been filled with
The KIDNEYS were seldom and slightly affected. They were somewhat enlarged in three cases and of diminished consistence in six. of thirty-sis
caiscB. Their color was darker than usual in seventeen of forty-two cases, and this coloration was more frequent in those who died early. The mucous
memhrane of the pelves was thickened and injected in one case, and in a second, presenting similar injection, it was bathed in pus.
The lining of the bladuer was injected in six cases, somewhat softened in two, and in one slightly ulcerated near the urethral entrance.
The PEiticARUirM was seldom altered ; in seven cases it contained a little serous liquid, which, in one instance, was sanguinolent. None of the
cases presented the slightest trace of recent inflammation, in this difl'eriug from oases of other acute maladies and esiiecially from cases of pneumonia.
OK TIIK COJNTINUED FEVERS. 421)
purulent matter. Excess of liquid, from inroo to six or eight ounces, was fojind in ten cases, 13G, 170, 173, 206, 302,
307, 327, 328, 329 and 383, in two of which, 206 and 307, the pericardium is said to have been thickened, and in two
others, 173 and 327, somewhat injected; the lungs were more or less engorged in four of these cases; in three the
pleural cavities contained effusion, while I'n three, 170, 206 and 328, there was no concurrent inflammation of the
lungs or pleune.
The condition of the heart is recorded in seventeen of the fifty ti/jihoid cases, in thirteen of which it was
normal; in one, 18. pale: in one, 11, soft and llaliliy; in one, -12, tuberculous on its surface, and in one, 1.5, having its
right cavities dilated. In addition to these observations the contents of the heart were noted in five instances in
which no intimation is given of any abnormity of texture. In the malarial series the heart was mentioned as normal
in twenty-six cases, and in ten others in which reference was made to its covering or contents no alteration of tox-
tu;o was indicated. In twelve eases there were morbid changes: In 2.")2 and 291 the heart was small; in 78 and 377
it presented thickened valves and hypertrophied walls, and in 261 an opaque-white membranous spot on the sur-
face of the right ventricle; it was pale in 262; flabby in 278; pale and llabby in 376; fatty in 251; slightly softened
and ecchymosed in 386, and in 90 and 27t) there were evidences of pericardial inflammation. In the tiiplio-mularial
series it was recorded as normal in twenty cases, and in eleven others in which its covering or contents were men-
tioned its condition does not seem to have called for remark. Its texture or appearance was altered in nine cases:
It was large and hypertrophied in .53 and 96: pale in 112; soft in 67; flabby in 57, 59 and 265; pale and flabby in 267,
and flaccid in 75. The heart is said to have been normal in seventy-one of the mixed cases, and in thirty-three,
in which its coverings or contents were mentioned, the condition of its tissue does not appear to have been
materially altered. Morbid changes were noted in thirty-one instances: In 317 the heart was reported atrophied;
in 310 displaced: in 206 enlarged; its ventricles dilated in 169, 186 and 190, and its mitral valve thickened in 359; in
the remaining twenty-four cases the organ had lost its normal color and tonicity: In 193 it was soflened; in 212 and
243 thinned and softened, the right ventricle in the latter case being said to have been as thin as glove-leather;
in 133, 219 and 333 pale: in 191 pale and soft, this case presenting a small purulent deposit near the apex; and flabby
in seventeen, in ten of which, 137, 148, 154, 176, 182, 184, 203, 212, 214 and 2.30, no other qualification was stated;
but in four, 150, 227, 311 and 324, the organ was also said to have been pale; in one, 345, small; in one, 347, anaiiiiic,
and in one, 355, soft. In addition to these, antecedent inflammation is indicated by the appearance of the pericar-
dial lining and contents Ln certain of the cases mentioned in the last paragraph.
The CONTEXTS OK THE HEART were stated in only seven of the typhoid cases, and in one of these, 48, there
was no clot. Both sides of the heart in five cases contained clots, which were fibrinous in 8 and 23, black in
24, mixed in 32, fibrinous in the right and mixed in the left cavities in 26. In ca.se 45 there were fibrinous clots in
the right side, but the contents of the left cavities were not recorded. Of the sixty-three malarial cases the c:iidiao
contents were specified in eighteen : In one of these, 277, there were no clots. Fibrinous deposits were observed in thir-
teen, in two of which, 71 and 293, the side of the heart was not particularized ; in four, 258, 276, 292 and 373, they were
present in both sides; in seven, 115, 2.57, 2.")9, 261, 274, 288 and 377, in the right side only, one of these, 274,'contain-
ing a mixed clot in the left side, and another, 261, a venous or black clot. In 287 there were mixed clots in the
right and fluid blood in the left cavities; in 84 and 90 the right side contained black clots, the left in the former pre-
senting a narrow clot of unstated color and in the latter a mixed coagulum; in 291 the right ventricle contained fluid
blood, the left being empty but for a small fibrinous clot attached to the chordic ten(linea>. The contents of the
chambers of the heart were recorded in sixtjeen of the Ujplw-mnlarial cases: Fibrinous coagula were reported in ten —
in the right side only in six, in one of which, 266, there were venous clots in the left side; in the four others the
fibrin was deposited in both sides. Clots of unspecified color were noted as present in the heart in 69, 86 and 264,
— small and imperfectly formed, in a black and ditllueut blood, in the two cases last mentioned. Clots were also
found in the right side in 106 and in both sides in 62, but in neither is the character of the coagulum stated; in 96 the
right chambers contained fluid blood while the left were empty. The cardiac contents are stated in fifty-three of
the mind series, in four of which, 137, 165, 194 and 329, there were no clots. In three cases clots of an unspecified
character, in one mixed clots, in one black clots and in one uncoagulated blood were reported as having been observed
in the heart, but the containing cavity is not stated; in three cases unspecified clots were found in the right side
and in three in both sides; in one instance mixed clots were found in both sides. Fibrinous coagula were noted in
the right side in twenty-seven instances, in twelve of whicdi the contents of the left side were not recorded, but in
nine ca.ses similar coagula were found in this side — in one an unsiiecified and in one a mixed coagulum, in two ven-
ons clots and in two no coagulum of any kind. The right chambers contained fluid blood in 190 and a mixed clot in
221 and 305, the left chambers of the latter instance being filled with dark clots. The right cavities contained venous
coagula in four cases, 159, 169, 139 and 201, associated with similar clots in the opposite side of the heart in the second
case mentioned, with a filirinous deposit iu the third, while in the first and last the contents of the left side wore
not recorded. In 172 and 203 the heart presented a fibrinous clot in the left ventricle only.
Larynx and trachea. — These parts appear to have met with as little attention at the hands of our medical
ofBcers as the contiguous section of the digestive system. Morbid appearances were noted in only six of the typhoid
The HEAiiT was normal in sizp, consistence and color in twentj-three of tlic forty-six ca-sos. Its tissue was softer than natural iu seventeen cases,
Id eome to so marketl a dejrree that the organ was flaccid and easily torn. Loss of color and thinning of the walls were generally associated with the
wltening. These changes were usually more distinct on the left than on the right side ; and, like the alterations in the liver and spleen, were more
prominent in pitients w ho died at an early period of the attack. Similar changes were found, but with less frequency, in eases of other acute diseases.
In the typhoid affection when the heart was but little softened its cavities, especially those of the right side, contained (ibrinoHS clots; whereas when
the softening was greater the inclosed clots were black, and when the highest degree of flaccidity was present the cavities contained only a few drops of
blood miie<l with air-bubbles. While these facts seem to indicate a connection between the state of the bloo<] and that of the heart it does not appear to
be k necemrf one, as in certain cases of pncnmonia, iu which the heart was very evidently softened, it contained fibrinous clots in its right cavities.
430 PATlIOLOGirAL ANATOMY AND PATHOLOGY
cases: In 12 the epiglottis was swollen : in 30 ulcerated and (Edematous, the vocal chords being similarly affected; in
1 the lining of the larynx was thickened l>y an exudation in the submucous cellular tissue; in 8, 23 and 32 the
jnucous membrane of the trachea was congested. In the malarial series the mucous lining of the trachea was jiale in
84; inflamed, congested or purjjlisli in 90, 115, 259, 277 and 28X; the larynx was covered with false membrane in 371;
the epiglottis ulcerated, the lining membrane of the larynx and trachea thickened and the vocal chords nearly
destroyed in 248. In the tijplw-inalarial series only four observations were recorded: In 68 ecchymosed spots were
found on the posterior surface of the trachea, and in 101 its mucous membrane was inflamed and ulcerated; in 51
the laryngeal membrane was congested and ulcerated and a small abscess was observed between the cricoid carti-
lage and the pharynx, and in 67 the epiglottis and chords were a-dematous and an abscess was connected with the
right arytenoid cartilage. Seventeen observations were made in the mixed series: The trachea was congesteil in
181, 240, 307 and 333, and in 182 the larynx also was involved. The lining membrane of the trachea was soft and
dark-colored- in 301 ; of a purple color in 155, 183, 187, 199 and 304, and to this, in 156, some spots of whitish exudation
were added. In 329 the mucous membrane, which was thick, soft and discolored, presented a slight exudation on
the vocal chords and the laryngeal surface of the epiglottis ; while in 122 and 308 the larynx was lined with false
membrane. In 185 there was an ulceration below the vocal chords on one side and another in the thyroidcan angle.
Lastly, in 339 the trachea was inflamed, the larynx ulcerated and the glottis occluded by oedema.
The THYROID BODY was mentioned in but two of the cases, both belonging to the mixed series: In 204 it was
enlarged on one side, and in 193 the left lobe contained a calcareous mass as large as a walnut and a small cyst filled
with dark-brown liquid.
The condition of the bronchial tubes was seldom reported. They were inflamed in a few cases, as 29, 32, 38
and 47 of the tii2)hi)id series; 115, 249, 258, 274, 283 and 362 of the malarial; .55, 62 and 102 of the iy2)ho-malarial, and
124, 148, 169, 185, 191, 193, 239, 245 and 380 of the mixed series. In 281 and 331 the smaller tubes were plugged with
fibrinous exudation, and in 362 they were so thickened and indurated as to appear on section like small prominences.
The LUNGS were pronounced normal in only five of thirty-four typhoid cases in which their condition was stated.
They were engorged or congested in fourteen cases ; cedematous in one, 3 ; more or less hepatized or solidified in twelve,
5, 6, 7, 9, 23, 24, 29, 32, 38, 41, 43 and 45; splenified in one, 8, and in one, 42, tubercular. Generally the engorgement
and hepatization were in the lower and posterior parts, but sometimes the whole of a lung is said, as in 38, to have
been affected. Generally, also, both lungs participated in the pneumonitic processes, but in some, as in 6, one lung
only was involved. The third stage of inflammation was reached in case 5. In 29 and 32, hepatization was localized
in nodular masses from the size of a chestnut to that of a hen's egg; splenization in 8 was also lobular. It is probable
that the term engorgement, congestion or hepatization was used in some instances to indicate that condition of the
lung-tissue recognized by Loois as splenization, for in case 25 the solidification is evidently distinguished from that
caused by inflammatory processes. The lungs were altered in thirty-two of fifty -eight oljservations in the malarial
series, normal in twenty-three, and unrecorded in three in which pleuritic adhesions are mentioned. They were
engorged, splenified or hepatized in thirty cases, two of which. 258 aud 288, were marked by subpleural ecchymoses,
three, 252, 276 aud 289, contained abscesses, and four, 105, 274, 278 and 377, tubercle; in 113 the lungs were emphy-
sematous, and in 87 the left lung was compressed by a purulent collection in the pleural sac. In the tijpho-malarial
series the lungs in nineteen of fifty-one cases were normal aud in thirty-two altered. Of the latter they were tuber-
cular in one, emphysematous in a second, oedematous in a third and congested, splenified or hepatized in twenty-nine,
in one of which, 65, there was a large abscess in the middle lobe of the right lung. They were normal in forty-seven of
one hundred and sixty -three cases of the mixed series; congested, splenified, hepatized or infiltrated in one hundred
and four, in three of which purulent collections had formed, multiple and small in 138, single in 315 and 383 and of
large size in the last-mentioned case ; emphysematous in four, tubercular In seven and in one, 340, compressed by
a large quantity of bloody liquid in the left pleural sac.
The PLEUR.E. — Adhesions in three of the typhoid series, 9, 37 and 45, ])robably antedated the typhoid attack;
but in 5 aud 32 they were certainly associated with the fatal sickness. The pleural cavity in 12, 23, 32, 36 aud 42
contained serous eft'asion which was connected in all except, perhaps, 23, with other and distinctly marked signs of
Tho EPIGLOTTIS was covered with false membrane in two cj^s in which the pharynx was similarly affected ; in one there was a rod spot on it;*
inferior aspect and in seven it wa« more or less ulcerated, the pharynx participating in the ulceration in three of the cases. From the rarity of ulcei-a-
tion of the epiglottis in other acute diseases Lotris regarded this lesion like the similar affection of the pharynx aud a-sophagus as of a character peculiar
tu typhoid fever.
The GLOTTIS was cedematous in two cases, but this condition was found to be equally common in imeuinonia.
The MUCOUS MEMBRANE OF THE LAEYNX was blacklsli aud softened in one case, covered with false membrane in three and sliglitly ulcerated in oue.
The LINING OF THE TRACHEA was scldom altered in color and in no case ulcerated.
The BRONCHIAL MTJGOus MEMBRANE was ofteii of a red color; but it was thickened in only one case. Generally the tubes contained a thin bright-
red mucus ; in three cases they were enlarged.
The LUNGS in fifteen cases were healthy or only a little darker in color posteriorly, with or without some rounded spots a few lines in diameter and
depth. Ill two cases they were somewhat emphysematous. There was splenization in nineteen cases, generally in one or both of the lower lolies, the ■
splenified part being heavier than water, firm, of a dark bluish-red color, giving issue on section to a thick dark-red liquid and destitute of the granular
aspect of hepatized lung. Congestion or hepatization was present in seventeen cases, some of which had the lower lobes splenified; the eon;.estion
was sometimes lobular, more frequently so than the hepatization, but generally both were continuous, although not occupying in any case a large portion-
<if the organ. Abscesses were found in one of the hepatized lungs. In one case the lung contained a filamentous tumor one inch in diameter; in four
cases some semitransparent granulations, and in one case crude tubercle.
The PLEURiB. — Although adhesions were present in nineteen of the forty-six cases, there were signs of recent inflammation in two only, in one a
soft false membrane and in the other a floceulent efl"usion; the pleural sacs, however, in nineteen cases contained a reddish serosity varying in quantity
in individual eases from three to thirty ounces. But similar conditions of the bronchial tubes, pulmonary tissue and pleural membranes were observecl
in thirty-five cases of other acute maladies exclusive of pneumonia and pleurisy.
ov TiiK contikuf;d fkvers. 431
iiiflaTiiinatiou of tlio membrane, and in 42 with tiibeiTular disease of the Iinigs; blood was clfiised into the ])leural
cavity in HI. In tlie nialarhil series adliesions were foiinil in the five eases, 251, 3(i2, 3(11, 371 and 377, but tlieir
recent character is not indicated; on the otlier hand, in 71, 73, 87, 21!1, 2C>><, 288, 289 and 387 there is evidence of
pleuritic complication. The adhesions in 57, 5!l, 6() and 2(!(i of the li/])liu-maluriul series are also of old or uncertain
date; but in 85 the clinical history shows their recent formation, and in 62 the lymph on the base of the lung connects
the small quantity of bloody liquid in the pleura with intlaumiatory action, although it is not certain that the larger
quantity of serum in 69 was the result of other than passive piocesses; in 65 the right xdeura was inflamed, and in 100
the right sac contained four ounces of sanguinolent serum. I'lenritic adhesions, without other indication.s of pleural
inllaiiimation, are mentioned in twenty-three of the mij-nl serii's; in about half of this niiinUer they certainly ante-
dated the fatal attack and jiroliably also in others. In four cases, 128, 23.S, 321) and 368, etVused liipiid was found in
the pleural cavities, but whether as the result of active or passive processes is uncertain. In three cases, lis, 21!l
and 283, which presented l)otli adhesion and etiiision, the date of neither is defined. Tliirtei^n ca.ses showed decided
indications of recent inflammation of the .serous memliraiie — 173, 185, 195, 309, 311, 315, 318, 331, 3.55, 3.57, 360 and
380. In aiUUliou to these 168 and 333 had in each pleural sac a small (juantity of dark sanguineous serum, appa-
rently connected with pulmonary engorgement and hepatization, while 310 presented on one side a largo eflusion
of a similar character, which compressed and consolidated the corresponding lung. Pleuritic adhesions in 203 and
effusion in 311 were of tubercular origin. The presence of purulent matter in the pleural sacs of 383 was due to the
rupture of pulmonary and intermuscular abscesses into them.
The iiUAix AND ITS MEMHKANES woro nonnal in five of eleven typhoid cases in which their condition was
stated: The membranes were congested in two cases, 8 and 26; in the former the cerebral substance was soft and
there was a small iiuantity of li(iuid in the ventricles; in the latter the brain was apparently normal. In neither
of the.se is mention made of eli'usion in connection with the meningeal congestion; but in three others there was a
quantity of serum in the subarachnoidal spaces, especially at flie vertex, and this was associated in 45 with a normal
brain-substance, in 42 with softi'uing of the brain and serum in its cavities, and in 9 with congestion of the cortical
substance, marked vascular puncta in the medullary tissue and efi'used liquid in the ventricles; in 47 there was
nmch serum in the ventricles. The condition of the brain or its membranes was mentioned in seventeen of the
malarial cases, and in six of these both were normal. Of the eleven in which attention was directed to abnormal
appearances the brain alone was mentioned in three — in 276 as ameniic, in 84 as softened, and in 259 as softened
and with the ventricles distended with effused serum; in two others the membranes alone were mentioned, the
meuiugeal vessels being injected in 104 and the pia mater aua'uiic, opaque and wrinkled in 291; in one case, 288,
the pia mater was congested in its posterior part while the brain was firm. Of the five cases remaining the sub-
arachnoid spaces and ventricles contained effused liquid in 278; the pia mater and posterior part of the brain were
congested in 247; the membranes congested, the subarachnoid spaces distended with !i(iuid and the surface of the
cerebrum and the floor of the fourth ventricle ecchymosed in 287; while two cases only, 80 and 257, presented definite
evidence of recent inflammation — in the former lymph on the surface of the hemispheres, in the latter on the base
of the lirain and in both iu the ventricles. The brain or its raemhranes were affected in seven of thirteen tijiiho-
malarial cases in which they were examined; In 268 attention was directed to the brain only as containing a tumor;
in 264 and 297 the condition of the brain was not stated, probably because in neither did it present any abnormity — in
both the meningeal vessels were engorged; iu 99 and 109 the membranes were auanuic, in the latter the cerebral
matter was also amemic, in the former white and soft; in 86 there was general congestion with eliusion into the
subarachnoid spaces and ventricles, while in 111 eflusion into the ventricles was associated with thickening and
opacity of the arachnoid over the interpeduncular space. The brain or its membranes were normal or healthy in
twenty -eight of the mixed cases, and in two others, 140 and 148, the firmness of the cerebral substance may not be
regarded as morbid. Changes from the normal were reported in twenty-one instances: In 202 the cerebral vessels
were engorged; in four the condition of the brain alone was stated — as firm and congested in its posterior parts in
3W, congested and with a snuill quantity of bloody liquid in the ventricles in 301, congested and softened in 281,
and congested to a crimson color in its upper and anterior portions in 194; in 156 there was some roughness of the
ventricular lining but no meningitis. In eight cases the condition of the membranes alone is stated, the brain sub-
stance inferentially beinj, normal ; in four of these, 168, 208, 343 and 349, there was a slight subarachnoidal eflusion;
in 344 the meningeal vessels were ana'mic and seemed to contain air-bubbles; in 160 and 180 these vessels were con-
gested, and in 117 there was a slight degree of arachnitis, but the facts on which this conclusion was based were
The CRRRBRAL MKMRRANKS. — Four cases had two or three small spoonfuls of ctear serum in the upper part of tfie ai-achnuid ; am! in one of these
■one albuminout. |tarticles adliered to the visceral layer, while in a fifth ease the corresponding part of the pariebil layer was similarly affeeted. In four
CMe0 then- was some opacity, but no eflTusion, at the upper iKirt of the membrane, a lesion regarded by Louis as antedating the typhoid attack. The sub-
anrhnnid cellular tissue contained serosity in twenty-eight cases; copious iu four but slight in the others, and in some occupying only the occipital sulci.
In Do c»ee was there adhesion Ijctweeu the arachnoidal layers. The pia mater was injected in a number of cases and remarkably so in eleven, in most of
whkh tbe upper cerebral veins were distended ; in one case some air-lmbblea were observed in these veins.
The CEREBRCM. — The cortical substance was of a uniform roseate hue in seventeen cases, speckled with blackish points in one case, and in two
ouen darkened almost to violet; tbe medullary sul>stjince was deeply congested in seven cases and slightly injected in thirty-two. In general thisconges-
tion of the brain-tissue was proportioned to the injection of the pia mater. The cerebral matter was firmer than usual in six cases, softer than usual
m flte; but these alterations had no relation to existing conditions of congestion. Louis henco concluded that iucreiused firmness represented merely
phjaiological differences in the tissues of the organ, but that diminished consistence, which was more distinctly marked, might be considered a morbid
f«rfoo analagons to the softening found in many cases in the liver and heart. No .serosity was found in the third ventricle in any of the cases; in the
Uteiml ventricles there was in six cases no effusion, in twenty-eight slight effusion anil in twelve several spoonfuls of liquid which in two was turbid.
The CEREBELLUM participate..!, but not in all cases, in the changes which affected the cerebrum. Similar encephalic lesions and in nearly the
«■>• proportion were found in patients who died of acute diseases other than typhoid,
432 PATHOLOGICAL ANATOMY AND PATHOLOGY
not recorded. In four cases, 139, 175, 183 and 217, in which the brain was reported healtliy, there was injection of
the pia mater with subarachnoid effusion. Lastly, in three cases in which the brain and its membranes were both
mentioned as having undergone alteration, there was iu 299 effusion into the subarachnoid spaces and ventricles, with
contrestion of the brain-tissue, in 379 some exudation on the arachnoid, with engorgement of the brain-substance
aud distention of the lateral ventricles with blood-tinged serum, and in 303 lymph at the base of the brain, with
injection of the membranes and turbid serum in the ventricles.
The BLOOD was found in an unusually fluid condition in the typhoid case 25, in the malarial case 70, in the ti/pho
malarial cases 96 and 261 and in case 150 of the mixed series ; in 204 of the last series the blood was said to have con-
tained few white corpuscles.
CEdema was noted in few cases: the iieck was affected in 12 and the legs iu 36 of the typhoid series; the lower
extremities in 70 and 78 of the malarial series ; the hands and feet in 346, and the body generally iu 307 of the mixed
series.
Purulent infiltrations and deposits.— In one of the typhoid cases, 38, pus was deposited iu the greater
pectoral muscle and in the knee, elbow aud wrist joints. The articular cartilage of the kuee was destroyed and the
joint and synovial bursa filled with lymph and pus in 289 of the malarial series. Purulent deposits were found in
several of the mixed series: Within the sheath of the rectus abdominis iu 151; in the abdominal walls in 244; iu the
subperitoneal cellular tissue on the left side a little below the diaphragm in 199; in the muscles of the arm and
shoulder in 253; in the pectoral region opening into the pleural sac in 383; along the track of the psoas magnus
in 382; between the muscles of the lower extremities in 125; in the right buttock, communicating externally by a
small aperture near the anus, in 185, and in the prostate in 239.
Extravasations of blood in the voluntary muscles. — Blood-clots were found within the sheath of the
rectus abdominis in 248 of the malarial series, in 63 of the typjlio-malariul and 157 of the mixed series; the upper third
of the muscle was affected in 63, the lower third in the others. To these may be added 136 of the last-mentioned
series, in which the anterior abdominal wall was said to have presented contusions aud subperitoneal blood-clots,
and 98 of the typho-malarial series, in which an emphysematous and engorged condition of the tissues of the left
side of the neck was believed to have been the result of an ante-mortem blow.
Petechial or ecchymosed spots or blotches on the skin were noted in the post-mortem records of two of
the typhoid cases, 36 and 45; but in six others the clinical history refers to their existence during the course of the
disease: Thus, in 5, 21 and 49 there were petechiie on the chest, abdomen aud thighs; in 16 a few minute reddish
spots which did not disappear on pressure; in 2 blotches on the face, abdomen and chest, aud iu 34 vil)ices on the
abdomen. In eight of the malarial cases, 260, 261, 289, 292, 293, 295, 386 and 387, the surface of the trunk or of the
body generally was more or less ecchymosed ; in 292 and 293 the skin was reported also as dingy or bronzed. Of the
typho-malarial series 273 is the only case in which the record notes t\\e post-mortem appearance of spots of this char-
acter, in this instance situated on the abdomen and chest; but the clinical history of 86 and 114 indicates their exist-
ence, while that of 93 shows the body generally, except the face and neck, covered with vibices. In the mixed series
of cases only nine instances were recorded of ecchymosed or purpuric spots on the skin. In two of these, 205 and
235, the clinical history is the source of the information that ecchymoses appeared on the chest and alidonien. In
the others the jjost-mortem records show diff'used ecchymoses on the bodj' in 201, a few faint reddish sjiotsor petecbiir
on the chest or abdomen in 202 and 203, purpuric spots iu 351, 354 aud perhaps 303, and a purple pustular eruption in
334. Petechia) were noted on the epigastrium in the ty2>hus case 389.
Bed-sores formed on the back aud hips in cases 5, 23 and 34 of the ly2>hoid series, in 289 and 366 of the malarial
series and in 101 of the typho-malarial series; in the last case they were developed also over the angles of the rilis
on the right side. In the mixed series the clinical history of 117 aud 166 states that the skin over the sacrum becanl(^
red and painful, manifesting a tendency to slough; in 125, 199 and 300 large sores were developed over the sacrum
and trochanters, and in 218 the skin is said to have been excoriated aud denuded.
(Gangrenous spots apjieared on a blistered surface in case 93 and in connection with parotitis in 1U3 of the
typho-malarial series.
Gangrene of the feet is recorded in six of the cases: 278, a malarial case in which amputation was per-
formed at the metatarso-phalangeal articulations; 112, typho-malarial, in which amputation was effected by the cir-
cular method above the ankle, and 138, 143, 163 and 164 of the mixed series. In all the cases both feet were affected;
in the three first mentioned the condition was attributed to frostbite.
Suppuration in the ear occurred in many oases, but in 56, typho-malarial, it appeared to be intimately con-
nected with the fatal event.
Ulceration of the cornea was mentioned in but one case, 49, of the typhoid series.
In connection witli the above the following abstract of a bynopsis of autopsies in thirty-
five typho-malarial cases is submitted. The examinations were made by Assistant Sur-
geons H. Allen and George M. McGill, U. S. Army, at the Lincoln hospital, Wash-
ington, D. C, during 1863 and 1864. The report was filed in the Surgeon General's Offic ,
The SKIN was jaundiced in two cases, affected with erysipelas iu four cases and with eschars in eight. The cellular tissue of the neck wa>
emphysematous and the skin of the part greenish in one case. This condition was found iu eight cases of death from other acute diseases; and in
some of these the emphysema was general, but specially marked in the intermuscular septa of the lower extremities. As the heart and liver were soft-
ened in all these cases and the latter organ itself emphysematous in three, Louis attributed the condition to a morbid Change in the fluids of the body.
The VOLUNTARY MUSCLES Were healthy iu all of tho forty-six cases.
OF THE CONTINUED FEVEKi?. 43^!
Init the general results of the observations were published in the American Journal of the
Medical Sciences* It may be stated that most ol" these cases are to be found in the post-
mortem records that have just been analyzed.
In oiit< i';iso tlio/niiccs and rjiii/lolliii were eoveicil with (liiilitlieiitic iiicMiiluanes, the mai;;iii8 of the epiglottis
and linin}; of the Uirynx ulcerated; in another there was tliifkeniii^f of the uienibrauo but no ulceration. In one
instance the trmlua was decidedly inflamed, but witliout coincident laryngitis or pueuniouia. The aaophaijuii and
phunjnx were healthy iu twenty-seven cases, intianied in three and ulcerated in five. Several of the ulcers were cov-
ered with a greenish exudation, and two, which had perforated the mucous coat, exhaled a gangrenous odor. In
one of the cases of inflammation without ulceration an abscess about the size of a hazelnut was found wIumv the
tube is crossed by the left bronclins.
The /«ii;/s were mottled in every case, owing to the ch-posit of black pigmentary matter; congestion was foiiiid
in fifteen and red hepatization iu ten. Under the heading of congi^stion is embraced every variety of engorgement
from simple excess of blood to a turgidity of the parenchyma, absence of crepitation and the jirescnce of an excessive
amount of sero-sanguineons liquid; all the specimens on section gave issue to a thin dark-red ami frothy fluid.
This conilition ditVered from .siilenization, as under pressure the lung collapsed when the li(iuid was expressed, while
a splenifie<l lung would break down when subjected to this treatment. Hut splenization was frei|nently found asso-
ciated with this sero-sanguiueous engorgenu'Ut. In tlirce of the ten pneumonitic cases both lungs were aft'ccted and
in seven one only: of the latter two were on the riglit side and live on the left. One case was tuberculous, one showed
capillary bronchitis and the remaining eight were normal. J'liiirixii was observed in three cases, in two of which it
was simple and in the other complicated with pneumonia.
The A<'<ir( was generally pale; in twenty-nine cases lirm and in six soft. It contained clots in all except three
cases, and the larger clots were invariably associated with pneumonic complications. Pericardial adhesions were
found iu two cases; the (luantity of effused liquid varied from one fluid drachm to three fluid ounces.
The Jiccr was firm in twenty-four cases and flabby in eleven, but three were fatty, four congested and two
bronzed. Hile was generally present, in quantity from two to twenty fluid drachms. It was usually black, lliick
and tar-like, occasionally dark-greenish, brown or ochre-colored, and in other cases of a more yellowish tinge.
While fre(|uently viscid it was sometimes thin, with a light floci ulcut deposit.
The sjil'iii iu twenty-one cases was firm anil healthy: in fourteen flabby or pultaceous. It was generally gray-
ish-purple externally and bluish-gray or dark-brown internally. In some the softening was so extreme that the
organ would break under the handling necessary to remove it from the body, and whin siiueezed the pulp uoiilil
flow out in a thick coniiniu'd stream as from a sponge.
The iiiltslhii's. — In twenty-eight cases the morbid conditions were confined to the small intestine; in seven the
colon was also inv(dved. The mucous membrane was more or less softened, and in protracted cases of illness its
folds in the lower third of the ileum were obliterated. The parts immediately around the ileo-c;ecal valve were
uniforndy the scat of greater pathological changes than elsewhere. From this point the glandular evidence of disease
cxtenilei'. several feet up the caual, in one instance reaching the distance of ten feet above the valve. No ulceration
was detected above tiie jejunum. The greater lesions were invariably observed iu the clo.sed glands. These in the
earlier stages were tumid, thickened, of a whitish color, with high abrupt walls. Of the whcde niniiber of specimens
eighteen jiresented ulceration in tumefied patches; fourteen in patches not tumefied; in three the (-onditiiMi of the
patches was unnoticed. The character of the ulcer varied as it existed in the swollen or the shrunken gland: In
the former its walls were high, its ba.se red, its form generally circular or sub-oval, with occasionally a low form of
exiulation on its surface. This form was never confluent, and in no instance was the entire surface of a pat<'li the
seat of nlcerative change. Several distinct ulcers, however, were seen in one patch, ami in three instances the whole
area was (lilted with punctate ulcers, giving the gland a hoiu^y-condped appearance. This condition of the agmi-
uated glands w:is always accomjianied with a similar change in the solitary follicles; the enlarged follicles were
fre<|uently so numerous as to give the surface of the gut a manuuillated ajppearance. In the shrunken gland the ulcers
were always of a duller hue, the walls seldom high, and if so, only in the periphery of the aft'ected patch, forming
a rounded subeverted border, the area within constituting the ulcer. The base was chiefly of a dark-blackish color,
due to the presence of pigment. The form of the ulcer was, as a rule, irregular, a condition resulting from the
une<|nal ravages of the undermining process which had taken place at the baiie of the individual follicles. In eight
cases the borders of the patches were scooped out to the depth of a line by this action : in two perforation of the
intestine had taken plai-e in ulcers near the ileo-ciecal valve, and in both of these peritonitis was extensive. The
iWoM was con:;ested in seven cases, in four of which there was follicular enlargement and in three ulceration : in one
case its mucous membrane was thickened and its solitary glands ulcerated, and in another, in which the innnediate
cause of death was hemorrhage, large quantities of blackberry seeds were found in the actively inflamed tissues of
the alimentary canal.
• iluteal abscess was ob.served in oue case. The parotid glan<ls were inflamed in six cases, in two of which sup-
puratiim was noticed. Inflammation of the thyroid gland with Ihyroirl apoplexy and abscess of the salivary glands
was observed in one case. In another an abscess containing a drachm of healthy pus was detected iu the cellular
tissue beneath the diaphragm at the epigastrium.
Tlie scattered facts presented by the records of individual cases having been, for con-
*Vol. XLIX. p. V-iftflKq.
Med. Hist., Pt. Ill— 55
434 PATHOLOGICAL ANATOMY AND rATHOLOGY
venieiK-e in study, consolidated in tlie above analytical summary, some remarks suggested
by their consideration, and references to matters of interest untouclied upon in the analysis,
are herewith submitted.
n.— THE ALIMENTARY TRACT AND ABDOMINAL VISCERA,
The salivaky glands. — The parotid gland was inflamed in 4.1 per cent, of the cases.
No predilection was shown for either side, and in several instances both glands became
involved. In some cases the inflammation subsided after a continuance of many days; but
in the greater number purulent infiltration speedily resulted. As an illustration of the
rapidity with which this was effected case 31 may be instanced, — the gland was observed
to be swollen on the eleventh day of the month, and on the fourteenth, when death occurred,
disorganization had already taken place. In 222 the matter escaped by the ears; in 193
by apertures in the mouth between the root of the tongue and the inferior maxilla, and also
externally a little below the mastoid process. Parotid swelling occurred only after a pro-
longed attack of fever, and was recorded among the malarial as well as the typhoid cases.
It must therefore be considered a result not so much of the direct action of the fever-poison
as of the lessened vitality and deteriorated condition of the blood produced by the con-
tiniftince of the febrile state. Its occurrence in the later stages of typhus* also indicates
its independence of a specific febrile cause. The frequency of parotid swelling in the con-
tinued fevers of the war, as compared with those of civil life, has already been noticed in the
section on symptomatology."}" It seems of interest as one of several morbid phenomena
that occurred in our camp fevers intimating a tendency to typhus, or rather to a return of
the clinical features that characterized the fevers of the unsanitary camps, ships and prisons
of the middle ages. The rarity of notable inflammation of the submaxillary (suppuration
having occurred in this gland in but one case, 384) or sublingual glands or of the pancreas
was in marked contrast with the frequency of these parotid abscesses. HoffmannJ ascribes
the destructive character of the inflammation in the parotid after typhoid to j^ecuiiarities in
the anatomical situation of the gland. The density and inelasticity of its fascia and the
bony structures among which it is embedded prevent expansion during the congestion and
corpuscular accumulation attending the process, so that impaction and necrobiosis are more
readily produced. But although this is true in part, and corresponds with our knowledge
of inflammatory results in similarly situated localities, as in the familiar example of paro-
nychia, the febrile poison appears to exercise a certain influence on the progress of parotid
swellings in view of the infrequency of suppuration as a result of the inflammatory condi-
tion in mumps.
That the pharynx and cesophagus were not more frequently observed to have suff"ered
from inflammatory action appears due to the fact that their condition was seldom examined
by our medical officers. Dr. Harrison Allbin's notes aftoitl the only data for estimating
t!ie frequency of their morbid appearances. The mucous membrane was normal in twenty-
seven of his thirty-five cases, — when altered its changes were such as have been recorded
by Louis in his typhoid cases; it was inflamed in three and ulcerated in five. The post-
*MritciiisnN, 11.216, reports the apitearance of parotid pwelliiigs in 211 of 14,676 patients* admitted into the London Fever Hopi)ita! in the ten years
lSfil-70, and refei^ to tlieirjiresence iu the typlius of military writers, as noted by Monro in the British army operating in Germany in 1761 and hy jAcql'oT
in llie typhns of ttie French army in the Crimea.
f See supra, p. 298.
I Vtdri-mihnnrifn i'lher die PaOioladisch-Anfilmnmhm Veraudrnniijut d-r or<j<nie Imm Ahdomnvilhi^dms. — C. E. E. Hoffmann, Leipzig, 1869, p. 189»
OF THE CONTINUED FEVERS. -llv't
mortem records presented above show in addition the occurrence of ecchynioses, diphtheritic
exudation and abscess.
Tlie observations on the STOMACH were not numerous. This organ was altered in
appearance in 75 per cent, of sixteen typhoid cases, in 51.7 per cent, of twenty-nine malarial,
in 62.5 per cent, of sixteen typho-malarial, and in 50 per cent, of seventh-four mi.xed
febrile cases. In most of these there was more or less consestion, sometimes eenei'al, at
other times circumscribed in patches and in a few cases punctiform; this was often asso-
ciated with softening and thickening of the mucous membrane and in three cases with
ulceration. The ulcers were minute and situated along the small cinvature in 386, near
the middle of the large curvature in 354 and near the pylorus in 96. These hypera^mic
conditions are essentially the same as those found by Louis in his typhoid cases, and con-
sidered by him to be of secondary importance as he had encountered them in death from
acute diseases other than typhoid fever. But it is evident that the changes found in the
malarial series of continued fevers were occasionally of a more intensely congestive char-
acter than those of the typhoid series; ecchymoses and thorough disintegration of the
mucous lining of the stomach, which was filledwith a dark grumous liquid, may be men-
tioned in illustration. Similar conditions were observed in the cases submitted in the last
chapter as belonging to the paroxj'smal fevers. There appears, therefore, some warrant for
referring them to the presence of the malarial poison when they are discovered in certain
cases of the typho-malarial and mixed series.
The condition of the lining membrane of the duodenum was seldom specially recorded,
but when noted in the typhoid cases the lesions were'similar to those observed by Louis
and regarded by him as of minor importance since they had been found with equal frequency
in other acute. diseases. The duodenum was seldom affected alone; generally it participated
in the morbid aflPection of the storaacii. Thus both of these portions of the alimentary
txact were inflamed in 29, 116 and 354, ulcerated in 96, and disintegrated in 71 and 243.
When only a part of the duodenum was aflPected the morbid action was restricted to the
upper third; and even when the whole of this portion of tlie canal was implicated the
jejunum was frequently, ;is in 317, healtliy. On the other hand there occurred some cases,
as 276 and 354, in which the duodenum was affected while the stomach was considered in
a healthy condition; in these the morbid action had extended from below. Briinner"s
glands were noted as enlarged in some instances and in one case, 307, as ulcerated.
The JEJUNUM was mentioned with sufficient frequency to show that it became altered
by the extension of the diseased action from below and not from above.* The lowest part
of the tube was affected when only one portion was said to have suffered, and when the whole
was implicated the action in its lower part was more diffuse and intense than in its upper.
In addition to congestion there was sometimes a softened and thickened condition of the
membrane with enlargement of the solitary glands, and in rare cases ulceration. In many
instances, however, in which the record states only an ulcerated condition of the small
intestine, it is probable that the ulceration affected the jejunum as well as the part of the
canal lying below it.
Intussusception of the small intestine was occasionally found, but not with the fre-
quency recorded by Louis in his typhoid cases. It cannot be regarded as having a special
•HoFFM-^sx — Op. cii., p. [tr — ?a.vR that he hii.* Imt seldom found disease of the jejunnra in typhoid; that when it does occur it is e.\tremely rare f'>r
,lt> upper portion to be involved, and that the duodenum i.s exempt in a still greater degree.
436 PATHOLOGICA]. ANATOMY AND PATHOLOGY
relation to the febrile cases, as it was found with perhaps equal frequency in the diarrhoeal
series.*
LuMBKicoiD WOKMS were also noted in a few cases, but it does not appear that they
had any special connection with the continued fevers.f In 378 a worm crawled into the
larynx of the patient and caused death by suffocation. Specimen 290, Army Medical
Museum, exhibits this worm extended in the larynx, trachea and right bronchus. In 348
the intestinal canal was extensively colonized.
A tumefied, inflamed or ulcerated condition of the patches of Peyee or deep and cir-
cumscribed ulcerations of the intestine which, in view of our knowledge of the typhoid intes-
tinal lesion, might be ascribed to the destruction of these patches, were found in all the cases
of continued fever except those that have been separately presented as probably due solely
to the action of the malarial poison and two of those that were regarded clinically as typhus.
It is evident that the glands in the vicinity of the ileo-csecal valve were especially prone to
become affected, for in some cases it is stated that the diseased action was in progress only
in those occupying the lower part of the ileum; while in cases in which the whole of the
intestine was involved the ulcerative process had made greater progress in the glands near
its termination than in those of the jejunum. This is illustrated by many of the specimens
that have been preserved in the Museum. Three, four or more pieces from different con-
volutions of the same ileum invariably show a progressive increase of the diseased action as
the ileo-cajcal valve is approached. Thus the seven successive portions of the ileum con-
stituting specimens 171-177 present the most gradual transitions from the slightest thick-
ening of Peyer's patches in the first piece to the large ulcerations just above the valve in
the last. Thus also the five portions of the ileum, specimens 376-380, present from above
downwards a gradual enlargement of the agminated glands, the summits of which are more
or less ulcerated in the last three pieces; many of the solitary glands are also diseased,
forming in the lower pieces oval, ulcerated elevations similar in chai'acter to those in the
patches of Peyer but smaller in size. The plate facing this page, prepared from a water-
color drawing of the fresh intestine, reproduces the appearance of the second and last of
these epecimens. The section of the intestine on the left side, taken from high up in the
ileum, shows two of Peyer's patches somewhat thickened, rising from the surl'ace of the
mucous membrane with abrupt edges, the lower decidedly thicker than the upper, but neither
ulcerated; the tawny-yellow mucous membrane is considerably injected and a few slightly
enlarged solitary follicles are scattered over its surface. The section on the right side of the
plate, taken from just above the. ileo-csecal valve, shows in its lower part a large patch much
thickened, with abrupt edges, its surface ulcerated and stained with biliary pigment; eight
similar but smaller ulcerations of various sizes seem to have originated in the solitary glands.
and a number of these glands are enormously enlarged but not ulcerated; the pale cream-
colored mucous membrane is highly injected in patches, which appear as irregular red
stains. The case from which these specimens were obtained is given as 336 of the pod-
mortem records. J Prints from negatives of the mounted specimens are submitted (Facing
pages 410 and 412) for comparison with the chromo- lithographs of the fresh intestine.
It is also evident that the diseased action had a progressive upward movement, for in
but few instances were the upper glands affected while those below were in a healthy con-
* See p. 313, Part Second of this work. f See j«fra, p. 591. t See awte, p. 410.
OF THK OONTINl'K.D KKVERS. 437
ilition. Tn case 290 llicfe wcio thirtv-twD jmIcIu's hI' Pc\-it varyiii<r IVnin liiilf an iiidi lu
three iiiclies in leiiiftli, ami twciity-seven of Lliose were mucli Uiiokeiieil and generally
iiiHanieel I>ut not nleerated; the first two patches of tlie series were not thickened; a large
patch dotted with Mack pigment hut otherwise healtliv was t'ouiid on each told of the ileo-
ca'cal val\e, and th(> next pidcli alin\'e these appeared to he healthy. In another exceptional
case, 200, tiie twelve iip|Hr patches were healthv, the thirteenth uleerati^d, the liinrteenth
healthy and the remainder ulcerated and sloughing, some even through to the peritoneum.
The atl'ected }>atclies in the continued fever cases were usually circular or oval, from
half an inch in diameter to three or four inches in their longest measurement, that parallel
with the long axis of the tulie. Occasionall}', however, they were of unusual size. Thus
specimen 399, Army Medical Museum, from case 198, exhibits in the ileum immediately
aliovethe ileo-ca^cal valve a patch eight indues k^ng, tJie u|)p(U' extremity of which is covered
with minute ulcerations.
The thickening of tlie patches varied from a just perceptible tumefaction, such as is
seen in th<' upper part of specimen 377, to a prominent nude rising gradually from tlie sur
face of the surrounding mucous membram"; but in many instances the margins of the nodes,
as seen in the plate of specimen 380, were abrupt, and in some, as in 565 (see plate
facing page 380), the patches were so constricted at the base as to present the appearance
of Hat sessile fungoid growths. The enlargement was opaque, soft and of a white, yellow
or grayish color, more or less reddened l)y congestion. In some flu^ mucous membrane
covering the patch presented a slightly reticulated appearance from the irregularity of the
underlying surface; this is well seen in the lower part of specimen 377, a:s shown in the
photographic print.
When the morbid action had made furfh(>r progress in such plaques, ulcers ajipeared on
the proiainences and afforded escape to the softened and broken-down portion of the con
tents. These ulcerations became enlarged by the destruction of the interlj'ing glandular
and mucous tissue and the coalescence of adjoining ulcerations until the greater part or whole
of the node was removed, leaving a shallow cavity containing the remains of the glands and
the infiltrated submucous tissue usually stained of a dark or greenish color by the intestinal
contents. Patches seen in various stages of this destructive process presented a variety of
appearances: In some a few minute ulcerations on the apices of individual glands; in others
one or more larger ulcerations at some points, with the remaining surface intact or only
minutely penetrated; and in others again a large irregular ulcerated surface more or less
stained and perhaps bridged in part or overlaid by fragments of the softened mucous covering.
The edges of the completed ulcer were sometimes ragged from the persistence of shreds of
the mucous membrane, but generally they were well defined by a thickening of this mem-
brane and its underlying tissue. Some of these appearances are admirably shown in the
chromo-lithographs of specimens 177, 185 and 189, Army Medical Museum, herewith sub-
mitted. The first of these has already been referred to as one of seven successive portions
of the ileum showing a gradual transition from the slightest thickening of the patches of
reyer in tiie upper part of the canal to extensive ulceration in the lower part. It is from
the case of a soldier of the 6th Pennsylvania Cavalry who was admitted into the Judiciary
Square hospital April 26, 1863, and died May 2. The details of the case were not fur-
nished. The chromo-lithograph facing page 440 represents the ileum in the vicinity of the
ileo-csecal valve; the mu<^ous membrane is reddened by congestion except near the valve,
438 PATHOLOGICAL ANATOMY AND PATHOLOGY
where it is gravish. witli occasional stains of brownish pigment; tlie patches of Peyer and
several of the solitary glands are thickened and ulcerated, the contour and surface of the
ulcers being irregular from the imperfect destruction of the overlying mucous membrane.
The specimens 185 and 189, plate facing this page, were taken from a soldier who died
of fever in the Finley hospital, Washington, D. C, during the summer of 1863. His history
was not recorded. The left piece, representing a portion of the upper part of the ileum,
shows four typhoid ulcers, two evidently based on Peyer's patches and two apparently on
diseased solitary glands. A number of slightly thickened follicles are scattered under the
cream-colored mucous membrane, which is lightly streaked with an arborescent redness.
The contour of the ulcers is irregularly rounded or oval, their surfaces dark colored with a
greenish tinge and their edges thickened and pale but in parts somewhat injected. The right
piece, taken from just above the ileo-ctecal valve, shows two large ulcerated Peyer's patches
and five ulcers apparently due to disease of the solitary glands. The mucous membrane is
thickened, of a livid crimson color and raised at several points into small rounded elevations
by enlargement of the solitary crypts. Tlie contour of the ulcers is irregularly round or oval,
but in some of the smaller lesions the long diameter is at right angles to the axis of the
tube. The surface is stained of a dark-green color, but in the lowest, the largest ulceration,
there are some spots of reddish congestion. The edges are abrupt and thickened and par-
ticipate more or less in the dark injection of the mucous lining.
In many cases, however, some of the ulcers, particularlj' in the lower part of the ileum,
extended through the submucous tissue and exposed the transverse fibres of the muscular
tunic in the bottom of the cavity. In many cases, also, the muscular coat became involved
in the process of disintegration, and the serous covering of the intestine gave way at the
weakened jioint. P>ut in a small proportion of the cases the nodes, instead of breaking down
in this gradual manner, sloughed away en masse; or a part of the thickened patch became
subject to progressive ulceration while another part was removed by sloughing. The patches
are sometimes stated in the record to have been converted into soft pultaceous sloughs.
Thus in cases 13 and 14 of the typhoid series the so-called typhoid deposit was removed
by sloughing, as also in cases 200 and 385 of the mixed series. In 200, according to the
record, one of the patches of Peyer was converted into a blackish-brown irregular eschar
one and one-fourth inches square and one-fourth of an inch thick. In 385 tlie patches were
blackish in color, marked with livid-red and their margins indistinctly defined. Pho-
tographic prints of a jmrtion of tlie ileum in each of the last two cases accomjiany this
report, facing pages 388 and 418. The first, representing specimen 241, Army Medical
Museum, shows a large irregular pulpy slough, its transverse diameter nieasui'ing three
inches and its longitudinal diameter one inch and a half; several small shallow ulcerations
may also be observed on the specimen. The second, representing specimen 182, shows a
large, thickened, sloughing patch, several oval ulcers based on the solitary glands being also
present. When the destructive process was effected in this rapid and genera! way the tend-
ency to perforation was obviously increased.
In the analysis given above of the post-mortem records of the series of fifty pure
typhoid cases there is ample ground for the assertion that the mucous membrane of the
small intestine was affected chiefly, and not unfrequently solely, over and immediately
around the tumefied or ulcerated patches of Peyer. The absence of a general congestion
of the mucous membrane in some cases proves that its presence was not essential to the
•^ V;,
K-
\
"W"^:
f
A
OK THK CONTlNUlil) FKVEKS. 439
diseased condition of the glands. Their affection must tlierefore bo considered the primary
lesion, and any extension of inflammatory processes to the general mucous surface must be
regarded as secondary and as much a consecpience of the morbid action in the glands as its
extension to the serous mcndiranc after the destructionof the muscular f unir. This secondary
congestion of the mcndiranc between the ulcerated patches was usually confined to the
lower part of the ileum, where the diseased action had made most progress. In some
cases, however, it was more generally diff'useil, but in these it was invariably', so far as the
records show, less intense in proportion to its distance from the ileo-csecal valve. Speci-
mens from some of the cases of tliis series, as from 10, 43, 48 and 50, were received at the
Museum and have been preserved, but unfortunately none of them were submitted to the
artist for the preservation in colors of their appearance when recent. Nevertheless the
absence of a diffuse congestion of the mucous membrane in the vicinity of typhoid ulcer-
ations, at least in tln' upiiri- part of the iKnim, is shown by the chromodithograph of speci-
men 185 on the left side of the plate facing page 438. As the history of the case from
which this specimen was obtained is not on record, it is uncertain whether it was or was
not modified by a malarial element. But even had the case been so modified the value of
the drawing as an illustration of typhoid ulceration, unaccompanied by diflfuse iidlanima-
tion of the lining membrane, is by no means impaired. As will be seen directly, a dilTusely
congested or inflamed condition of the membrane was more frequently met with in nmd
ified than in unmodified cases; hence, while the general congestion of 189, shown on the
riirht side of the same plate, may be viewed as due to a malarial complication, the absence
of a similar congestion in 185 cannot be ascribed to an interference of that nalunv
In the malarial series of continued fever cases presenting adynamic symptoms the
condition of the patches of Peyer was not reported in twenty-six instances; and as in most
uf these some details are given of the appearances presented by the mucous membrane of
the small intestine, it may lie iiderred that the patclies were not so altered as to attract
special attention, or in other words, that they or tlie membrane covering them were lieaitliy.
congested or inflamed according to the condition of the general mucous lining. The}- were
healthv in seven cases and not ulcerated in two cases, although in six of these, 257, 260-
263 and 367, the mend)rane was more or less congested or inflame<], and in the last-men-
tioned case ulcerated at one point to perforation. When special attention was given by
the reporters to the condition of the patches they were generally said to be reddened or
altered in color by deposits of black or bluish pigment: They were reddened, congested
or infiamed in ten cases, in four of which the state of the mucous membrane of the small
intestine remained unnoted, while in six it was moi-e or less hyperasmic; it is to be
observed also that in one of these cases, 373. contrary to what is found in typhoid fi'ver,
the glands and mucous membrane ot the upper part of the intestinal tract were i\\v. seat
of the congestion. In case 84, in which the agminatcd glands were reported pale, the
mucous membrane of the small intestine, although showing some streaks of congestion,
was generally bloodless. In 386 most of the glands were healthy, but a few were inllanieil
and slightly thickened, while the ileum was inflamed in patches, some of which were
intensely afTected. In 387 the glands were opaque-wliite and slightly thickened, but did
not ai)pear positively diseased, and the mucous membrane generally was of a pale-cream
color. In the remaining fifteen of thi^ sixty-three cases the patches of Peyer were colored
by deposits of pigment, which will be more particularly referred to hereafter.*
* S«»e tn/nt, p. Hyfi
o
440 PATHOLOGICAL ANATOMY AND PATHOLOGY
The mucous lining of tlie ileum was congested in nearly two-thirds of the cases of
this series. In some the congestion formed streaks and patches, and in these there appeared
no marked partiality for the lower part of the intestine; generally, however, the congestion
Avas diffused throughout the whole of the ileum. The mucous membrane was frequently dai'k-
ened by the intensity of the engorgement and occasionally spotted with ecchymosis; in one
instance the ileum is said to have been gangrenous; nevertheless ulceration was rarely
present. In a few cases the membrane was softened, thickened or thinned. In some it is
stated that there was no congestion of the membrane, and in others the absence of any
statement with resard to its condition, althouo-h the changes in its glands were noted, leads
to the belief that it was not materially affected. In fact the condition of the mucous lining
of the ileum in these continued malarial fevers did not differ from that found in the par-
oxysmal malarial cases submitted in the preceding chapter. The hypereemia of the mem-
brane in the malarial series differed from that met with in the typhoid cases not only
in its greater extent and intensity but in its mode of development. In tlie latter it was
a secondar)' result of the morbid action in the closed glands; in the former, on the contrary,
it must be regarded as a direct result of the virulence of the febrile cause, — a primary lesion
because unconnected with any antecedent focus of inflammation. The agminated and soli-
tary glands were frequently healthy or participated only in the general congestion. In
one exceptional case the gut was perforated, but usually no circumscribed areas of special
activity appear to have been developed, although the engorgement was such that in t\v
cases eccliymotic blotches, and in one gangrene, were recorded as its consequences. In fact,
while the inflammation in the tvphoid cases was confined to the glands, penetrating deeply
on account of their anatomical relations, and spreading laterally along the continuity of the
membrane to but a limited extent from these primary foci, the hypersemia in the malailal
cases was general and primary, differing as much in appearance and distribution from that
in the typhoid cases as the developments on the skin in erythema or erysipelas differ from
those in small-pox during its period of maturation.
In the sixty-one cases of the typho-malarial series the patches of Peyer were tumefied
and more or less congested, as in the earlier stages of the progress of typhoid feyer, in twenty-
one instances. They were ulcerated, as in the later stages of typhoid, in thirty cases;
in some of these, as 56, 93, 110 and 298, they were in process of healing, while in one.
92, their disorganized condition is suggestiye of that remoyal by sloughing which has been
mentioned as occasionally occurring. In ten cases in which the condition of the patches
was not entered on the record, the ileum or small intestine was congested or ulcerated and
in several instances perforated. Deposits of black pigment were found in some of the glands
in three of these typho-malarial cases.
In this series the mucous membrane of the ileum, exclusiye of that covering the affected
glands, was generally congested or inflamed throughout its whole extent ; but in a few
cases the hypersemic condition was confined to its lower portion, and in one it was reported
as forming only an areola around each enlarged and ulcerated patch. In a few cases, also,
softening, thickening, thinning or pigmentation was noted.
Conditions of the mucous membrane and patches of the ileum similar to tliose observed
in the typho-malarial cases were found in the mixed series. Some difference in the frequency
of certain observations may, however, be noted. Thus, it lias been seen that twenty-one
of the sixty-one typho-malarial cases proved fatal at a time when the disease of the agmi-
OK TKK CONTINUED FEVERS. 441
nated glands liad not advanced beyond the stage of hyperseniia and tumefaction. Deatli
occurred in these moditled typhoid cases at an earlier period of the typhoid career than
is usual, and this result must i)e a.scribed to the influence of a concurrent and probahlv
antecedent malarial fever. But uuly twelve of two hundred and thirteen cases of the niixi'd
.-series are reported as having presented luniftiiMl but unideerated glands. This accords w:ih
our knowledge of the constitution of this group of cases. It consisted of pure and m>"lilii'ii
typhoid cases in unknown j)roportions, but the proportion of coincident malarial fevers was
necessarily less than in the typho -malarial series, in whidi every case was moditied by a
malarial euuiplication. The relative iafnijueui'V of unulcerated patches of Pevr in the
mixed series of cases may thus be readily understood.
The LARGE INTESTINE was recorded as more or less altered from the normal <>v li.ahhv
condition in 35.4; per cent, of the typhoid cases, 6S per cent, of the malarial and in o| j,er
cent, ol the fypho-malarial ami the mixed scries of cases. These figures, however, express
only approximately the relative frequency of the implication of the large intestine, as in
many cases in which its condition was not stated there is an uncertainty as to whether or
not it was examined. The appearances indicated that congestive or inflammatorv [irocesses
had been in progress during the fatal sickness or at some period shortly anterior to it. The
mucous membrane was reddened in eiythematous patches or more diffusely and de, ply con-
gested. The latter condition was frequently found at or near the extremities of the gut; the
former in the intermediate parts. With or without this conuested condition in their vicinitv
thesolilaiy glands were in many instances observed as prominences sometimes as large as small
shot and frequently ulcerated. Occasionally the presence of larger nlcerafions was recorded,
hut whether these were based upon the glandular substance or a result ol' the inlhinimatiuii
of the mendjrane independent of the condition of its crypts is uncertain.'" Jn some, how-
ever, as in case 23, it is said that the ulceration was unconnected with the state of the soli-
tary glands. Sometimes the more deeply congested parts were spotted with ecchymoses, and
in a few cases the canal contained extravasated blood. Those parts of the mucous mem-
brane that were but slightly congested were frequently mottled with patches and streaks of
a slate-gray, bluish, greenish or other dark color. Frequently, also, and particularly in these
cases of mottling, the solitary glands, whether jtrominent or not, presented points of black
pigmentary deposit in their apices. In a few' cases softening with thickening, or rarely
thinning of the mucous membrane, was recorded. Ulceration without specially noted con-
gestion appears fivcjuently in the reports of the typhoid cases, while congestion without
ulceration seems to have characterized the majority of the malarial cases. Oidy 30 per
cent, of the large intestines that were observed in the typhoid series presented congestion
without ulceration, while 35 per cent, presented ulceration without particularized congestion;
but in the malarial series 63 per cent, showed congestion without ulceration, while only 16
per cent, were ulcerated, and the mucous membrane in these was inflamed, ecchymosed,
congested or mottled with slate-culored patches.
It may reasonably be supposed that the lesions of the large intestine in a few of the
cases were those of diphtheritic dysentery, as for instance in 323, in whicli the intestine
was softened and disorganized; in 80, in wliich it was said to have been diseased, and in
311 and 316, in which its lower end and lining membrane were reported respectively as gan-
grenous and converted into a pulpy mass. Dr. Woodward has instanced cases 141, 192, 226,
• See infra, p. 450.
Mel. Hi.^^T., Vt. Ill— 56
442 PATHOLOGICAL ANATOMY ANP PATHOLOGY
278 and 800 of Ins (liarrhoeal series as examples of the coincidence of typhoid fever and
diphtheritic dysentery.
The SOLTTAEY GLANDS Were reported altered from the normal or healthy condition in
26 per cent, of the typhoid cases, 38 per cent, of the malarial, 24.6 per cent, of the typho-
malarial and 23.5 per cent, of the mixed vseries. These figures cannot be regarded as accu-
rate expressions of the frequency of such changes in the glands owing to the obvious imper-
fection of some of the records. Nevertheless a more frequent involvement in the malarial
eases seems to be indicated. This deduction may be accepted the more readily as it has
already been shown that in these cases the congestion of the mucous membrane was more
difTTuse and intense than in unmodified typhoid. Not that the affection of the glands was
always associated with existing congestion, for in many instances their tumefaction or ulcer-
ation is the only abnormity mentioned, and in the chromo-lithograph of specimen 185, facing
page 438, they may be seen enlarged on a mucous surface which is not reddened; but from
our knowledge of the histology of catarrhal diarrhoea it is certain that tumefaction of the
follicles originates in hypereemic conditions of the membrane, which at a later period may
subside before the glands have returned to their normal condition. Moreover, pigmentation
of the glands was more frequently found in the malarial cases than in the typhoid; thus,
while in the latter deposits of pigment were reported in but two of thirteen cases in which
attention was given to this point, they were noted in ten of twenty-eight malarial cases, in
five of fifteen typho-malarial cases, and in nine of fifty-one cases of the mixed series; and,
as will be sliown hereafter, this pigmentation was dependent on an antecedent congestion.
The records show also, with some uncertainty, however, owing to their occasional want
of precision, that the glands of the ileum were more commonly affected than those of the
large intestine, and that while the former were altered with nearly equal frequency in all the
sedes of cases the latter appeared more liable to become changed in the malarial than in the
typhoid cases. Thus, the solitary' glands of the small intestine were in an abnormal or
unhealthy condition in 84.6 per cent, of thirteen typhoid cases, in 92 ])er cent, of twenty-
lour malarial cases, in 70 per cent, of seventeen typho-Tiialarial cases and in 78 per cent, of
hfty of the mixed series ; while those of the large intestine were similarly altered in 38.4 per
cent, of the typhoid, 62.5 per cent, of the malarial, 35.5 per cent, of the typhd-malarial and
40 per cent, of the mixed cases.
Louis, while setting aside the changes in the patches of Peyer as peculiar to the typhoid
affection, regarded the congested or inflammatory condition of the intestinal lining, including
also the enlargement and ulceration of the solitary glands, as of an accidental or secoiid;ir\-
character, since he had observed them in cases of death from other acute diseases. In the
})resent section they have been found of even more frequent. occurrence in fevers that did not
exhibit the specific lesions of typhoid than in those. that did, but evidently constituting an
essential of the disease in neither of these classes. Dr. Woodward,* however, has shown
the invariable presence of congestion and the frequent occurrence of an affection of tlie
solitary glands in catarrhal diarrhoea; and since, in the cases of continued fever which were
characterized by these appearances, there had invariably been an antecedent diarrhoea, it is
not surprising to find that the changes in the solitary glands in these cases were precisely
tliose that have been described as characteristic of the simple diarrhoeal aifection. In fact
the case reported as 300 of the post-mortem records of the continued fevers furnished the
* Page 326, Second Part of tliis work.
OF TIIK lONTINUED FFA'ERS. 443
specimen which was used in the microscopic deHneation of the chanjres in the mucous mera-
biane and its solitary ghiiids in cases of acute diarrhwa, — see, in the Second Part of this
work, the steel engraving facing page 326 and the photograpliic print facing page 328. Tlie
patient died of a complicating dysentery associated with a febrile movement of a paroxysmal
character.
The plate facing page 380 of the present volume shows the solitary glands enlarged to
the size of small peas. The portion of the ileum represented, constituting specimen 565,
Army Medical Museum, was taken from near the valve, the case being that reported as 147
of the post-mortevi records. The patch of aggregated glands in the lower hal I' of the specimen
is much and irregularly thickened, and the villi are so enlarged as to give the mucous sur-
face a plusli-like aspect. In connection with the marked enlargement of both the solitary
and agminated glands in this case, it may be stated that in general the solitary glands in
typhoid cases presented characters similar to those of the patches of Peyer, as if they had
been invol\-fd in the same morbid action ; when the latter were largelj' tumefied, extensively
ulcerated or in a sloughing condition, the former were in most instances similarly' affected.
But tumefaction and ulceration commencing in the solitary glands of the ileum not
unfrequeutly extended beyond their boundaries. The surrounding mucous and submucous
tissues became involved, and by the coalescence of neighboring morbid areas ulcers of com-
paratively large size were produced. When small the ulcers were round or oval, when
large thev were less regular in form and not unfrequently their greater diameter lay across
rather than along the intestine. Their edges were usually abrupt and their cavities stained
like those resulting from the disorganization of the patches of Peyer, — see the cliromo-lith-
• graphs of the specimens submitted on the right of the plates facing pages 436 and 438.
The morbid action in the solitary follicles of the colon resulted in similar enlargements
and ulcerations. In some cases the mucous surface was raised by minute rounded promi-
nences; in others pin-hole apertures, produced by the sloughing of the apices of the glands,
permitted their softened stroma with its recent abnormal deposit to be extruded, leaving
small cavities in its place; in others again the extension and coalescence of neighl»oring
ulrcrs gave rise to larger patches of irregular outline, sometimes even an inch in diameter,
and in these the muscular coat was frequently exposed. The appearance of the colon when
altered by follicular ulceration has been illustrated in the Second Part of this work, — see the
photographic prints of specimens 206, Army Medical Museum, facing page 516, and of 195,
facing page 526. The former exhibits ulcers varying in size from a mere puncture to a
break one-tenth of an inch in diameter, with a series near the centre of the specimen enlarged
by progressive ulceration and coalescence to a diameter of over half an inch. The latter
shows a more extensive ulceration, which originated apparently in a morbid condition of the
solitarv glands.
The changes in the minute anatomy of the mucous membrane'^' in typhoid, whether
* To permit of ready comparison with the statements in the text, a g\immary of the views and observations of some reeent investigators in herewith
snliiiiillwl. KoKlTANSKV— i>/.rf.tir-» ,1,-r P.Mnl.i/isihni .t i..i(. .iin>, Vienna. ISGl, Vol. Ill— says that two stages may !» ol>serve<l in the typhoid prcx-ess
affertiiii: tl»e mu>'ous memlTane of the small intestine. In the first there is an acnte catarrhal inflammation of the ileum, chiefly of its lower half; the
niemltrnne is injected, its villi tnrgescent and its apninateti and solitary glands visibly enlarged. In the second the hy]Mfnemia is coni-eutritetl upon (he
elands, which Ipecome swollen in cons^fijuenco of evndation and hy|terplasia of their structural elements. .\n injectetl va.scnlar network surrounds the
I<ilclies. which are ihirkeneil and have an abruptly rising margin ; sometimes a constriction around the base gives them a fnngns-Iike .-ipiMMrmce.
The glands are firm and have a grayish, yellowish or pnle-red color, visible not only through the mucous coat but also through the outer layers of the
intesline ; or they are s«>ner, more yielding and of a darker or bluish-re4l color. \ section of one of these tumefied patches shows a uniforiri degenen»ti»m
"f its glandular stnicture and its bed of connective tissue into a marrow-like substance, which invades the overlying membrane, and in some instances
f<enetrates beyond the submucous layer into the muscular coat. This degeneration is the result of an excessive development of the exuiled plastic ele-
ments. The solitary follicles are in like manner enlarged, firm and surrounded by a va-scular zone. The diseased process hji-s two uhkIcs of tenninatiun —
moltition and sloughing. When resolution takes place the swollen glands become less dense and resistant ; a grayish opaque liquid replaces the firm
444 PATHOLOGICAL ANATOMY AND PATHOLOGY
pure or modified, appear to have depended wholly on a condition of hyperplasia. The first
of the observed changes was a congestion of the capillaries and small veins, particularly
noticeable in the vascular circlets surrounding the closed glands. This was followed by
an increase of the lymphoid elements of the adenoid tissue of the mucosa and the submucous
connective. These elements accumulated in the mucous membrane between the follicles of
Lieberkuhn, which were pushed apart, and in some instances occluded, giving rise to the
appearance of closed cysts embedded in the prominent mass of the new elements. They
accumulated also in the solitary and agminated glands or at particular points in or beneath
the membrane, wliich, when thus raised into prominence by the newlj^-developed mass,
were undistinguishable from enlarged glands. Numerous swarms of these lymphoid cor-
puscles were found also around the swollen glands or pseudo-glands in the vicinity of the
small veins, and disposed in irregular stellate groups corresponding in outline to the serous
canals of the connective tissue. Accompanying these aggregations of the corpuscular ele-
ments was an infiltration of plasma which relaxed the cohesion of the reticular matrix and
increased the size of the lymph-spaces.
The tumefaction caused by this accumulation of the lymphoid elements disappeared
gradually, the site of the aggregation resuming its normal aspect as resorption of the plasma
and broken-down corpuscles was effected; or the swelling continued to increase until by
pressure on the nutrient vessels a necrosis occurred at various points, leading to the devel-
opment of ulcers varying in size with that of the necrosed tissues. In some instances these
ulcerations, beginning as mere points, became extended and coalesced into larger areas by tlie
progressive infiltration of the surrounding tissues and the concomitant interference with
nutrition. In other cases in which tumefaction was suddenly developed tlie whole mass
elements auiJ, aftpr tbo absorption of this, there remains a slate-gray or black pigmentation of the mucous membrane and glandular plexus. Slongh
ing of the agminated glands nut only involves wholly or in part the membrane covering them, but also other and otherwise normal adjacent tissues
through which the typhous product has become diffused. The portion to be thrown off has meanwhile been converted into a yellow or yelluwisli-brown
substance like yellow tubercle, deriving its surface coloring from the presence of bile. The process seizes upon the part uniformly throughout, or fre-
quently distinct portions of a patch are removed by sloughing while other parts undergo a simple resolution. The solitary glands piii-sue the same
course ; but they are slower in their progress and their slouglis are small and round. When the muscular coat is involved the peritoneal coat thus hiid
bare soon becomes gangrenous and peritonitis ensues ; even when the muscular coat has not been originally implicated a necrosis of its tissue in layers
may take place at a later period and the process extend to the serous coat with the same consequences. Perforation is generally effected at some distance
above the ileo-caecal valve. Sometimes the development of the agminated glands is inconsiderable ; the swellings do not rise much above the general
surface ; they are relaxed, and occasionally their individual cysts become disorganized and burst through the mucous membrane, giving by the nunn'i"
ous resulting depressions a net-like aDDearance to the surface. In rare cases only a single group of glands attains to an extreme stage of the typhoid pro-
cess, while in others there is no glandular involvement and the intestinal affection is limited to a catarrh of the mucous membrane. In other casei*
there are present thick, hard, glandular tumors passing into a fungoid condition at the intestinal surface and accompanied with intense hyperaeniia nf
the surrownding parts, which gives rise to hemorrhage ; or in some instances the typhoid matter developing towards the exterior penetrates the muscular
tunic and gives origin to a pseudomembranous efflorescence on the peritoneal surface. After the separation of the slough the mucous membrane around
the margin of the ulcer sinks to the level of the latter and appears, in proportion to the original thickness of the gland, as a more or less broad, free
and movable border, at fii"st rather elevated, red and injected, and afterwards more relaxed and of a dark-gray color. Healing proceeds from the cir-
cumference towards the centre; the overlying iimcous border unites with tlie exposed layer of submucous cellular tissue, from which a cell-growth
springs up and the surface becomes transformed into a facet having a lustre like that of a serous membrane. Over this the advancing edges of the sur-
rounding muruus membrane are gradually extended, though not with equal rapidity from all parts, until they finally meet. Occasional instances are
met with in which a membrane furnished with villi and crypts is found to cover an extraordinarily large area where loss of substance had taken
place, and imperfect villi may be observed in the verj* centre of the facet-like cicatrix ; these circumstances render it probable that a mucous formation
takes place from the cicatrix itself. After the healing of the ulcers a shallow depression remains, due to the tJiiuned mucous membrane adhering more
intimately to the defective layer beneath ; and not unfrequently there is seen in the centre a small portion of the smooth lustrous cicatrix still uncovered
by mucous membrane ; in other instances the mucous coat is smooth, without folds, less pliable and in comparison with the surrounding tissue less vas-
cular, and in patches less rich in villi. These appearances are sometimes found after a lapse of thirty years. Only in rare cases, in which there has been
an extensive loss of substance, does contraction of the cicatrix give rise to a noticeable stenosis. Occasionally the mucous margin around the ulcere
becomes bypertropbied and remains permarently raised, contributing nothing to the covering of the cicatrix, while sometimes it has no connection with
the subjacent layer and projects into tbi- hollow of the bowel. Harlet — in Ii€ijuoM''s Si/siein of Medicine, Vol. I, London, 1866, p. 572 et setj. — says that in
the earliest stage of typhoid inflammation the patches of Pej^erare slightly swollen and a little more vascular than in health. The swelling implicates
the network of mucous membrane chiefly, the ridges between the crypts becoming more vascular, wider and prominent, aud the intervening depres-
sions more contracted and deeper, while the glands themselves apjioar unaltered. The influnimatory jiroducts are therefore furmed around the closed
glands and not in their interior. Careful observation leads him to speak positively on this point ; bat an examination of the illustration on page 449,
infra, suffices to disprove this. He has never seen the glands project on the surface of the patch ; they are placed below and between the swollen mucous
ridges, and in the later stages are completely buried beneath the inflamed surface. When this covering becomes disintegrated they are discovered lying
deeply in the abundant submucous tissue and exhibiting little or no increase of size. The cellular texture is infiltrated with finely granular corpuscles
of various sizes, chiefly spherical and averaging 35*35 of an inch in diameter. In the more advanced and ulcerated patches the cells are equally numer-
ous, but are large and of more uniform size, averaging 5^55 of an inch, and a little more darkly granular. In still more advanced stages the eniargad
.^'^uxofrapked iyMrKCiim:
'-rUv^mer.
THREE PERPENDICULAR SECTIONS OEILEro^
enlaxgemeiit softenmg and ulcer atiorL
of tke solitary- glands .
Mis?n]fi«l 12 diameter?!
OF THE CONTINUED KEVERS. 415
of an infiltrated and impacted patcli, with much of the underlying and surrounding submu-
cous tissue, was involved in the necrosis antl separated as a slough. Many of the micro-
scopic sections tluit have been preserved show the vessels of the affected parts filled with
blood corpuscles and their j)eriphery >>urrounded by swarms of the new corpuscular elements,
but in none of these sections, nor in those recently cut for examination, were those plugs of
micrococci observed which Klein invested witli thr important rolf of cunsing tlu^ death of
the tumefied parts.
Enlargement, softening and ulceration, as affecting the solitary glands of tho ilrum and
their site iit the mucous and submucous tissues, are illustrated liy the plate facing page 44-1.
This is an engraving on steel from photograjths of specimens in the microscopic collection.
The section on the left of the plate represents specimen 1745, the middle section 1747 and
that on the right 1750. These are three of a series of six specimens, 1745-1750, showing
various stages of the ulceration of a solitary gland in the ileum from a. case tlu; history of
which is unknown, but in which tlie patches of Peyer were thickened at their edges an<l
destroved in their interior by eroding ulcers, and the solitary glands the subject of what has
been called pinliead enlargement and ulceration. The gland in the section on the left, of
the plate is slightly enlarged and elevated, and embedded in a mass of the new lyniplioid
cells which ajipear as a well-defined and darkened setting. In the middle section the out-
line of the gland has become obscured by the impaction of the surrounding ti^nsuo with
corpuscular elements, which have also extended through the submucous connective in more
or less dense swarms as far as the muscular tunic. In the section on the right the mucous
membrane has given way, forming an aperture into a small cavity containing and surrounded
by the altered tissues of the mucous and submucous coats.
cajwiil«>s i-(iiit:tiii with<Tiilp« of oil ami there is imu-h iiiteiT(»rpnm;iiI;ir iiioli-cular iimtter. Swelling of the iiKlivtdual glanils at this iK-riod is duo tn the
♦■nlHrgi-mriit nf the (orimm-les funning their )mn'nrh.vnia. lIoKtM.vNN — ('ulnntiihimycn Hber die Patholotjisch-Antifomm'hen veriimleruuynt tlrr Orginie bi-im
AMr-miunt Itiphns, Leipzig, 1HC9, p. KiTt el se.y.— states Ihjit typhnicl frvrr is nsht-reil in hy aente cjiturrhul changes in the intestinal mnrnns nienihnine, the
rapillaries h«-i»niinp dilated and the circulation retarded, whilf marU.d cxudatinn takes place iu the nnietius tissue. Fre<|Ufntly after death the affectt-d
CHpitlaricM of ih'- rarlit-r etagt's uf tin- disciiae, together with tlioN- of (hi- dri'|H-r layi-rs of the mucons coat with whirh tliey roiiiii'ct, are still found enlarged
and fiHcl wilh hhM»«l coi-piiwU'>, tin- red as a rule predominating, although sonn-tiniL's white rurpnsehs aggngatcd in spotw are ohsi-rvt-d in eonsidcrahle
niimtM-n-. Towanls and within lln- follicles the ve.vsids diniiitlsh in calilire. The thi( kncss of the vascular walls corresponds to their enlargrnient, so
thai whih- thf vcswds in Ihe >nune<IJate vicinity of the follicles show a double contour, in those more distant this condition becomes less distinct and Is
often wanting. ri>on the dilatation of the vetwels and Ihe engorgement in connectten with it depend in jiart the nuirhid appearances in the early stages
of Ihe diseaw' ; tlie tui-gid vascular network around the folli(des and other fully-charged vessels throughout the tumefied tissues give to the nuicous sur-
face its n-^t color. lU-sulting from these vascular conditions is a slowness of circulation with a corresponding exudation into the mucous tissues, pro-
moting an ahumlant shtnlding of thec])itlieliuui. The dilated state of ihe vessels is often associated with small extravasations, and occasionally, in sevoro
rawfi, with more extensive ecchyniotic blotclns ; nioreovir, tin* pigmentation frequently observed in the later stages points to the fact that such extrava-
mtioiis had iNcurred. While this enlargement of the capillaries is fouial very generally in the early period it subsides gradually as tuinefaetion increases.
Although Ibe swelling of the glands is rtshered in with an exudation into the mucous tissue, it is deix-ndent ujion this only in a slight di-gree ; it is due
in ^n-»t jiarv to the ex«-essivo development and increase of the structural ideinents. In recent cases large cell-structures are seen, some himilar in aitpear-
once to lymph curpuseh-s, but twice, three times and even eight times as large, and others puly-nuch-ated and occa*ioiially notihed in one or more places
as if in the wt of division. This occumng nt)t only in the iutcl>e<j of Peyer atui solitary follicles, hut also in the ad.iacent mucous tissue, seems to point
to All eimrmoiis increase and enlancement of the original lymplwells ; the new cell-structures are the progeny of the ohl lymph corpuscles and possess
nothing spii-ifie. The enlarg«.Ml follicles eh-vate the nu-nibiane covering them an>l impart to tho surface a niammillated aspect ; sriruetimes they project
w> much as to assume ;i p>dypoid ap|Haranc"-, and wcitsionally by their enlargement in an oppo^ite dirertion they press upon the niusi-nlar coat and give
riiM* to an intiltration i.f cell elements through its interstices to the serous coat, where thiy form small grayish bodies beneath the jientiuieuni. To this
inHhratioii of the cell eli-ments is also due the occasional tuberculated cotulition of the edges of ulcerated patches. Resolution is ushered in «itha
diniini.sh- il aftlnx of blo«Kl. Its simplest form is observed in the upjKrr portion of the bowel and preferably in the lea.st tumefied patches, where it occurs
as K rule in connectitm with others, and may even be so ass<Kdated with them that one part of a phmue is subject to it and Ihe rest to aindher, or what is
of more cumnion ocrurrcnce different portions of the bowel are respectively subject to differeut forms of retrograde change. In the simpler proccN* great
nunitM-Ri of cells und«Tgo disintegration; among thejie are included the large strueturej* so abundant iu the follicles an-l contiguous tissue before the dis-
pa*»fHl process hail n-arliHi its height. \\'lien resoriitiou goes on with uniformity throughout all the structural element*; of a patch the tumefaction sub-
«ide« evenly; but when the contrary obtains inequalities remain on iU surface. Absorption, for instance, may go on more energetically within the folli-
cIcH than ill the ihterveuing thickened areolar tissue, which, through the sinking in of the more rapidly diminishing follicles, iM-eomes more prominent
and thus giv«« rise to n reticulated aiqiearanee of the surface of the phiqiu-. Sometimes the contents of tlio glands, including the stroma as well as the
altered masw. undergo fatty degeneration, become dissolved and are evacuated ; ttie small cavities which result also give rise to Ihi' reticulated appear-
ance just n<»t<ti. After the evacuati<m of the follicles numerous miuute IdoodveRsi-ls are seen to pass through their cavities like vessels trav<Tsing tho
holluw of a pulmonarj- al>8«'ess. This condition has an intimate connection with tlie punctate jiignientation frequently seeu in Ihe glands. This color-
ation is due to little blewlings into the empty follicles from rnptun? c)f the minute ix>nneating vessels during the process of disorganization and evacua-
tion ; and the extravasations, at first of a red color, become later dark -blue, jirobably from the action of the intestinal gases. The process of follicular
destniction just descritx-d constitutes one of the less grave forms of iricer-formation. Sometimes fatty degeueraliou commences at sufierficial points of
limited size, where se|«ratiou from the tissues beneath takes place and a more extensive ulcer is fomud, whi« h finds its limit ultimately iu neighboring
446 PATHOLOGICAL ANATOMY AND PATHOLOGY
The plate facing this page shows an extension of the folUcular ulcer in all directions
by the impaction and subsequent necrosis of the tissues. The interior layer of the muscular
coat has been almost readied. Laterally the morbid action has progressed more rapidly in
the submucous tissue than in the mucous membrane, so that the latter is left as a tlnckt'ned
edge overhanging the cavity in the former. This is a steel engraving of a photograph of
specimen 1756 of the microscopic collection, the section having been derived from the same
source as the three that have just been presented.
In the colon the solitary glands usually began to ulcerate before any considerable
enlargement or protrusion above the surface of the mucous membrane had taken place.
When the corpuscular elements were set free a minute cavity was formed, which became
enlarged by progressive ulcerative action in the infiltrated submucous tissue and the caving
in of the undermined mucous membrane. This process has already been illustrated by the
plates facing pages 568, 570 and 572 of the Second Part of this History.
The changes in the agminated glands were essentially of the same character. The plate
facing page 448, infra, shows the typhoid thickening of a patch the mucous membrane over
which has been in a great measure destroyed, while the glands and submucous connective
are converted into a somewhat uniform cellular mass by the dense aggregation of the cor-
puscles. This }>late was engraved from a photograph of specimen 1704, one of a series of
thirty-two perpendicular sections of tlie ileum of a dark mulatto woman who died in the
Freedman's Iiospital, Washington, D. C.
This patieut, twenty-six years of age and nursing an infant three months old, was admitted vSept. 5, 1865, with
typhoid fever. She had been suffering for four weeks from fever, headache, anorexia, thirst and pain in the
abdomen; pxilse feeble and rapid, 120; skin hot and dry and tongue coated with a thick yeUow fur; the bowels
were moved once daily, the passages being of a greenish color, but diarrhcea set in prior to death on the 13th. At the
murons stnictures supplied with normally ubuiidant blood vessels and organically unaltered. Such nlcors have moderately elevated edges and are often of
cousiderable extent ; occasionally tlu-y penetrate the muscular tunic and lead to perforation. ^V'lleu iu process of healing, there spring up on thf floor of
the ulcerated cavities fine granulations which become covered with a transparent and sometimes pigmented membrane. The more frequent and dangerous
process of ulcer-formation i)roceeds with greater energy: The tissues which by cell-niuItipHcatiou and enlargement have been deprived of their uutritioii
separate in defined patclu's by sloughing. After the di'tachmenf of the slough the surface is in many cases moderately red with strongly injected edges;
'n others dark-red and often ecchymosed from the presence of a capillary network on the surface of an extremely delicate granulating tissue in which a
b'sion readily leads tc» Iiemorrhage, These sloughing ulcers Bometimes extend to the submucous, muscular and even to the serous coat of the bowel.
Sometinie.-i the two modes of ulcer-formation occur in the same plaque, the milder attacking the margin of sloughing ulcers and forming confluent sores
of large si/e, Sometinurt^, too, the destructive and reparative proccjflSes are jtresent in the same ulcer, the former going on in the centre and the latter at
the circumference. While this is generally diflficult to demonstrate, instances have been observed in which' the marginal structure bears so decidedly the
characters of new tissue that there can hardly be any doubt of attempts at repair. The tissues which border the ulcers towards the exterior aspect of the
bowel haTe generally their natural firmness increased by the efi"usion of plastic elements, but occasionally these structures become brittle or gangrenous
and either lead to perforation or predispose to peritoneal inflammation. Typhoid cicatrices present themselves in the form of smooth formations, rerl at
first but later deeply jugmented, a peculiarity occasionally observed even after the lapse of years. No villi are found on these cicatrices, and even th'-
mucous tissue itself fails to bo developed from the granulating material when the ulceration had penetrated to the muscular coat. Gangrene as a rule
makes its appearance in spots of limited size in parts that have been excessively infiltrated. In some cases of extensive iilceration diphtheritic inflamma-
tion complicates the tyidioid jirocess and affects both tlie small and large intestine to a variable extent.' This is seldom confined to one li'i atity, but fixes
at the same time \\\wn several portions of the digestive tube; frequently it starts from the larger ulcers and is a cause of recurring liemorrhages;
sometimes no relatiiui to existing ulcers can lie determined, and in these instances secondary ulcerations, resulting from the diphtheritic jnfianimation,
often appear at a late periotl. According to Rindfleisch — Paihnlngicnl Histolngtj, New Sydenham Society, Loudon, 1872, Vol, I, p. 4;58 et seq. — the closed
glands of the small and large intestine participate in a catiirrha! inflammation of the mucous membrane. The solitary glands appear as dull-gray
pearly nodules the size of a jiinhead, surrounded by a hypera-mic plexus of vessels ; and each of the individual glands of the patches of Peyer become
similarly affected. After this the glands pass into the stwge of medullary infiltration in which the solitary follicles attain a size even six times great"*r
than the normal, and the perifollicular connective becomes infiltrated. The aggregated follicles of a patch coalesce with the interstitial tissue to form
a soft, rose-colored, seemingly homogeneous mass resembling the medullary substance of the foetal bniin, the entire patch appearing as a flattened eleva-
tion two lines iu height, of an elongated oval outline ami marked off from the surrounding mucous membrane by a precipitous edge. The infiltration is
composed of a numerical increase of the corpuscular elements antl an increase in the size of these individually. They contain a larger proportionate
quantity of protoplasm than the simple lymph corpuscle ; the protoplasm of the latter scarcely equals the contained nucleus in amount, but in the
typhous cell it usually takes up more space than the nucleus. The morbid product is removed by a process of colliquative softening, the cells becom-
ing disintegrated into oily matters which are absorbed ; or failing this the deposit passes into a stat^^ of cheesy necrosis and is removerl by ulcerative action.
Klein— in his Report on the hiliinatf Anatmniral Changes in Enteric or Typhoid Fever, in the Report of the Ijocal Government Board, London, 1875, pp. 80-1-24
— describes the clumges in the intestinal mucous membrane as beginning with a distention of the vessels surrounding the lymphatic fi>llicles. This is
followed by swelling of the solitary glands due to an accumulation of ordinary nucleated lymph corpuscles. Similar accunuilations in tlie mucosa exer-
cise a destructive compression on the crypts of Lieberkiihn, detaching their epithelium and converting it into masses of cells, which by tlm occasional
oiclusion of the follicular aperture appear sometimes to be contained iu a closed cyst. The lymphoid corpuscles are also increased in the submucosa,
particularly in and around the bases of the solitary and agminated glands. But this observer objected to consider all the minute prominences on the
mucous membrane to be enlarged glands, as he had been able to trate back tiieif devehqiment to small accumulations of the lymph corpuscles in the
mucosa, and moreover, the solitary glands are not so numerous in man as are frequently the minute tumefactions found iu typhoid fever. Following
OK THE CONTINUED FF.VEKS.
447
iwst-morlrm exaiiiiiiiitioii sixteen hours alter death t;rt>at ciiiaeiation ami marked rigor mortis were noted. The lower
lolies of the lungs were somewhat congested. The duodeuum and ileum were inttamed throughout, the jejunum in
patuhes. The agminated ghmds wero enlarged and thickened gradually from above downwards; each of those in
the lower third of the ileum jiresented one or more points of ulceration ; some near the valve were completely ulcer-
ated away, leaving the fihres of the muscular coat exposed, while on the valve and for ahout four inches above it the
whole mucous surface was a nuiss of enlarged and thickeued patches, each presenting several points of ulceration.
The ascending colon was inllanuil and deeply ulcerated in transverse oval patches, some of them two ini-hes in
diameter and with overhanging edges, — there were also a few enlarged solitary follicles the size of peas, some of which
were ulcerated on the apex; the transverse colon presented a few small round ulcers which hail |)enptrated to the
muscular coat: the descending colon was inllanu-d in patches and had in the sigmoid Hexure a group of snuiU oval
ulcers ami slightly enlarged solitary follicles with specks of pigment in each; the rectum also presented a few snnill
ulcers. — Husjiilul SUward J. ./. Shufhiil, V. S. Army, Fnrdman's Mospiltil, Washiiigtoii, D. C.
The photo-engraviiig which follows this paragraph illustrates the appearance of a per-
pendicular section of a patch when its superficial layers have been removed by necrobiotic
processes. The section shows a shallow ulcer with abrupt edges, involving the whole patch.
The glar.dular stroma and intervening submucous tissue are indistinguishable on account
of the great accumulation of the corpuscular elements. The tissues around the impacted
portions are freely beset with swarms of new cells and liberally supplied with vessels
which are generally filled with blood corpuscles.
section of a ly|»li.>i'l |iatch: Specimen 74S9, microscopic coHection, .\riny Medi,-.il Museum, magnified 13 dianiett-rs .'lud sulisoqucntly rf.iurtd om^-tliiid.
The record of the case from which this specimen was obtained reads as follows:
Private (Jeorge Hayes. Co. R, 12th U. S. Inf.: age 2.5; was admitted from Russell barracks, Washington, D.
C, Aug. 2"!, IStit), with typhoid fever, file had been confined to the guardhouse at the barracks from May Id.
About .\ugust I he complained of diarrhiea and was excused from fatigue duty. Afterwards, symptoms of typhoid
fever having appeared, he was sent to the post hospital.] On admission he was quite stui>id, but could readily bo
aroused. On the afternoon i>f the "Jtith he became d<-lirious and during the night required constant watching and
restraint to keep him in bed. This continued until the forenoon of the 27th, when almost com|)lete loss of sensi-
bility eiisueil. lie could not swallow; an attempt was made to give him a spoonful of beef-tea, but it nearly
strangled him. Heavy stupor continued until about noon of the 28th, when death took place. Post morlcm exami-
nation tive hours after deatli: There was an opacity of the arachnoid at the base of the brain, with some eftusion of
lymph just below the medulla oblongata on the posterior portion of the spinal cord. Foyer's patches were much
thickened and ulcerated, especially in the lower part of the ileum; the villi were hypertrophied and the solitary
follicles enlarged to the size of peas, many of Ihem ulcerated at their apices. The solitary follicles of tlii' large
intestine were similarly all'ected.
this enlargemcDt there ap]H<ar in tbo swollen ttt«iieK some cells two to fonr times a^ large jw the lymphoid eorpU(*rIe,s, but wilh a larger nueleiis than
the lattpr ; and sometimes this nucleus is ap|>arently umlergning division. As intermediate forms are observed between tliesc large cells and the lyni-
phiUi rorpuscles it s.eiuB that tin. whole of thi' rorpusiiilar mass originates in the lymphoid elements. Gradually tlie ordinary lymphalie eorimsch'S
become eulirg<'<i or the enlarg.'d rells iiuorporati' the sinallir ones, until the adenoid tissue contains only cells of the larger sizi', each erirlosing an
OToid, transjMirent nucleus silualed iH-ripherally, and a varialde numlier of spherical nuclei cither isolated or in groui>s embe^Ided in the substane,.
of the c'dl or euc'oaed in a vacuole. In the centre of the tunjefied gland many of the cells assume the characters of true giant-cells, each conluiniug
fn>m ten to thirty nuclei ; but the giant-cells of lylihoid tuuefiulion diffir from those of tnlw-rcle in that their stronm is pri>vided wilh bloodvessels.
.* rhangr was also olwrvM to take place in some of the arterial capillaries of the impacted follicles ; they became more or less obstructed by a deposit of
vellowish i-olloid sulislancc lK-t'vt.cn the lining endothelium and an adventitial thin nucleated membrane; their walls were thickened and their lumina
distorted. In aaldiliou to lliese a]i|iearances in the stage of tumefaction, Ki,T.ix observed in the crypts of LieberkiiUn some highly refractive greenish-
448
PATHOLOGICAL ANATOMY AND PATHOLOGY
A section of a patch, constituting No. 7479 of the microscopic collection, from the
case just reported, is represented below. The lymphoid elements are densely packed in the
glands and adjoining stroma, and freely distributed in the mucous and submucous layers of
the surrounding parts of the intestine; the vessels in the submucous tissue are distended
with coagulated blood.
f '4
;a
■vV»,
^
'^^
Section of a typhoid patch ; Specimen 7479, microscopical collection, Anny Medical Museum.
The illustrations submitted above show the affection of the interlying tissue of the
submucosa to be as strongly marked as that of the glands themselves, so that had necrosis
taken j)lace it would have affected the patch as a whole, the surface continuing to break
down and be carried away with the intestinal contents until the disintegrated mass was com-
pletely removed. But it is evident from the reticulated appearance of many ulcerated
typhoid patches that certain parts were more susceptible to the morbid process than others.
The parts specially liable to impaction and consequent necrosis were the follicular compo-
nents of the patches. This is illustrated by the following photo-engraving of a specimen,
yellow corpuscles, varying from the size of a mere granular point to that of a human red-I>lood corpuscle. They were mostly spherical, hour-glass or
kidney-shaped, and seemed to be held together liy a transparent connecting substance ; some of tbem, particularly the terminal cells, contained minute
bodies resembling spores or micrococci. He regarded these as joints of the mycelial thre.ids of an organism similar to the Creuothrix polyspura,"
described by Cohn iu 1870 as characteristic of the vegetation discovered by him in the well-water of a district of Breslau noted for the prevalence of
enteric fever. Klein found the micrococci as zoogla-a nnusses in the lymph-spaces adjoining tin- tubular follicles, and also impacting the veins and
venous capillaries of the affected solitary and agmiuateil glands and of the a<lja<-cnt mucous and subnnu-ous tissues ; be found them also iu the alvine
discharges. When the tumefaction reached its height the corpuscular elements appeareil to fade, break ilown and become absorbed or detached as a
slough, while the stroma was converted into a dense felt-work of stiff highly refractive fibres. He did not consider this due wholly to compression <»f the
bloodvessels by the surrounding accumulation of new elements antl the encroachments on their lamina iiy the colloid deposit ; on the contrary, as he had
observed a fading of the corpuscular elements and other signs 'of a retrograde change specially marked in the neighborhood of vessels imiiacted with
micrococci, ho regarded these organisms as the chief cause of the necrotic developments.
X
PERPENDICULAR SECTION OF ILEUM
^,<W
Patch,
OF THK CONTINUED FEVERS. 449
7454 of the microscopical series, contributed by T)v. W. W. John'STON, of Washington, D. C.
Tlio celluhxr elements, while freely scattered throughout the raucous layer and the adenoid
tissue of the submucosa, are so densely aggregated in the glands that each is converted into
a distinct and separate cellular tumor.
-4
St-clion of a tyi)hoid patch : Spoclmcn 74.'>4, microscopical collection, Army Medical Museum.
Tlip case from which this specimen was obtained was that of a child three years of age, who had suffered for
ahn:>Ht a week with sli^rht fever and diarrha-a. He died apparently of syncope about an hour after swallowing,
through the carelessness of attendants, eighteen sugar-coated pills each said to contain three grains of r|uiniiie.
Posl-morlcm examination found the heart relaxed, the right cavities empty, the left containing fluid blood. The
lungs were congested posteriorly. The liver and pancreas were normal; tho Malpigliian bodies of the spleen
were well marked. The stomach was congested and eccliymosed; the duodenum and jejunum congested, their
glands conspicuous and villi hypertrophied. In the ileum also the villi were hypertrophied; the solitary and agmi-
nated glands were progressively enlarged, and the serous surface corresponding to the bases of the latter was
patched with arborescent congestion; the contents of -the intestinal glands were dark and granular. The mucous
membrane of the large intestine was congested and its follicles enlarged. The examination was made by Dr. 1). S.
Lamb, of the Army Medical Museum, Surgeon General's OtSce.
The plate facing page 450 further illustrates the special liability of the glands, as
distinguished from that of the surrounding adenoid ti.s.sue, to impaction and disintegration.
It is etched on steel from a phQ}:ograph of specimen 455 of the microscopic collection, one
"f a series of nine perpendicular, sections of the ileum, .showing the ulcers to have origi-
nated in the individual glands of the patch. These sections are from the case submitted
as 323 of the post-mortem records of the continued fevers. They show admirably the
softening and discharge of the glands each by its own aperture, the gradual enlargement
<.f the resulting cavities and the coalescence of these, embracing the whole of the patch
in the irregularly ulcerated area.
To illustrate the minute anatomy of the corpu.scular elements the two figures on the
following page have been introduced. The lower represents the deeper jjortion of a section
of an enlarged agminated gland, from the case which furnished the specimen delineated
in the figure on this page; the upper is a view of a more superficial portion of the same
section. These were drawn under a magnifying power of 700 diameters by Dr. J. C. McCox-
NELL of this office, and afterwards reduced by the photo-electrotype process to two-third.s
the size of tlie original drawing. In the deeper portion the endothelial cells are princi-
pally confined to the vessels; the intervascular spaces are occupied by a variety of lymph
■orpuscles, some of which, by their aggregation, suggest a multiplication by fission, while
others are possibly passing into the round, mononucleated vesicular form which is the pre-
vailing type in the superficial parts of the affected patches. Instances suggesting the tran-
sition of the ordinary lymphoid corpuscle into the nucleated cell may be observed on the
field This transition seems the more probable, as nearer the surface or in more advanced
stages the true lymphoid cells are found to have been to a great extent replaced b}' the
Mei>. Hist.,Pt. Ill— 57
450
PATHOLOGICAL AKATOMY AND PATHOLOGY
MHtttr fron th
-3
1 il I 1 t\ijbii(l I Itch
'^"^e
^f
€^^
i;
A
*=* ^
\
«*^ -^ *^r -
ii'4
c
rf
.^
f" <3§
/
<?-
V
<©;
larger nucleated and granular
cellular bodies. These appear
to become larger, hazier in
outline and ultimately to dis-
integrate into a molecular or
granular mass.
Erosion of the intes-
tinal MUCOUS me'mbrane. —
In case 23 of the post-mor-
tem records it is stated that
the ulceration of the mucous
membrane was unconnected
with the state of the solitary
glands. It seems that the
aggregation of the corpuscu-
lar elements in the mucous
membrane, aside from the sit-
uation of the closed glands,
sometimes gave rise to an
erosion of the membrane.
The destruction of the epithe-
lium left the underlvino; iufil-
trated tissues with an abraded
surface, which became ex-
tended and deepened by the
removal of the softening and
disintegrating corjjuscles.
AVhen such ulcers were small
and shallow their mode of
origin could usually be deter-
mined; but when large and
deep it was often impossible
to discriminate between them
and those that followed the
separation of a diphtheritic
slougli or the necrosis of a
follicle and its surroundinsr
tissue.
Hemorrhage, perfor-
ation AND peritoneal IN-
FLAMMATION.— The necrobi-
otic processes occurring in the
Blatter from tho defji'^r parts of a typhoid patci
diseased agminated glands, or in patches usuallv involving one or more of the solitary glands,
were attended in their progress by an increasing liability to hemorrhage from the intestinal
OK THE CONTINUED FEVERS. 4"il
vessels uud to an extension of tlie intlammatory action to the serous lining of the abdom-
inal cavity. Manifestly these dangers were proportioned to the rapidity of the processes,
for although the records are not sufficiently explicit to give a numerical expression to this
proportion, the disorganized condition of the intestine, in many cases characterized by clini-
cal or post-mortem evidence of hemorrhage or peritonitis, indicates that a sloughing of the
diseased patches rather than a progressive ulceration was under observation.
In some cases, particularly such as were duo wholly or chictly to the malarial influ-
ence, the occurrence of hemorrhago may be ascribed to that extreme congestion of the pails
wliich led to the extravasation of- blood even into the submucous tissues. In cases also
that were purely typhoid it is probable that the slight hemorrhages which were observed
in the early period of the disease were due to congestion.* But when bleeding took place
later, and especially when it was profu.se, it could with propi'icty be ascribed to no other
cause than a break in the walls of the vessels by the separating tissues of the small intestine
in typhoid cases and of the large or small intestine in those due to malaria or complicated
by dysenteric processes. Hemorrhage from the bowels was probably the cause of death in
the cases 21, 27, 110, 176, 323, 325 and 335.
Peritoneal inflammation in continued febrile cases was sometimes duo to other causes
than the extension of the intestinal ulcerations. The condition of the mesenteric iilands
was in some instances the determining cause; this, however, may be regarded as aji indirect
extension from the ulcerated mucous membrane. The degeneration of the abdominal recti
muscles in cases 63 and lol probably gave rise to the peritonitis i'rom which the patients
suffered, while in 249 it resulted from the rupture of a degenerated spleen. When due, as
was usually the case, to an extension of the morbid action from the ulcerated intestines,
the peritoneal inflammation was generally associated with perforation of the intestinal wall.
Nevertheless, a number of cases have been instanced in the analytical summary in wliich
peritonitis was present, although none of the ulcers had perforated; and several siiecimens
preserved in the museum show plastic exudation on the peritoneal surface in cases which
had no record of perforating ulcers. But while in some cases a local peritonitis may have
preceded the perforation with which general peritonitis was usually found associated after
death, the sudden advent of acute pain, tenderness, vomiting, hiccough and extreme pros-
tration indicates that tlie serous coat seldom became largely involved until the occurrence of
perforation and extravasation of the intestinal contents. On the other hand, perforation
sometimes'TJCcurred without giving rise to the symptoms or post-mortem appearances of peri-
toneal inflammation. Either the perforation was effected while the patient was in his dying
agony, so that there was no time for the development of the morbid a])pearances that gen-
erally attend extravasation of the intestinal contents, as may have been the case in 32, or
tlie adhesion of contiguous serous surfaces strengthened the point of impending rupture
and limited the area of inflammation by preventing communication with th-e peritoneal
cavity, as appears to have been the case in 385.
From what has been said of the circumscribed character of the diseased processes in
typhoid, as compared with the extent and diflfusion of the hvpersemia in the cases attributed
to malaria, it is not surprising that perforation should have proved so frequent a result in
the former and so rare in the latter. Case 367 is the only example of perforation in which
typhoid ulceration of the ]jatclies of Pever was not discovered at the post-mortem exam- .
•See mpra, p. 204.
452 PATHOLOGICAL ANATOMY AND PATHOLOGY
ination. Forty-three cases of perforation have been submitted to analysis, and as these
occurred in three hundred and eighty-nine cases of continued fever, pei-foration took place in
11 per cent, of the cases. But if the sixty-three malarial cases which furnished but one
instance of perforated bowel be withdrawn from the calculation the frequency of this acci-
dent in probably typhoid cases will be increased to 12.9 per cent. MuRCHisON, as the result
of a tabulation of 1,721 cases recorded by various observers, found that perforation occurred
in 196 or in 11.38 per cent.* In twenty of the forty-three cases the site of the perforation
was reported to have been the patches of Peyer; in eighteen the ileum; in two tlie small
intestine; in one the intestine; in one the caecum, and in one the sigmoid flexure of the
colon. It is evident from these figures that ulceration of the ag;minated glands was gener-
ally, and of the solitary glands rarely, the cause of the perforation, notwithstanding the
frequency with which the latter were affected b}' the morbid processes. Had perforation at
the site of the solitary glands been a common occurrence it would have been reported in tlie
large intestine with greater frequency than twice, cases 33 and 300, in forty-three cases.
As the sloughing or ulcerative action progressed at so many points in the same intes-
tine it not unfrequently happened that more than one break was found at the post-mortem
examination. Thus, in the series of pure typhoid cases there were two perforations in 16,
three in 32, five in 19 and several in 17, 18 and 50. Furthermore, on account of the irreg-
ularity of the advance of the destructive process in the same area of ulceration it sometimes
happened that more than one break was found on its floor, as may be seen in one of the
ulcers represented in the plate facing page 382. The specimen, 370, Army Medical Museum,
from which this was photographed was taken from the patient whose case appears as 159
of the post-mortevi series already submitted. The clinical record says that this soldier had
well-marked symptoms of typhoid fever; he was delirious and extremely prostrated, and there
was much distention and tenderness of the abdomen, but no diarrhoea until a few days before
death. Five of the ulcers in the ileum had perforated. Five specimens, 369-373, Army
Medical Museum, from this case have been preserved. The first, taken from high up in the
ileum, presents five irregular ulcerations from one-quarter to half an inch in diameter,
penetrating nearly through the muscular coat. The second, represented in the plate to which
attention has been invited, shows three irregular oval ulcers, each about an inch in diameter,
their edges thickened, their bases formed by the muscular coat -except where perforation has
been effected; the perforation in the upper ulcer is small, but a little to the left is a point
at which a break through the serous coat was about to take place; the middle ulcer presents
an oval perforation nearly half an inch long, having shreds of the peritoneal coat attached
to its margin, while immediateh^ above the perforation is a point wliere the serous coat has
been exposed; the lower ulcer presents in its centre an oval patch one inch in its long.diam-
eter, in the upper part of which the serous coat retains its position, forming the floor of the
cavity, while in its lower portion this coat has given way, forming four oval apertures sep-
arated from each other by shreds of the serous membrane; the solitary follicles are slightly
prominent, and there is pseudomembranous exudation on the peritoneal surface of the speci-
men. The third and fourth specimens, 371 and 372, present ulcers similar to those repre-
sented in the plate, one of which in each instance has perforated the intestinal wall; some
* His table shows that this undesirable result was of more frequent occurrence in the experience of English observers than in that of Continental
physicians. Thus, of 412 fatal cases recorded by himself, Bristowe, Jenneb and "Waters, perforation was found in 80 cases or 19.41 per cent.; of 270
cases by the French observers, Loris, Bretonne.vv, Chomel, Mo.ntault and Forget, perforation was discovered in 25 or 9.25 per cent., and of 1,039 cases
by the German observers, Griesinger, Hoffmann, Lebert and others, 91 or 8.75 per cent, had the intestine perforated. See his treatise, p. 566.
OF THE CONTINUED FEVERS. 453
miiuue punclied-out ulcerations, corrcspoiuling to the solitary glands, are also seen in these
sections. Tlie last specimen, 373, taken from just above the valve, has the mucous mem-
brane considerably thickened and studded with enlarged solitary follicles; there are also
several irregular ulcerations, one of which measures fully two inciies in its long diameter,
the floors formed bv the muscular coat of the intestine. These specimens may Vje accepted
as illustrations of the fact that the part of the ileum usually perforated in typhoid fever lies
more frequently some distance above the valve than immediately adjacent to it.
Perforation of the site of the agminated glands is also illustrated by the plate facing
page 343. The specimen, 452, Army Medical Museum, from which this was photographed
was obtained from the patient whose case is recorded as 43 of the post-mortem records of the
continued fevers. In this instance the perforated part of the ileum was not far above the
ilec-csecal valve. The aperture, small and oval, appears near the centre of a large irregularly
shaped ulcer with overhanging edges and a smooth and even floor, formed by the muscular
coat; its margins are as sharply defined as if the piece had been punched out. The speci-
men shows also some small ulcers of the solitary glands situated between the transverse
mucous folds and extendincr through the submucous tissue to the muscular tunic, while on
its peritoneal surface is a coating of pseudomembranous lymph.
The inflammatory condition of the ileum in a case of death from peritonitis consequent
on perforation is well shown on the chromo-lithograph facing page 391. The specimen, 147,
Army Medical Museum, from which tliis drawing was made was taken from the case
recorde'd above as 224 of iXxd 2^ost-mortem records. The peritoneal cavity contained a large
quantity of pus and serum. The serous membrane was generally thickened and congested;
over the intestine in some parts it was of a brilliant red color, in other parts deep red or
almost black. The ileum for five feet above the caecum was more or less ulcerated, and at
a point about eighteen inches above the valve it was perforated. The drawing on the right
of the plate shows the mucous surface in the vicinity of this point: The perforation, large
and oval, occupies nearly the whole of the site of the original ulceration, and the mucous
membrane, of a livid-brown color, lies in closely set transverse folds and shows several
ulcerated patches above and below the perforated point. The drawing on the left of the plate
represents the serous surface of the same specimen: The intensely injected peritoneum is
coated in yellowish patches with pseudomembranous lymph.
Reparation of the intestinal ulcerations. — But when, instead of extension and
penetration through the walls of the intestine, a reparative process was initiated after the
removal of the necrosed and disintegrated tissues, the vessels adjacent to the lesions became
enlarged and the ulcerated cavities filled with granulations over which the mucous membrane
advanced from the edges to the centre as a thin and glistening covering. The area of the
cicatrized surface was much less than that of the original ulceration, as the mucous mem-
brane became drawn over it by the subsequent contraction of the connective tissue of the
granulations. In the solitary glands the cicatrix appeared as a smooth central spot around
which the mucous membrane between the tubular follicles was thrown into radiating ridges,
giving the whole a stellate appearance, which has been illustrated by the photograph of
specimen 603, Army Medical Museum, facing page 528 of the Second Part of this work.
The contraction of cicatrized patches of Peyer was manifested by puckering of the surrounding
membrane and occasionally by the disposition of the transverse folds in the neighborhood
of each to radiate from it. Cicatrices left in the intestines after the healing of ulcerated
45-4 PATHOLOGICAL ANATOMY AND PATHOLOGY
patches have been ilUistrated by five plates, — one a chromo-lithograph of a recent specimen,
and the others photographic reproductions of preserved specimens.
JSTothing is known of the history of the case representeil by the chromo-hthograph.
The pkite facing this page shows the lower portion of the ileum and part of the csecuni.
On the mucous surface of the former are a number of oval ulcers similar to those freqiiently
left after typhoid fever; the cream-colored membrane is injected in reddish patches; the
colon, also somewhat injected, shows several follicular ulcers.
The photographic reproduction of specimen 597, Army Medical Museum, facing pao-e
456, shows a portion of the ileum witli the ileo-csecal valve and part of the csecum. A
Peyerian patch, one and a half inches above the valve, presents an oval cicatrix which is
somewhat obscured by the pseudoraembrane covering the whole of the mucous surface;
there are some small ulcerations near the valve. This specimen was taken from a soldier
who died of dysentery, apparently subsequent to his recovery from an attack of typhoid fever.
Private AVilliam Henry, Co. Gt, 8tli N. Y. Cav.; age 18; was admitted July 22, 1865, with chronic diarrhoea.
[This man appears on the records of the Augur hospital, near Alexandria, Va., as admitted from regimental hospital
June 24 with acute rheumatism, and sent to Slough hospital July 22.] He died on the 29th. Post-mortem examina-
tion: Body not much emaciated. The lungs were collapsed, of a gray color and without pleuritic adhesions. The
heart was normal. Externally the liver was clay-colored; internally it presented the nutmeg appearance. The
spleen was lake-red on section. The sigmoid flexure was folded down against the anterior wall of the pelvis, to
which it adhered by a layer of yellow semi-transparent lymph. Portions of the ileum were also adherent, the
adhesions enclosing a little yellow serum in the lower part of the pelvic cavity; the peritoneal surface of the last
foot of the ileum was much injected and its mucous membrane coated with whitish pseudomembrane; Payer's
patches were tumid and reticulated. The large intestine was thickened and its mucous lining, which was dirty
and blackish, presented a number of shallow irregular ulcers and patches of pseudomembrane. — Act. j^s't Siinj.
TV. C. Minor, Slough Hos2>ital, Alexandria, Va.
Specimen 459, Army Medical Museum, which is represented in the plate facing page
404, is from the case reported as 300 of tlie post-mortem records of the continued fevers.
The large intestine was said to have been thickened and ulcerated, and in the sigmoid flex-
ure perforated, while the mucous lining of the ileum was eroded and the agminated and
solitary glands ulcerated. The portion of tlie ileum represented was taken from just above
the ileo-csecal valve. It shows cicatrices in four of the patches of Peyer, — in the upper two
the process has been completed; in the lower two the ulcers are not wholly cicatrized. The
solitary glands are enlarged and prominent. Sections of the follicles from this specimen
have been presented in the plates facing pages 326 and 328 of the Second Part of this
History as illustrative of the follicular changes in acute diarrhoea.
The plate facing page 401 represents a portion of the ileum from the tract of the val-
vulse conniventes, taken from the patient whose case is reported as 298 of the post-mortem
records of the continued fevers. The record states that the mucous membrane of the ileum
was of a gravish-slate color, its villi hvpertrophied and dotted at their apices with black
pigment, and that the patches of Peyer were in every stage of cicatrization, the ulcers
smooth and the gut around them puckered. On the specimen represented hypertrophied
villi are seen on all parts except the cicatrices, which are marked by their smoothness and
■the breaks in the transverse folds of tlie mucous membrane. Three sections of a cicatrized
patch from this ileum, constituting specimens 470-472 of the microscopic collection, show
it to consist of condensed connective tissue, embedded in which are a few of the original
elands of the localitv.
The contraction of the cicatrix is so stronglv marked in the plate facing page 458
that the interrupted and adjacent valvulte tend to i-adiate from the newly-formed tissue;
01-" THE CONTINUKI) FF.VERS. 455
some small tuborcles are situated oil tlio peritoneal surface. The specimen, 887. Army Med-
ical Museum, wliich furnished this illustration has, unfortunately, no recorded history.
riGMKNT.VTio:',' OK THE INTESTINAL LINING. — There remain for consideration the pig-
mentary deposits sometimes observed in the intestinal walls. This pigment was seen only on
the fresh intestine; it disappeared under the treatment adopted for the preservation of the
specimen. Usually it occurred in streaks or patches of a gray, greenish, bluish or other
dark color, afTecting the general surface of the mucous membrane of the small or large
intestine. Sometimes it was aggregated in the apices of the hypertrophied villi of the
small intestine, giving a dark tinge to its plush-like surface. Large accumulations were
found ill the .solitary follicles and in the glands of the patches of Peyer, constituting what
was known as tlie shaven-heard appearance in the affected area of tlic latter.
The diffused streaks of pigment on the general surface of the mucous inemhrane con-
sisted of minute bruwn granules deposited in the lymphoid cells of the stroma I between the
follicles of Lieberkuhn, and most abundant about midway between the epithelial layer and
the muscle of Briicke. The deposits iir the solitary and aggregated glands consisted of
similar granules in the cells of their parenchyma. But in all these instances the ])igment was
occasionally observed in larger agglomerations, situated apparently between the corpuscular
elements rather than within them.
Parle colorations of the mucous membrane had long been recognized as due to ante-
cedent hvpersemic conditions. Louis regarded them as vestiges of an extinct enteritis,
and assigned a similar origin and meaning to the dark color of the mesenteric glands after
typhoid. But the stiaven-beard patches were wholly misunderstood Ijy our medical officers
during and after the war. Tliey were regarded as pathognomonic of the lualarinl form of
typho-malarial fever. Lideed a chromo-lithograph, reproduced in the present volume, and
liicing page 460, was published in Circular No. 6, Surgeon General's Office, Washington,
D. C, Xov. 1, 1865, as an illustration of the characteristic lesion of this form of fever.'*
The plate represents the congested condition of the membrane, the injection of the vessels,
the enlargement of the solitary follicles and the shaven-beard appearance of the patches of
Peyer. The case from which this specimen was taken is reported as 89 of the post-mor-
tem records of the continued fevers.
No further light was thrown upon this pigmentation of the closed glands of the intestine
until, in his remarks on typho-malarial fever, read before the Section of Medicine of the
International Medical Congress, Philadeljihia, 1876, Dr. Woodward gave an outline of what
he considered to be the clinical course of the malarial form of typlio-malarial fever, to which
was added an acknowledgment that post-mortem examination of the diseased intestines
in these cases showed no other lesion than those whicli were the invariable accompaniment
• "The niont characteristic specimens may bo tlius descrihecl : In the fresh intestine as received at tlie Mnscnni the ilenni presents patches of Jne]! •
congestion of variable extent ; tlic solitary follicles, enlariicd to the size of large pinhead.s, are frequently blaclt with pigment deposits. The I'cyer's iiatches
ftimelimis quite healthy are more generally the seat of iiigment dei>osits in the individual follicles comiwsing the patch, which appears of a gray color
dotted over with blaikish points, presenting a resemblance t.. the freshly-shaven chin. The name "shaven-lieard appearance " has l»en quite cur-
nently U'stowcd upon this c lition. In other cases the IVyi'r's patches are somewhat thickened and occasioually as much so as in ordinary cases of
enteric fever. In the pn-panitions as preserveil in the Museum the color of the pieces, including that of the l)igraent dejiosit, gradually disappears. The
enlarged solitarj- follicles ami the alterations in the I'cyer's patches are, however, well preserved. The solitary follicles are not ulcerated in these cases
except nindy some of the largest, which may present a minute point of ulceration on the apex. The form of fever from which tlie,«o speri?nens art-
vklaintHl is that whicli attracted attc-ntion in 1802, under the designation of Chickahominy fever, but which before and since has prevaile<l whenever
onr amdes have ojn-rated in malarial regions. It is a continued fever which presents also a more or less decidedly rennllcnt type at the beKiniiing at
le«rt. It is accompanied by diarrho a and abilomiual tenderness, but usually without tympanites. Cerebral and pulmonary comiilications are connuoll
as in ordinarj- enteric fever. Kniargement of the spleen is frequent and often excessive. The fever usually lasts from three to five weeks and termiiiatis
in a lingering ami protracted convalescence. This variety I have proposed to designate as the Malarial form of Typho-malarial Fever."— Dr. Woobwabu
in Circular So. 0, p. 140.
456 PATHOLOGICAL ANATOMY AND PATHOLOGY
of P. smart intestinal catarrh, to wit: Patches of congestion, enlargement, with sometimes
ulceration and pigmentation of the solitary follicles, and frequently a slight tumefaction of the
patches of Peyer with such pigmentary deposits as gave them the shaven-beard appearance.*
The next reference to the meaning of these accumulations is contained in the Second
Part of this work.f published in 1879. At this stage of his investigation Dr. Woodward
showed ofHcially the connection of the pigment with those hypertemic conditions of the mem-
brane that are manifested clinically by continued diarrhceal attacks. In view of the tes-
timony then presented there appears no ground for doubting the origin of tlie deposits in
minute extravasations into the mucous membrane or in the plugging of its capillary loops.
They were of more common occurrence in the patches of Peyer than in the solitary follicles,
notwithstanding the frecjuent and decided enlargement of the latter. Tlie former, althouo-li
seldom much swollen, were often more distinct than normal from participation in the general
hypersemia of the mucous and submucous tissues. Occasionally, indeed, a diarrhceal case
presented such morljid changes, including ulceration of the agminated glands, as were su"--
gestive of the presence of typhoid fever: Tn the plate facing page 300 is a thickened patch
which appears as a dark elliptical spot two inches long by an inch in its transverse meas-
urement, its surface not materially elevated above that of the surrounding membrane, but
thicker than normal, and by transmitted light more opac^ue than any of the other patches
observed in this subject. In the plate facing page 302 is a plaque which shows a greater
advance towards a morbid condition ; its surface, which is not materially raised above the
surrounding level, is marked by narrow broken lines studded with hj^pertroijhied villi similar
to those on the general surface of the specimen, and between these are irregular areas which,
•being destitute of villi, seem depressed below the adjacent level and give the patch a some-
what reticulated appearance; in its centre is a shallow oval ulcer an eighth of an inch in
diameter; half an inch below this, near the right margin, is a similar iilcer, and a third may
be observed near the upper end of the patch. But in cases of non-specific intestinal con-
gestion pigmented villi and the shaven-beard appearance of the patches were more frequent
■post-mortem observations than tumefaction and ulceration of the glands of Peyer.
These results of a completed study of the accumulated material relating to diarrhoea
necessarily deprived this pigmentation of the patches of its assumed significance in connec-
tion Avith typho-malarial fever. Dr. Woodward was prompt' to recognize this fact. He
observed: J "Tlie discussion of the interesting cjuestion of the relation of the lesion just
described to a particular form of malarial fever must be postponed to a subsequent chapter;
it must suffice at present to express the conviction that the intestinal lesion in the class of
fever cases referred to presents nothing by which it can be distinguished from the lesions
observed in other cases in which the febrile phenomena are not well marked or at least pre-
sent no specific characters."
This intimates that there is no specific intestinal lesion by which the malarial form of
typho-malarial fever ma_y be distinguished from the malarial fever which, beginning as an
intermittent or a remittent, becomes, like typhoid, subcontinuous, and in its later stages is
attended with typhoid, i. c, advnamic symptoms.
Had Dr. AVooDWARD been spared to complete his work one or other of two courses was
open to him in the discussion of his malarial group of typho-malarial fevers: Either to rele-
gate this group to the class of purely malarial fevers or to argue that typhoid fever is non-
* See pagD 35 of tlic paniphlet, Philadelphia, 187G. f See pp. 298 el acq. J Page 302.
OF THE CONTINUF.n FF.VKRS. 457
specific in its character and may supervene on an intestinal congestion such as may be due
to the incidence of the malarial poison when sufliciently prolonged to involve the patches of
Peyer, or in the presence of constitutional abnormities or peculiarities in the environment
tending to the development of that typhoid state which is the usual accompaniment of an
ulcerated condition of these patches.
It is needless to say that the correct coucse appears to the writer to be that first indi-
cated, as he has been led to adopt it by a clinical and pathological analysis, the various pro-
cesses of which have been carried on in full view of the reader of the preceding pages. More-
over, if the argument be continued on tlie basis of the similaritv between the condition of
the patches in intestinal catarrh and in the malarial group of the typho-malarial fevers it is
equally conclusive; The cases in question were either examples of a subcontinued malarial
fever with adynamic symptoms, showing on post-mortem examination — if the intestines were
implicated, which was by no means the case in every instance — the anatomical lesions which
characterized cases of intestinal catarrh and not those of typhoid fever, or they were cases of
typhoid fever so modified by the presence of malaria that the full action on the aggregated
glands was prevented. But while, as has been shown in the course of this report, there is
ample testimony in support of the former alternative, the latter is based on the assumption
that typhoid fever may be present without showing its existence by its usual action on the
aggregated glands of the intestine. If this assumption were allowed, typhoid lever, as known
to the medical profession for the past sixty years, would itself cease to exist, and in the
clinical and pathological chaos that would result it would manifestly be useless to attempt
the identification of a tvpho-malaiial fever when its typhoid element was acknowledged to
be unrecognizable. Fortunately the assumption is suggested by facts wliich niay be used
instead to strengthen and sustain views that are in accord with our present knowledge and
past experience : Undoubted malarial fever may assume clinically the appearance of typhoid,
while at the post-mortem examination the lesions of typhoid are not present. The gen-
eral experience that has found a particular lesion in all cases of typhoid naturally concludes
that in these malarial cases there was no typhoid element. It requires a forced rendition
of the facts to construe them into a proof of the modification of the typhoid lesion by the
coexisting malaria. If malaria exert such an interference in one case it sliould do so to a
greater or less extent in all the cases of typhoid which it complicates; yet the post-mortem
records that have been submitted contain many cases in whicli, although the malarial com-
plication was strongly marked clinically, the typhoid lesions were as distinct as in a specially
selected case of unmodified typhoid. It must therefore be concluded that the absence of
the typhoid lesion implies an absence of the febrile condition which is its cause, and not
an interference with the development of morbid changes in glands that are known to be not
recessarily affected by the poison which is assumed to have caused the interference.
The only course open for an attempt to sustain the malarial group of the typho-
malarial fevers in their position of modified typhoid fevers is to deny the sjsecific character
of typhoid fever and show that there is a more. intimate relationship between malarial and
typhoid fevers than has hitherto been allowed. This involves the subversion of the generally
accepted views of typlioid fever and the establishment of typho-malarial fever as the typical
and central figure of the subcontinued fever series, which becomes paroxysmal or continued
according as certain inflammatory processes are restricted to the general surface of the intes-
tinal mucous membrane or invade the substance of the agminated glands, results which are
Med. Hist., Pt. Ill— 58
458 PATHOLOGICAL ANATOMY AND PATHOLOGY
due not to specific differences in the febrile cause but to accidental circumstances pertaining
to the constitution, age and hygienic surroundings of the affected individuals. To sustain
this position in the face of our present knowledge of the malarial and typhoid febrile con-
ditions is impossible. The natural history of the causes of these conditions must be shown
to be wholly at variance witli our present conceptions before any attempt of this hind can
be other than a work of the imagination.
If the cases that have been instanced in the analytical summary 51s presenting pigmen-
tation of the mucous membrane of the intestine be examined it will be found that, where
the patient's condition for some time before death is mentioned, diarrhoeal attacks form
invariablv a part of his history. Notable jjigmentation was of much greater frequenc}^ in
the continued malarial cases than in those which presented a distinct typhoid element; in
the former pigmentation existed in nearly one-third of the cases, and in the greater proportion
of these the deposits were specially marked in the patches of Peyer. This corresponds with
what has already been observed concerning the intensity of the congestion in such cases.
In the true typho-malarial and the mixed series the proportion of pigmented cases was mucli
smaller; while in the typhoid serjes there occurred no instance in which deposits had formed
in the patches, and but two in which the solitary glands were their site, although the
mucous membrane of the colon presented in five cases an alteration of color which must be
ascribed to an antecedent hyperremia. This absence of the shaven-beard. appearance from
the patches in typhoid is susceptible of explanation on the one hand by the rarity of that
intense congestion which tends to relief by extravasation, and on the other by the removal
of each ecchymosed spot by subsequent ulceration or sloughing.
The prevalence of the pigmented intestine in the continued malarial fevers that were
reported as typhoid or typho-malarial is worthy of remark as compared with its infrequency
in the fatal cases of paroxysmal fever. Thus, while, as has been stated, 31.7 per cent, of
the former presented pigmentary deposits in which the aggregated glands were generally
participants, only one, case 98, of twenty-five paroxysmal cases, in which the intestines
were morbidly affected, had the patches of Peyer blackened, and in only two, 57 and
94, was the mucous membrane of the large intestine the site of these deposits. It will be
remembered, howevei', that death in the paroxysmal cases occurred usually after a short
illness, while in the continued malarial cases that were reported as typhoid or typho-malarial
the fatal attack was prolonged. Time was afforded in the latter for the development of a
pigmented condition, whicli in the former was reptresented by an existing congestion such as
led to ecchymoses in the pernicious cases 97-99, or gave a deeper color to the apices of the
solitary glands in 69, or produced in 59 an extravasation of blood. If these cases are taken
into consideration as presenting the earlier stages of the development of the pigmented
condition it will be found that the proportion of such cases in the paroxysmal fevers did not
differ from that in the continued malarial series.
The mesenteeic glands. — The writers of the post-mortem records seldom gave a
detailed account of the condition of the mesenteric glands; but enough has been said to
show that their affection was similar to that observed by Louls'-' in his classical typhoid
*See nute, p. 426, supra. Rukitansky, op. cif., siipya, page 443, describes the mesenteric glands as congested and swollen dnring Ihe initial stage
of acute catarrhal iuflammatiou of the ileum. Their tumefaction is progressive with that of the closed glands of the intestinal lining. They attain the
size of a bean or pigeon's egg and sometimes that of a hen's egg, those nearest the bowel showing the most enlargement ; their greatest size is reached
during the congestion attending the destruction of the intestinal follicles, when they are often so soft as to fluctuate under pressure. They appear
to degenerate into a medullary substance, sometimes firm and white, at other times softer and of a grayish-red or pale-red color. The areolar tissue
enveloping them shows a varicose vascular network ; occasionally their serous covering becomes inflamed and perhaps ruptured, giving rise to liemor-
rliage and peritoueal inflammation, and their parenchyma is converted into a yellow or yellowish-red, thick and difllueut mass. When the necrosed
OK THK CU.NTJM'Kl) FKVERS. 459
cases. Theii' increasing tumefaction and redness, their dark coloration and subsequent
softening, absorption and pigmentation as tlie general result, with rarely the formation of
pus and its escape into the peritoneal cavity, or its inspissation and transformation into a
calcareous deposit, have all been illustrated by the cases submitted. The occasional excep-
tions to the general rule, that the most severely affected glands were those in direct com-
munication with the diseased patches of Peyer, have also been noted in the analytical
summary. Sections of the diseased glands have been prepared in the Museum showing
the occlusion of the lympli passages by corpuscular elements differing in no rrspoct from
those found in the closed glands of the intestinal mucous membrane.*
The spleen. — The enlargement, softening and occasional darkening of tlie spleen found
by Louis in his typhoid cases were observed also by our medical officers in their fatal cases
of that disease; and as he found one instance of diminished volume in his forty-six cases,
so in the fifty cases that liave been reported in this work there also occurs an exceptional
case of this character.f
In a majority of their continued malarial cases our medical officers reported the spleen
as large, soft and darkened, and their records bear testimony to tlie existence of more actively
destructive changes in these cases than in those of the typhoid series. Thus, in three of
the cases noted in the anatomical summary there were purulent or caseous cysts or circum-
scribed sero-purulent infiltrations, with escape in one instance of the morbid product into
the cavity of the peritoneum. Specimens 325 and 326, Army Medical Museum, two per-
pendicular sections of the spleen, from a case recorded as 87 of this series, show the organ
{•ortions of the intestinal patclios have been removed the mesenteric glanils begin to derrease in size, though still retaining an abnormal dark bliiish-
rwl color; but by the tinu' that the intestinal ulcers are healed the glands have regained their normal size, and are froiini-ntly smaller than usual, wilted,
tongh, |HiIe and often pigmented. The swollen glands are, according to IlAitLKV, almost entirely constituted of corpuscles of various sizes, for the most
IBrt spln-riral and nncleatod; the most numerous average jbVo *^^ "" ■'"^'ti '" diameter; the larger, present well-furmed nutlei and avenige j^ of an
inch. UuFKMAXS states that the locality- of tlie glands most deeply implirated does not always correspond with that of the bowel in like condition, fur
in some instances the mesenteric glands may be decidedly enlarged while the intestinal affection is sliglit, and in others the tumefied glanda may bt-
found higher up and away from the seat of the intestinal disease. The tumefaction is often so rapid that in a few days the glands acquire double their
natural size, and by the time tlie disease has reached its height it is not uncommon to find them as large as a hazelnut or walnut, aiul in some instances
even as large as a hen's egg. In the initial stage they are hypera;mic; internally the peripherj- is of adee|>ertinge than the remainder of the section, but
more fr^Hjuvnily the interior is of a uniform rose-color, or of this color mottled with lighter shades of the same tint or with gray. The colomtinii and
iwelling continue for some time, and then decline ; as a rule the fading of the medullary su'bstance proceeds towards the cortical jwrtion, and the latti-r
commonly r%-tains its pronounced red coloring after the centre has become jiale-gray; gradually, however, the n*dness of the entire gland disappears and
the tumefaction iK-comes reduced, constituting the most simple and frequent mo<ie of resolution. In many cases, however, the glands tiike on a yel-
lowish iir even an intense yellow color, developing foci of purift.>nii softening, mostly small except in the centre, where they often acquire greater
dimensions. VTien the softening is of limited extent absorption readily takes place ; but when considerable the liquid comiionents disajipear leaving
a dry, cheese-like, yellow mass in which, at a later period, calcareous matter may be deposited. All the stnictural elements of the gland are subject
to enl&rgement, the stroma as well as the other constituents; large cells, resembling those found in Peyers patches, are observed in all jmrts of the
glandular tiseue, but most abimdantly in the lymph sinuses. Atrophy may follow both forms of resolution. As the changes coincide in general with
those in the iDt<.-stiDal follicles, and as both are developed simultjmeously and in corresponding localities, Hoffmann suggests a pathological conm-ction
Irtween the pnK-esses, — that the clianges in the mesenteric glands arc caused by matter brought into them by the lymph-current. According to KiNit-
rtKi^cH the histological characters of the primary infiltration are faithfully reproduced in the mesenteric glands. Catarrhal swelling is followed by
excessive -mlargement from medullar}- infiltnition. The follicles and their prolongatii ns are the principal seats of the morbid changes, while the lymph
BiDuscs and the connective ar»* only moderately intiltrated. The vei^sels are enlarged and many of the capillary loops plugged. The trabecular '>ecome
thne or four times thicker than usual, the ntxial points especially are swollen and the nuclei vesicular. Proliferation, chiefly fii^siparous, but a!su
endogenous, so fills everj' sjiace, not already occupied by the vessels, with corpuscular elements that it is impossible to inject the lymphatic path of tlio
gland. Degeneration and absorption follow, li-aving the gland shrunken and sometimes pigmented by exti'Hvasations that had occurred during the ante-
cedent congestion. Cheesy necrosis is regarded as a rare phenomenon. Peritonitis may be caused by the resulting suppurative inflammation, or the pus
may l>rconie inspissated, calcareous and encysted. The changes ol«*rve*I in the mesenteric glands, according to Klein, were similar to those descrilM-d
as occurring in the closed glands of the niucoits niembi-ane of the intestine; micrococci, formed in the proi)er glandular tissue and in the capillary^
blanches were always connected with the necrotic changes.
• See fitpni, i«ge 449.
t RoKiTANSKV describes t!ie spleen in typhoid as sometimes enlarged to six times its normal size, its pulp consisting of a soft pnltaceous matter,
cberry-red or pale-red in color and similar to that of the typhoid substance of the mesenteric glands ; occasionally the splenic jiarenchy ma becomes reduced
tua fluctuating mass. IIarlev detc*ted under the higher jiowers only " minute granular cor|mscIes, fibre-cells and molecular branched fibnrs." Hoffmann
aays that changes in the spleen are as regularly observed in autopsies in typhoid fever cases as changes in the intestines, and among them an increase of
Tolunu- is the most frequent and striking. Nevertheless, in every epidemic, cases occur in which this condition is not present, particularly in persons
over forty years of age. in whom expansion is n.-strained by the firnniess and thickness of the stroma ; similar restraints are imposed when a cai»Hule has
become thickened and unyi.-Iding as a res.ult of pn.viuns disease, and when extensive adhesions between the organ aud its surroundings have previously
taken place ; but it sometimes hapj»ens that in young persons splenic enlargement is wanting, ev«n in the culminating stage of the disease, without the
appearance of any conditions that might be considen-d as explanatory. In general the splci^n in typhoid gains rapidly in size at an early periml, and
continue?* to iuctease until the height of the disease is reached, when it remains without change for a time, and then subsides by a slower process than that
I
460 PATHOLOGICAL ANATOMY AND PATHOLOGY
enlarged and considerably infiltrated with metastatic masses. When fresh this spleen was
so soft as to be easily torn with the finger; it was partly bluish-black in color and partly
of a livid blood-color, while the so-called metastatic masses were briglit yellow; these foci
consisted of granular matter in which were embedded the partly disintegrated anatomical
elements of normal splenic structure. Nevertheless the proportion of cases in which the
spleen was small or normal in size and consistence was greater in the malarial than in the
typhoid cases. Similar conditions were found in the fatal cases of the paroxysmal fevers.*
The spleen presented abnormal changes in 93.3 per cent, of those typhoid cases in which its
condition was observed and recorded and in only 65.4 per cent, of the malarial cases. In
the typho-malarial and mixed series a medium as to frequency is found, the former furnishing
81 and the latter 75 per cent.; but although the proportion of abnormities in these cases
was greater than in the continued malarial series, the proportion of cases in which a pulta-
ceous or purulent degeneration had taken place was not so great.
The LIVER in our typhoid cases differed from that of Louis's observations in the very
general presence of an augmentation of volume: Although noted in but five of his fortv-six
cases, enlargement is mentioned in a majority of such of our records as call attention to
abnormities. The somewhat enlarged, pale, perhaps fatty, softened and sometimes con-
gested state of the liver in typhoid was present also, to a certain extent, in the malarial
cases, a result probably due in both instances to the action of the disease-poisons; for
since these manifest their operation by similar pyrexial symptoms and disordercl secre-
tions a similarity in the secondary morbid lesions might naturally be expected. But among
the malarial cases was found a larger proportion of congested livers, and instances of adhe-
sion and suppuration give evidence that the inflammatory conditions were more intense as
well as more general; there was also found that darkening or bronzing of its substance
which was observed in the paroxysmal but not in the typhoid fevers. The liver was altered
in eighteen of twenty-nine tyjohoid cases in which its condition was observed and recorded,
i. e., in 62 per cent., in thirty-two of fifty-three cases, or 60 per cent, of the malarial, in
twenty-six of forty-five cases, or 58 per cent, of the typho-malarial, and in eighty-seven of
one liundred and forty-two, or 61 per cent, of the mixed series. The bronzing and occa-
sional disorganization found in continued malarial cases were found also in the typho-mala-
rial and mixed cases.
by which its augmentation was effected. "While enlarging the organ is tense, firm and uniformly dark bluish-red, with the trabecular structure barely seen
in the outswelling pulp-mass ; but as the disease advances its substance becomes softer, the pulp assumes a pultaceous character and the stroma has lefia
cohesion. Later the capsule becomes wrinkled, white, cloudy and thickened, while the spleen itself diminishes in size. These changes depend upon an
alteration of the blood-contents and of the constituent elements of the spleen. In their entire character they exhibit great similarity to those observed in
the lymphatic system of the small intestine. There appear single nucleated lymph-cells of normal size and larger, together with great numbers of large
many-nucleated cells, which latter compose in great part the contents of the venous sinuses and are profusely distributed in the larger splenic veins.
This is especially the case in the commencing stage of the splenic swelling; in the second and third weeks the large cells are found in vast numbers in a
state of partial division, while in later stages the single nucleated cells preponderate. The original lymph-cells are supposed to be the source of the
cellular development. Coincident with the increased cell formation the trabeculie become extended and the vessels tense. The Malpighian bodies are
mostly distinct, somewhat enlarged and well supplied with blood ; at first they are abundantly filled with cells, among which are a moderate number of
the larger many-nucleated corpuscles. As long as cell proliferation continues active the firmness of the splenic tissue is maintained, but when it begins
to subside, about the end of the third week, the tissue becomes soft. With the ev.acuation of the cell-structures the tension and volume of the splenic
substance diminish and the larger trabecula' contract ; but the fibrous reticulum and capsule remain thickened during the further progress of the resolu-
tion. The cell elements leave the spleen by the vessels leading from the organ ; but as comparatively few of the large many-nucleated cells are seen in
those vessels it is inferred that, considering their abundance in the splenic tissue, they are broken up into small cells in the efferent channels. At this
period dark-red and even black hemorrhagic foci are occasionally found scattered throtighout the substance of the organ. Infarction is generally con-
fined to one portion, a wedge-shaped mass, having its base directed towards the splenic periphery. So long as the infarcted portion continues firm its
tissue preserves its ability to undergo a progressive fading, shrinkage and isolation from the surrounding parts by a dense capsule of connective tissue;
but when the infarction is large it is prone to become softened into a pultaceous grayish-brown mass. If the capsular tissue has already been formed
the portion within it, as a rule, alone becomes disorganized, but if it is unformed the softening process may extend beyond the infarction and lead to
peritonitis, .\ccording to Klein, the cells in the distended blood-paths of the spleen in typhoid cases resemble lymphoid cells changed in the same
manner as those of the intestinal and mesenteric glands.
* See ante, page 14G.
OF THE CONTINUED FEVERS. 461
The two (.-ases 111 and 199 are of interest in connection with that rave post-moj'tem
conilition eniphvsema of the liver. In tlie tir.st case, which occurred in the service of Surgeon
E. B. Bentley, U. S. Vols., at the Slough hospital, Alexandria, Va., the patient had recurring
chills followed by fever, sleeplessness, delirium and jaundice, witli death on the ninth day
after adniissidu. The patches of Peyer and mesenteric glands were enlarged and tlie
liver increased in size, its right lobe honey-combed, "full of air and of a very peculiar a)ipear-
ance," and its left lobe normal in texture but of a yellow color; the kidneys were normal.
Specimen 639, Army Medical ^^luseura, is a section of the right lobe of the liver from this
case, showing the honey-combing of the organ by dilated ducts which, according to the state-
ment of the Catalogue of the Museum, was filled when recent with a yellowish scrumdike
fluid. Tliis statement niakes no mention of the presence of emphysema. The second case
was reported by Assistant Surgeon Hareison Allen, U. S. Army, in eliarge of the Lincoln
hospital, Washington, D. C. The patient died on the seventh day after admission, but the
existence of bed-sores over tho sacrum and trochanters showed that he musi liavo been sick
for several weeks. He suffered from high fever and delirium, frequent retelling and violent
diarrhoea. The patches of Peyer were ulcerated; the mucous membrane at the iIeo-ca;cal
valve thickened, indurated and blackened and in the colon pale but dotted with spots of
black pigment. On the left side of the abdomen, about two inclies below the diaphragm,
was a subperitoneal ab.scess containing four drachms of pus. The surface of the liver was
generally of a grayish-blue color, but anteriorly the right lobe had a more healthy appear-
ance; minute collections of air were disseminated through its parenchyina, which was soft,
of the color of sanious pus and possessed of a disagreeable odor; the air-cavities and the
transverse sections of the portal veins gave a honey-combed appearance to the inferior. The
kidneys were in a similar emphysematous condition, the distinction between the pyramidal
and cortical portions being almost obliterated.
Perhaps to these might be added case 137, as presenting the color, odor and consistence
of the fully-developed emphysematous case, although no air is mentioned as present in the
tissues. This case, also reported by Dr. Allen of the Lincoln hospital, died on tlie third
day after admission, but no clinical history has been preserved. The patches of Peyer in
the lower part of the ileum were surrounded by congestion and had ragged surfaces and
purplish edges. The liver, of a dull greenish color, evolved a peculiar chicken-coop odor
and Avas so soft that the finger could be passed through it in cvorv direction; the gall-
bladder contained an ounce of dark ochre-colored bile. The kidneys Avere congested.
Fkerichs* refers to emjihysema hepatis, and cites Graves and Haspel as instancing
cases in which an abscess or hydatid cyst, after the discharge of its contents into the stomach
or intestine, became filled with gases from the gastro-intestinal canal owing to j^ressure
exerted by the abdominal walls or muscular tunics of the intestine; but he acknowledges
that it is more difl&cult to account for those cases in which air-cavities, from the size of a
millet-seed to that of a pea, are found permeating the hepatic substance. He met an
instance of this kind in the body of a woman who died from purulent inflammation of
the joints, death having been preceded a short time by abortion and the appearance of
petechias. He also cites some cases observed bv others. — by Stokes in a person who died
from the rupture of an aneurism into the oesophagus, by Louis in a tubercular patient, by
Cambay after dysentery and peritonitis and by Piorry after small-pox.
* ^1 Clinical Treatise oh Diteasea of the hirer — New Sydenham Society, London, 18G1, Vol. II, p. 3G9.
462 PATHOLOGICAL ANATOMY AND PATHOLOGY
111 aclJition to his tubercular case above cited Louis"^ found this empliysema of the
liver iu certain cases of acute disease; but iu the typlioid affection he never encountered it,
and he comments with astonishment on what seems to him a fact, that this apparently putre-
factive condition of tlie liver should be absent in a disease which has been long known as
putrid fever while present in other acute maladies tliat are not so intimately associated with
the idea of putridity. Emphysema of the liver in his cases coincided with a similar condi-
tion of tlie neck and limbs.
J. FoFuSYTH Meigs has reported a case in which the liver was found iu this condition
after typhoid fever. f In this case there was much exhaustion, which was regarded as due
to ;ui unusual destruction of the red corpuscles of the blood indicated by tlie amount of tlieir
coloring matter in the urine. The patient died after profuse hemorrhage from the bowels
about the eighteenth day of his attack. The patches of Peyer and many of the solitary
glands were ulcerated and the mesenteric glands enlarged, vascular and softened. Tlie
liver was much enlarged, brownish-yellow, spongy and crepitant, so light as to float iu
water and so soft that the finger could readily be thrust through it; on pressure inueli dirty,
frothy, thin liquid escaped, which looked like ichor but not like pus; the gall-bladder was
filled with thin yellowish bile. The kidneys were enlarged, dark colored and congested;
they crepitated distinctly but did not float in water. There was subcutaneous emphysema
of the sides of the neck and thorax, and much discoloration from stasis in the dependent
parts of the body. On microscopic examination, the liver was found to be fatty; fat in large
drops was scattered over the field, and all the small angulated and irregular cells contained
much fat in minute refractive points. On the other hand, the kidneys were not fatty, but
till.' tubes were large, swollen and crowded with dark cloudy cells. Dr. Meigs remarks that
there was no emphysema of the neck before death, or at least none was observed, as he
believes it would have been had it existed; but he considers it difficult to suppo.se that the
singular cribriform and spongy character of the liver could have been produced in the eleven
hours and a half which elapsed between death and post-mortem oliservation, especially as
there was no decomjiosition of tlie tissues in other parts of the body, and assuredly none in
the kidney, which also, although to a less extent, was emphysematous.
Tlie lionev-combino;of the liver iu case 111 was certainlv due to dilatation of the duels,
by a serum-like fluid, according to the statement in the Catalogue, connected with wliich
was the jaundice of the clinical history; but the language of the reporter leaves no room
for doubt that emphysema was associated with this condition. Without additional cases
and more precise details it is difficult to say what may have been the origin of the emphy-
sema; but in view of similar conditions in the kidneys in some of these cases, and in the
muscles of the neck in case 98, it seems probable that it was the result of post-mortem
changes. In tissues that have become so profoundly altered from the normal condition
during life it is not surprising that chemical reactions, in advance of bacterial or putrefactive
changes, should have given rise to the evolution of gaseous products as soon as vitality
ceased to act as a preservative.
* Paris, 1S2<1, t. I, p. 809.
t PhitadelphUi Medical Tiin£H, 1872-73, Vol. Ill, p. 1. — Referring to the rarity of this condition of the liver Dr. Meigs says : "In that great treasure-
house of pathological medicine, RoKrrANSKV's Pathological Anatomy, I cannot find a single specific reference to it. I have looked through seven vol-
umes of the Year-Books of the Sydenham Society and did not find a case. Bamberger, in Virchow's Hand-book of Pathology and Therapeutics, iu the
chapter on the liver, makes no mention of it. Neither Biidd in his Treatise on the Liver, nor Watson in his Practice, nor Graves, wlio saw so much
typhus in Ilublin, in his great work on the Science of Medicine, nor the writers on Typhoid Fever and Diseases of the Liver in Reynold's System of
Medicine, nor the Compendium de Medecine Pratique even glance at it."
OF THE CONTINUED FEVERS. 1G3
The GALL-BLADDER in the continued fever cases presented no special cliaracteristics. It
was large or small, empty, distended or charged with various quantities of bile, usually
dark-colored and viscid, but sometimes thin, straw-colored or watery. As accidental com-
plications may be mentioned the perforation of its walls in case 95, in whicli constant nausea
and vomiting, jaundice and subsequent peritonitis obscured the symptoms of typhoid, and
its disorganization in 327 as the result of its participation in a general peritonitis.
Tiie PANCREAS was normal in twenty-seven of forty-one observations and but slightly
altered in the remaining fourteen, the alteration consisting of an asserted hardness, softness
or change of tint. The resistance of this gland to the typhoid and malarial poisons may be
fairly assumed from a consideration of the many cases in which it was healthy, although
the other abdominal organs were extensively diseased. Even when the parotid gland became
atl'ected it does not appear that the susceptibility of the pancreas was increased, for while the
condition of the latter was stated in but one of the cases in which the parotids were inflamed
it was normal in that case, 263. But the inference that on this account there is a fj-reater
difference between these glands than is generally supposed is hardly warranted, since the
submaxillary glands were so rarely affected.
The KIDNEYS w^ere less frequently affected in the continued fevers than the liver or
spleen, but the morbid changes that were observed were of a similar character. The large
number of instances in which their condition was not stated detracts from the value of the
statistics for certain purposes; but of the cases that were examined about one-half were
reported as in a healthy condition. In 52 per cent, of the tyj)hoid series the kidneys were
more or less altered; in 57 per cent, of the continued malarial cases; in 35.7 of the typho-
nialarial,and 42.6 of the mixed series of cases. It is inferred from these figures that although
an altered condition of the kidneys was as frequent an attendant of malarial as of typhoid
fever, the conjunction of these was not expressed by an increased frequency in the lesions
of this organ. Nevertheless an examination of the analytical summary, by showing a
somewhat greater prevalence of acutely inflamed cases in the tyiiho-malarial and mixed
series, suggests that the coincidence of the febrile poisons may have been manifested bv an
increased gravity of the lesions. The kidnevs were congested, in many cases soft and flabby
and in soine pale and fatty; occasionally the congestion resulted in ecchymoses, and at
times the inflammatory action proceeded to suppuration. The emphysematous kidney in
case 199 has already been referred to in speaking of the lesions of the liver.
As has been shown in a previous part of this chapter,* no general connection was
observable between dysuria or i-etention, and delirium or stupor, although it is probable, as
argued by Murchison, that cerebral symptoms are in some instances the result of an accu-
mulation of urea in the blood.
m.— THE ORGANS OF RESPIRATION AND CIRCULATION.
As the condition of the larynx and trachea was observed in so few of the cases, the
relative frequency of their lesions can be ascertained only by the figures supplied by Dr.
Harrison ALLEN.f In only three of his cases of camp fever was the trachea or larynx
implicated. In one the fauces and epiglottis were covered with false membrane, and the
margins of the latter and mucous lining of the larynx were ulcerated ; in a second there Wiis
thickening of the membrane but no ulceration, and in the third a decided inflammation of
*SK<m(e, pages 298 and 308. t See <iit/f, page 433.
I
464 PATHOLOGICAL ANATOMY AND PATHOLOGY
tlie tmeliea unaccompanied by laryngitis or pneumonia. From the paucity of such lesions
in tliirty-tive cases it seems probable that the reason why the larynx and trachea were not
more frequently mentioned in our post-mortem records was the absence of morbid appear,
ances in these parts. Observations were made in six of the typiioid, eight of the malarial,
four of the tvpho-raalarial and seventeen of the mixed cases. The alterations consisted of
thickening of the lining membrane by congestion, oedema, exudation into the submucous
tissue or the development of false membranes on its surface ; not unfrequently the membrane
was ulcerated,* and occasionally small abscesses were formed in connection with the laryn-
geal cartilages. Unquestionably these conditions were frequently the causes of the alter-
ation or loss of voice and the dysphagia that were at times present in the progress of the fever.
CEdema was a dangerous lesion in some instances, as in 339, in which it caused death by
occluding the rima glottidis. Perliaps also this was the cause of the sudden death in 36;
in this case, as there was oedema of the lower extremities and effusion into the serous sacs,
the fatal result may have been occasioned by the pericardial effusion, which suffices to account
for the masking of the heart-sounds, the dyspnoea and prsecordial pain; but it is not certain,
in the absence of post-mortem observations directed to the larynx, that an cederaatous con-
dition of the glottis arising from the anaemia may not have been the immediate cause of death.
Generally, however, oedema glottidis was connected with local congestive processes. Occa-
sionally jjseudomembranes were the proximate cause of the fatal issue, as in cases 122 and
308; but it does not appear that diphtheria was specially a complication of typhoid or other
continued fevers, for it appeared in patients enfeebled by other diseases and, indeed, by gun-
shot wounds. Its occurrence seems to have been determined by the deteriorated condition
rather than by the specific cause of the deterioration.f
Emphysema of the neck has been attributed to the existence of ulcers in the larynx :|
but ill the only instance, case 98, in which this condition of the cervical cellular tissue was
noted, the lar3'nx does not seem to have been examined, and the emphysema, on account of
a coexisting ecchymosis, was referred to a hypothetical ante-mortem violence. In case 12
the oedematous condition of the neck was apparently connected with processes affecting the
throat, as the epiglottis was much swollen.
The condition of the bkonchial tubes was seldom observed or noted, but they occa-
sionally appear to have been congested irrespective of the condition of the pulmonary tissue.
In a few cases,. as 281, 331 and 362, there were distinct evidences of inflammation.
The condition of the LUNGS was variousl}- reported by our medical officers as engorged,
congested, oedematous, splenified or hepatized. They weighed more than in the healthy
state from the afflux and stagnation of the blood and the subsequent exudation or transuda-
tion of its element?, in certain parts, generally their lower and posterior portions. Undoubt-
edly this condition arose, in many instances, during the great prostration that immediately
preceded death, for it was found in cases in which there had been no symptomatic manifesta-
tion of its presence; but in otlier cases the morbid action was of a more active character,
leading to a true hepatization. Generally the sanguineous condensation was diffuse, but it was
* According to Liebeemeister, Ziein«setr« CycJopedia, Am. Ed., Vol. 1, p. 160, laryngeal ulcers are of comparatively frequent occurrence in typboid.
He cites IIoffmakx as h.iving found them in 28 of 250 autopsies of typhoid fever, and Ueiesingeb in 26 per cent, of his fatal cases.
t See diphtheria, itifrtt, p. 739.
I MuRcHisox refers to Wilks as having demonstrated the association of emphysema of the neck with ulcer. "A boy, aged 12, berauK- enipliys'-'ma-
tons on the twelfth day of an attack of enteric fever, the emphysema commencing in the neck, spreading to the face, arms and chest, and greatly impeding
deglutition. Death occurred on the twenty-second day, when it was found that the air had escaped tbrougli a sloughing ulcer of the larynx, situated at
tbo posterior junction of the vocal cords." — Op. cU., p. 558.
OF THE CONTINVED FKVKRS. 465
occasionallj ciriuinscribed in lobular masses as if the result, ol" catarrhal [)rocesses. Owing
to want of definition in the records it is uncertain to what extent hemorrhagic infarction con-
duced to the production of the morbid appearances.
The lungs presented a larger proportion of morbid changes in the typhoid than iu the
malarial cases. They were altered from the normal iu 85.3 per cent, of thirty-four typhoid
cases in which their condition was noted, and in but 55.2 per cent, of fifty-eight malarial
cases, the typho-malarial and mi.xed cases taking a middle position in this respect, the former
presenting 62.7 per cent, of fifty-one cases and the latter 71.2 per cent, of one hundred and
sixty-three cases; but while the lungs, like the spleen, were less frequently affected in con-
tinued malarial than in typhoid fever, they presented in the individual cases of the former
more extensive or aggravated diseased conditions, as manifested by the occurrence of ecchy-
mosis with congestion and by the greater frequency of purulent collections. Hurried respira-
tion, although generally due to local hypera3mic conditions, was in some instances attributable
to nervous agitation, to febrile excitement, to pressureon the lungs by the tympanitic abdomen,
or, as in case 25, to a combination of these conditions.
The fleur^. — As compared with the frequency of congestive and intiamniaioiy pro-
cesses in the parenchyma of the lungs, morbid changes in the pleural membrane were of
great rarity. Adhesions unconnected with the febrile attack are of course excluded froni
the list of abnormal appearances. The pleural cavity sometimes contained a serous effusion,
due in some instances to a transudation from engorged capillaries, but in others to more
active processes, as may be inferred from the flakes of lymph or purulent turbidity described
as present; recent lymph appeared occasionally on the surface of the membrane and the
serous efl'usion was sometimes tinged witli blood.
This rarity of the pleural affection in continued fevers among the white troops is strongly
contrasted, according to the published statements of Surgeon Robert Reyburn, U. S. Vols.,
by its frequency and fatality among the negroes. In a report* which gives the results of
the treatment of 7,949 cases of sick and wounded freedmen in the District of Columbia from
June 1 to December 31, 1865, he states that typhoid fever constituted the most fatal although
by no means the most numerous class of cases; there were one hundred and sixteen cases,
of which forty-nine, or nearly 41 per cent., proved fatal. He considered that pneumonia,
which so often occurred in the progress of typhoid fever affecting the Caucasian race, became
in the negro pleuro-pneumonia of a low grade, and was generally accomj^anied with a large
serous or sero-sanguineous effusion, which after death was found filling the pleural cavities.
In fact, inflammation of the serous membranes seemed to be more frequent and dangerous
among negroes tlian among whites. That the effusion was not Pi jjost-mor tern transudation
was proved by its quantity, which entirely precluded that idea, and by the fact that in
many of the cases percussion revealed it^ existence during life.
The pericardium was less frequently affected than the pleurae. Sometimes an excess
of serum was present, and occasionally this was tinged with blood or associated with a slight
redness of the membrane. Rarely, as in 90, 206, 276 and 307, there were such indications
of inflammatory action as fibrinous flocculi in the effused liquid, exuded lymph on the serous
surface or a thickening of the membrane. Many of the cases presenting these pericardial
changes had the lungs or 2>leural cavities in a morbid state, but in some, as 170, 206, 262
and 328, there was no coincident implication of these pai'ts.
*See AmmcanJo»nialo/lheliedicalScie«ca, 1866, p.SMetieq.
Meu. Hist., Pt. Ill— 59
466 PATHOLOGICAL ANATOMY AND PATHOLOGY
The condition of the hkart was mentioned in less than one-half of the cases; and in
these it was frequently said to have been normal or healthy, as, for instance, in 82 per cent,
of twenty-two typhoid cases, in 75 i:)er cent, of forty-eight malarial cases, in 77.5 per cent,
of forty tjqaho-rnalarial and in 77 per cent, of one hundred and thirty-five cases of the mixed
series. Usually, when described as altered from the normal, the words pale, anemic, soft,
flabby, flaccid or atrophied were emjjloyed to express its condition; in a few cases it was
said to have been fatty. From these observations it would be difficult to infer the frequency
and great importance of the degenerative changes in the muscular tissue of the heart induced
by the continuance of the febrile movement as demonstrated by the investigations of Hayem,*
VALLiNf and others; but it is known that these changes, involving a cloudiness of the
stripe of the muscular tissue apparently by albuminous granules in the fibres and inter-
fibrillar protoplasm, and even a fatty degeneration of the muscle, are gradual in their progress
and may be shown by microscopic examination to be notably advanced although the organ
may not attract attention by changes in its macroscopic characters.
But although the heart was so frequently reported in a healthy condition by the post-
morteni observers, the attending medical oflUcers recognized in the symptoms a tendency to
a failure in the powers of this organ, and were inclined to attribute cases of sadden or other-
wise unexplained death to this cause. Nevertheless, in the series of cases that have been
submitted there is not one case that may with certainty be instanced as having proved fatal
by the sudden failure of a degenerated heart. In case 18i, which had a suddenly fatal ter-
mination during an ap^iarently, favorable convalescence, the heart was flabby. In the large
number of cases in which death was the result of progressive prostration, and which were
unmarked at the autopsy by the presence of a particular lesion known to be mortal, it is
possible that the heart was materially implicated, but the records do not say so. Thus, in
cases 13 and 14, in which it is stated in terms that the cause of death was asthenia, the
condition of the heart is not mentioned. On the other hand, while there is no certainty
that this degenerated condition of the heart was the cause of death in the cases in which it
was present, it is deserving of note that in a large proportion of them there was no lesion
of the viscera that could be cited as the immediate cause of the fatal result. In about one-
third of the three hundred and eighty-nine cases that have been presented the cause of death
could be ascribed to some particular complication or lesion, as coma, hemori'hage, perforation,
pneumonia, etc.; but of the thirty-nine cases in which the heart was stated to have been
pale, ansemic, softened, flabby, atrophied or fatty, a lesion to which death might with proba-
bility be assigned was found only in six or seven cases, — gangrene of the feet in 112 and
278, gangrene of the intestines in 311, perforation of the bowels in 347 and pneumonia in
243, 333 and perhaps 182. In view of what is known concerning the degeneration of the
muscular tissue of the heart in continued fevers it is not unlikely that death in many of
these thirty-nine cases may have been due, to a certain extent, to the special influence of
this morbid change.
Physiological considerations lead to the expectation of a greater frequency of congestion
of the lungs in connection with a degenerated condition of the heart than in those cases in
which this organ was reported healthy; but this expectation is not sustained by an examination
* Hechtrch&i sur les Happorls exiitant etUre la Mori Snbile ei les oUiraluytK vaxculaira du Cceur dam la FUvre Tiijthdide, par Georges Hayem. — Archives de
rhyeiologie Normale et Pathologique, Paris, 1869, t. 2**, p. 6D9.
■f Dea Alterations TTialolofjiqn^.? dii Cmur et des Muscles Voloutaires dans les Jitlvres pemiciettses ct remittent's, p:ir 31. E. Tallin. — Memoires de M^decine, Ac,
Militaries, 3™ scric, t. XXX, Piiii.s l.STI.
OF THE CONTINUKT) FRVEKS. 467
of the records. The condition of the lungs was not stated in four of tlie thirty-nine cases in
which the heart was said to have been degenerated; in twelve the lungs were normal and
in twenty-three congested or more actively diseased; they were, therefore, altered in 66 per
cent, of the cases in which their condition was reported. On the other hand, in looking at
the cases in which the records do not state the heart to have presented this flabliy condition
of its walls, the lungs were hypersemic in one hundred and eighty-six, normal in eighty-five,
while in seventy-nine their condition was not stated, t. e., they were congested or otherwise
altered in 68.7 per cent, of the cases in which their condition was recorded. In view of these
tigures, showing the association of a larger proportion of congested lungs with hearts that did
not attract attention by their morbid conditions than with those that were reported as more
or less degenerated, it is to be inferred that pulmonary congestion in these fevers was uncon-
nected with tiie condition of the heart or that the naked-eye appearances of the latter organ
gave by no means a true impression of its actual condition.
The contents of the chambers of the heart were noted in ninety-six of the three hun-
dred and eighty-nine cases of continued fever. In nine of these it is stated that no clots
were present: In 48 the heart was pale; in 329 firm; in 137 flabby; in 165 and 277 it was
said to have weighed nine ounces; in 96 it was reported large, the left ventricle empty and
the right containing uncoagulated blood; in 150 and 190 the blood was uncbagulated ; in
194 there was a thin wafer-like formation on the tricuspid valve. Manifestly, from the
small number of cases in which the heart was reported as having been found free from clots,
its contents were specially noted, as a rule, only when the attention of the recorder was
attracted by these coagula.
Clots occurred with greater frequency in the cavities of the right side than in those of
the left. In a few instances the records do not specify whether the coagula or fibrinous
concretions were formed in the right or left side or in both sides, the statement being simply
as to their presence in the heart. But if their existence in the chambers of both sides be
assumed in these cases, it will be found that of eighty-seven recorded cases of heart-clot both
sides were affected in forty-nine. Of the remaining thirty-eight cases the right side con-
tained clots in thirty-five and the left in three instances. Of those containing clots in the
righ chambers onlv, tlie left side contained fluid blood in two and no clot in two, while in
thirty-one assurance is conveyed of the absence of clots by the fact that their presence was
not recorded. In the cases containing clots in the left chambers only, the right side con-
tained fluid blood in one instance and no clot in another; in the third no statement of its
contents is given. The greater liability of the right side of the heart to the accumulation
of coagula may be gathered from these figures. Clots were noted in the right cavities of
eighty-four and in the left cavities of fifty-two hearts.
But the character of the coagulum had a tendency to vary according as the right or
left chambci-s of the heart were its seat. Of the eighty-four coagula noted in the right
cavities fifty-six consisted of fibrinous concretions or deposits, frequently filling the cham-
bers and projecting into the great vessels, eight were venous or black clots, six a mixture
of fibrinous deposits and venous coagula, while in fourteen the appearance of the clot was not
entered on the record. Of the fifty-two coagula in the left cavities twenty-five were fibrin-
ous, eight venous, seven mixed and twelve of unstated appearance.
Dr. Woodward has discussed the general question of heart-clot in connection with it.'-;
468 PATHOLOGICAL ANATOMY AND PATHOLOGY
occurrence in diarrhcea and dysentery /'' He concluded that although iibrinous coagulamay
be formed during life they must be regarded in the vast majority of instances as occurring
during the death agony. He pointed out that no facts had been presented to show that
clots were formed more frequently in cases of sudden death than in cases of the same disease
in which death took place in the usual way and without any symptoms referable to the
heart; and that there was no evidence that the clots in the one group of cases differed from
those that occurred in the others as to size, texture, adhesions, etc. Dr. Woodward dealt
with this question before the whole of the data relating to it had been submitted. It is
true the further evidence contained in the records does not unsettle his conclusions; but if
there had been before him the cases of lieart-clot recorded in the chapter on the paroxysmal
fevers,^ with cases 271 and 377 of the continued fevers and 34 of the secondary pneumonias,J
it is jDrobable that he would have given a more emphatic acknowledgment of the existence of
heart-clots of ante-mortem development, and conceded them as a whole a higher place in the
scale of importance. The clots being manifestly of ante-mortem formation in some cases, it
is assumed that they must have had a similar liistory in other cases unless it can be shown
that in the latter they were o^ post-mortem origin. It is admitted that in most instances
these clots were formed when the patient was about to succumb. The question at issue is
their relation to the death agony. If they were formed during the agony and because of it,
they had only & post-mortevi value; but if, as seems likely from the cases presented, they
were due to some cause which induced a tem])orary stasis or retardation of the flow of the
blood through the chambers of the heart and brought about the agony by the rapidity of
their development, they become of importance as the determining cause of the fatal issue in
a large number of cases and as indicating the necessity of preserving patients from such
influences as are known to be efficient in precipitating the deposition. When the predis-
posing conditions were not strongly marked, as in a case of typhoid in which the patient
ajiparently retained strength sufficient to enable him to help himself in many of the neces-
sities incident to his condition, a notable impress on the system might be required to con-
stitute the immediate or determining cause of the fibrinous deposits, as the faintness which
followed the exertion of rising to stool in cases 271 and 379, or the chill in 96 of the
paroxysmal series. But on the other hand, in the presence of strongly predisposing condi-
tions, such as were constituted by the prolonged duration of the fever, tlie existence of
pulmonary liypersemia, the exhaustion of diarrhoea or hemorrhage or the collapse attendant
on perforation, the agency that determined the deposit and the closely-following fatal result
might have been so slight as to have passed unnoticed; yet it may not be allowed that there
was no exciting cause to occasion tlie deposit and death at that particular time.
In the majority of cases in which heart-clots were formed there was no lesion of the
abdominal viscera, brain or lungs obviously inconsistent with the continuance of life. To
no one in particular of the inorliid changes in these organs could tlie role of executioner be
assigned. The patients died from the totality of the morbid changes produced by the fever,
typhoid or malarial, as the case may have been, or from the asthenic conditions bearing on
the thread of life in the diarrhoeal, pneumonic or other cases in which heart-clot was found
as i\ post-mortem appearance; — or they died i'rom lieart-clot. But while the tutahty of the
morbid changes was an inconstant quantity and of an uncertain value, the heart-clot was
constant and efficient. In view of these considerations it is not surprising that our medical
* See p. .5:i!) ,1 srq. uf tlie Secoml I'ai I nf tins work. \iiGe sitjim, page l:i8. | See ii»/r«, page 788.
OF THE CONTINUED FEVERS. " 469
officers came to regaivl the libriiiou.s cougula as llie immediate cause of tlie fatal issue iu the
cases presenting them. If a patient manifestly died, as in 110, from exhaustion con-
sequent on repeated hemorrhage from the Iiowels, wliat may be conceived to have been the
modus operandi of the cause? The hemorrhage predisposed to death by syncope, but the
patient did not die until a clot had formed in his heart. He might have lingered for some
time longer, notwithstanding the weakened action of the heart and the altered condition of
the blood, had not some slight exciting cause determined llie deposition of the fibrinous
coagulum, which speedily interfered with the continuance of the cardiac How. In case 112,
in which the patient may be said to have died of gangrene of the feet, there was no condition,
so far as is learned from the record, to occasion the immediate extinction of life until the depo-
sition of iibrin was effected by some trifling, but under the circumstances all-sufficient cause.
In some of the cases of peritonitis from perforation, as 45, 106, 156, 245 and 347, or that in
which the gall-bladder was perfoi'ated, case 95, there appears no cause for the destruction of
life .at one particular moment rather than at another, if the fibrinous coagula in the heart are
excluded from consideration. So, too, in such pneumonitic cases as 62, 198, 281, 357 and
369, in the pleuritic effusion of 340, and in the cases 217 and 304, which passed into death
from a condition of coma, the agency that determined the occurrence of the fatal event at one
time rather than another must be conceived to have been the development of these clots,
owing to some temporary, and but for this not necessarily permanent, stasis in the passage
of the blood through the chambers of the heart. Even in such a case as 122, in which the
occlusion of the larynx by diphtheritic membranes may be readily assigned as tlie cause of
death, it is probable that the immediate cause was the fibrin deposited in the heart during
the stasis occasioned by the last of the suffocative paroxysms; since, if this had not occurred,
the patient might have lived to have added another to the suffocative paroxysms that he had
already experienced. The proposition that certain cardiac concretions are formed during life
does not therefore rest exclusively, as it appeared to Dr. Woodward, upon the anatomical
characteristics of the concretions;* but in some cases very clearly on tlie symptoms, and in
others less clearly on positive and negative pathological evidences. These, indeed, suggest
that sometimes the ordinary black coagulum may have an ante-mortem formation and be the
cause of the death agony.']'
Theoretically, one of the conditions provocative of the deposition of fibrin in the heart
• Page Ml, Part 11.
fThe tint* futluwiiig cases are briefly presented as illustrating the ante-mortem occurrence of all the varieties of clots that have been found in the
heart: Ut. Filirilhiti-d dot^ wiili central softening and arterial projcctiong into their roots, which manifest with certainty their ante-mortem origin;
2tl. Fihriiitiurt dots which soUR*tinu-s by their symptoms, as in the canes already given in the text, are known to precede and cause the death agony ; Sd.
Ordinary blood coagula, which ai*e usually ascribed to pttnl-morttfin changes, but which may, iu some cases, he the innuediate causi- of death. The lirst is
ri'latwl by John G. M. Kenurick, E<Iiuburgh Med, Jonr., Vol. XV, 1809, p. 39G. The patient, a woman of 10, was admitted Keb. 2;i, isr.'t, and died March I.
She was li>w-spirited and anxious, but complained only of slight cough and frontal headache, particularly towards evening. The most renmrkable phe-
nomenon of the case was a constant moaning of the patient during sleep, which was usually distvirbed by frightful dreams. Nothing relieved this distressing
symptom except propping her head aud shoulders high with pillows. One morning, having been in her usual state till breakfast time, she suddenly
became wors*;, dying at 10 a. m., apparently from congestion of the lungs. In the right auricle there was a white irregularly pear-shaped clot about the
feise of a large walnut, attached by several band-like processes at its narrow end to the musculi pectinati in the apex of the appendage. This clot, of
Arm consistence and slightly tloccular appearance, had a cavity in its centre communicating with theexteriorby asmall rent in its substance. In the left
auricle a ftnn white clot, attach<-d to tb<' columnar carueie, divided into two bnincheB, one of which occluded the mitral orifice and the ottier extended
into the aorta. Hy|N»rtropby of the left ventricle, thickening of the anterior flap of the tricuspid valve and imperfect closure of the foramen ovale, were
ftlsooLKM-rved. The lungs were mn«h congested, and a few ounces of serum were found in the left pleural cavity together with a little serum in the peri-
cardium, but there was no pericarditis. The clots, on microscopical examination, were found to be of fibrillated structure, holding in its meshes numerous
coriMisculnr bodies with comigatt-d edges ; sevenil minute bloodvessels from the endocardium entered the root of one of tlie band-like processes of the clot
in th» right auricle, but, as fur as could be observe<l, did not penetrate its substince ; the epithelial layer of tlio endocai-dium, with the subjacent one of
elastic liwne, s<^-emed to be reflected upon the root of the clot and to run along with it for a few lines. The second case is given by Dr. ri.AVF.MR, in the
Tnia«. /'<i//i. goc.. London, Vol. XVIII. 18C7, pp. CS-TO, as having occurred at King's (College hospital. The patient had complained of paii# in the right kn.p,
but th.-re wa# no swelling or tenderness of the |tart, nor feverishness. An alkaline mixture was prescribed. She was not seen next day. On the third
monting »he expressed herself free from luiiii and s:iid she had jmssed a good night ; but shortly after this she complained of feeling weak, and a^^ked
for a bed-]«n that she might not have to k-.ive her bed. She was then seized with hurried breathing anil diet! before the house physician, who was
MDt for, could arrivo. On poMt-ntortem examination all the organs and structures of the body were found to be healthy. A firm solid ilot of fibrin of
470 PATHOLOGICAL ANATOMY AND PATHOLOGY
is that degeneration of its muscular fibre wliicli in prolonged fever gives rise to the charac-
teristic feebleness of the pulse. But the records do not show a greater frequency of clots
in hearts reported pale, flabby, flaccid, etc., than in those reported healthy or which did not
attract attention by any abnoi'mal appearances. Of thirty-nine cases in which a degenera-
tion of the heart was noted it was free from clots in two cases, its contents were not stated in
twenty-nine cases, and it contained clots in eight cases, or in 20.5 per cent, of the number
observed. The eight cases were 75, 276 and 347, in which fibrinous clots were present in
both sides of the heart; 112 and 184, in which they were confined to the right side, and 148,
154 and 219, in which coagula, the character of which was not specified, were found, pre-
sumably, in both the right and left chambers. Of three hundred and fifty cases in which
the condition of the heart was not stated or stated to be healthy, seventy-nine, or 22.5 per
cent, of the whole number, contained clots. In view of what has already been advanced
conciTuiiig tlie difficulty of deciding upon the actual condition of the heart from its micro-
scopic appearances, this similarity in the percentages of heart-clot in the two sets of cases
might be construed as indicating that the heart was possibly as much weakened in the cases
in whicli its condition was not stated or said to have been healthy as in those in which the
observers considered it flabby or otherwise degenerated,
As congestion of tlie lungs was so commonly present in the final hours of continued
fever, occurring in as many as 68.3 per cent, of the cases, the frequent coincidence of clots in
the heart with siich congestion was to be expected. On questioning the cases for a possible
connection between the presence of fibrinous clots in the right chamber of the heart and an
engorged or other condition of tlie lungs interfering with the circulation <>( the blood through
their tissues the following inforiuiition is obtained;
In the five cases (if tyi'luiiil in which separation of fibrin look pUice there were iiuhiimiarv conditions (hiring
the last stage of the fatal illness involving stasis of the hlood-cnrrent.
hi four of the fourteen eases of the malarial series in which there were fibrinous coagula in the right eliainbers
the lungs were not seriously affected: In 259 some injection and a small nodnlar consolidation was recorded, but
the weight of the lungs was inconsistent with any material engorgement; in 71 the lower part of the pleura on one
side was said to have been inflamed, whence it may he inferred that had the pulmonary tissue presented any notable
al)noruiity it would have been observed and recorded : in the two cases, 292 and 293, the lungs were expressly stated
as having been in a healthy condition.
Of the ten typho-malarial cases presenting librinous clots in the right side the lungs were nornuil in four, 77,
95, 102 and 271, while in a fifth, 2{;(j, old pleuritic adhesions constituted the only abnormity. Moreover, lOti, in which
clots of an unspecified character were found in the heart, had the lungs in a iKJalthy state.
Lastly, of the thirty-one cases of the mixed series in which fibrinous or partly fibrinous clots were observed
in the right side of the heart, the lungs were normal in four, 167, 220, 221 and 347, while in a fifth, Ifif), the pulmonary
disease consisted merely of a few softened tubercles in the apex of each lung.
From the above figures it may be calculatetl that congestion of the lungs was present
in 75.4 per cent, of those fever cases in which the heart was found to contain fibrinous or
mixed clots in the cavities of its right side. This increase in the percentage of lung
disease in the heart-clot cases may be considered an expression of the influence of pulmonary
a pale-yellow color was found in tile right Bide of the heart and pnlnionary artery, adhering to tlie valves and fleshy columns. If this clot was formed
during the death agony, why did the deatli agony occur? If tlie woman did not die of tienrt^;lot, wliat was tlie cause of deatli ? Dr. Pi.ayfaih's theory
was that tlie clot had prohahly heeii forming duriug the night precediog the fatal result, and that so long as the patient remained quiet sufficient blood
passed through the obstructed vessels to carry on the organic functions, but when she was obliged to exert herself there was a sudden call for blood, which
could not he supplied through the occluded artery, and death resulted. Br. .Iohn A. Liukll, of New York, gives the third case, — Am. Joui: v/ Med. iSin.,
Vol. XHV, 1872, p. 32S, — that of an intern penite woniuii, who, when recovering from an attack of epileptic convulsions, was seized with dyspiia?a, and died
in an hour. The left juilmonai-y artery was obstructed with coagula. The heart was eiilai'geil, fatty externally ami tlabby; its cavities were dilated aud
those of the right side filled with dark -colored clotted lilood. The right lung was much congested and o'dematousaiul the left inteiiseiy congested. It was
supposed that the coagula in the artery had at first formed a part of the mass found in the right side of the heart, which was conceived to have originated
in the stasis of the blood attending the epileptic convulsion, and that these, after the patient had recovered her couscimisuess, had been carried to the
point where they were found. It is tnie the opinions of Pi.wkaik and LioKl.l, arv merely coii.iectiires, but they are conjectures founded on pofl-mortcm
and negative pathological evidences, in view of the history of the iiatieiit during the later hours of life.
OF THK CONTINUf:i» FEVERS. 471
conditions as predisjxjsing to the fornaation of clots; but, in view of tlie relatively large
number of these cases in which the lungs were in a healthy or comparatively healthy con-
dition, the clots may not be referred for causation to the pulmonary congestion alone.
The opinion is very generally entertained that in the course of continued fevers the'
blood becomes progressively altered by the diminished nutrition of the patient and the abnor-
mal action of the various organs concerned in elaboration and elimination, irrespective of
the morbid changes that rnay be produced in it by the more or less direct action of a specific
fever-poison. But the character of the blood-changes has not been sufficiently studied.
When inflammatory conditions prevail in the system the fibrin, as is well known, becomes
largely augmented. In such cases there would be no difficulty in appreciating the existence
of a predisposition to coagulation. But the deterioration in fevers that are not symptomatic
of acute inflammatory processes seems rather to tend to a dlsnolutio sanguinvs manifested
by the fluid and disorganized condition in which the blood is sometimes found after death,
and by the eccliymoses, liieiaaturia, epistaxis and other hemorrhages that appear in the
progress of the disease. The one series of changes offsets the other so far as relates to the
j>roportion of fibrin in the blood, and involves the occurrence of fibrinous coagula in the heart
in corresjx)nding obscurity.
Since jjoHt-mortem observations on the pale, weak and flaccid heart fail, as has ]»-f\\ si'.-u,
tu connect it as a strongly predisposing element with the heart-clot of fever; since pulmonary
lougestion and inflammation give but a slight increase in the percentage of these clots,
and since the condition of the blood itself does not appear to be notably favorable to their
development, it follows that for their production there is needful an immediate or exciting
cause of an intensity proportioned to the inadequacy of the predisposing factors. Generally,
no doubt, this is constituted by some unusual exertion on the part of the j>atient, perhaps
sometimes by mental impressions; but accurate details of death scenes in fever are nec-
essary to complete our knowledge of the immediate causes and progress of these fibrinous
depositions.
The blood. — Few observations were made on the condition of the blood in the con-
tinued fevers. It was said to have been thin, uncoagulated or unusually fluid in the five
cases, 25, 70, 96, 150 and 264. It is singular, in view of the general belief in the connec-
tion between a disorganized condition of the blood, such as exists in scurvy, and cutaneous
blotches of a hemorrhagic nature, that in none of these cases is there a record of petechial spots
or cutaneous or internal eccliymoses. In one case, 70, the liquidity of the blood was asso-
ciated with cedema of the lower extremities. In ease 204, in which a decrease in the num-
ber of white corpuscles was recorded, it is observed that the spleen was remarkably bloodless
and the thyroid gland enlarged.
According to the records ecchymoses of the internal organs were .-arely coincident with
eccliymoses of the skin; whence it may be inferred that the former were in general the
result of local congestions rather than of a deteriorated condition of the blood, and similarly,
that the latter were frequently due to local rather than general conditions. Thus, in the
typhoid series there were blood-clots in the pleural cavity in 31 and a bloody or reddish serum
in the |>ericardium in 26. In the malarial series the lungs were ecchymo-sed in 258 and 2S8,
and in the former the fileura contained a quantity of bloody serum; the stomach was ecchy-
ifiosed in 202, the intestines in 91 and 365, and the upper surface of the cerebral hemis-
pheres in 2S7. In the typho-malarial series the ileum was affected in 273, and in this
472 PATHOLOGICAL ANATOMY AND PATHOLOGY
instance the skin also was implicated. In the mixed series of cases the pericardii;:!! con-
tained reddish serum m 182 and 183; a similar effusion was* found in the pleural cavities
in 168, 333 and 340; the oesophagus was ecchymosed in 301 and 329, the stomach and
bladder in 342, the ileum in 203, the colon in 162, 301, 318 and 370, the liver in 380 and
the kidneys in 181 and 187. But in none of these cases, except 203 and 273, was the pas-
sase of the blood from the vessels of the internal oraians associated with a similar leakage
from those of the skin. The post-morteyn records are, however, very defective so far as
relates to the condition of the skin. This is shown by the number of typlioid cases in
which, although petechise were present according to the clinical record, no mention was made
of their existence by the post-mortem observer. It may be claimed, therefore, that in the
cases instanced above there is no evidence that the skin was free from petechiee, purpuric
spots or ecchymotic blotches.
If, however, the cases which presented such spots or blotches be examined for concur-
rent leakage in the internal organs, it will be found that few instances of coincidence are
recorded. The eight typhoid cases in which the skin was more or less spotted had no inter-
nal ecchymoses. The eight malarial cases tliat presented superBcial blotches showed similar
internal appearances in but one case, 386, in which the heart and the colon were affected.
Of the four cases, 86, 93, 114 and 273, of the typho-malarial series that had the skin ecchy-
mosed, tlie last mentioned had the ileum also spotted. Finally, of the nine cases of the
mixed series that showed purpuric spots on the cutaneous surface only one, 203, had ecchy-
moses of the internal organs. Although petechise or other superficial colorations may have
been overlooked by the recorders in cases presenting internal ecchymoses, it is not likely that
the latter would have been overlooked where the record preserves the existence of the former.
Thus it may be concluded that internal ecchymoses were not invariably associated with
cutaneous transudation, and that in manv instances each of these was due rather to local
conditions than essentially to the deteriorated condition of the blood.
But perhaps the facts would be expressed with greater accuracy by the statement that
while the situation of the extravasation's and transudations was dependent on local condi-
tions their existence was rendered possible only by 'the changes which had taken place in
the Ijlood. An abnormal state of the blood, frequently manifested by petechite, vibices,
blood-colored urine and passive hemorrhages has already been noted as characterizing per-
nicious cases of the paroxysmal fevers. In cases of continued fever of malarial origin a sim-
ilar condition might naturally be expected. In typhoid cases it is difficult to assume a
healthy condition of the blood, in view of the prolonged interference with the normal action
of the various organs concerned in its preservation at a particular standard. Assuming this
unhealthy condition to have existed, it would probably have been especially marked in pro-
longed or pernicious cases; but since, as has been shown by the records of the Seminary and
other hosjiitals, it was precisely in such cases that petechise and vibices were of frequent
occurrence, it may be concluded that a connection existed in typhoid between the condition
of the blood and these ecchymotic appearances, although the few observations on the blood
in tlie post-morton records of tlie continued fever fail to show it. This view is sustained by '
the hemorrhagic blotches of scurvy, which are known to depend on a deterioration of the
blood constituting the essence of the disease, by the ecchymoses of typhus and by tlie
transudations which, occurring in association with a liquid and uncoagulable state of the
blood, gave the name of spotted fever to those febrile cases characterized by a special impli-
OF THE CONTINUED FKVERS. 473
cation of the cerobro-spinal systoiii. It is sustained also by the extravasations of altered
blood observ(>d in the paroxysmal fevers; and as in these there was the same want of coin-
cidence between external and internal hemorrhagic manifestations that was found in typhoid,
it follows that ecchvmotic spots were probably as much due t(^ an altered condition of the
blood in the latter as in the former cases.
But although the connection between a degenerated blor)d and its escape from the ves-
sels may require argument, in view of the non-coincidence of superficial and intiTiial ecchy-
nioses in the recorded cases of the continued fevers, it is scarcely needful to ai-gue the exist-
ence of an abnormal condition of the blood in them. This has been shown in the malarial
cases to have been the immediate consequence of the pervasion of the system by the febrile
poison. Not one of the typhoid cases that have been presented demonstrates the disorganized
condition of the blood as the direct result of the febrile cause; but this was observed in
the following rapidly fatal case which, in this respect, was precisely analagous to the per-
nicious malarial cases that have been submitted. The patient died after a delirious attack
of twentv-four hours, and post-7nortem observation discovered- the blood in a litjuid state,
the skin covered witli purpuric spots, the patches of Peyer thickened and some of those
near the ileo-ctecal valve remarkable for their' pultaceous character, the spleen enlarged
and the lungs engorged or hepatized. In this instance the disease did not last long enough
for the blood to become deteriorated by gradual processes based on the imperfect operations of
tlie organic functions. The fluidity of the blood must therefore be referred to the action of
the fever-poison. The case has already been published* as 163 of the diarrlioeal series.
Dr. AVooDWARD presented it, along with several other cases of fever that had been similarly
recorded as diarrlioea, in order to illustrate a class of errors of diagnosis which were no doubt
of frequent occurrence;! but as it illustrates matters of greater consequence J than these
errors, its presentation in this connection has been deemed advisable:
Private Tliomas Kelley, Co. A, 124tli N. V.; admitted Dec. 12, 1862. Diarrhwa. Tlio iiaMent was not confined
to bed. On tlio Ifitli lie was moving about and in tlie eveiiiii}? ate Iiis supper with other patients. Tlio same night
he was slightly delirious. Died Deceinlii'r 19, at 11 I'. M. Autopsi/ next day: Body not emaeialed ; apparent age about
28 years; upon the body, especially the tliighs, there were a number of irregular spots of purpura from the size of a
flea-bite to that of a dime. The blood was very li(inid and poured forth from incisions of tlie skin and all the internal
organs. The brain was examined but exhibited no unhealthy marks. Pleuritic adhesions throughout, on both sides,
of not very old date: left lung crepitant but engorg<Ml with a Idoody li(iuid; the upper lobe of the right lung hepa-
tized, the lower lobe congested. There was slight atheroma tlironghout the course of the aorta. Liver sofi , Indian-
red in color and large; spleen large, flabby and on section dark Indian-red, its convex surface exhibiting thi^ remain <
of a former inflammation. Stomach, pancreas, kidneys and suprarenal bodies healthy. Small intestine pink in
color: the agminated glands thickened and mostly bright-red in color; the lower glands were a line in thickness and
contained a white cellular deposit; none of them were ulcerated. Mesenteric ghmds somewhat enlarged. Mucous
membrane of the large intestine dirty slate-colored, with streaks of inflammation here and there.— Jc(. Akh'I Surg.
Joseph Lrithj. [Nos. H8 to !M), Med. Sect., Army Medical Museum, from this case, are successive portions of the ileum,
in each of wliich is a large thickened Peyer's patch; in ill) the patch is remarkable for its great size and the i>ulta-
ceous character of the thickening, there are also several large solitary follicles in this specimen.]
MuRCiiisON§ recognizes two conditions of the blood in typhoid fever: One rare, in whicli
it is dark-colored and liquid, the other of more frequent occurrence, in whicli it is disposed
to concrete in firm white coagula. He conceives that a close relation exists between the
state of the blood and the symptoms during life; that when death has been jM-eceded for
some days by the typhoid state the blood is usually dark and fluid; while in other cases,
as when due to perforation or pneumonia, it often contains fibrinous coagula. The first of
these observations does not apply to the typhoid cases observed during the war; for, of those
* In the Second Part of this work, page IIT. ^U.,va%ebn. J See >n/ra, page 480. g Page 631 of his Treatise.
Mkd. Hist. Pt. Ill— »iO
474 PATHOLOGICAL ANATOMY AND PATHOLOGY
submitted as constituting the post-mortem records of the continued fevers, many presentino-
fibrinous heart-clots were not cut off by pneumonia or peritonitis, but died while in the
typhoid state. The dark-colored and fluid condition of the blood appears rather to have
been characteristic of rapidly fatal cases, such as that given in the preceding paragraph;
and this observation is sustained by analogous changes found in fulminant cases of mala-
rial, cerebro-spinal and typhus fevers.
The condition of the blood in typhoid fever has not been made the subject of special
study by medical observers or physiological chemists. Chomel, while recognizing that the
blood in this disease differed from that of pneumonia and other acute inflammations, con-
cluded fi'om his observations that its changes did not constitute a primitive lesion whence the
symptoms of the disease were derived, nor even a secondary phenomenon.* Lehmann
states that during the first eight days of a typhoid attack the blood is like that of plethora,
in which the corpuscles are increased, the fibrin normal and the albumen but little above
the usual proportion ; but that later it resembles the blood of antemia, in which the corpuscles
are diminished in number and the serum watery and deficient in albumen and other organic
constituents although richer in salts.f Viechow holds that in typhoid the fibrin is dimin-
ished; but as he states also that an increase of the colorless corpuscles may be looked for
in diseased conditions attended with a notable swelling of the glands of the lymphatic sys-
tem, this increase must be inferred as present in typhoid. In cases presenting a large black
spleen he found pigment-cells .resembling colorless blood corpuscles, spherical, often elon-
gated and having granular contents, among which appeared black pjU'ticles of various sizes;
these pigmented bodies were observed also in other diseases attended with a rapid exhaus-
tion of the vital properties of the blood and productive of cachectic and anaemic conditions. J
Alonzo Clark is of opinion that the most important of the lesions of typhoid fever is
found in the blood; and from some experiments at Bellevue hospital he concludes that the
blood-change is characterized by a progressive loss of coagulabilitv.§
But although so few observations on the quality of the blood in typhoid fever appear
in the records of medicine, the belief is generally entertained that a depraved condition is
invariably present in this and other continued fevers. Sir William Jenner deduces the
existence of a deteriorated condition of the blood from the suppurations which are consecu-
tive to the disease. He argues that the exudation of a blastema possessing the same prop-
erties in so many places at the same time, indicates the existence of a definitely diseased
condition of the fluid from which that blastema is formed, just as the deposit of many masses
of cancer-blastema in the same body at the same time is held to indicate the existence of a
definite disease of the blood in the person who is the seat of them.|j
The degeneration of the blood, at first due to the more or less direct influence of the
fever-poison, becomes afterward increased and modified by the retention in the system of the
products of that retrogressive metamorphosis of the tissues which appears to constitute the
essential of the febrile condition, no matter what may have been its exciting cause.^ Urea
* He drew blood from thirty patients, eiich of whom was in the early stage of the disease. In six tbe clot was firm and buflfed ; in twenty it was
firm but not coated ; iu four diffluent and curdled. His conclusion, as given in the text, was based on the small number of cases in which the bluod
was diffluent et cnUlehott, and the fact that a similar condition is found in diseases other than typhoid, some of which indeed are not of a serious character.-
From the firmness of the clot in the twenty-six ciises he opjwsed the belief of those who held that in grave cases of fever the blood suffered a lossof coagu-
lability.—A. F. Chomei., Lfr-ius de Cliniqiie M^di'tde — Fiiivre 1)/pho)'de^ Paris, 1834, p. 50.
t C. G. l.EHii Mis—Hamlhiuh d^r Pfniswloyitichen Cftemie, Leipzig, 1859, pp. 230 and 232.
tVlRCHOW— t'eHH/<irP<i/Ao?uyiV, Berlin, 1S5S, p. '201.
gSee Medical Keeurd, New York, Vol. XIII, 187M, p. 2G2.
II Mediml Time.'i and Gitzeile, Vol. XXVII, London, 1853, p. 463.
^ J. MiLNER FoTHERGiLL has a suggcstive article on The Typhoid Condition, iu the Ediiiburgb Medical Jotmitd, 1873, Vol. XIX, Pt. 1, p, 225.
OF THE CONtlNUED FEVERS. 475
and carbonic acid are the ultimate products of this metabolism ; but between these and the
organized albuminous matters of the living system are a vast number of complex transition
jiroilucts concerning which little is known either chemically or physiologically. Wlien the
skin and kidneys are inactive, as is generally the case during the febrile continuance, these
products accumulate in the blood, and coincident with this accumulation the patient falls
into wliat is known as the typhoid condition. As urea is susceptible of quantitative deter-
mination, its retention in the blood and its pernicious influence on the system can be dem-
onstrated. The poisonous action of carbonic acid, or of the concomitant deprivation of
oxvgen, as shown by the circulation of venous blood, is manifested by the insensibility and
convulsions of asphyxia. Other products of tissue-waste, concerning which our knowledge
is meagre, are plausibly assumed to be detrimental to the system in whicli they are retained.
TliiM-e is no jn-oof that they are the cause of the typhoid condition; but the invariable appear-
ance of the latter after a -prolonged period of unusual change in the tissues and its uiore rapid
development when the eliminative organs are inactive, are strongly suggestive of a causative
relation between the metabolic products and the typhoid state. If this view of the occur-
rence of the typhoid condition be correct there is no difficulty in understanding tlie super-
vention of the so-called typhoid symptoms inmalarial or other fevers* unroniplicated by the
special poison of typhoid fever.
The great prostration which was characteristic of the continued fevers not uuly in their
'■arly stages but even from their onset, must be attributed to the condition oi' the blood,
depraved primarily by the influence of the fever-poison and secondarily by tlie disorder of
the functions of the body. The latter will readily be admitted as a debilitating cause. The
former has been well argued by Louis as regards specific typhoid cases, in which the primary
debility was more marked than in malarial cases: We cannot attribute it to the diarrhoea, as
it is often present before the flux has developed, nor to the abdominal pain, which is often
slight, nor to the cephalalgia, which is generally dull and which, when severe in other acute
affections, is not accompanied by a like loss of strength, nor to any appreciable lesion of the
brain or stomach, as shown hy post-mortem observations; lience it is needful to recur for its
explanation to the special changes in the small intestine as acting sympathetically on the
brain, or still further, to the typhoid fever-poison which produced these changes.-j-
The intense prostration of the later stages of continued fever is the result of a complexus
of I'anses originating in the disordered state of the blood. Prominent, however, among them
is that degeneration of the muscular system which has already been mentioned in tlie par-
oxysmal and continued fevers as affecting the substance of the heart. ZknkerJ first called
the attention of the profession to the frequency and extent of these changes in the muscles.
He considered them wholly unconnected witli inflammation; but by Waldeyer§ and
I[.\yem|| thej were on the contrary viewed as resultin-g from inflammatory processes.
The latter attributed them to the morbid condition of the blood, placing them among those
•See Poenmonic Fever, infra^ page C13. f See his RecJiercheg^ t. II, i ■-'*'■'.
J /rn'KRR — I'eh^ (/iff VtTuiiJtrmi'jeit tier tpHlkurlicJiint mwikeht im Tgplitutahdvmiimli*, Leipzig, 18G4.
£ Wa l-fFYFR— i>(> VerihiJtnlitijeu tier iptertjt^rei/ien MiiKkeln hei der Ktilziiiiilititif uml detii Ti/phti>],n>zeng, etc. VlRPHOw'3 ArrI,,, t. XXXIV, 18l»o, J). 47.1.
1 Havksi — Etatie* mr W jlf*/*wi/M Stjutjituuittti'iiitii — Arfliirrx tie 2*liijititilt>gle ^ Paris, 1870. He considers (page 581) that lie has esUiI>lisIu-il tliree degrees
or successive pli.oses in tiie progic*H of the mn^-nlur let^ions. The first i(* chamcterized hy hypen-emia, the connnencenient of vitreons and grainilur
degviifrutionit of the fihres and sometimes a sliglit degree of altenttion of tlie walls of tlie vessels. In the second is fonnd the contpleti" deveioitnient of
the vitn-oas and grannlar degenerations of the striated contents, witli a proliferation of the celhilar elements in the interior of tin; sarcolenima, which
activity sometimes extends to the vascular walls. The thirxi degree inclndcs on the one hand the atrophy, disorganization and complete disapiKfar-
anre of the degenerated fibres, and on the other the work of regeneration or reiKinition, involving the return of the muscles to their normal i-ondition.
Tile new muscular fibres fonned during this last |ieriod originate in pre-existing muscular cells, the proliferation of which was evident in the second
phas4' of the morbid changes.
47G PATHOLOGICAL AKATOMY AND PATHOLOGY
disorders of nutrition tluit are produced in many of the tissues by diseases attended with a
notable dyscrasia.
Connected witli the deterioration of the blood and the degeneration of the muscles were
those ecchymoses simulating contusions; and the large extravasations that were in some cases
found in the voluntary muscles, particularly in the lower part of the rectus abdominis and
in tlie muscles of the neck, as in 63, 98, 136, 157 and 248. To these causes may also be
attributed the purulent infllti'ation of the muscles sometimes observed, as in 151, in whicli
the sheath of the rectus abdominis was the affected locality, and in other instances noted in
the analytical summary.
Scurvy has been by some considered a very important cause of the peculiar characters
exhibited by the fevers that affected our troops ; but this opinion is not sustained bv the
records that have been preserved. In but one case, 316, was a notable scorbutic element
present. If the ecchymoses, pur|)urio spots and hemorrhages that supervened during fever
be regarded as symptoms of scurvy, this complication was of frequent occurrence; but there
is no ground for supposing that these phenomena were dependent on the scorbutic taint,
except in so far as it formed one of many influences which tended to their production, the
determining factor being the great and sudden impress on the blood effected by the febrile
poison. Certainly these extravasations occurred in cases in which, prior to the febrile attack,
there was no suspicion of scurvy. They ma}' not therefore be regarded as scorbutic svmp-
toms when observed in the progress of fever.'^'
Diminished vitality resulting from disordered nutrition led to the formation of sloughs
and gangrenous patches in situations determined by local conditions of impeded circula-
tion, as on the sacrum and hips from continued pressure, in the parotid region and on blis-
tered surfaces. Probably the absorption of morbific detritus from these gave rise to pypemie
developments in some instances, as bedsores were present in three of the cases, 125, 199 and
289, in which purulent deposits were found in other parts of the body. In some pysemic
cases, however, as in 38, which presented purulent collections in the joints and pectoralis
major muscle, there is no record of the existence of bedsores or j^arotid abscess. Excluding
these cases of purulent accumulations in the joints, there is no instance of disease of the
bones following continued fever to be found among the post-mortem records, although the
clinical accounts of severe rheumatic pain endured b^' convalescents render it probable tliat
the periosteum and bones occasionally became affected, and that the large burrowing
abscesses sometimes observed were associated with caries or uecrosis.-|' A single instance of
« Soe iii/m, ].. 622.
■f- Sir James Pacet iuis observed that periostitis following typhoid fever generally affected the tibia, but occasionally the femur, ulna and intrietal
bones. It was always circumscribed in a space of one to three inches in area, When necrosis occurred its extent wa-s less tliau that uf the inflamma-
tion over it, and generally only the compact structure or outer table perislied ; it was never attended with the delirium, fever or other severe symp-
toms associated with acute necrosis. Periostitis of the ribs so resembles ordiiniry scrofulous periostitis that he sometimes tboti^ht it should be retianled
as an evidence of scrofula educed by the feebleness of the nutrition consequent on the fever ; but it has occurred after t,vphoid in jwilients of so robust
and apparentl,v unblemished constitutions that it would seem absurd to impute scrofula to them. The swelling, painful and tender, is usually on the
front of the chest, and su]>puratiou slowly occurs in it, the thin, pale pus making its e,\it thi-ough small openings in the skin ; but he ha-s seen pus bur-
row between the abdominal muscles, forming a great abscess, which had to be opened in the groin. See SI. Burtholometc^ a Hospital Reports^ Vol, XII,
Loudon, 1S"G, p, 2, Keen', page 12 of his paper cited in note, page 2l»7, supra, says that of 47 cases of disease of the bones 10 arose during the first two
weeks of the fever, 27 in from three to six weeks and 10 followed ten months after the fever. lie attributed the earlier cases to thrombosis or embolism,
and the later cases to enfeebled nutrition, whose effects, especiall.v in structures which var,v so slowly as the bones, may readily extend over such long '
periods. Quoting .\itkk\'s remark that *'No man can be considered fit for work or for general military service for three or four months after an attack
of severe typhoid fever,"— Holmes' SiffUem of Surgeri/, 1st ed., Vol, IV, p. 50, — he gives a case in which extensive necrosis of the long bone-s, disabling the
patient for three or four years, was the result of hard work in the use of a ten-pound hammer, undertaken before the system had sufficiently recovered
from the effects of the febrile attack. He also describes a moDarticuhir form of intlanimation, a subacute synovitis, which affects the larger joints and
especially the hip, where the Kwelling is sometimes obscured by the muscles. Usually it arises spontaneousl,v, but occasionally from periostitis or
necrosis invading the joint. It rarel,v provinces suppurative or fistulous openings, the result being generally u gradual return to n.sefulness. These joint
troublesare very infrequent. lie cites Gl'TEKBock as responsible for the statement that in the t'Larite (Berlin) and in the Hamburg hospitals not a case
OF THE CONTINUKD FEVERS. At!
ilestriu'tion of bone, possibly connected with fever, is furnished by the case of Carleton
Bergan, private Co. B, Purnell's Maryhind Legion.*
When admitted into hospital at FretliTick,Md., this patient liad a Itedsoifovt-r ibe.saenim ; his body was bathed
ill hwoat and eDvcivd with sudaniina: tonj^iu' dry and eovt'ied with soides. It was reporU'd thai he l»a*l bt'cji tiealtd
in camp with hirge tb>ses of mercurials, hn( the reconl does not show tliat lie was salivated on admission. Two days
afterwards a ra^j^ed ulcer was observed on the ri;;ht e<I*;e of the tonijue, which in ten days extended to the check and
roof of the mouth, exposing by sloujihin;^ the entire upper maxilla. Six weeks later the whole of this bon*', the ver-
tical plate of the palate bone antl a narrow strip of tlie left maxilla were removed, they beinjj; at the time (luite sepa-
rated fn)m the healthy bone. The ri«;ht eye was destroyed and sunken; the right half of the upper lip, the right ala
uf the nose, the adjacent portion of the cheek and the right superior maxillary boue were gone, leaving an extensive
opening directly into the cavity of the mouth and right nasal fossa. f
But tlie most striking of the uncommon results of the disordered condition of the
blood was the gangrene of the feet, recorded in six of the three hundred and eighty-nine
cases constituting the post-mortem records. These numbers perhaps exaggerate the fre-
quency of this occurrence, inasmuch as the unusual nature of the complication may have
led to the preservation of the cases presenting it, when otherwise they might have remained
unnoticed. Its uncoliiraon character is evidenced by the fact that in one-half of the cases
in which it occurred it was regarded as the result of exposure to cold.
Spontaneous gangrene, usually of parts in which the circulation is languid, is rare in
the general experience of typhoid fever, but of greater frequency in typhus. In some epi-
demics the nose has been the site of the gangrenous attack, J in others the feet have suffered,
as in the cases from our war records. §
cMTurred in a ttcrice of ymr^ and in the A'ienim General liosiiital from 1SG8 tu 1871 only two cases among 3,130. MvRCiiisnx docs nut mention tliia com-
pli4-3ition, nor any other of our text writers on surgf ry or pmctic** except Volkmaxn, who gives a few lines to it in Pilhn tnut liUlmOi's llnni{bui:h. Some-
times the di>te(i(<iun of the synovial cavity gives rise to ronditious in which s^Kintaneous dislocation occurs, and in a majority of the cases studied tlio
actual dislocation was the first fact observed relative to the condition of the joint ; this arose from the sulacute nature of (lie lesion and the aitathetic
etate of the patient.
• An account of this cjis*- is given in the First Part of the Surgical volume of this History, pp. 37a-S"7.
t This frightful deformity was successfully treatM hy Dr. Ouruos Bitk.— See Traimtctioii^ of the New York Medical Society^ 1861, p. 173.
t M. J. tlVTBKRl.rr— (Wr ,Ue hUwe S(W fwi <U-m l)/phtis hdlivtis— in Hi'/ehmtrs Journal, Bd. Xl^II, ISlt'., part VI, p, 101— says that tlie " hlue nose"'
wan 1*011 only in overcrowdrd military hospitals inft-ctcii with the typhus contagion. Exposure to cold was not coiicerne<I in iU pnKluclion. It was met
with during the hottfst months of ISifJ in the Austrian h«i«pitals at Xickolshurg ; during the mild damp winter of IROTHO at Erlau in upi>er llung;iry,
and during the rigorous winter of 1813-14 in the military hospitals near Wiirzhurg. The patients were generally convalescents from fever who,
allhiHigh sft far improved as to have a good npiM-tite, did not gain iu strength ; they had at the same time an exciteil pulse, a hot dry skin, and were
alwaytt tin-*l, languid and diiiiuclineil to leave their heds even iu the warmciit weather. Some were soldiers with their systems completely exhausted by
rolliipiativc diarrhiea of many we^-ks or months continuance ; these were attacked inmiediately on their adnii.«sion. Nurses were seldom affected, even
though tiM-y had by a buig stay in ho.'^pital aiquin-<l tin* siillow, cachectic appeanuice or so-called " hospital complexion.'' The gnivcr symptoms of ner-
vous fevrr, surli as delirium and stupor, never accompsinied the "blue nose." The ass>oci;tted fever was not st-vt-n- ; the patient w;is languid, indiffrn-nt,
»p>*kt> little and unwillingly, but answerfil nueslions corriH-lly; he had mostly a frequent watery but not p;»rticularly offensive diarrhiea, and always a
fixetj though not very severe |»ain. inm-ased by pressur«; in the unddliial region; he made no complaint, but his countenance was anxious and he
i«|>je< tfl to any tartile cxaniiiiatioii of his ali<lcinnii, which was suukeu, retracted and had a soft doughy feel ; respiration was nu'stly thoracic. The dis-
ww did not Kpn-ad from the partieiihir hospital, but its occurrence was regarded ns a sign of the presence of a high degree of Ihe typhus contagion.
GlTBCRl.f:T paw lK't«e.'n two and thn-e huuilre*! cases during the years \^19 and ISlO, and sul>sequeutly during the winter of 1813-1 1, uU of irhvii rrrrc
fatal, IVath geiiemlly ensued in from twenty-four to thirty-six hours after the attack, luit sometimes it was delayed to the tliinl, fourth or fifth day.
Ho poti-itiTlrtH obK>rvattons were made, but the disease w;is thought to be connected with a gangrenous affection of the intestine, in I{.^RKER and
Vut:\ MF.'s .t'VONii/ ,>flhr FrvfT hthhj I'piitntm- in /r(7.uj((~ London, iSiil— I>r. Bkackks of Waterford reports from his hospital, during the winter of 1818-10,
eighteen rases in which death ipiickly folbiw^-^l a lividity which, affecting tirst the nose, extended in a short time over the face and eai-s. The fever
prevailing in Ireland at this time luul been pn.T<'tle<l by excessively rigorous winters and cold diiin]> summers. During the first of these uupropitii-u-i
harvest seas'Uis much of the grain remaine<l uncut and was altogether lost ; and a greater part of that which was saved had germinated in the husk and
bfcoinf in proportion imttaiDil as an article of OxkI. The potatoi-s of that year were small, wet and deficient in nulnnient ; turf or iK-at, constituting
the chief fuel of the poor, could not Ik- cut aud dried, S4> that dampiiesi> of clothes and be<tding, impcrfe<:t cooking of food and ventilation of apartments,
defirienl rleunliness of ix-rson and dwelling, co-oporated with a deficiency of food in lowering the vitality of the |H-op!e. "The failure of the crop.- iu
I8lr. was not much felt till the spring of the following year, but scanity then becoming general, attained its greatest height alHuit niidsurnmer, and
Mtending toall the prrHluctions of the earth occasioned extreme distress. In some places the poorer chisses were compelled to the sinl necessity of c<»l-
lecting varioiL-' ewuleut wild vegetables, uettb-s, wild mustard, iiavew and others of the same kind to sustain life ; and in places distant from I>ublin
wret^hetl l"iugs wi-D" often seen exploring the fields with the hoiH> of <ditaniing a supply of this niisinible ffMwI. In districts contiguous to the sea various
marine plants wi rt- harl n-^'ourse to for the purjiose of allaying the cravings t>f hunger ; anil we have Iteen informed that on the eejicoji/,! of Ballysbatinon
many of the po*ir during several months at this jieriod subsi.<teil either chiefiy or altogether on cockles, muscles, linijK^tJS or oven the putrefying fi^h they
could procure on the shore. In some districts eceil- potatoes wen; laki>n up from the ground aud the ho[>es of the future year thus<lestroy('d for the n-lief
of prp(«ent necessity; and the tdood drawn from the cattle in the fields and mixed with oatmeal, when this could Ik- procureil, has not unfreijnently sup-
plird a meal t» a starving family. So general wjis the distress and insufficient the supply in some parts of the country thnt a few unhappy suffenrs are
«id to have died of at^dute want of f»»od, and many must have sunk under Ihe combined impressions of hunger, damp, cold and tin- anguish of mind
nere!««rily attendant on sjid anticiiKitions of the future." — Op. rU., pp. M-T*. — The connection between these conditions and Ihe unusual prevalence and
pwuliarilies of the continui'd fevers that aflerwanls scourged the «<»nntry was acknow ledged by all the repurtemi.
i >lMrtifi.-ation of the Vm-h and fe^-t oreurn-d in a few instiinces in the epidemic iles^ribeil by Barker and CllEyNC. — See Vol. I, jiage 34^ J. A.
EsTtAM-r-R. ill an arti. le in I.n.-,^,./«.i\ jr.i... fv.r Klmitche t'himnjie, Berlin, Vol. XII, pp. 4..i;-M7— -m *..„„„, tth, l.nr^r r^h-r„Uiirx iu T>,,,hu* >Vr/T—
478 PATHOLOGICAL ANATOMY AND PATHOLOGY
An impoverished condition of the blood, resulting from a deficiency of food, and the
other co-operating influences to which a poverty-stricken people ai-e subject have been so
generally present not only in epidemics but in individutil cases of fever characterizod by
gixngrenous tendencies, that the ai>poarance of the latter warrants a strong belief in the pre-
existence of the former. The deprivations and exposures to which our soldiers were liable,
together with tlie prostration incident to repeated attacks of antecedent diarrhcea or other
lowering diseases, render it probable that in occasional febrile seizures the specific cause of
the fever found the patient in a condition as tavorable for the development of spontaneous
gangrene as if he had undergone the preliminary course of starvation so common in Ireland
during the years of famine and fever. On this view of the conditions associated with gan-
grene Dr. Keen's summary of the causes may be accepted as accurate. He attributed it
to an altei'ed blood, a weakened heai't and the mechanical difficulties in carrying on the circu-
lation, especially in distant parts: but in view of the usual seat of the aflection in the lower
extremities he concluded that tlie last two causes were the more immediately determining
factors.* To these, perliaps, should be added exposure to cold, as the six reported cases
occuri'ed during months when frostbite from exposure on active field service was not uncom-
mon, although unknown amid the comparative comforts of camp and hospital life. A
degree of coldness of the feet resulting from displaced blankets; which, under ordinary con-
ditions, would have been immediately succeeded by healthy reaction, may in these devi-
talized cases have sufficed to determine the development of gangrenous phenomena.f
Nevertheless it is to be noted that in none of the six cases is there any record of special
deprivations: on the contrary, in one, UU, the body of the patient was said to have been
not emaciated. Hence it is probable that in certain cases something more than depression
of the vital powere was needful to the occurrence of gangrene. MitrchisonJ speaks of
spontaneous g}\ngre>ie as a result of arteriid thrombosis, ajid Estlander found the clot in
many of his cases. Case 112 of onr post-mortem records is the only instance in which the
arteries are said to have been occluded.
IV.— THE BRAIN AND ITS MEMBRANES.
Cases of the continued fevei^s in which the condition of the brain and its membranes
was examined constitute but a small percentage of the whole number. In some of the hos-
pitals wlv— ■ ' ' ■ ■"V -;*-^\tions were systematically pursued the brain was examineil
IwsinI uiH»u ol\<j^r\ .»n. :iv ;,m,u .inrmc ;»n -I't.i.mu- « nu-ti pn'VailM in Filin1.^lu1 tturing the fsmillf of lS6ft-CS. slat*-* tb,l( (lu^ .-iftVclion vn%s no doubt tin*
to thi> iuleii^ily of thf typlms cont*j:ion. .-isrsnvvatiM l»y .a \«^nl of fiX^i nm^ pT\^|vr c-^rv during tho disfAS*'. Willi n-pinl to its immttliHte *-auso it is swid
that of twenty -one oai^o^ nu^t witli thotv wx^rx^ thr\«mtu in the princi|*al artery of the limb in fonrtwn ; ami it is hottl that the^^ wer? plainly the can^e iif
the pinsrene, as their |>ty>i!*-'nce w«s oj:tat»lishwl hy examination of the artery vhirinsr Hie ami aft»^r death, t^enorally no pul^tion cv>uM lie felt in the
Tn^i^^l of the atKvtrtl liniK while that of the A-os*! <.^ the opjxisite side couM N^ r«»dily det«vte<l. The otv^tnieted artery felt like a har\l coni and was
wholly without s*M>sation, Sow and then, below the kntH\ it wouM feel hai>Vr and morp n^is^ting than usual, and in the vieinity of Pou|wrt*s liga-
ment would stiU pulisite IVvhly and ol»seurel,v, yet sk> evidently as to render it univnain whether any *>tKS(mction actually existeil : but on amputation
the hemorrhage w-as trifling, — no l»hxxi iT*n»e ft\mi the femoral or lH>pli^^>»l. and only a little fivm the smaller mns^-ular hranehes, while a tibrinous
plug fil1t\l the ves%*l and prvxjex'teri be.vot>d its retraeteti end. Sl^vt of the thr\>tnbi were exsuniurtl ; they generally tenninatrti Ivlow where au abnipt
narri^wing rtvurrt^l, as at the division of the tH>plite,'il artery, or as was the *-T»se in one instan»>\ at the origin of the profunda femoris, fr.>m which the
thriMubus extendtM upw~at\l. In one cas^' in which the |«rt ri^movM by amputation w%'»s not wholly disoriraniwHi and a plug wns fonntxi at the
bifurcation of the |H>plitx*al, the \->>S!?*'ls Ih'K^w this p»>int wen^ i^^upletely fi^>' aud stuind ; in another cas<^ in which ampnt;uion had Nhmi i>erforme»l at
the upper thii\t of the leg, the anterior and jxisterior tibial and the |vTvneal arteries wvnt^ found empty. RsTi.,vxnKti was of opinion that when the
v^betntcting c^xtg^ilnm did not extt*nd fKmi the iK^pliti^l artery higher than the tendon of the adductor magnus gangn'ne either did iiot r\*snlt or involved
only a toe or a small portion of the foot; but when it extendwl WyomI the origin of the prvtfuuda femoris thediseas*^ invidv»>tl the up|vr thin! of the leg;
this w^*s illifcstratt^l in eight or teti <^ts««. The enilK>li wvrv lH^lieve\l to have originatt^i in the lefl ventricle of the heart when, owing to debility, con-
traction was imivrfect and evacuation iuo\»mplcte, .\fterwT»i>ls, wlieit tlie luvtrt In^-ame stiv»nger, the c^v«gula weiv* exi>elUHl and tXYlndeil the vt^ssels.
This gaugreae from ^«)»s1ruction was ob6>i*rv»\l only at the end of the fever or after the commeutx-ment of oonvales»rence. Gangrene, whert> no olistniction
was found, showe^i it«^lf by jxvuliar sym(»toms even at the N^giuning of the fewr and attacktnl both sidess Wing confine*! gx^uer^lly to some of the t^ies
or to other small ivrtions of the f^v>t ami only in the ssi^vviv^st cases exteutliug as far as the ankle-joint.
* See pag* So of his Ijtvh^rf^ citetl ng>m, note to pwge 29".
t See ivport c* Suij, J. H, TAiLOK, C. S:. V,, »^»m, p. Sia J P»«« 458 of his IVotftic
OF THE OONTIN0ED FEVERS. 479
as a matter of course, but in others where apijarently the object of the examination wa?
merely to verify a diagnosis or find an adequate cause for death, the intracranial examina-
tion wa-s frfqu-ntly omitted unless specially called for by clinical manifestations. Hence it
may be assumed that the cases in which time was devoted to o|>ening the calvariaand exam-
ining its contents w^ere as a whole characterized by a prominence of the cerebral symptoms.
Nevertheless, in a large proportion of these no abnormal appearance was observed. The
brain and its membranes were considered normal in 45.5 per cent, of the purely typhoid
iTi- - ' •■_■ -stion and effusion were present, but none of the cases presented undeniable evi-
1 existence of inflammatory action. Of the malarial cases in which the cranium
was opened abnormal appearances were observed in 64.7 per cent. The hypersemic tendency
attained a higher development in these cases than in typhoid; and this was shown as well
I'V the intensity of its manifestions as by their frequency, for in one case, 287, the cerebrum
was eccliymo5e<l, and in two, 80 and 257, the active character of the hypenemia was evi-
denced by the lymph that had been exuded. ^Morbid changes were found in 54 per cent, of
the typho-malarial cases and in 41.2 per cent, of the mixed series of raises.
In a large number of cases in which the brain and its membranes were said to have
presented a healthy appearance nothing is known of the associated svmptoms; in certain
other of these cases, as 23, 36, 106, 112, 116, 289 and 380, no mention was made of head
symptoms, although what must be regardetl as the clinical characteristics of each case were
stated by way of preface to the pod-mortem record. There remain, however, sorue important
■ - rvations which show that very notable disturbances of the cerebral functions occurred
w.iuout leaving in the brain or its membranes any trace by which their existence could have
been pre<licated. Thus, in 7, 24, 29 and 199 delirium was present, prolonged in the last-
mentioned case for a week before death; in 370 the patient was deaf and unconscious; in
368 he fell into a lethargic state twenty-four hours before death; and in 56 coma and
delirium were reported, apparently in connection with inflammation of the middle ear.
Looking now at the cases in which some abnormity was discovered in the brain or its
membranes, it is found tliat in many of these no record of the associated symptoms has been
preserved, while in others, as 42, 80, 99, 264 and 276, although certain symptoms were
reported, no mention was made of any referable to the encephalic lesions. Delirium was
m. r.tioned in ten cases, 8, 109, 111, 117, 247, 278, 281, 287, 291 and 297, as the prora-
.: • .il cerebral symptom. Generally it occurred as the precursor of death, su|>ervening, as
in 287, a few hours before the fetal issue, or lasting, as in 278, for several days with occa-
sional lucid intervals. This was associated in the majority of these instances with con-
_■ "ion of the pia mater, leading in case 287 to ecchymosis, with or without congestion of
ti... cereVjral substance or effused serum in the subarachnoid space and ventricles. In one
case. 111, in which delirium was associated with insomnia, the arachnoid at the base of
the brain was thickened and opaque and the ventricles filled with efiused liquid. But iu
contrast with these hypersemic appearances the brain and its membranes in 109 were pale
and anaemic, and in 291, in which delirium lasted for several days, the brain was normal
and the pia mater anaemic, opaque and wrinkled.
In nine cases, 9, 26, 45, 47, 86, 104, 257, 303 and 304, the cerebral implication was
marke<l by unconsciousness, usually succeeding to delirium or insomnia, and passing into
I- "li by coma: In 45 and 47 the only abnormal appearance consisted of a serous transu-
daiion into the arachnoidal sac or ventricles, and in 26 and 104 of a simple injection of
480 PATHOLOGICAL ANATOMY AND PATHOLOGY
the membranes, while in 9 and 86 both injection and effusion were said to have been pres-
ent. In oO-i the condition of the membranes was not stated, but the cerebral substance wa,s
firm and slightly congested posteriorly. In two cases only, 257 and 303, were definite signs
of infiammatory action presented — a coating of lymph on the base of the brain and a turbidity
of the ventricular serosity.
In two cases, 343 and 349, the encephalic symptoms were said to have been those of
meningitis, but the prominent post-mortem lesion in each case consisted of subarachnoid
effusion. In 299 signs of cerebral congestion, noted clinically, were verified hy post-')7wr-
tem examination. In 160, in which the cerebral disturbance was manifested by craziness,
the usual hypei'semia of the membranes and subarachnoid effusion were observed. Lastly,
in 379, in which death overtook the patient suddenly and quietly while in bed and supposed
to have been asleep, the brain and its membranes were engorged with bright blood and the
ventricles distended with sero-sanguinolent serum.
Although headache, dizziness, insomnia, delirium, dulness, stupor and coma were in some
instances associated with changes in the brain and its membranes, to which they might with
propriety be attributed, the encephalic lesions were in other cases wholly incommensurate
with the intensity of the cerebral symptoms; and in many cases noted the latter were, indeed,
unaccompanied by any observed lesion. Louis long ago demonstrated that the existence
of delirium in typhoid could not be in all cases explained by the condition of the brain. He
argued also that the intestinal lesion could not be regarded as the cause of the delirium,
for although there is delirium in pneumonia there is no concomitant intestinal lesion, and
it is unlikely that the sympathetic action on the brain of organs so different in function and
structure as tlie lungs and alimentary canal should be similar.* He attributed the delirium
to the pyrexia, as it was the only pathological factor common to all the cases. It has already
been shown, in speaking of the alteration of the blood resulting from the persistence of
fever, that the febrile condition may develop delirium by an accumulation in the blood of
the noxious transition products of tissue-waste. The coma that was the frequent prelude
of death may also have been due in many cases to this altered blood, for free effusions were
often discovered in the serous and subserous spaces without a concomitant congestion.
Effusions unconnected with inflammatory processes were observed in other serous cavities,
particularly in the pericardium, and these must be referred to that watery condition of the
blood which occasioned oedema of the legs in the paroxysmal fevers and in some, as 70 of
the malarial series, of the continued fevers.
But cerebral synq)toms unconnected with notable hypergemic conditions of the brain or
its membranes were not in all cases due to that alteration of the blood which resulted from
the continuance of the fever, for in some instances they were developed from the beginning
of th£ attack.f The patient in the case presented on page 473, supra, died after an illness
of twenty-four hours marked by slight delirium; and while the brain exhibited no unhealthy
appearances the blood was so liquid that it had become extravasated subcutaneously in irreg-
ular purpuric spots and issued freely from p>ost-mortem incisions into the skin and internal
organs. Here the disordered condition of the blood was evidently a primary lesion mani-
fested by cerebral phenomena.
* Louis,— i?tT/(er.7ie,-!, tfrc, t. II, p. 17G.
t Speaking of delirium in typlioiil, Bartlett, in his Treatise on tite Fevers of the Uiiikd Staie», Philadelphia, 1852, p. 65, wiys: "In a small nnnibor of
caaesthis8yniptinnispres(!iitat the conuiioncfinen tor very early in the disease. * * * As a general rnle, it appears early in proportion to the gravity and
rapid progress of the disease." MuucHlsoN gives two cases, one of whieh was fatal on the first and the other oh the second day. "The symptoms in
these rai'id eases are usually severe headache and acute delirium, with profuse diarrhiea or great engorgement of the lungs.'' — The Contiwtetl Fei-frs of
Great BrUaitt, London, 1873, p. 548.
OF THE CONTIXL'ED FEVERS.
481
v.— AGE OF PATIENT, STATE OF NUTRITION, ETC.
In addition to the anatomical changes in the various organs the post-mortem records
frequently make note of two points which maj' be briefiy referred to at the jiresent time —
one the age of the subject, the other the nutrition of the body.
The AGE is stated in thirty-seven of the fifty typhoid cases; the minimum, 15 years,
in case 30, the maximum, 53, in case 47, and the average 24.7 years. Of the sixty-
three malarial cases the age is given in forty-one; the minimum, 16 years, in case 364,
the maximum. 63 years, in 73, and the average 25.8 years. In thirty-eight of the sixty-
one cases of true typho-malarial fever the average was 24.8 years; the minimum, 16 vears,
in cases 266 and 29S, and the maximum, 53, in case 96. The age is given also in one kun-
dre<l ainl twenty-six of the two hundred and thirteen cases of the mixed series; the mini-
mum. 16 years, in 299, 348, 359 and ;>72, the maximum, 55, in 334, and the average 27
years. While these figures show that the average age of the victims of continued fever of
malarial origin was greater than that of the tyi^hoid subjects, it is evident that the observa-
tions are not sufficiently numerous to offset the, influence of the intrusion of a few cases of
an exceptional character in this regard.
If the cases constituting the clinical records of the continued fevers be incorporated
with those presented as post-mortem records, it will be found that four hundred and thirt)--
one cases have been submitted in which the age of the patient is stated. These, tabulated on
the following page, indicate that the especial victims of the continued fevers were soldiers from
eighteen to twenty-four years of age ; but inasmuch as it may be said that this merely expresses
tiie preponderance of men of these ages in the army, two columns have been added showing
the relative frecjuency of fever among men of certain ages as compared with the ratio of their
numbers to men of all ages in the army.-'' From these it will be seen that soldiers under
twenty, and particularly soldiers from twenty to twenty-four years of age, suffei-ed much
more from these fevers, in proportion to their number in the ranks, than men of more mature age.
Men between twenty and twenty-four years of age constituted only 28.03 per cent, of the
army, but they furnished 38.98 per cent, of the cases which form the basis of this calcula-
tion. On the other hand, the number of cases in men over twenty-five vears was less than
it would have been had they been affected in proportion to their number in the ranks.
• It is in)pn«*jiible tu olitain an accurate expression of the relative numbers of men of various ages in the army during the war. The percentages
given in llie tjihic have bivn derived from data gathered from the second volume of Dr. J. H. Baxter's S(<«i»(iV», Medieal ami Aiidirojiologicul, nf llin Procod
Martlmt Omrrar* BiireaH, WaMu-jImi, D. C, 1875. Table XIX, covering iiages 401^05 of the volume cited, embraces the statistical results of the exam-
ination of 3.'W,.321 recruit.-*, substitutes, drafted and enrolled men of various nationalities. From these statistics were obtained the following figures,
vbich give the relative number of men of the ages stated, based on an examination of 211,705 men accepted for military duty:
Age.
Number f)f men
^ examined.
Number rejected
for special
causes.
Number accepted
for military
duty.
Ratio of ac-
cei)ted men of
stated ages per
100 of the total
accepted.
Coder 2U
SO-M..
58,952
78,039
56,711
45, 777
50,456
43,786
15,815
19, 305
18,721
18,833
23,349
26,593
43,137
59,334
37,990
20,044
27,107
17. 193
20.38
28.03
17.94
12.73
12.80
8.12
SS-29
30-M
35-39 ._
40 and over
Total
334,321
122, 010
211,705
100.00
ilEU. Hist., Pt. lU— 61
482
PATHOLOGICAL ANATOMY AND PATHOLOGY
Table LI.
Showinff the ages of four hundred and thirty-one cases of Continued Fever, and comparing the frequency
of these fever's at certain ages icith the relative number of men of those ages in the ranks of the
Army.
Age of patients.
Number of
cases.
15.
16.
17.
18.
19.
20.
21.
22.
23-
24.
25
26.
27.
28.
29.
30.
31.
32
33.
34.
35-
36
37.
38
39.
40-
46-
54-
1
9
9
42
40
31
36
36
38
27
18
18
10
13
10
16
4
7
9
6
9
6
Number of cases of
the ages bracketed.
Ratio of cases of
the ages bracketed
per 100 cases of
continued fever.
101 , V
23. 43
168
38.98
Ratio of men of
tlie ages bracketed
per 100 men of all
ages in the Army.
20.38
69 I-
16.01
42
9.75
7
3
27
24
28. 03
17.94+
12. 73
6.26
12. 80-f-
8.12+
Inasmuch as malarial fever is well known to affect men of all ages, this susceptibility
of the younger soldiers to attacks of continued fever must be attributed to the influence of
the typhoid element, the more so as statistics from civil and military life are alike unanimous
in indicating a greater relative prevalence of enteric fever in young than in old persons.*
The mean age of the four liundred and thirty-one tabulated cases was 25.06 years.
* The early writers on typhoid fever, as distinct from typhus, were inclined to regard the age of the patient as an element in the formation of a
diagnosis. Chomel and Loris, in 1839, declared that they had never observed the disease in subjects under tifteen nor over thirty years of age ; but
.Chomel himself had occasion to report at a later date five cases in which the patients were over the latter age. Xt tirst many cases of typhoid in persons
over forty yeare were regarded with doubt as possible cases of typhus ; but in progress of time instances were reported which could not be set aside in
this way, and ultimately hospital statistics settled the point, showing that age conferred no immunity from enteric attacks. Murchiso.v, page 439 of bis
Treatise^ gives a table of the number of typhoid cases admitted into the London Fever hospital in each given jwriod of life during the twenty-three years
1848-70, the total of admissions being 5,911, from which it appears that 56.70 per cent, of the cases were from fifteen to twenty-nine years of age, 4.54
per cent, over forty-five years, 1.37 per cent, over fifty years and .44 per cent, over sixty years of age. Liebermeister states, in his article on typhoid
fever in Ziemssen's Cijdopedia, that of the patients received into the hospital at Basle during the period 1SG5-70, 58 per cent, were between the ages of
twenty-one and thirty years, 7.12 per cent, over forty years, 2.12 per cent, over fifty years and 0.12 per cent, over sixty years. Leon Colin — p. (>i, De la
FiZiTc Ti/phoide dans VarmCe^ Paris, 1878— gives a table from the Medical Sttttislics of the Cifil Hosjiitah of Paris for the years 1861-64, which shows the special
incidence of the disease on persons between twenty-one and thirty years of age. He says that it is among soldiers of .twenty-two years of age that typhoid
fever selects the greater number of its victims.
OK THF, CONTINUKD FEVEKS. 483
The condition ok the body. — The body was generally represented as greatly ema-
ciated, a result of defective assimilation and increased tissue-waste during the continuance
of the febrile movement. Naturally, however, there were exceptions in this regard. On
the one hand, in rapidly fatal cases, death occurred before the loss of tissue became particu-
larlv marked; on the other hand, death arising from some accident during convalescence
raisiht leave the body in a fairly nourished condition. Again, when the fatal result was due
to the sudden or early development of some secondary lesion, as occlusion of the rinia glot-
tidis, pneumonic congestion, perforation of the intestinal walls or hemorrhage from an eroded
vessel, the subject was frequently said to have been but little emaciated. These exceptional
cases were more common in the malarial than in the typhoid series.
VI.— GENERAL CONCLUSIONS.
Til a large majority of the cases it is impossible to learn from the records what may
have been the immediate cause of death or the anatomical factor in determining the fatal
result. The patient was prostrated by the circulation of an altered blood; and after death
the intestines were found congested or ulcerated, and the liver, spleen, kidneys, lungs, heart
and brain more or less altered from the normal, but none of them presented lesions which
of theraseK^es sufficed to account for the fatal ending. Frequently death in these cases was
considered due to asthenia, failure of the heart's action being manifest in the symptoms; in
others coma was the harbinger of death. Among the former an exhausting diarrhoea or
hemorrhage was often credited with the result; amono; the latter were found instances in
which the condition of the brain failed to account for the fatal issue. In all these cases
the primary influence of the fever-poison on the blood must be regarded as having been the
specially dangerous element. The probability that the formation of heart-clot was the
immediate cause of death in many such cases has already been argued.
But there were certain cases in whicli the post-rno7'terii appearances concurred with the
symptoms during the closing hours of life in indicating that death was due to a particular
cause. Thus, in forty-three cases the intestine was perforated, in one the walls of the gall-
bladder were destroyed, and in sixteen there was peritonitis apparently independent of per-
foration. The lungs were more or less congested in 68.3 per cent, of the cases, Ijut in a large-
number of these the lesion was manifestly insufficient of itself to account for the fatal result-
Nevertheless in sonie, which may readily be selected from the records, it is evident that the
congested or hejmtized condition of these organs was inconsistent with the continuance of
life, and was accordingly the special factor that determined the issue. In this connection
congestive conditions of the larynx, including the formation of diplitheritic membranes^
have already been instanced. In other cases death may be referred with more or less prob-
ability to gangrene of the intestines, of the feet or of blistered and erysipelatous surfaces,
as also to parotid abcesses and purulent accumulations in other parts of the body, while
occasionally it was the result of accident, as in the instance of suffocation In- tlic intrusion
of a lumbricoid worm into the air pas.sages, case 378, or, as seen in the clinical records, by
the unwitting suicide of the delirious patient, case 41.
In reviewing the symptoms of the continued fevers dm-ing the war certain differences
were found between the typhoid fever of our camps and the disease as known to the literature
of medicine. Certain differences were also observed between our typhoid cases and those
in which the typhoid was associated with a malarial element; and these differences attained
48-4 PATHOLOGICAL ANATOMY AND PATHOLOGY
tlieir maximum when continued fevers of a purely malarial origin were subjected to com-
parison with those that were regarded as unmodified typhoid. So, in the examination just
concluded of the post-morteyn appearances of these cases, certain differences are discoverable
between our camp tvphoid and that of civil life, and between the former and the continued
malarial fever with which it was so frequently associated.
The typhoid of our camps was distinguished clinically from the typhoid of civil expe-
rience bv signs which indicated a higher degree of deterioration of the blood. In many
cases this deterioration was equivalent to a greater intensity of the typhoid fever-poison,
for it has already been, seen that a depraved condition of the blood was a primary result of
the action of the poison and a secondary consequence of the increased tissue-waste charac-
terizing the febrile condition. This virulence of the typhoid influence "was indicated by
greater prostration, delirium of a lower type, the occurrence of hemorrhagic blotches, the
frequency of purulent infiltrations and the increased fatality of the disease. Post-mortem
observations make note of the blotches and infiltrations; but as the records do not recognize
any special differences, other than these, in the organs of the body as compared with their
appearance in ordinary typhoid, the increased fatality must be referred to that alteration of
the blood which was the probable cause of the purpuric spots and purulent collections.
Our typhoid fever was distinguished clinically from fevers of malarial origin associated
with it by the presence in the latter of symptoms indicating a more frequent or more intense
implication of the stomach and upper part of the intestinal tract and of the large intestine.
A greater gravity of the cerebral symptoms and of those referable to the liver, and a greater
fatality of the disease also attended the cases in which a malarial element was associated with
the operations of the typhoid poison. Correspondingly i\^Q jjost-mortem records disclose an
increased frequency and intensity of the congestive changes in the stomach and duodenum,
a more diffuse congestion of the ileum and a more frequent affection of the large intestine,
particularly of its solitary glands. A greater frequency and intensity of the hypertemic con-
ditions of the liver and brain and a somewhat lessened frequency but greater intensity of
the morbid changes in the lungs and spleen are also observed. The malarial cases were in
fact characterized by the intensity and extent of their congestions. The greater fatality of
the typho-malarial cases was largely due to these local conditions of the brain, lungs and
intestinal canal; but it must also be in part ascribed to that altered condition of the blood
which constituted the primary lesion of the paroxysmal fevers. In association with the
similar abnormal changes that occurred in typhoid the primary impairment of the blood was
of necessity greater. Thus may be understood the increased prevalence of , hemorrhages,
suppurations and gangrene in protracted cases, and the more rapid course of those cases tiiat
occasionally suggested to our medical officers the presence of the typhus poison.
It is believed that the typhoid cases presented in the previous sections of this chapter are
such as would have been submitted under this title by Dr. Woodward had he been spared
to conclude this work. Those which he would have presented, so far as can be gathered
from his remarks at the International Medical Congress at Philadelphia, Pa., in 1876, as
illustrations of tyjyho-malarial fever with the vialarial element predominant, have been here
reported as continued fevers of malarial origin; for the study prosecuted in the progress of
their j^reparation for publication has not only failed to show in them the presence of a typhoid
element, but has assimilated them to the fevers due to a purely malarial cause notwith-
standing their so-called typhoid symptoms. Those that have been described in the foregoing
OF Tll'i COKTIXUED FEVERS. 485
pages as truly typho-malarial in Dr. Woodward's acceptation of the term, constitute the class
to which he would have applied the title ttjpho-malarkd loith the typhoid clement evidently
predominant. His sco7-l)utic class of cases has formed no separate series in the presentation
here given, for in but few of the cases were the symptoms of a scorbutic complication promi-
nently marked. Scurvy, as will be seen hereafter, was one of many causes which occasion-
ally co-operated to render the typhoid of our camps different from tliat of civil life, and to
increase the m-avitv of our malarial and tvpho-malarial cases. Being essentiallv a dcteri-
oration of the blood it could not fail to aggravate diseases that owed not only their primary
danger but many of their serious secondary evils to a depraved condition of that fluid; but
unless undor this title be gathered all the many causes that tended to deteriorate the blood
of our soldiers on its formative aspect, to it alone may not be ascribed the wliole of the
increased sxravitv tliat characterized our continued fevers.
VI.— ETIOLOGY OF THE CONTINUED FEVERS.
I.— COMMON CONTINUED FEVER.
The symptoms characterizing this fever, as reported during the first fourteen months
of the war, were those which at a later date were generally accepted as indicating the prob-
able presence of the typhoid poison. But a fever ushered in by chills or malaise, with
headache, dizziness, ringing in the ears, epistaxis and light delirium, and running a variable
course of from one to many days, presents nothing specific in its aspect. Even had this
febrile condition been associated with diarrhcea and more or less abdominal tenderness, a
diagnosis of typhoid would hardly have been warranted, in view of the great prevalence of
diarrhceal affections among the troops.
Our soldiers were exposed to a variety of depressing influences, and especially to over-
heating by violent exercise, to subsequent chill, continued exposures in the hot sun, cold, damp-
ness and foul air from overcrowding in closely shut tents and huts and from decomposing
substances on or near their camping grounds, each of which has been shown by experience
to be capable of inducing a condition of marked febrile reaction, ephemeral in character
under favorable hygienic surroundings, but persisting for a longer period under continued
or recurring exposure to the exciting cause.* These fevers, unaccompanied by local inflam^
mations, may be conceived to have been the result of a temporary deterioration of the blood,
which in some unfavorably situated cases reduced the jiatient to the adynamic condition so
generally as.sociated with typhoid fever. But clinically they differed from enteric fever,
and etiologically they have not been proved to be identical.-j- It is therefore a subject of
•Surgeou-Major William G. Poer, in an article on the Endemic Cotitimml Fevers of $ubtropical latitudes, — Britiek Med. Jonr., Vol. II, 1880, p. 738, —
states as tliL' geitprni cxijorieuce in tlie subtropics that cases of coatinued fever constantly occur wbicli liavc not only no constant specific couiplication
but no nppreciaMe le.-ion of any kind.
t William S. Khuab, Surgeon 32d III., in an article giving his views on tbe nature and origin of Cam^t Typhoid Fever, — Chicago Medical Exam-
iner, Vol. V, lsr4, p. 05, — refers tbe disease to iioii-s[iecific influences, sucb us Imve been indicated in the text, as the cause of common continued fever.
He holds that the fever resulted from a mal-nutrition and depr.ivatiou of the blood, attributing the defective nutrition to derangement of the digestive
function and the overcharging of tho circulation witli impurities to torpor of the excretory organs, the skin, kidneys and liver. Uotli of these abnornml
conditions are assumeil to be consequences of deficient nerve-foree induced by various inllueuees operating on the nervous system, as excessive and long-
continued toil without sleep or rest, rendered more exhausting by depressing mental causes, as constant fear or anxiety, the cheerlessness and monotony
of camp life, the deprivation of home joys, of the society of friends, of accustomed amusements, in short, of all those tilings which in tlie previous lives of
the men fostered a cheerful and happy state of mind. He allows that tlip influence of such causes may not be readily apparent in every case of this fever,
but claims that careful inipiirv- will elicit in a!t tlo- antecedent existence of a <listurliance of the cerebral functions. He regjirds tiie disease of Peycr'sglautls
and other morbid states of the alimentary canal aa merely incidental and due to the acrid and irritating secretions resulting from impaired digestion.
486 , ETIOLOGY OP THE
regret that tliey were dejDrived of an apjjropriate title on tlie Monthly Reports of Sick and
Wounded. Bv their separation from recognized febrile conditions some information might
have been gathered concerning their causation and kinship.
II.-TYPHOID FEVER.
Tliere are few papers on file relating to the causation of tyjihoid fe^^er, although many
incidental references were made in genei'al reports to the hard service of the men, tlie inclem-
ency of the weather and insanitary conditions in camp as connected with the prevalence of
this fever. In the extracts which are submitted below Faeley attributes the disease to
hard service and its incidental exposures, Bache to the unaccustomed mode of life of the
young soldiers, AVaeren chiefly to a pytliogenic miasm, Lyman to overcrowding and bad
ventilation and Jamison to hardships and exposures, although he also suggests a transmis-
sion of the disease from the localities whence the men were recruited. Dr. Sanford B.
HuNT^' states that the first case of typhoid fever in his regiment occurred at Baltimore, Md.,
while the command was en route southward from I\e\v York. During the illness of this
patient "two or three of his family in the healthiest part of Tioga county died of typhoid;
of course my man brought the fever from home with him."
Surf/eon Jas. M. Farley, 84/7i. JV. T., June 30, 1862. — The regiment has mareheil fluiing the quarter 345 miles,
oecuiiying nineteen days, being an average of eigliteen miles per day. All the camps were finely located except the
■one at Bristol, which was in a swamp, and during three days of the time we were there it rained incessantly. This
caused a large number of cases of a low grade of remittent fever and some of typhoid.
Brir/iide Surf/. T. H. Bache, HaUeras Inlet, N. C, Dec. 31, 1861. — The ground in many places occupied by our
troops during the first part of the quarter was a sandy waste, a portion of which the water is continually asserting
its right to hold. A mile above Fort Hatteras we have Fort Clark, where there is a little marsh grass; a few small
scrub-oaks were there formerly, but I learn the rebels cut them down when they occupied the place. Half a mile
above Fort Clark the island becoming broader, we have a tract of ground covered with a scanty vegetation, inter-
sected by marshes producing a very coarse grass which yields a jjoor support to some very diminutive cattle. This
•condition of country continues for about four miles up the coast, when suddenly we come to a narrow part of the
island where there is no vegetation. Here we find a sandy plain called Bald Beach. In barracks just below, liut
bordering on Bald Beach, the greater part of the command is now located. From this description one can readily
understand why the chief diseases are intermitten-t and remittent fevers. These fevers are only to be dreaded during
the spring and autumn. The typhoid (enteric) fever cases we should have expected in regiments containing young
men who are living a life so different from that formerly passed by them. Many are too thoughtless to take jiroper
care of their health, and unfortunately, they frequently have company officers over them who are ignorant of the rules
to be enforced for protecting their men, or, if told, do not understand the importance of such measures. The regiment
would be much less sickly if company officers insisted upon personal cleanliness, proper ventilation of quarters and
thorough cooking of the government rations. The last we have found both ample and of excellent quality.
Brigiuie Surg. J. H. Waeeen, Washinyton, D. C.,Nov. 26, 1861. — Having inspected the various camps at Meridian
Hill, Kalorama, &c., near Washington, D. C, I have the honor to report that the 52d Pa. has more cases of sickness
than any other regiment visited. The prevalent disease in this command is typhoid fever, of which there are thirty-
live or forty cases. The cause is conceived to be the malarial location of the camp. The soil is a heavy, cold clay,
incapable of allowing the water to filter through if ; and consequently the ground is very cold and damp. Near the
camii is a deep ravine containing mineral springs (magnesia, I believe). These, with the vacillating temperature of
the present season and the obstruction of drains with decomposing waste,_such as coffee-grounds, beans, bread, old
bones and slops from the mess-pans, are the principal agents which conduce to the large amount of febrile disease
in this regiment.
Seport on the condition of the llth X. Y., hif J. H. Wakrex, Brigade Surgeon, Washington, Jan. 27, 1862. — This reg-
iment is encamped upon the western slope of Meridian Hill. The ground is as good for camping, owing to its gravelly
and porous nature, as any in the vicinity; but the atmosphere is impregnated with a malarial odor, arising from
the decomiiosition of animal matters just below iu an open field, where a large number of dead horses are deposited
upon the surface and allowed to remain and decompose. This, with rather poor policing of the caraj), has given rise
to typhoid fever, from which, I regret to say, we have lost some ten or twelve men already.
Medical Insjjector George H. Lymax, ZT. S. A., on the sanitary condition of Fort TTood, Xete Tork Harbor, Feb. 18,
1865. — The command numbers 1,175: The permanent garrison 418, recruits, stragglers and deserters 122, and convales-
cents just discharged from -sarious hospitals and awaiting transportation to the front 605. The barracks are unfit
. * Buffalo Mai. ami Surg. Journal, Vol. II, 1S02, p. 202.
CONTINUED FEVERS. 487
for use; theirocciiiianoy is calculated to semi the men soon liack toliospital. The floors rest on thegrouml; the ceilings
are low ami the light insullicieut. At this time many men are oliliged to sleep on the floor, and I am told that rooms
which onght not to contain over 50 men (though with hunks for 80) often have 120 occupants. Forty-five of those
now in hiis]>ital are from the convalescents: and tlie cases arcalmost exclusively of a low tyjie — lyplioid fever, pneu-
monia, erysipelas, &c.; of the last-mentioned disease there were six cases iu January and seven this month.
Siirijeoii.lso. S. Jamison, 86^/i X T., Good Hope, l>. C, 7)pc. 31, 1861. — Our present camp is situated on thehorder
of iin open woodland, timhered with oak and chestnut, upon a rise of ground facing south, sides sloping east and west,
with a snuill stream of clear pure water at the foot of each declivity. This location is free from mud, the soil drying
otV ra|iidly aftereach rain-storm. It would become ohjectionahlo, however, later in the season, when the temperature
is sutlicientry high to favor the rise of malaria from the decaying vegetable mould upon its surface. Typhoid fever
and pneumonia have prevailed to a considerable extent during the months of February and March, the former having
caused fourteen and the latter five deaths in the regimental hospital. The whole number of deaths from fever in
the regimental and general hospitals will not, probably, exceed twenty-tive. The tendency to this fever in camp
at present gives cliceriug evidences of an abatement iu prevalence and severity. I can mention no causes beyond
those ordinarily referred to where many men aic crowded together and exposed to the vicissitudes of weather common
to this region of country. The long and weary march of ^xteeu miles through mud and rain to Camp (irilliu, Va.>
the stay of the regiment there for a month exposed to constant storm, the sun rarely making its appearance, and the
march hack to this locality may with propriety be referred to as strongly exciting causes of sickness amongst our
men. Predisposition to tliis fever may have been laid before the men left the vicinity of their homes, where the disease
in question has prevailed to a considerable extent during the fall and winter. Certainly a wide diti'erence in climatic
inllueuce must be felt by the men who have wintered in this ciimate, so different from that of the rugged hills and
frozen winters of Western New Vork. The troops are daily em])loyed in the ordinary military exercises of the field.
The habits of the men are fairly good, bathing once or twice weekly, changing underclothing weekly, ventilation
and cleanliness of teuts observed and streets well policed.
A report by Ass't Surgeon Milhau, U. S. Army, contrasts the condition of the 11th
and ll:th U. S. Infantry, stationed at Perryville, Md., in the early period of the war. The
former regiment was licalthy, the hitter scourged with typhoid fever. Dr. Milhau referred
the disease to the bad quality of the water used by the men of the 14th and to stable
manure in the vicinity, although so far as concerns the latter, the teamsters, \\\\o were more
exposed to its odors, were unaffected. From what has been already advanced concerning
the prevalence of typhoid fever among new levies, it seems as if in this instance the explana-
tion must lie in the character of the living material constituting the two commands, although
both were new and untried regiments, organized and recruited during the previous summer
and autumn.
The quarters of the 14th U. S. Infantry were shortly afterwards occupied by the lOih
N. Y. Cavalry. The regimental surgeon, R. W. Pease, on inspecting the camp of the 11th
Infantry and that assigned to his own command, attributed tlie insalubrity of the latter to
defective drainage and a more recent turning up of the soil for agricultural purposes. Meas-
ures were taken to remedy these objectionable features, but in a few days diarrhoea and
intermittents became prevalent, and in three weeks many cases of remittent fever were
developed, two of which assumed a typhoid type. At this period the regiment was removed
to Havre de Grace, Md. It does not appear, however, that the typlioid symptoms devel-
oped in these cases were due to enteric fever; for although the special report fails to follow
up the history of the regiment, the ]\Ionthly Report of Sick and Wounded for the following
month, April, shows twenty-eight cases of remittent fever and only one rejiorted as typhoid,
all of which ended favorably.
Ass't Surgeon WooDHULL, U. S. Army, testifies to the absence of typhoid fever from
the ranks of the two old regiments, the 2d and 10th U. S. Infantry, with which he served,
attributing their freedom to the more seasoned condition of the men as compared with the
susceptible material of newly-organized commands.
Ass't Surg. J. J. Milhau, V. S. A., on the saniiary condition of troops stationed at Perryville, Md., Feb. 10, 1862.
Elerenth U. S. Infantrij. — Hospital in a one-story stone house containing two rooms and a garret; the rooms 18 X 18
feet; only cue used as a ward. An additiou of boards serves as a dispensary and kitchen and a further extension as
488 ETIOLOGY OF THE
a sick ward for teamsters. The building, -which is heated by a stove, will answer as long as the number of sick is
small. A few of the patients sleep in the garret on bunks and sacks. Sick in hospital 10, in quarters 16 — total 26;
none in general hospital. Strength of regiment 340.
Ilheanes. — There are no serious cases; no typhoid or other fevers.
The han-acks consist of four board huts each accommodating one company, and each 85 X 18 X 74 feet to plate;
no ceiling; ventilators in centre of roof; windows on one side only; bunks double and in two tiers, each with a bed-
sack. There is an addition to each set of quarters for a kitchen and mess-room. The houses are a little raised from
the ground: the soil is a pretty dry sod. Po/ice very good. C7o(/iiH(; ample; men neat. Messing good.
Water is obtained from a small spring.
Sinls built over the river and well attended to.
Fourteenth XJ. S. Infantry. — Hospital in two unceiled board huts: one 72 X 14 X 'i feet to plate, with dispensary
14 X 14 attached ; the other 40 X 14, same height. These huts are pretty well located, raised from the ground aud fur-
nished with full windows on each side and two ventilators in the roof; they are heated by stoves. In the large ward
are twenty-six wooden bunks, in the smaller ward fifteen iron bedsteads. Sick in hospital 41, in quarters 96 : total 137.
Strength of regixuent 850. Ten new cases were taken sick this morning.
Diseases. — In hospital : Typhoid 20, measles 7, mumps 4, diarrhcea and convalescents 8, erysipelas 1 aud injury 1.
lu quarters: Many cases of diarrhoea, catarrh and fever.
Barrackn. — Board huts enclosing a quadrangular space or parade ground, into which the windows and doors
open : there are no openings on the outer walls. The ground is an old ploughed field nearly level, the soil clay. The
huts are raised from one to three feet, according to the undulations of the surface; in their front a rough stone walk
has been laid and a ditch dug to carry off the water. Each set of quarters is 80 X 18 X 71 feet to the plate; no ceilings;
half windows on one side only; two ventilators in the roof; heated by stoves; two tiers of double bunks, each with a.
bedsack. Each company has a kitchen under the same roof. FoKce good. Clothing ample. Messing good.
TTaier is drawn from a well six feet deep; it is cloudy and has a strong vegetable taste.
Sinks over the river.
The sanitary condition of the regiment has not been good for some weeks owing to the prevalence of typhoid
fever. The disease commences with severe vomiting and purging of a colorless fluid, which continues one or two
days, greatly prostrating the patients ; chills ensue, followed by continued fever, the tongue becoming dry, with red
edges, and the other symptoms of typhoid soon show themselves. There have been a number of deaths from this
disease and from measles. I carefully inspected every part of the barracks, the jirovisions, etc., and failed to find
any satisfactory cause of disease except iu the water used by the regiment, which I consider bad. I understand that
the inhabitants (To not generally use the well-water during the winter, but the river-water, which is said to be
healthier. There is an extensive mule-yard and stable adjoining the barracks on one side, though there are neither
doors nor windows opening on that side. A good deal of filth had accumulated in this yard, but when the troops com-
menced to fall sick it was cleaned out aud much of its manure removed. There may be something in the soil which
so far has escaped detection ; but there are over two thousand teamsters camped in the vicinity and there is little or
no .sickness among them.
I recommend the well to be closed up and the river-water only to be used. I also recommend quinine-whiskey
to be given to the men to counteract what I suppose to be a malarial influence. If the disease be not checked iu a
few days the regiment should be moved.
Surgeon E. W. Pease, Wth X. T. Cav.,Savre tie Grace, Md., March 31, 1862. — About the first of March orders were
received to move to Perryville, Md., and occupy the quarters of the 14th U. S. Infantry. On the 7th we entered these
quarters, and while we found them commodious aud in good condition, we learned that the regiment which had just
left had suffered severely from typhoid fever and diseases of alike character. The barracks are situated on the eastern
shore of Chesapeake bay, an elevated and pleasant situation. About 400 yards distant were the quarters of the 11th
V. S. Infantry. This regiment, I am informed, notwithstanding its contiguity to the 14th, was almost exempt from
disease. Dr. Page, the post surgeon, states that river- water was used by both; the camps were equally well jioliced
and the general management of each equally good. The only solution he was able to give of the difference in sanitary
condition was the fact that the ground of the 14th was diflicult to drain; that it had been jdoughed more recently
than that of the 11th aud a good sod had not formed on it. With these facts before.me it was my object to render
the drainage as complete as possible, thoroughly to clean the Ijarracks and to find a new source from which to obtain
our supply of water. The drains were opened aud improved, and an excellent spring was found convenient to the
quarters, yet exempt from its drainage. The weather soon became settled, and the mud which had heretofore been
very deep disapjieared ; everything apparently promised well. But about the 10th diaiThcea began to prevail, and a
few days later symptoms of malarial fever appeared. On the 26th orders came to move across the bay to Havre de
Grace. On the 27th numerous cases of remittent fever were developed, while acute diarrhoea had become epidemic.
It is safe to say that during the last twelve days we have had a larger number of sick on our list than for the whole
of the previous month. Two of the fever cases have assumed a typhoid type. The diarrhoeal cases obstinately resist
the ordinary treatment, quinine being essential to a cure in almost every instance. The general character of our men
is good. They have been regularly and fully supplied with rations and their cooking has been unusually good. Our
hospital accommodations have been excellent, aud the sick universally bear testimony to faithful care and a full aud
ready attention to their wants.
Jss't Snrg. A. A. Woodiiull, U. S. A., 2<Z and 10th V. S. Inf., Sejit. 30, 1862.— There were, at least iu this command,
very few instances of any form of continued fever, and although a generally weakened state of the system was quite
prevalent, and chronic cases of almost every disease fell into an adynamic and almost typhoid condition, there wa»
CO>"TINUED FEVEKS. 489
woudorfuUy little (cfrtainly not one-half per cent.) of tho tnii' typhoid or enteric fever in the battalion. One reason
may be found in the older and more seasoned condition of the men in the regular regiments. It is probable there
were many cases among the newly-recruited forces, but I utterly repudiate the idea so often advanced that enteric
fever was the prevailing disease. Of the few cases I saw some were remarkably mild, almost escai)ing detection, and
one or two recovered in tents that I believe never could hare survived in a building. Xo fatal case of enteric fever
came under my notice iu camp.
TLe oocupation of a camp in which typhoid fever had prevailed appears to have deter-
mined its occurrence in some instances, as in that of the 23d Mass., recorded by Surgeon
George Derby. This regiment had endured many hardships and exposures sucli as have
frequently been charged with the causation of the disease; yet the command continued
healthy until a short time after it occupied the tents and camping ground formerly used by
a confederate regiment that had suffered severely from tyjihoid fever. Within six weeks-
after the occupation of the infected camp one-third of the strength of nine hundred men
became affected with fever and twenty-two of the cases proved fatal. Immediately after
this the epidemic subsided, just as in the army as a whole it began to subside in 1861, when
the susceptible individuals who responded to the first call of the President for troops had
undergone their attack. Instances of this character manifestly show that bad air, improper
food, exposure to wet and cold, great fatiguev anxiety and other depressing and insalubrious
causes do not of themselves develop typhoid fever, although they may render the individual
less able to withstand the violence of its attack.
The 17th Mass., on duty at New Berne, N. C, during the quarter ending June 30,
1SG2. was fully exposed to the general causes of sickness that operated on the army as a
whole. Typhoid fever was the most prominent of the diseases affecting it, but even this did
not prevail to a great extent. Surgeon Gallocpe considered the comparative immunity
enjoyed by his regiment as the salutary result of a careful observance of the general princi-
ples of hygiene. This may be allowed; but in connection with the slight injury effected by
typhoid at this time, it must be remembered that his regiment had already been exposed to-
the special poison of the disease. The diminished susceptibility of the meJn must therefore
be taken into account in estimating the value of the hvgienic measures.
Siiri/ron Geoiu;e Derby. V. S. VoU., on the Medical Hintoyi/ of the 23rf Mass., from yovemher, 1861, to June, 18ii2. —
[Tliis regiment, numbering 900 men, left Massachusetts in Xoveniber, 1)<61, and occupied a salubrious camp at
Annapolis. Md., tiutil January 6, 1862, when the men were closely stowed in transports for thirty-two days. To care
in ventilation and cleanliness, including the daily airing of bedding on deck, is attributed the good health of the
command during this period. On arriving at Koanoke Island, February 7, the men were exposed to rainy weather,
and had to wade through the swamps during the engagement which took place there. On March II they embarked
for Xew Berne, X. C, where, after the battle, they occupied tents abandoned by rebel troops, among whom, as was
afterwards learned, fever had prevailed.] Until our arrival at New Berne, March 14, the health of the regiment,
in spite of every hardship and exposure, had been good and but few deaths had occurred. We had, however, n»
sooner settled in camp at the Fair grounds, just outside the city, than typhoid fever of a severe type was developed.
In April three hxiudred cases occurred with twenty-two deaths. It was the same fever we have iu Massachusetts,
characterized by tenderness on pressure iu the iliac region, diarrhoea, tympanites and rose-spots. In a good many of
the earliest cases the force of the fever-poison seemed to fall upon the brain, and a low muttering delirium, marked
nervous depression and subsultus were observed; later in April the type was less severe and fatal. Treatment was
almost entirely expectant: our chief reliance was upon fresh air, careful nursing aud supporting the strength, treating
more actively symptoms as they appeared. The causes of this severe visitation seem to be found in the depressing
insalubrious conditions in which the regiment was i)laced on shipboard both before aud after the battle of Koanoke
and \i\< to the time of its arrival at Xew Berne: Bad air, improper food, exposure to wet and cold, with great fatigue
immediately following a long period of inaction. Some influence may also be ascribed to the occui>ation for several
weeks of tents from which many of the enemy's sick had recently been removed. Since the subsidence of fever in the
last of April the health of the regiment has been tolerably good. Many men were permanently disabled by t be hard-
ship and exposure which they had endured and have since been discharged.
Siirgron Is.\AC F. Gallovpe, I'ih Mass., June 30, 1862.— During the last three months this regiment has l>eea
stationed at or near Xew Berne, X. C. The country in the vicinity is low, level and marshy and the soil universally
sandy. The climate at tuis season is favorable to health and no sickness has resulted from this cause. The food and
Med. Hist. Ft. Ill— 62
490 ETIOLOGY OF THE
clothiiii^ Lave lieen ample and of good quality. The water is bad, but particular care in filtering or boiling has
preveuted any extensive illness from this cause. The tents used by the men are of excellent quality and ^Sibley)
pattern, but too few in number. The crowding together of from fifteen to twenty men in one tent has in some instances
created a tendency to typhoid fever. The troops have been almost constantly engaged on picket duty, and exposure
to night-air in low, moist districts and sleejiingon the ground have been the causes which have operated mostcft'ectually
in producing sickness. The disease most prevalent is typhoid fever, but even this has not existed to a great extent.
It is remarkable that so little sickness has been produced by the causes which ordinarily are considered eft'ectual in
inducing disease. The comparative immunity from sickness which we have enjoyed I attribute to the constant care
which has been exercised in relation to the sanitary condition of the men and their quarters. Daily inspections have
been made of the food, clothing and tents, and the whole camp, including everything that might influence the health
of the men, has received due attention: order, neatness, cleanliness and temperance have been enforced as military
duties. The good results of this care give me great satisfaction; for, while disease has wrought extensive destruction
among the troops in this vicinity, I have the satisfaction of reporting but three deaths from disease in this regiment
during the quarter. Our hospital accommodations have been all that could be desired ; the best houses in town have
been used for hospitals, with all the contrivances for comfort and ease which our escaped enemies left behind.
Siirffeon Isaac F. Galloupe, llth Mass., Camp Andrew, BaVimore, Mil., Dec. 31, 1861. — The duties and employment
of the troops have been such as did not interfere with their health except in one instance. Five hundred meu of the
regiment went to the Easteru Shore of Virginia under General Lockwood in the month of November, where they
remained about three weeks. During their absence one of them died of typhoid fever, and soon after their return to
Baltimore twenty-four were taken sick with the same complaiut iti a severe form, which inoved fatal in six cases.
In all these cases the disease must have been contracted while the men were in Virginia.
Although tlie disease was apparently propagated in many instances by the infection of
a locality there is no illustration on the records of a direct contagion from one individual to
another. Fever cases in the general hospitals were often treated in the general wards, yet
no suspicion of direct contagion was roused. Here, however, there was usually a larger
air-space, better ventilation and greater attention to cleanliness than in the regimental or
field hospitals. Surgeon Beck, 3d Ind. Cav., refers the production of typhoid fever to faulty
methods of cooking and the fatigues and exposures of active scouting duty during the winter
months; but his language, in speaking of the manner in which mild and unimportant attacks
of other forms of disease terminated after contact with fever cases, is highly suggestive of a
contagious quality of the latter. If contagion existed, the crowded regimental hospitals
certainly afforded every facility for its activity. Although such an epidemic as affected the
23d Mass. at New Berne must be attributed to the operation of the same influences on the
command as a whole, it is probable that in other instances the disease was propagated and
its existence in the command prolonged by contagion from one hospital inmate to another.
Some of the unwholesome conditions existing in the regimental hospitals may be appreciated
from the statement of Surgeon Colgan, 59th X. Y., that his few hospital blankets were used
over nearly three hundred men in a period of three months.
Surijeon E. W. H. Beck, Zcl Inch Cav., Camp Carter, Met, Dec. 31, 1861. — This battalion has been in the field about
five months. My observations are confined to November and December. We have about five hundred men well
mounted on their own horses, encamped in pine woods near the Potomac river on a hard clay soil holding water on
its surface. This section of the country is somewhat miasmatic, the citizens suft'ering every autumn more or less
with bilious aftections. These troops, however, being from malarial districts in Indiana are not climatically aft'ected
by the transition. We have plenty of provisions, but lack vegetables — potatoes especially are scarce; we only have
them once a week or fortnight. Our men eat too much grease, frying their hard bread in grease and eating fat bacon ;
this i)roduces indigestion. We get beef as a general thing twice each week. The meu have been very careless about
cleanliness, many of them of their persons and nearly all of their quarters. They complain of not getting straw
often enough to change. They have neglected changing their underclothing. The surgeon has labored to correct
these evils. We have no proper winter-quarters, but live in tents with chimneys attached. Green pine wood is the
only obtainable fuel. We are the only mounted troops this side of W^ashington on the Maryland side of the river.
Our men have been employed as scouts, pickets, messengers and orderlies, giving them constant hard labor; they arc
on guard every second day. They go on scouting expeditious by squads and companies without tents, or, at most,
only one for ten men, with bread and coftee only for food, depending for shelter, food and forage upon good luck,
sleeping when night overtakes them in the woods or fields, making forced marches, taking prisoners to the city night
or day, and all this during the cold weather of October and November. Until December 7 only about twenty-ei^ht
men in each company had overcoats. These hard marches and exposures, coupled with indigestion from the large
quantities of strong coflee and grease or fat meat, brought many to hospital or to quarters with typhoid fever,
COXTIXUED FEVEKS. 491
lirouchitis aud catanli. Low fevers prevailed. Mild miimpoitaiit attacks of other forms of sickness coming in
contact witli tliese fevers, in defiance of our iuteiference, gradually assumed, in a majority of instances, the for-
midable symptoms of delirium, involuntary discbarsjes. snhsultus, picking of bedclothes, sudamina, rose-colored spots
and sordes. The cases re<iuired the strongest stimulants, from twelve to sixteen ounces of brandy being used per
diem: and without this they die. Derangements of the digestion liy fried food and fats, fatigue and exposure. I think
brought on these low fevers.
Siirgion Joseph P. Colg.vx, o^lh X. T., Camp Sherman. Fort Gooil llopc, 1). C.,Jti)uiar)/, 1,S02. — Our hospital accom-
modations are confined to two tents in which we are often compelled to crowd thirty patients with their" attendants.
We have been allowed twenty blankets, ten bcdticks and ten pillow-ca.ses for the use of all these persons for three
months. This renders it necessary that these few blankets be shifted over nearly three hundred men in that time.
Tho supply is wholly inadeiiuate to provide covering for the number of men we are compelled to shelter, and but for
aid received from the Sanitary Connnission in the form of iiuilts and lilankets our sick would often have had to sutler
more in hospital thau in quarters from want of covering.
From the statistics and special reports relating to typhoid fever a specific cause must
be assumed to have existed irrespective of hard service, exposure to tlie weather, over-
crowding, insufficient ventilation, defective police and other insanitary conditions. Appa-
rently this special poison was capable of infecting localities, which afterwards transmitted
the disease to new-comers. Probably, also, it infected the locality of an aflfectcd indiv.idual,
leading to direct or indirect contagion in the crowded and ill-conditioned hospital ward,
barrack-room, tent or winter-hut occupied by hirn. Certainly insanitary conditions of camps,
quarters and hospitals developed the susceptibilities of the occupants, thus facilitating the
propagation of the disease and increasing the gravity of its effects. But it is equally certain
that these susceptibilities did not survive the attack. Among the cases submitted there are
only two in which a second attack of typhoid fever is doubtfully suggested.* Local epi-
demics occurred but once in a regiment unless its ranks, depleted by the casualties of war,
became filled up by new men, in which case the recruits suffered while the veterans remained
unaffected. Notwithstanding the superlatively foul condition of the enclosure at Anderson-
ville, Ga., and the presence of the special poison of typhoid fever, only sporadic cases occurred
among the prisoners. This establishment was opened when the war was well advanced
and the prisoners, mostly veterans, had lost their susceptibility to the typhoid poison. In
the early part of the war prisoners were seized with typhoid fever in the absence of such
conditions as existed at Andersonville. Ass't Sursjeon DeWitt G. Peters, U. S. Amu-,
speaks of its presence in 1861 at some depots in the harbors of New York and Boston. It
appeared in spite of careful attention to cleanliness, ventilation and other hygienic condi-
tions. During a period of two months there were constantly under treatment, exclusive of
convalescents, at least seventy-five of six hundred and thirty prisoners. Most of the cases
consisted of typhoid fever in the persons of young and delicate subjects who had not attained
their full development.
But many men had lost their susceptibility prior to enlistment, and the proportion of
protected recruits was greater among city than among country levies. According to Ass't
Surgeon J. T. Calhoun, U. S. Army, regiments raised in the country and composed of
farmers boys suffered more from typhoid fever than city troops, although the former were
superior to the latter in physique.
One of the healthiest regiments in this division and in the army is the Fourth Excelsior (2u X. Y. Fire Zouaves),
composed almost entirely of New York firemen. Their losses from tyj.hoid fever (if they have lost any at all from
that disease) must be very small, while in the same brigade the 120th X. Y., composed of the better class of farmers'
sons from the river counties of Xew York, although not liaving seen one-tenth the service or suttered one-twentieth
the hardships of the regiment just referred to, have been almost decimated by typhoid fever.t
The information contained in the war reports of our medical officers relative to the
•S« mpni, p. 312. f J. T. CalboTs, in Ihdical and Siu-giail Beporter, Vol. X, Phila., 18C3, p. 97.
492 ETIOLOGY OK THE
etiology of typhoid fever is so meagre that to appreciate the causation of this disease in our
camps it may be well to refer to the results of general professional investigation.
We speak of the typhoid-fever JOO^s■o?^, but tlie facts establislied concerning the natural
history of the disease are inconsistent with the idea of a non-vitalized organic compound as
a causative agent. Such compounds on reaching the stomach or lungs are immediately
absorbed into the blood, and if possessed of deleterious qualities manifest their toxic effects
in a short time. Thus, prussic acid may be almost instantaneously fatal ; and although death
in other instances may not occur so promptly, the symptoms caused by the poisonous presence
are speedily manifested. But, as is well known, the typhoid-fever cause lies dormant in the
svstem for a period varying usually from one to three weeks. Even if we call in the unex-
plained catalytic action of the chemists, and assume an organic poison developed from the
albuminoids of the body and capable of setting up an alteration in the living tissues so slow
and gradual in its progress that the so-called period of incubation may be accounted for, we
are met with the objection brought forward by observation and experiment that such organic
compounds are unstable in their constitution, whereas the typhoid-fever cause is known to
have remained in full possession of its virulence for months, perliaps for years. We must,
therefore, assume a living cause for the disease, an organism which, on its admission into the
intestinal or pulmonary tracts, requires time for its increase under the favorable conditions
of heat, moisture and suitable pabulum, and for the manifestation of its presence by definite
local lesions and constitutional disturbances.
Several observers, including Klein, Eberth, Klebs, Koch and Letzerich, have
announced the discovery of a special form of micro-organism in the local lesions of typhoid
fever. Klein discovered microphytes in such numbers and so definitely arranged that he
believed their importance could not be questioned for a moment.* Nevertheless, the appear-
ances thus regarded as organized were shortly afterwards shown to be merely results of the
coagulation of albuminoid matter by the methods employed f Klebs announced the presence,
in the typhoid placpies, of bacilli which occurred with a constancy that proved their genetic
nature. J Moreover, when animals were inoculated with the supposed specific germ symptoms
analogous to those of typhoid fever, such as a febrile rise in temperature and enlargement of
the spleen and patches of Peyer, were claimed to have been produced. But the causal rela-
tionship of a micro-organism to the disease has not been established. Septicsemic results of
inoculation do not appear to have been excluded in considering the evidence. In fact,
diseased conditions produced by inoculation with bacilli must be viewed with caution, since
Klein has demonstrated the insusceptibility of the animals operated on to the typhoid poison. §
Eberth did not find his short rounded bacilli in every case of typhoid, but Koch, by the use
of better staining methods, showed that they are never absent during the active stage of the
disease. They are distinguishable from the micro-organisms of other diseases and may be
artificially cultivated, but the specific disease has not been reproduced by them, as no sus-
ceptible animal has been discovered. Nevertheless Koch considers the assumption warranted
that this bacillus stands in an etiological relation to typhoid fever, while he regards that
figured by Klebs as an unimportant invader of the necrosed tissues. ||
* Local Govcmmenl Board lleport, Loudon, 1S75, p. 95, f Proceedings of the Boyal Socidii, June lo, 187G.
i Archh: f. Experiment Pathol, nnd Pharinalologie^ Leipzig, 1881, BO. XIII, p. 381 etseq.
JKlein', p. 83, oj). cU., failed to convey enteric fever to animals by mixing their food with the fresh dejecta of patients suffering from the disease.
He experimented on Guinea-pigs, rabbits, dogs, cats, white mice and monkeys, not only when they wore in a healthy condition but after an intestinal
catarrh had been set np by elatt^rium, aloes or castor oil. He used the typhoid material in its recent condition and also when more or less decomposed
by keeping for some time mixed with water.
Ij Gaffkv, in MUtheilumjeu a. d. Ic. Gesitndheitsamtej Bd. II, p. 372 et seq.
CONTINUED FEVERS. 493
Altliougli the typhoid germ has not been recognized its existence is generally allowed,
and many of the conditions needful to its development have been demonstrated.
The passage of the germ directly from an infected person to another has been some-
times suggested, but none of the cases. brought forward in illustration are without their weak
points. When the instance has involved a large number of patients the influence of local
conditions affecting the whole of the sufferers has not been excluded.'-' When, on the other
hand, the instance has involved only a few persons in direct contact with the infected indi-
vidual, an indirect contagion conies forward as a possibility.f Liebermeister denies the
directly contagious quality, asserting that the idea is only a relic of the past, when the proper
distinction between typhus and typhoid fevers was not made, and when whatever was proved
of the one was supposed to be true of the other.J
It is, however, generally conceded that the spread of the fever is in munv instances
attributable to an indirect contagion through the medium of infected intestinal discharges.
Von Gietl§ and BrDD(| conceived that in all cases the disease was thus propagated. MuR-
CHISON has recorded that of 1,048 hospital cases of typhoid fever under his care onlv one
originated in the wards, and yet the night-stool often remained for hours unemptied; more-
over, he has known other patients to sit over the evacuations of enteric fever patients without
becoming affected thereby.^ But although the discharges have thus been proved to be harm-
less wiien recent, it is well known that after a time, as decomposition progresses, they become
capable of projiagating the disease. Laundresses, bj^ contact with soiled bed and body linen,
are particularly exposed to attack. A want of cleanliness in the sick chamber, as wlien the
patient has involuntary passages, may give rise to a suggestion of direct contagion, the
materies morbi emanating not from the patient but from alterations which have taken place
in the matter with which the bedlinen or blankets have been contaminated. The theorv
is that the spore or germ of tlie disease when it passes from the system has to undergo a
stage of development outside the bodj^ before it is capable of inducing the specific fever;
• MiRCHisox states that during twenty-three years, 1S48-70, 5,988 cases of enteric fever were admitted into tlie London Fever hospital, but only
17 residents in the hospital contnicte<i the disease, and most of them h.id no personal communication with patients sick of enteric fever. Of the IT cases
9 were nurses, only 4 of whom wer^ employed in the enteric fever wards ; 1 was a laundress, 1 a medical officer, and 6 servants residing in a building
detached from all fever wards. Twelve of the 17 cases occurred subsequent to 1804, ami, with certain others, were referred to defects of drainage. "My
experience in fact has led me to the conclusion that wheu enteric fever originates in a hospital, there is as a rule something radically defective in the
nnitary arrangements." See his Treiilue, pp. 4IV2-IB. Sir W. .Ienxer, however, in his niihloniiin Lecturer on Uie Aciile /pceittc ilisemes—3lfd. Tim^aaml Giixlle,
XXVII, ISUi, p. 20",— attributes this prevalence among the nurses of the London Fever hospital to a concentration of the contagious principle by
>ggr«g»tion of the sick and imperfect ventilation. For he says : " I can remember only two instances of the extension of typhoid fever when cases of
tbat disease were scattere.1 through the wanis of a general hospital ; and in these cases it was the friends of the patient,— the mother in one instance, who
bad watched by her son night and day, who suffered."
tThe following illustrations suggestive of direct contagion are from the BrilM .Vei(. Journal, Vol. II, 1880, pp. 732 and 739 : Seymour J. Shaekev
relates four cases which originated in the medical wards of St. Thomas' hospital in the persons of nurses employed in the wards. It is customary at this
hospital for the same nurses to do duty alternately in the surgical and medical wards, n>maining a month in each. Dr. Sh.vbkev emphasizes the fact
that on no occasion has a ca.se of t.vphoid fever arisen in any of the surgical wards ; arguing that since the drainage and other arrangements are the same
throughout the building the cases originating in the medical waitls must have been due to contagion. J.\s. JIcXeili., of the Homerton Fever hospital,
irives an account of sixteen cases which occurred in 1S7C in six houses on the sparsely settled island of Colonsay, near the Argyleshire coast. The distance
l>etweeu the houses in which the disease prevailed, with the exception of the secoud and third, was more than two miles ; between the excepted houses
there was only a distance of about one hundred .yards of level ground. .\11 the affected families obtained their water from diffiMent wells, and other
families using the same wells were not affecteil. Each had a sufficient number of cows to provide its own milk supply; their other provisions were
obtaine^l from various sources. They had !io drainage in common ; subsoil water could not permeate from the premises of one family to those of another,
and none of the houses were connected with sewers. Carbolic acid was used in the bed-pans and the i)assage9 were emptied into a hole dug some forty
or fifty yards from the house. The disease was introduced by a convalescent from the mainland. It is difficult to exclude the recognition of a direct
contagion in some of these cases. Thus, when the members of the fifth family were ill a woman came a distance of six miles to visit the?u ; she did not
rtay in the house longer than ten minutes, nor did she lurtake of anything while there, but she noticed a very disagreeable o.lor from a recent alvinc
discharge, and at the end of twenty-one days, iluriug which she was in her usual health, she wiis taken with typhoid fever. In an etlitorial notice, page
748 of the same journal, reference is made to a report to the Local Government Board on the prevalence of enteric fever in the Pontanlawe Rural District
^y ^f- FR.VSKLIN Pah«on8; A young man affected with the fever came from Swan.sea to the village of Mawr Llangnicke and infected six persons.
•'Altogether it did not api>ear that there was any mode by which the infection could have been conveyed from case to case except by direct transmission."
A similar outbreak iu the townshiji of Rhyndwyclydach is also mentioned.
tZtcTwssoi"* O/rtype'lia, American Bl., Vol. 1, p. 46,
g Fraxj X. vox GiETL — tfie rrwicAfii ilfa Enleriwlten Tinthim in MnncJien, Leipzig, 18G5, pp. 2 and 85.
1 WiiiiAM IllDn- On Inleitinal Fecer.—Tlie Lancet, London, ISoG, Vol. U, p. 618.
t See first edition of his Tnatit, Loadon, 1862, pp. 4504.51.
494 ETIOLOGY OF THE
and while undergoing this change it multiplies, especially when in contact with masses of
decomposing animal matter, as in the sewer, privy or dung-pit, so that an epidemic focus is
there established, whence the disease may be propagated by exhalation or water-carriage or
both, in accordance with local conditions.
Although emanations from specifically infected matter have oftentimes been recognized
as the cause of local epidemics, and in sewered cities as the cause of the endemicity of the
fever, the water-supply must be held responsible in many instances for the outbreak. Nor
is it difficult to understand wliy this sliould be. If the privy, cesspool, sink or manure pile
become a liotbed for the propagation of the specific germ, that germ will percolate in the
usual line of drainage and the subsoil and its water will become infected. In localities
where the inhabitants are careless as to the cleanliness of their surroundings even the surface
of the area of drainage may become infected with the excreta of some primary case, as it has
already been contaminated by the accumulated filth of years of uncleanly occupancv. The
soil of cities is generally extremely foul; a sewerage system in probably all instances was'
introduced only after the soil was honey-corabed with sinks and vaults or cavities filled with
filth. Wells in densely populated sections are, therefore, specially liable to become infected.
In certain outbreaks the disease has been traced to the waters of a given well, persons living
in adjoining houses having been aflfected or not according as they used the infected water or
obtained their supply from some other source. Shallow wells are necessarily more exposed
to infection than deep ones; hut deep wells and springs may become infected not only by
leakage from the overlying surface or subsoil, but even from their more distant surface origin,
as in the case of the Lausen epidemic,* where intestinal discharges contaminated the surface
on one side of a mountain and caused enteric fever in those who used the water of the .'springs
on its other side.
River-water polluted with infected sewage has also been known to occasion the disease,
as in the case of the epidemic at Plymouth, Pa., in 1885. f
A violent and general outlireak in a community w.as needful to establish an aiipreeiatiou of the propagation
of typhoid fever by the water of running streams ; for the cases that ordinarily prevail in a city having a river-water
supply more or less contaminated by the sewage of the upper settlements are attributed to sewer-gas, exhalations
from specilieally infected foci and the use of specifically contaminated well-waters. Perhaps each of these factors
has its influence on the prevalence of the disease, but so long as the epidemic at Plymouth is attributed to the pollu-
tion of the mountain stream which filled its reservoirs, and the Lausen outbreak to infected sewage in the radicles
of its water-supply, it will be difficult to accept the doctrine that river-water is harmless in this respect.
The evidence on behalf of the wholesomeness of a river-water that has been tainted by sewage consists of a
demonstration by chemical means of the purity of the suspected water. It has been shown that after a flow of a certan
number of miles the water of a running stream becomes as pure as it was previous to the inflow from a certain sewerage
system. Sedimentation and the fermentative processes that accomplish the reduction of dead organic matter to the
inorganic conditions of annnonia, nitric and carbonic acids, do much to preserve the purity of our rivers, as deter-
mined by chemical analysis, but it is a mistake to consider that this purity is synonymous with wholesomeness.
Well-waters that have given excellent results ou analysis have been convicted on other evidence of having pi'opa-
gated typhoid. The virulent essence of the disease cannot be detected by chemical means ; and it may be present
when the natural processes of purification have destroyed the ordinary sewage matters which at an earlier period
were associated with it. These processes as exercised on a water which percolates through the soil into a well are
more powerful in their action than when operating on the organic matter of a running stream. This is shown by
the fact that well-waters are on the average so much purer than surface-waters that both cannot be rated by the
same valuation of the analytical results. Organic impurities are found and considered allowable in river-waters
which, if present in filtered or well-waters, would be regarded as indicating a dangerous or unwholesome (luality.
^ In 1872 an epidemic occurred wliich was traced to the springs that supplied ihe village with wafer. These springs were derived in part from an
adjacent valley, the drainage of which found its way by an underground channel to the Lausen side of the mountain ridge and brought with it the
typhoid infection. The connection between the valley on the one side of the ridge and the springs on the other was demonstrated by the use of salt.
The failure of wheat starch to pass through with the water and salt showed that the conimuuication was not by direct channels, but in part by ix-rcola-
tion through porous strata. The particulars of this epidemic are given by Cayley in his Croonian Lectures On some points in the Pathology atid Treatment of
Typhoid Feeer, Loudon, 1880, p. S, and are quoted at length by Wilson, p. 128 of his volume On the Contitined Fevers, New York, ISSl.
t First Annual Report State Board of Health and Vital Statistics of the Connnonicealtk of Penn.'^yhaniu, Harrisburg, Pii., 1S8G, p. 17G.
CONTINUED FEVERS. 495
But the .igencit's which ])uril'y a wcU-water lioiu onliuary sewage matters fail to destroy the typhoid cause: ami,
since these are impotent, it is inconsistent to assume that the weaker intlnences operating ou the water of a running
stream would be more etiicient. Hence we may conclude that the typhoid cause having once entered a river-water
will retain its virulence, although organic matter of a less stable nature associated with it uuiy be destroyed. More-
over, typhoid fever is so prevalent a disease that it is impossible to consider the sewage of a large city as other than
an infecteil and correspondingly dangerous sewage.
As bearing on this i|uestion it is of interest to observe that typhoid fever is relatively lessfrei|neut in cities that
exercise care in the exclusion of sewage from their water-supply. Where the drainage area furnishing the supply is
carefully guarded from excremental taint typhoid fever is at a minimum. Where the water-supply is taken from a
river containing the sewage of large cities tyjihoid fever prevails extensively and constantly. Its prevalence may
be said to be proportioned to the amount of sewage inflow into the water-supply. Sewerage-works and water-works
are intimately related; the one ([uickly follows the other in the sanitary history of our growing cities. Hitherto it
has been customary to attribute all improvement in the health of a community to the sewerage-works; but it may be
inquired if perhaps the greater part of the benefit is not really due to the inlluence of a purer water-supply, — one less
contaminated by sewage than the well- or river-water that was previously used. Certainly this appears to be the
case so far as typhoid fever is concerned; for lialtiniore, Md., which has no system of sewers, has experienced during
the past twenty years, since the introduction of its general water-snpply, as large a decrease in the death-rate from
tyi>hoid fever as any city which has been sewered as well as systematically supplied with good water. The health
reports of New Orleans, La., also illustrate the connection between comparative freedom from typhoid fever and a
water-snpply untainted by sewage. That city labors under many unhygienic^ disadvantages on account of the pecu-
liarity of its site. There is no sewerage system: but. fortunately, there are also no wells. Mississippi river-water is
]uiniped up, but is used mainly for street « ashing and as a safeguard against tire. The domestic water-supply comes
from raised cyjuess-wood cisterns which, while often foul from accumulated sedimentary uuitters washed from the roof,
is never tainted with sewage or its associated typhoid germ. In view of these considerations a river-water that has
been once contaminated by sewage must be regarded as dangerous in this connection, no matter how excellent a
character may be given it by chemical researches.*
Many epidemics have been ascribetl, especially in England, to an impure milk-supply.
The well on the dairv farm has become infected and its water, used illogall^v as a diluting
adulterant, has introduced the o;erm of the disease into the milk. The oriraiiic analysis of
milk is not required to show that it contains all the proximate organic principles needful to
the support of human life, as this is demonstrated in every nursery. Theoretically such a
liquid, if kept at an appropriate temperature, furnishes as favorable conditions for the mul-
tiplication of the germ as the human system itself. The instability of milk is well known.
Professor Lister has demonstrated that its coagulation is due to the influence of a bacterium
(lactis), and that if it be protected from invasion by this bacterium and exposed to other
germs ordinary coagulation will not take place, but instead, other changes will be developed
depending on the nature of the micro-organisms which have been introduced.f Milk must,
therefore, be accredited with notable qualities as a culture fluid for micro-organisms. lu
some cases, in which the infected water was used only to rinse out the milk-jDans, a multi-
plication of the germs so introduced must be assumed to account for the disastrous conse-
quences which followed in the line of the milk-supply.
There is a difference of opinion as to whether the disease-germ is always derived from
a previous case. Some hold that the disease may originate de novo. Murchison conceives
that the miasm may be generated in decomposing animal matter in the absence of the dejec-
tions of a typhoid fever patient, that at some particular stage of the process a pythogenic
fever-cause is developed which, if taken into the human system, will produce enteric fever as
truly as if it had been propagated from a previous case. He allows that enteric stools may be
more prone than other organic matters to the fermentation by which the poison is elaborated,
but denies the existence of a specific germ. It is a matter of common observation, however,
that places notoriously filthy from excremental accumulations, which on this theory ought
to be the breeding places of the fever, have continued exempt from it for years until infected
•See Smart, On niiolaome Water /i>r Cilia ami Ibinu.— P/n7n. Med. riiuM, Vol. XVI, 1880, p. 697.
t Joseph Lister,— Ou tactic /ernKnlaliaii and il» beuring upon palhology.—BraUkicaiU't Itetmspecl, Vol. LX.WII, 1S7S, yip. 1-8.
496' ETIOLOGY OF THE
by the discharges of an imported case. City practitioners, who have the fever always with
them and the sewers constantly contaminated with the discharges from such patients, gen-
erally regard the disease as propagated by a succession of patients. But the country physi-
cian, who does not have it always with hiui, — who, on the contrary, has it springing into
existence in his practice at isolated houses without a recognizable connection with any j^re-
vious case in the locality, — is often inclined to quote his experience as throwing doubt on the
general application of the accepted theory of indirect propagation from case to case, if not
indeed as warranting a belief in a de novo origin.
Dr. Cabell of the University of Virginia has protested against the assumption of con-
tagion, direct or indirect, as the only means of propagation of typhoid fever. He com-
municated with the members of the Virginia Medical Society and others, soliciting their
views on the subject and a report of the observations on which they were based; and in
reply to tiie enquiry: Can you recall any case of typhoid fever originating under such cir-
cumstances as to exclude the probability of the importation of the disease from some other
locality? he received 58 affirmatives in a total of 69 responses.* Dr. Pinckney Thomson
gives strong expression to a belief in an origin independent of the contagion of a previous
case, and instances certain cases of spontaneous origin in sparsely settled districts wliere
previous cases could not have escaped detection. f Farquharson" of Iowa conceived the
disease in America to be due to exposure to emanations from the decay of vegetation during
the hot season, and wholly independent of contagion from the intestine of a previous case
as urged by Budd, or of feecal accumulations as claimed by Murchison.| To illustrate
the character of the testimony on wliicli tiiese opinions are based the following are quoted
from Dr. Cabell's paper:
Dr. L. B. Edwards, Riehmoiul, Va.: A farmer who lived eight miles from Lynchburg, near the base o" the
Tobacco Row mountains, had not for mouths before his attack been where there was sickness. For several weeks
prior to his attack he had been engaged personally in clearing and plowing some new ground on the side of the
mountain. There was nothing in the history of the case that indicated an importation of the disease.
Dr. W. H. BRAMBLETT,Isewburn, Va.: I can recall a number of cases occurring under such circumstances as to
exclude the probability of importation. In a thinly settled country, as that to which my ])ractice is most restricted,
there are many isolated neighborhoods cut oft' by mountains and streams from other portions of the county. The
families composing these communities never have a visitor from a distance; they rarely go out of their own neigh-
borhood and never out of the county; in fact they occupy a position so cut off from communication with the rest of
the world that the appearance of the disease in their midst would appear irreconcilable with the modern theory of
its propagation. Some of these neighborhoods I have had under observation for ten years, and it is here that typhoid
fever often seems to have its beginning, and can be traced to none of the ordinary sources of contagion agreeably to
the modern theory. The same community is never visited on the year following an outbreak, and new outbreaks
occur In communities which have not been invaded for ten years or never before at all.
Dr. W. H. Macon, Hanover County, Va.: Mrs. E., living in the county of Kent, had typhoid fever for thirty or
forty days, convalesced, relapsed and died. She had not been anywhere to contract the disease ; had not left her farm,
certainly not the neighborhood. No other case occurred. This case must have originated there, if I may use the word,
spontaneously, and several other cases similar to this might be mentioned.
Dr. Bedford Brown, Alexandria, Va.: 1 have many reasons to believe that typhoid fever may be generated
tcithin tlie system spontaneously. In my own experience cases have originated on high isolated points where the
locality was sterile, the drainage most perfect, the water pure and limpid, gushing out from rocky mountain sides.
In one of these instances the building was new, made of wood, airy and comfortable, supported on pillars two or
three feet high, underneath which the pure mountain breezes had free access, and the situation was on a high mountain
point without the vestige of a local cause in the form of privy, sty, cesspool, inclosure, decaying animal or vegetable
matter. Yet in this building were two well-marked cases of malignant enteric fever following in rapid succession.
Neither of these victims had left the premises for weeks previously.
* On the Etwlogtj t>f Enteric Fever, read before the American Medical Association in 1877.
t In the Report of the .State Board of Health of Kentncky for 1S83 he says : "As I study the literature of the etiology of typhoid fever, coupled
■with an experience in the practice of medicine for thirty years, I am forced to the concluaion that typhoid fever does originate from other causes than
the contagion of a previous case."
j The Typhoid Fever o/^nrmca, read at the meeting of the Iowa State Board of Health November 2, 18S3.
COXTIKUED FEVERS. 497
Dr. Al.n.vx S. I'.vyxk. Eaiii[iiifi- {'diuity, ^'a.: I ivmemlx'r as far liack a.s tlie winter iil' ISIil that a grntli'iiiaii of
wealth, living fmir miles we.st of Warrinton, pr()]Miseil to emigrate with his negroes ihuiiig the coming spring to
Jlississipiii. In the winter months a strange malady broke out amongst the negroes, and by the following spring he
had lost thirty by death. This was typhoid fever. There was no sickness anywhere else ofa serious character within
a liuudred miles of this plantation. It was a very dry winter, and the springs on the plantation were never of the
liest. In all other respects the topography was good. Privies are seldom used by these hardy mountain people, and
excrementitioiis matter is generally dried iu tlie sun or carried ofl'iuto water courses by the rains.
Several instances are sriven in which the disease was attributed to the decav of wood,
as ill outbreaks that sometimes occurred in the negro cabins of the shxveliolders. Con-
cerning tliese Dr. Cabell observes that:
There seems to be little or no room to doubt the existence of a morbific influence derived from the old cabins,
but that the factor in question is decaying timber is not, I think, equally certain. * * * In a few cases of this
kind, which have falleif under my own observation, another and very potential factor was discovered in a mass of
sludge, which had been formed under a very badly-jointed floor by the drippings of slops, and possibly, to some extent,
of the excreta of children. In these cases there was thus soil-coutaminatiou of the worst sort.
An outbreak of typhoid fever, apparently independent ofa previous case, occurred among
the U. S. troops engaged in the Modoc campaign in 1S73. The command, consisting of
B. Ui Cav., B, 4th Art'y, F, 21st Inf., and E and G, 12th Inf., was stationed at Fort
Ivhiinath, Oregon. The foUowing is from the report for September, by Ass't Surg. Henry
McEldeery, U. S. Army:
Nine of the ten cases of tyi)hoid fever reported as taken sick during the month belong to Co. G, 12th Infantry,
and were received into hospital from company cjuarters. The company at the time were quartered in tents near and
to the north of the stockade in which the Modoc Indian i>risoners were confined. These men were all taken sick
within a few days of each other. Upon inspecting the company quarters with a view of ascertaining the cause of
thedisease, it was found that the common tents, in which the men were living, were in almost every instance floored
with boards, and that the boards rested directly on the ground or on poles, and that no provision whatever was made
for ventilation underneath the floor. L^pon the floor being taken up in several of the tents the ground underneath
was found to be damp and mouldy. I recommended to the commanding officer that the company should bo removed
to a new locality, the tents rcpitchcd : that if the tents were floored the boards should be raised at least eight or ten
inches from the ground and provision made for ventilation underneath; that at least twice a week the tents should
be raised and the ground exposed to the sun. These suggestions were favorably considered and acted upon by the
commanding ofticer, with the result of completely arresting the disease. One case of fever was received into hospital
the day after the change was made. No case has occurred since.
Exception may be taken to this report in that it fails to state the grounds on which
the disease was regarded as typhoid. The clinical records of the post do not preserve a cir-
cumstantial account of anv of the cases, but from the data furnished bv tlie registers' of sick
it is evident that the disease, so far as our present knowledge extends, could have been no
other than the typhoid aflPection. Although no new case occurred in Co. G, 12th Inf., during
the month of September, as stated in McEldeery's report, two cases appeared early in
October. The September cases were taken sick on the 20-24th ; the two subsequent cases
on October 8. Of the twelve cases ten were returned to duty after an average stay of
two months in hospital, one ended fatally and one was discharged for disability. The alimen-
tary canal of the fatal case was forwarded to the Army Medical Museum, where, on exam-
ination, the stomach and upper part of the small intestjne were found in normal condition;
Peyer s patches were progressively enlarged and some of them slightly ulcerated — those
immediately above the ileo-csecal valve were greatly thickened and mammillated but not
ulcerated ; the colon was dotted with enlarged and ulcerated solitary follicles, which were
most numerous in the descending portion. The specimen was accompanied by the following
special report :
Private Henry Everett, Co. G, 12th Inf., was admitted to post hospital, Fort Klamath, Oreg., Oct. 8, 187.3, with
the ordinary symptoms of typhoid fever. The patient seemed to be much prostrated and very ill. He said he had
been sick for several days. Five grains of sulphate of quinine every four hours, acetate of ammonia and beef-essence
everj- two hours were ]>rescribed, with milk and eggs three times a day: the patient was sjwuged occasionally with
ilEi). Hist., Pt. Ill— G3
498 ETIOLOGY OF THE
■warm water. As he seemed to improve under this treatment it was continued during the four following days. Half
an ounce of whiskey every two hours was added on the 12th, as the patient appeared weaker. Hi.s bowels had been
acting regularly and never ofteuer than twice in the tweuty-four hours ; but on the evening of this day he had .several
passages, one of which, al)Out daybreak of the 13th, contained a considerable quantity of dark-colored blood. A
camphor and ojiium pill every four hours was prescribed, with turpentine emulsion and persulidiate of iron every
two hours and a teaspoonful of whiskey every half hour. He had another abundant hemorrhage from the bowels
about noon and a third about 4 p. m., fifteen minutes after which he died. Post-mortrm examination revealed ulcer-
ation of the patches of Peyer and erosion of a mesenteric arterial l>ranch. The spleen was greatly enlarged and
nnich softened. The other organs appeared normal.
AVitli refere?ice to the case discharged for disability the post records give the following
ill fori nation :
Private Landmesser, Co. G, 12th Inf., was taken sick Sept. 21, 1S73, with tyjihoid fever, and discharged Auf.
19. 1874. for consumjition following typhoid fever.
It may also be objected that a possible previous case from which the ten September
cases were derived is not satisfactorily excluded. Of course Dr. McEldeery may have over-
looked it; but there is no doubt that he gave full consideration to all the possibilities before
reaching his conclusions as to the cause of the disease. Certainly his men were and had
been for months so situated as to allow a full understanding of the conditions affectino- their
health. In fact it seems impossible for the previous case to have been imported or his men
exposed to its influence without his knowledge.
An interesting case, reported by Ass't Surgeon Hoff, U. S. Army, will be referred to
in another connection.*
Similar experiences in Europe and in India have also been recorded. "j" The argument
against the value of such cases as conclusive of a miasmatic origin, independent of a specific
contamination from a pre-existing case, is based upon the persistency of the typhoid-fever
germ. It is known to j^reserve its vitality, and presumably to multiply, under favorable
conditions, for many months; and there is no reason for supposing that it might not thus
remain potent for an indefinite period. A certain covered ditch or drain which has been
disused for years is opened, and those who have been exposed to its exhalations become
shortly after prostrated by typhoid fever and may form the nucleus of a series of cases con-
stituting a local outbreak. A pile of manure, the accumulation of years at a country house,
is dug up and carted away, and those wdio have been engaged iu the operation subsequently
* See itifia, p. 522.
f Tlte Brilish Med. Jotn:, iu one of its issues for 1880, Vol. I, pp. 733 and 740, has two articles on isolated and apparently spontaneous cases of typhoid
fever. K. Bruce Low, Sledical Officer of Health, Helmsley, Yorkshire, shows that he has had frequent opportunities of investigating the origin of
typhoid cases, free from the ordinary sources of error which surroiinu similar inquiries in large towns and populous centres. Sewer gas, infection in the
water or milk-supplies, and direct contagion were excluded from the generation and propagation of his cases by the conditions under which his patients
dwelt. The first which he relates requires an acknowleilgment of a de novo origin or of its connection with a case which had occurred in the house
thirty years before. MrRCHisoN would have found no difficulty in assigning to this case a pythogenic origin, as tlie privy was full to the level of the
seat, the smell from it otfensive, the cottage dam2>, dirty and overcrowded, and the general habits of the inmates in keeping -with tlieir surroundings.
As the patient suffered from repeateil attacks of diarrhoea prior to the developmeut of enteric fever, Dr. Low suggests the possibility of the latter being
due to the progressive elaboration of a specific poison from a succession of attacks of non-specific diarrhcca originating in filth fermentation. In the second
instance a study of the possible causes points to one of three theories of origin : 1st. A foul and overflowing privy near the house, but seldom used by
the patient ; 2d. A momentary exposure to a disgusting odor from a bullock's hide in an advanced state of decomposition ; and 3d. Drinking a cup of
tea in a house in which a fever case ha<l been treated three years before. P. Herbert Metcalf mentions a characteristic case of enteric fever which
occurred on Norfolk Island, in the Pacific, iu .lanuary. ISSO, without any apparent connection with a previous case. Tlie island is four hundred miles
from the nearest inhabited laud. In 1868 a febrile epidemic of some kind prevailed, and in the beginning of the year 1877 a man was reported to have
died of enteric fever. The gentleman who was taken sick in January, 1880, reached the island four months before his attack. Several years before he
left home he lost a brother and sister from enteric fever, but since that time he had not been in contact with the disease. This ]>atient had used water from
a well that had the reputation, unknown to him, of communicating with an open ces.«pool. On cleaning out the well its bottom was found to be layered
with four feet of foul mud iu which were embedded the skeleton of a duck, a pig's jaw, three empty preserved meat-cans, thirty old tin mugs, etc.; but
it is conceived that the specific poison of typhoid fever could not have been present, even supposing a previous case of the fever to have existed, for the
cesspool contained only kitchen waste, and the open privies were far from and ou a lower level than the well. Niemever, iu his Text Book of Pntdical
Medicine, Yol. II, Am. Trans., New York, 1800, page 573, says that the miasmatic origin of abdominal typhus is rendered probable by cases occurring iu
places removed from travel, where no case of this disease has occurred for years and where there is not the slightest suspicion of a contagious origin.
Surgeon General C. .\. Gordon, in his report on EtUeric Fever in reUUion to British Troops in the MmJrm Cmnmand. Madras, 1878, has shown that fevers with
enteric lesions occur iu India which cannot reasonably be accounted for either on the assumption of a direct propagation or on that of a filtii origin de
wn-o. Sir Josepu F.wrer, in his Croonian Lectures On the Climate and Fevers in India, London, 1882, p. 50, holds that fever in India with diarrhffia, Pey-
erian ulceration and tyidioid symptoms is not necessarily caused by a specific contagion derived from fa?cal matter or from the intestines of another person.
CONTINUKD FEVERS. 499
sicken of typhoid fever and may transmit the disease by their uncared-for discharges as
eflPectually as if they had received it from tlie discharges of a recent patient. The antece-
dent case is assumed to have existed and to have contaminated the drain or pile. In cer-
tain epidemics of obscure origin which have been thoroughly investigated, the previous case
has not unfrequently been detected. The faihire to discover it has therefore been regarded
rather as illustrating the difficulties in the way of a thorough knowledge of the facts than
as demonstrating the non-existence of the previous case. But it is claimed, on the other
hand, that if in many instances a careful examination of all the points bearing on the possi-
ble origin of a typhoid outbreak fails to discover a connection with a previous case of the
disease, we are warranted, notwithstanding the frequent superficiality of cur modes of inves-
tigation as compared with the obscurity of Nature's methods and the subtlety of the jwison
in question, in assuming that in one at least of these many instances the whole field has
been viewed and the presence of the previous case excluded. If this be ceded in one case
the argument is at an end. The truth will never be known if evidence which does not
agree with our preconceptions be excluded. All intelligent testimony should be admitted
as tending to an accurate knowledge of the matter in question. When an educated physi-
cian, possessing a full knowledge of the facts and not unlikely a personal acquaintance
ranging over years with the house, its inmates and neighborhood, has examined the subject
and failed to trace a specific infection, it is more reasonable to refer the origination of the
fever to local fermentative conditions than to assume that the specific germ has been in
existence there for years without manifesting its presence, or that some unknown person,
necessarily a walking case of the disease, had visited the premises and left no other trace
of his presence than the infection of the privy or well. To this latter supposition, absurdly
one-sided as it appears, we become reduced in many instances of country-house typhoid if
the spontaneous origin of the fever be denied.
In a recent treatise on the continued fevers J. C. Wilson* denounces the theory of a
spontaneous origin. He says:
If we assume that a fever so specific in its clinical and anatomical characters must be due to a specific cause,
and that the specific cause is an organism of some kind, the view that the poison does not arise independently but in
every instance from a parent stock becomes a logical postulate from these assumptions; otherwise we are forced to
accept the theory of spontaneous generation.
This author's enthusiasm in behalf of a specific germ transmitted from case to case leads
him too far. His argument as stated is correct, but it does not apply to the case in hand.
The view that the poison arises in every instance from a parent stock is a logical postulate
from the assumptions, but not that the parent stock is in every instance jiropagated in and
discharged from the human intestinal canal. I'r. Wilson does not touch upun tliis point,
which is nevertheless the very point at issue. Moreover, sjDontaneous generation on the one
hand, and on the other a transmission from case to case through the sewers, which Dr. Budd
fancifully yet practically regarded in this connection as a continuation of the diseased intes-
tines,f may not be presented as the horns of a dilemma. Ague is a specific disease, and if
we assume it to be due to a specific cause and that the specific cause is an organism of some
kind, — all of which may be readily allowed, as it is considered proved by many observers,
— the view that the poison does not arise independently, but comes in every instance from
a parent stock grown in the human system, does not follow as a logical postulate from the
assumption, nor are we forced to subscribe to the theory of spontaneous generation, — for the
• WomT, Library of Standard SleduxJ ^ii//mr«, Xew York, 16S1. ^Lancet, Vol. II, 1S5C, p. C18.
500 ETIOLOGY OF THE
ague-germs live their lives and generation follows generation in congenial soils and
circumstances.
The apparently spontaneous origin of typhoid fever, noted by many observers, indicates
tliat, as in ague, we have a miasm or germ, specific in character, propagated in and evolved
from certain matters in the soil under favorable conditions as to heat and moisture; yet, as
proved by other experiences, the disease thus originating de novo is capable of being trans-
mitted from case to case by means of decomposing excreta containing its infection. In other
words, typhoid fever is a truly miasmatic-contagious disease.
Ague, including the more pernicious manifestations of its cause, is a purely miasmatic
disease of telluric origin, although in its literature there are not wanting cases which suggest
a contagious quality. Dysentery is usually referred to miasms of telluric origin, yet in
many instances, especially where cases are aggravated, as during an epidemic, contagion
from the excreta is allowed; typhoid fever follows dysentery in this respect, its contagious
qualities being more frequently observed. The two serve to connect the ])urely miasmatic
intermittents with tlie purely contagious disease, small-pox, which the observations of cen-
turies have indicated as requiring the human system as a nidus for its propagation.
LiEEEKMEiSTEK uses the term miasmatic-contaeious in a different sense to that o;iven
above.* He does not allow that typhoid fever is contagious as is small-pox, passing directly
from person to person ; but follows BuDD in his theory that the germ thrown out from an
infected person is propagated in decomposing organic matter, and thereafter evolved to infect
the hunran system and be again thrown out. On the other hand he considers it to differ
from the purely miasmatic class in that it originates outside the body only when an infected
body has furnished the germ. The poison is therefore miasmatic, but with a qualification.
As the tape-woi'ra cannot be transmitted directly from person to person, Ijut has to pass
through another stage of development before appearing again in this form, he considers that
a development outside the body is needful to the reproduction of the germ of typhoid. The
fresh discharges of an enteric-fever patient contain the germs in that stage of their develop-
ment in which the living body does not furnish the conditions necessary to their propagation.
They are therefore harmless. But if they remain until decomposition has begun, and espe-
cially if in contact with masses of decomposing matter, a large propagation occurs and a
development which empowers them to produce the specific fever when introduced into the
human body. To classify the typhoid germ and others resembling it, such as those of dys-
entery and cholera, which he regards as miasmatic with a qualification and contagious with
a qualification, he has suggested the term miasmatic-contagious; but it is submitted, with
clue respect to the opinion of so high an authority, that as regards the term it does not con-
vey the theoretical ideas on which it was framed, that is, the assumed peculiarities of the
class which it was intended to define; and that as regards the theoretical ideas, they cannot
be sustained in view of the occurrence of typhoid fever under conditions which exclude the
possibility of a germ from a previous case. On the other hand, in using the term miasmatic-
contagious in the sense of the meaning of its components, as has been done in this discussion
— miasmatic, as originating without the system, yet capable of producing a specific disease
■when taken into the system, and contagious, as capable of direct or indirect transmission
from person to person, full expression is given to theoretical views^ which must be allowed
to be in accordance with observed facts.
*See his articles on the infectious diseases and the etiology of t.viihoid, in Vol. I, Ziemssen^s Ct/dvpedia.
CO>'TIXUED FEVERS. 501
"What the conditions may be wliich are needful to the propagation or evolution of the
tvplioid germ is not definitely known. The disease appears in a community on the disap-
pearance of ague. The purely malarial fevers liave their habitat in the wilds or in forming
settlements, while typhoid fever appears in I'ormed settlements.* This has been so well
recognized that ague has been called a disease of the country and typhoid fever one of the
town or city.f But it has been observed that the latter fever has prevailed along mountain
slopes, while ague has been its cotemporar}' in neighboring valleys; and that ague, prevalent
in wet seasons, has given place to typhoid during long-continued droughts. This suggests
the possibility, nay, the probability, that moisture has to do with the evolution of the ague-
poison and a comparative dr3'ness with that of the fever under discussion. J This comparative
dryness is the result of the development of the village into a town, where the malarial gives
place to the typhoid germ evolved from the soil. Later, when sewers are built and the town
evolves into a city, with typhoid fever endemic, indirect contagion manifests its influence in
the propagation and continuance of the disease. Dr. Cabell quotes several instances of
the supervention of endemics of typhoid on those of malarial fever when the moisture of the
soil has given place to dryer conditions; of the cotemporaneous existence of the two fevers
in neighboring localities having different degrees of moisture in the subsoil; of the replace-
ment of typhoid by malarial fevers when, by unusual seasonal or other influences, the moisture
has been again restored, and of the coincident occurrence of both fevers in the locality and
apparently indeed in the individual at certain intermediate stages in the progress of the soil
from moist to dry or the reverse. The following are given as illustrations; but many such
may be gathered from' recent literature, particularly from the Transactions of the American
Medical Association and of State and local medical societies.
Dr. R. S. Payxk, of Lynchhnrg, Va., recalling tlic changes produced iu the medical topograpliy of that city
and its surroundings by the construction of the James Rivor and Kanawha Canal, which was commenced in 1831,
says : The low grounds lictween the hills and tlie river hanks were watered by springs from the hills, and as the river
hank was higher than the foot of the hill the low grounds were necessarily swampy in character, and until the
grounds were drained by the canal we had ague and fever along its line every summer and fall. While the canal
was in progress of construction the laborers engaged in this work, as well as those upon the farms for twelve or
fourteen miles below Lynchburg, suffered severely with congestive chills. If the patient did not die during the
third or fourth chill the case generally became complicated with severe diarrhoea, and the fever assumed a continued
type, frequently marked with tympanites and delirium. After the newly lifted earth had been exposed to the winter's
frost and a summer's sun the miasmatic features were greatly abated, and the fever now generally assumed very
distinctly the characteristic features of typhoid. Still, on the same farms and sometimes iu the same families, you
would see during this epidemic a well-marked case of chill and fever, but if not arrested within five or six days, and
especially if the patient took an aperient, however mild, a diarrhoea would set in, the intermission would be less and
• It is Jianily uetnlful to furniph illnstrations of tliese well-known facta. In recent yean* every medical man who has gone West to grow up witll
the country has exiHTienceil tlie so-called change in Vie Utpe of fevere. Many references to it may be fount! in the Tj-ansactions of the American Medical
AaocinlUm, as, for instaucc ■ "In all the Southern meiliral journals of recent date we find it stated that throughout our whole malarial middle countrj-,
and indeed, though less strikingly, in our lower alluvial districts also, typhoid fevers are becoming more and more frequent iu places ami settlement-*
and und'T circumstances where hitherto the ordinary autumnal remittents and intermitteuts prevailed extensively." — 8. 11. Dickson, Vol. V, lsr)2, p.
liT. "We have heard no reijiark regarding our fevers ofteuer made by physicians in different parts of the State than that which refei-s to the evident
annual increase of continued or typhoid fever over the ordinary endemic or biliou.s fever of the country, the former being disposed as it were to displaco
the latter as the improvement of the agricultural districts advances." — Iteporl of a Committee on the Diseases of Missouri and lotpa^ Vol. VIII, ISS',, p.
li»".. A similar change has attended the settlement and improvement of reclaimed lands in other countries. Thus, according to Lavf.rax,— TVdtfc'rfeo
.l/.i/mhv» el ipidanies des .lnii/«, I'aris, 1875, p. 248 :— " In the early years of the occupation of .\lgeria by the French typhoid fever was as rare as malarial
fevers were comnion, and this was one of the princiiHil facts which served as a iMisis for the theory of antagonism ; but more recently the former disease
has become as frx'tpient an affection among the troops in Algeria as among those serving in France : In 1SG8 the army of the interior lost 3.05 men ikt
I,'W effective and the army of .\Igeria 4.G3 per 1,0(J0 from typhoid fever."
t -Vlthongh in growing cities malarial fevere are replaced by tyjihoid, a noted exception to this is found in New Orleans, where the prevalent fever
I" of malarial <.rigin. In this city there are no sewers ; excremental tilth is collected, removed and coiuiigned to the river under the sniierinteudcnco of
the Board of Health, and the water-snpi>ly is free from soil contamination by its stomge in raiseil wooden tiiuks. These facts have been adduced in expla^
nation of the comi«r,itive rarity of typhoid fever ; but since, according to Dr. Jnxr.s, not only the city but the entire alluvial portion of Louisiana,
snffera less from this disease than the more elevated |«rts (sec the Iteport of Uie Hoard of Health of Loiiisi>ma, 1881, p. 21il)— it seems probable that tho
water-logged condition of the soil is an important factor in determining the prevalence of the paroxysmal fevers and the infrequency of typhoid.
t MiBcHlsox has shown that in England the seasonal occurrence of typhoi.l fever is after hot and dry weather, from Augiuit toXovcmber, and that
years, such as ISOO, noted for decreased prevalence have been unusually wet and cold. See his Treatise^ pp. 448-49.
502 ETIOLOGY OF THE
less marked, and ultimately the fever take a typhoid character. This iieculiarity was confined to the poiiulation
residing on the river. About two and a half or three miles from the river typhoid fever broke oiit on a plantation
with a large family of negroes, and many died. There was no malarious complication here. The only chill I saw
was produced by myself in sponging a patient with cold water with a view of reducing the high temperature. A
chill came on by the time I had sponged the face, neck and one arm, and the patient died in less than two days.
Dr. R. T. Lemmon", of Campbell County, Va.: — I have had frequent occasion to mark an apparent antagonism
between typhoid and malarial fevers. In the year 1845 this section of the State was fearfully scourged by a typhoid
epidemic. The backbone or ridges suffered more severely, while the malarial region on the banks of the Staunton
Kiver and some large and old mill-ponds escaped entirely, the usual amount of ague prevailing there. The line of
demarcation was very apparent. Subsequently I have seen cases of typhoid within the malarial region, but no cases
of intermittent at the same time.
Dr. S. Putnam, of Montpelier, Va.: — During a somewhat extensive country practice for thirty years and more,
typhoid fever has more generally occurred as an epidemic from August to November, particularly in dry seasons, after
a succession of yellow, snwlaj days, without storm, xvinds or electrical disjilay, the beds of streams and ponds having
become dry or half dry and stenchy, aud vegetation parched or shriveled. Under these circumstances, constituting,
as I conceive, an epidemic influence, typhoid fever has often soon appeared, more frequently in families residing on
the banks of streams or ponds, but often also in the farm-houses scattered over the hills here and there, without any
possibility usually of tracing the importation of the disease or its spread from house to house by contagion. Under
these circumstances in the fall of 1865 I saw thirty -seven cases and made notes of them.
The following from a paper by J. H. Claiborxe, of Petersburg, Va.,* is also of interest
in this connection:
Some further light is probably thrown upon the nature of the disease in this immediate locality from the fol-
lowing facts: During the past year (1879) there was perhaps a smaller rainfall jnst in this section of the country than
for any one year in the memory of the oldest inhabitant. It is doubted whether the ground was ever thoroughly
wet from April, 1879, to January, 1880. A gentleman who had been observing the opening of a number of graves
in the month of December informed me that he had never seen the earth so dry — even in any summer month. There
was, therefore, great sluggishness in the streams and runs of the vicinity — even where they Avere not totally dried
up. For similar reasons the sewers and gutters of the city could not be flushed, viz: on account of the scarcity of
water and the necessity of economizing its use. There was on this account imperfect drainage both in the city and
the surrounding country, and a great accumulation of garbage and other noxious stuff which is usually swept off by
our rapidly flowing streams when flooded by storm-water. Though situate just at the head of tide-water, the land
rises in the city and vicinity from 50 to 300 feet above the sea; and jjer consequence the streams — several of which pass
through and around the city — have quite a fall and of course a rapid current. This gives us excellent natural
drainage, and in heavy rains we usually get a good washing out. During the protracted drouth of the last year these
natural advantages availed us nothing. But these accumulations from lack of drainage were not of a vegetable nature.
On account of the want of moisture the ordinary luxuriant vegetation of our aluvial soil was lacking, and there was
very little vegetable mould or decomposition. The noisome products which had been left to seethe and ferment by the
dried and drying streams were rather of an animal origin. The ordure of more than twenty thousand people, the
refuse and oft'al of half a dozen abattoirs, the garbage from the kitchen, cookshops and tish-stands — all contrib-
uted to the savory mass left to ferment in our midst and about us. Now, coincident with this condition of things,
shall I say as a sequence there appeared this new form of fever, partaking more of the nature of typhoid fever than
of malarious fever and yet not essentially either. In addition to these facts it is notable that there was almost a
total absence of the usual climatic remittent and intermittent fevers. Indeed, so far as my own practice is concerned,
I can say that not one uncomplicated case of simple intermittent fever was brought to my notice during the summer
or autumn of 1879. In its place came this new evil — typho-malarial fever I suppose it must be called — originating
perhaps in the infection begotten of uudrained ditches, sewers and streams, and having implanted upon its nature the
habit of periodicity which our malarial fevers have been establishing in the systems of our people for so many years.
Another circumstance favoring the supposition that a comparative dryness of soil is
essential to the development or proj)agation of the typhoid cause is found in the connection
between the prevalence of the disease and the level of the subsoil water. Buhl and Pet-
TENKOFEE have shown that in Munich typhoid increases as the water-level falls and decreases
as it rises. Virchow has demonstrated similar facts in Berlin. In this country H. B.
Baker of Michigan noted the condition of the water-level in connection with reports of
typhoid received from his correspondents in various parts of the State during the years
1873-83. His investigations appear to demonstrate that a fall in the subsoil water-level,
beginning usually in June and continuing until October, corresponds with a somewhat later
* Ttjplio-malaykil Fever : Iiem(iyl;s on mt Etideimc Fever, \S1^, in the City of Petersburg and vicintige. — n)';Tmm 3[edicid Blontidy, Vol. VII, p. 89 et seii.
CONTINUED FEVERS.
0U3
but similarly progressive increase in the prevalence of typhoid, and tliat the subsequent rise
of the water-level is followed by a dimiuisbed prevalence of the fever. '='
The Munich observers suggested in explanation that the matter which, by its fermen-
tation, gives origin to the causes of typhoid, lies deep in the earth and undergoes fermenta-
tion only when freed from excess of moisture by the fall of the subsoil water-level. Lieb-
EKMEiSTER regards the increased prevalence associated with low water in the wdls as du(^
to a concentration of the infective matter resulting from the increased area of drainaore and
the diminished quantity of diluting water.f Baker holds in a similar manner that the
specific poison of typhoid fever from neighboring privies and infected soil is more likelv to
enter the wells when the water is low. He, however, announces that in ]\Iichigan the law
of correspondence, as formulated by Buhl and Pettenkofer, does not hold good during the
winter: "Typhoid fever follows low water in summer and high water at that season of the
vi'ar when the ground is usuallv thoroughly frozen. ''t
The proposition that water percolating- through a soil contaminated with the specific
germ or cause of typhoid fever may carry the infective principle into wells and springs
appears to be definitely established. The Lausen epidemic has shown that filtration through
the soil is incompetent to remove the cause of typhoid fever from water. § Again, the
proposition that a well or spring infected in this manner is more dangerous when it contains
little than when it contains much water, is higlily probable. But neither of these prop-
ositions excludes the possibility of the fever originating independently of germs that have
had a previous habitat in the human system; nor do they demonstrate that the causes of
* Ttfphoid Fernr and Low Water I'li Tl'e(b.— See Anmial Report Stale Board of Health of Michigan far 1S84, or Reports and Papers of the American Public
a<dOt Atociation, Vol. XII.
tS<'e American Translation Ziemssen's Cyclop.^ Vol. T, p. 71.
JTlie year 1SS2 fnruislied Dr. B.\ker witli liis most uotaWo illustration of
high*groun(l water corresponding with a considerable prevaleuco of fever in the
winter season. It is noticealde, however, that in his diagram for the year nien-
tion^^ the increased movement of the fever followed the lowerinj; of the subsoil
water-level so slowly that, although the lowest level was noted in July, the maxi-
mum of prevalence was not attained until October. The high rate of prevalence in
January may not therefore he comi>ared with the high-w-ater level of the same
month, but with the level of one of the later mouths of 1S81. What this may have
been i3 not known ; for since the wells examined were not the same wells in both
years, " no comitarison," as Dr. B.vker points out, "can be made of one year with
the other as to the exact height of tlie water during the year as a wliole or of one
month with tlie corresponding month in another year." The high-water level in
the wells observed in 1881 was IGO inches below the surface; the low level 25G
inches. The highest level in lSv'<2 was 104 inches, the lowest 180 inches. liut as the
frt^iuency of typhoid iu both years was determined in tlie same manner, the rates
prevailing in the spring of 1882 are susceptible of comparison with those of the pre-
ceding winter ; and these show a gradual decrease from 37 per cent, of the reports
fumUhed in October, 1881, to 32 iu November, 25.in December, 21 in January of the
following year, 16 in February, 12 in March, 8 in ,\pril and 7, the minimnm, in May.
As the general ten.lency of Dr. B.vker's researches favors the establishment of a
l^lationship between high water and diminished prevalence, it seems likely that
this gradiul divline in the fever-rate was jircceded by a correlated movement of tho
level, even although high water was in this instance associated with a high preva-
lence of the fever. It may also he pointi'd out that if Dr. B.\kf.k be warranted in
inferring a connection between high water and increased prevalence in January and
Febniary, 1882, the connection between low water and diminished prevalence iu
July wi.uld bo equally authorized ; but this last is opposed to the general tenor of
the ot»!!ervations. There appears, however, in some of his duigrams a slight want
of that corresiwndence between the water-level and the prevalence of typhoid that
Is known to exist during the summer and autumn. Vhen the ground is frozen the
privies and other sources of ty-jihoid contamination are al.so frozen ; the water-level
1» low in the absence of percolation from the surface, and tjphoid fever is at a mini-
mum. Wien, on the other hand, in the cold months the ground is not bound up
by fr<^t and percolation from the surface is unimiietled, the water-level niay rise, and
this rise be followed by an incre.ase of typhoid rather than a decrease.
g See svpra, note *, page 4IH.
Dl.\GRAM showing the relation hetivcen the height of the enhMil tcater-
levet tntd the prevalence of ttjphoid fever in the State of
Michigan daring tlie year 1882,
5 « 5 o. d-" 5 T- 3 ST U J? ^
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504 ETIOLOGY OF THE
typhoid lie so tleep iu the ground as to be incapable of reaching the system except hv the
water-supply. The only deduction allowable from many of the experiences on which they
are based is that a certain dryness of some layer of the subsoil overlying the water-level is
needful to the development of the cause. Whether this layer be deep or superficial has not
been demonstrated, but so far as the evidence goes it is apparently rather superficial than
deep. A certain amount of moisture is necessary to the production of malaria. Typhoid
follows malarial diseases so promptly in some instances, that the symptoms of both diseases
may be developed coincidentally in the same person. This absence of interval indicates
that the superficial layers of the soil, or those incompetent to evolve malaria on account of
their dryness, are the site whence the typhoid germ is evolved.
LiEBEEMEiSTER takes occasiou to remind us that in discussing the influence of low
water in wells the influence of season must not be forgotten. The summer heats certainly
lower the subsoil water-level, and are known to be favorable to fermentative processes.
Both of these effects may be assumed not only to increase the virulence of a water-supply
derived from an infected area of drainage, but to favor the development and evolution of
the typhoid miasm from a suitably dry and otherwise congenial soil. But as all works of
improvement, engineering, agricultural or civix;, which lower the level of the subsoil water,
promote the disappearance of malarial fevers and the subsequent appearance of typhoid
cases, the proper condition of the soil as to moisture seems, under ordinary ranges of temper-
ature, to be the determining influence in the evolution of the typhoid cause. The lowering
of the water-level in wells is a coincidence, but not an essential of the prevalence of typhoid
fever, although it may aid in the propagation of the disease by concentrating a percolated
infection or miasm in the drinking-water.
Besides a certain dryness of soil and a temperature suitable for fermentative processes,
nutritive material of an organic nature seems to be requisite for the development of the
miasm or germ. Formerly animal matter was considered essential — an opinion originating
no doubt in the general acceptance of Budd"s theor}' of propagation from intestine to intestine,
or of Muechisok's pythogenesis, — but the evidence certainly favors the belief that vegetable
matter affords a congenial soil for the increase of the typhoid cause; and some of the
instances seem to indicate that to be effective the quality of this need not be such as to
constitute filthy surroundings in the ordinary acceptation of this phrase.
From the considerations involved in the abov'e inquiry it seems probable that typhoid
fever is a miasmatic disease arising from the concurrence of certain conditions of the soil,
and propagated as well by indirect and perhaps direct contagion as by purely telluric exhala-
tions and percolations, contaminating air and water with the specific poison or germ. If
we assume the disease to be miasmatic-contagious in this view of the meaning of the com-
pound term, the probable origin and mode of propagation of an outbreak in civil life may in
many instances be determined. In country districts the normal environment of the sufferers
is well known, and the unusual, among which are the typhogenic, conditions may be studied
with proportionate facility. In large cities, where the environment is complicated, the
origin of local epidemics is necessarily involved in corresponding obscurity. In an army
the difficulties attending an investigation into the causation and transmission of typhoid
fever are increased by the possible existence of unknown and unsuspected factors. To these
difficulties may be attributed the absence of special rej^orts on its causation in our camps.
Xotwithstanding the great prevalence of typhoid fever reported by our medical officers
COXTIXUED FF.VEKS. 005
'.luring the first year of the war the epidemic was never general. It consisted of a series of
local or regimental outbreaks. One regiment suffered while that encamped iu an adjacent
held was unaffected, although the shelter, duties, diet, water and soil were to all appearances
of the same character in both instances. One regiment suffered severely — a second was
affected to a less extent — ami in both the rapid sequence of the cases indicated a local
i-pidemic; but in a third command the cases were scattered over a longer period and a
typhoid epidemic was not recognized. The surroundings of each regiment were subject to
constant change, — by the general movements of the army, by the special movements of indi-
vidual detachments in compliance with orders assigning them to various duties within the
lines of the army, and by transfer to distant military commands. A close study of the
medical history of each regiment is essential to a knowledge of the typhoid epidemics of the
war; but the materials for this have not been furnished.
Nevertheless, from what has boon already submitted, the appearance of the disease ia
a regiment or otiier unit of military organization may be granted as having been due in some
cases to importation from the localities in which the command was recruited; in others to
camping on ground infected b_y its former occupants; in others again, to miasmatic influences
affecting the air or water, encountered amid the changeful conditions of field service and due
to a dryness of soil inconsistent with the development of unmodilied malarial fevers. Gen-
erally this condition of the soil as to moisture depended on its porosity and on ordinary
meteorological influences; sometimes, howe\'er, it was produced artificially, as when tlie
subsoil water-level was lowered by the work of military engineers; even the means adopted
bv the men to make themselves comfortable iu field-quarters were frequently the cause
of small local outbreaks, which assumed the proportioi^s of an epidemic when multiplied
by a multiplication of the causes. In view of the miasniatic origin of typhoid, the huts
constructed by the troops in the early part of the war afforded all the elements needful to
its production. The shelter-canvas was pitched over low walls built of logs; the ground
around the walls was trenched to keep the floor dry, and the earth removed from the trenches
was banked up on the exterior of the logs to close up the crevices. Organic additions were
made to the soil forming the floor of the hut by crumbs and scraps incidental to the messing
of several men in this confined space. Heat only was required for the fermentation of the
soil, and this was afforded by the fire built for interior warmth. The external cold j^revented
emanations from the camp-site as a whole, but each tent or hut became a hotbed for the
development of the typhoid miasm — in small quantities, no doubt — but in a high state of
concentration; for the energies of the occupants were devoted rather to excluding the cold
than to ventilating their quarters.* ]\[any medical officers were active in their endeavors
to suppress fever in their commands by destroying these hotbeds or by diluting and dissi-
pating their emanations.
Probably in no instance that occurred during the war could a miasmatic origin of the
• M. L^ox Colin — in Lti Fi'r-re typho'idc dam VAntn-e, Paris, 1878, pp. 100 and 102 — considers the spontaneous origin of typhoid establislied by instances
occurring in Frcucb garri-^ons in time of peace. His argument is this : " When a number of persons coming from a perfectly salulirious locality, j. c,
nut carrying any germs of typlioid fever with them, are sulyected to crowding witliin entirely new premises, but are protected at the same time from tlio
Admission of any external inllnence of a putrid nature, — typhoid fever, should it make its appearance among them, must be held to have originated
sponlaneously.'' He specities. as a case in point, an epidemic that occurred in the '^'M batt.aliou of Chai^enrs. This ci>r]>8 was sent from Limoges to IJellac
(Hnule Vienne) in February, ISTfi. Its new station was a healtliy little city which had never before been garrisoned. As none of the barracks in prop-
aratiun for the trooijs were Anished, 160 men were qtiartcred in three confined rooms, each of which had but two windows and no ventilating shaft.
The nir-s)kace per man lianlly amounted to 130 cubic feet. Bad weather confined tlie men to their quarters even during tlie day, and caused tliein tu stuff
op catvfully all apertures tliat would have given entrance to air. From February 21 to March 2.5 typhoid fever attacked 18 men, one of wlioju died. Tho
water-supply, although impure, was nnconnected with the outbreak, for the non-commissioned officers and othei-s belonging to tho connnand, who had
iK'tler quarters, were unaffected. M. Du C.iz.iL, who reported the outbreak, referred it to infection of tho air by organic emanations from the human
body— fc miagiiw hmittim — and M. Coi.ix concurs in this explanation.
Meu. Hist., Pt. 111—64
506 ETIOLOGY OF THE
fever be aemonstrated. Instances in which no other origin could be indicated may not have
been uncommon, but the many and varying exposures to which the individual or the eom-
mt'^d might have been subjected, unknown to the regimental medical officers, invalidate all
conclusions reached by the method of exclusion. Nevertheless the striking illustration
furnished by the experience of Ass't Surgeon McEldeeey, in the Modoc campaign, shows
that typhoid of a purely miasmatic origin may have been frequently present during the war,
since the conditions that developed the disease in Company G, 12th U. S. Infantry, in Oregon,
were of common occurrence among our volunteer troops.
By recognizing as one cause of enteric fever a telluric germ capable of naturalization
in the human system and of indirect, and perhaps direct, transmission from person to person,
the existence of the specific disease may be acknowledged in cases where, on other theories,
a malarial fever only could be allowed as present. The prompt acceptance of the term typho-
malarial by a majority of the profession in this country, where, in our growing settlements,
the condition of the subsoil as to moisture is such that malarial and typhoid conditions alter-
nate, shows the tendency to avoid a diagnosis of typhoid when the previous case is wanting
to account for the specific poison. Were these cases acknowledged as typhoid, and their
infectious qualities allowed, disinfection of the intestinal excreta would be in order, with a
consequent diminution of the prevalence of the disease. So long as they are regarded as
malarial, because the connection with a previous case cannot be established, quinine will be
administered as the one thing needful, the chambers, sinks, privies and sewers will become
charged with the specific germ emanating from the obscure febrile case, and a local epidemic
of a dangerous but preventable disease may be the consequence.
AVhen the disease originated in miasmatic influences a violent but short-lived outbreak
resulted; for although the whole of the men susceptible to the miasm may not have been
directly affected by it, the large number of primary cases quickly established a focus of infec-
tion which threw its baleful influence over all the command, and perhaps beyond it, into
neighboring camps, if prompt and effective measures were not taken to stamp out the disease.
A similar rapidity characterized the outbreaks resulting from the occupation of localities
infected by their previous occupants.
When the disease originated by direct or indirect contagion, affecting in the first instance
one or at most few individuals, its progress was less rapid. Transmission from man to man
through the medium of the sinks, close communication in quarters, infected blankets, etc.,
necessarily separated one case from its progeny by- at least the period of incubation. The
prompt removal of the cases from quarters to hosj^ital, although primarily in the interest of
the sick man, was practically an imperfect isolation which tended to confine the sphere of
infection within limits under the special surveillance of the medical officers.
The water-supply, although frequently detected in transmitting the specific germ of
typhoid in civil life, was seldom arraigned by our military surgeons except in the absence
of other and more evident insanitary influences. In large and crowded camps it was impos-
sible to preserve the streams from fsecal contamination. Every rainfall washed more or less
of the filth of the camps into their current. Wells, also, were liable to become dangerous
from typhogenic miasm or infection from a previous case. It may be assumed, therefore,
that the water-supply was not unfrequently the vehicle of transmission and even of primary
invasion.
The diet was sometimes included among the insanitarv agencies tending to the devel-
CONTINUED FEVERS. 507
opment of the fever, and at least two medical officers regarded it as the pi-unwn mobile of tlie
disease.* But men became aflected whetlier tliey were well or poorly fed, and of regiments
on the same rations some were attacked while others escaped. The diet was anparentlv
unconnected with the causation except in so far as a state of mal-nutrition may have increased
the susceptibility of the individual to this as to other diseases by diminishing the resistance
of his system to morbific influences.
Hardships, fatigues and exposure to the vicissitudes of the weather were often men-
tioned among the causative agencies, but their action was evidently of the indirect and gen-
eral character attributed to an insufficient dietary.
Overcrowding was certainly unconnected with the causation of the disease. Of com-
mands on similar areas some were scourged while others escaped visitation. The disease
prevailed among troops stationed in barracks which gave a larger air-space per man to their
occupants than was furnished by buildings of similar construction to troops who remained
unaffected. Xevertheless, overcrowding was as certainly a chief factor in the propagation
of the disease. Its importance in this respect cannot well be overestimated: It afforded
facilities for every mode of transmission from man to man, — by the latrines, the wells, the
infection of beds, bed-clothing, wearing apparel and other articles, and by direct contagion,
if this last mode be allowed. Moreover, it increased the virulence of the disease and added
proportionately to its fatality, — effects which were experienced also by the victims of other
acute diseases, the most common of which were remittent and continued malarial fevers and
pneumonia. Xon-specific ochletic emanations by aggravating the disorder of the blood in
typhoid intensified the cerebral symptoms and gave rise to cutaneous maculations by which
the fever became confounded with typhus.f an error sustained for the time being by the
actively contagious qualities which the disease apparently manifested.
But, aside from the essential miasm or infection, the principal element in determining
the occurrence of a regimental epidemic was without doubt the presence of a susceptibility
to the disease on the part of the membei-s of the command. This is demonstrated by the
accessions of fever which were associated with the advent of new and so-called unseasoned
men and the decrease of the disease as these men became converted into veteran soldiers;
by the freedom of the old regiments of the regular army from typhoid, as compared with
its prevalence in new regiments, whether regulars or volunteers; and by observations sliow-
ing that troops recruited in cities where typhoid is endemic were less susceptible than those
raised in country districts where the disease is relatively less frequent. As a matter of
fact, the extent of the epidemic, other things being equal, depended, as in the eruptive
fevers, on the number of susceptible individuals in the command.
This inherent susceptibility, so far as is known, can be exhausted onl}' by an attack of
the disease. A gradual exposure of the system to the causative agencies of typhoid is
assumed by many to give a certain amount of protection, or to inure the individual to the
morbific presence; but there is no valid ground for assuming that anything more is proved
than that the susceptibility of the individual was not originally of a high order, or that it
had already been exhausted by an attack of the disease.
That which is true of the individual may be predicated in a general way of the assem-
blage of individuals : Regiments have a susceptibility which is destroyed only by a thorough
• Sec note t, p«ge 485, and report of Snrgeon Bece, page 490, tupra. t See nipra, page 325.
508 ETIOLOGY OF THE
exposure to tlie typhoid germ; but it does not follow tliat every regiment must undergo
an epidemic visitation.
Altljougli medical officers can do much to prevent the occurrence of first cases, it is
impossible for tliem to be always or even often successful. The known channels of attack
during active service are too numerous to be effectively guarded; and, moreover, until the
conditions of miasmatic evolution are ascertained with precision no exercise of care or caution
can guarantee protection against its occasional manifestations, although, with the co-opera-
tion of commanding officers, the attack may be prevented from assuming the proportions of
an epidemic. This may not be possible where a general miasna prevails, as when the soil,
barracks or other quarters have been highly infected by previous cases, or when tlie morbific
cause has operated through the water-supply. In such instances the immediate abandon-
ment of the infected locality and the separation of the sick from the well are imperatively
required to check the progress of the epidemic.
When, however, the primary cases are few in number and depend on importation or
individual exposure in infected localities, an epidemic may be avoided, irrespective of sus-
ceptibility, by measures of general sanitation in camp and the prompt removal of the patients
to a hospital where ample space, strict attention to cleanliness and the disinfection of stools
and contaminated bed- and body-clotliing will limit the spread of the disease. General
sanitary measures not only destroy epidemicity but exercise a- powerful influence in mod-
erating the intensity of the typhoid phenomena in individual cases; they may even i^revent
the primary development of tlie fever by removing such local sources of typhoid miasm as
may have existed in certain tents, huts or barracks.
The direct miasmatic derivation of typhoid prepares us for the occurrence of the disease
in suscejDtible regiments, notwithstanding all care in the hygienic government of their camp ;
but this is no reason why such care should not be exercised. Proper construction and ven-
tilation of the huts, ample space, purity of soil and care that neither the water nor the air
of the camp be contaminated by its refuse, will often prevent the introduction and always
limit the spread of typhoid fever as a camp disease.
Ill— CONTINUED MALARIAL FEVER.
It is unnecessary to do more than mention the continued malarial fevers in this place;
their miasmatic cause, a specific malaria, has already been discussed, together with their
complication by adynamic or typhoid symptoms resulting from disorganization of the blood
by typhogenic influences.
IV.— TYPHO-MALARIAL FEVER.
Kor, after what has been said on the subject of typhoid, is it needful to dwell at length
on the causation of the true typho-malarial fevers, — an exposure to the co-existing miasms
of typhoid fever and malarial disease, as when the pregnant soil is in transition between the
comparatively moist state essential to the production of the latter and the comparatively dry
state apparently as essential to the former, or the exposure to the typhoid cause of an indi-
vidual already under the influence of the malarial miasm. But a few remarks on typho-
malarial fever, as presented to the profession by medical writers and teachers since the close
of the war, may not be out of place in this history. In truth, the literature that has crys-
talized around this term may be regarded as a medical product of the war of the rebellion.
COXTIXUED FEVERS. 509
At the close of their service the medical officers of our volunteer-armies returned to the
duties of civil life carrying with them an enlarged experience of fevers, together with the use
of the term tvpho-malarial. The effort made in this volume to estimate the current value
of this term during the period of the war has shown that clinically it was involved in uncer-
tainties and obscurities which were increased and intensified by the ambiguity of its patho-
logical meaning. Clinically it embraced, or was at liberty to embrace, all the continued
fevers of our camps excepting such as were examjsles of what may be called text-book typhoid,
for all deviations from a typical course might be regarded as modifications by the ever-present
malaria. It embraced also all febrile manifestations resulting from the malarial miasm when
upon these supervened tlie low or tvphoid condition dependent on the retention in the blood
of the products of tissue-waste. The aggregation of many of these purely malarial cases
under the typho-malarial heading gave to the so-called fever a rate of fatality inconsistent
with the presence of a specific typlioid element. This satisfied those who reported their
advnamic remittents under the new heading that they were correct, or at least by no means
alone in their method of classification, and obliged those who claimed the presence of a
specific typhoid in all the reported typho-malarial cases to fall back upon a favorable influ-
ence exerted on the typhoid element by the co-existence of the malarial poison. In fact,
as the name scarlatina indicates to the popular ear a much less dreaded enemy than scarlet
fever, so to many w-ho examined the reported figures without considering the facts repre-
sented by them, the' term typho-malarial became a euphonious appellation in which the
gravity of typhoid was comparatively dissipated.
In the absence of instructions concerning the pathological conditions characteristic of
tvpho-malarial fever, cases presenting typhoid impaction or ulceration of the patches of
Peyer and solitary glands, as well as those free from such lesions, were necessarily included
under the title. Tliis period of uncertainty as to the pathological value of the ambiguous
terra lasted for more than a year. Indeed, it may be said that no guide or guard for its use
was at any time announced to the medical officers of the army; for although Dr. "WoOD-
W.VKD published his view of the meaning intended to be attached to it fourteen months after
its introduction, the publication was incidental and evidently not S2:>ecially intended to invite
attention to probable errors of diagnosis. It may be assumed, however, that this incidental
reference) or the volume on Camp Diseases, issued shortly afterwards, succeeded in reaching
some of the reporters on account of the increased fatality-rate of the fever subsequent to the
date of these publications.* Xevertheless, it may be considered a fact that the majority of
our medical men left the service for civil duties with as much uncertainty concerning typho-
malarial fever, clinically and pathologically, as when the term was first introduced.
Soon afterwards the profession in civil life appreciated the labor-saving value of the
title, and typho-malarial fever became common in the health reports of cities and towns and
in the private practice of jahysicians where formerly only common continued, typhoid and
malarial fevers were known. We may assume that the errors of diagnosis, and doubt as to
pathology, which vitiated the army statistics were propagated with the term and operated to
create confusion of ideas among the profession in civil life. The lack of clinical records
illustrative of the typho-malarial fever of the war}- may be attributed only to the generally
• S<w Table XLII, p. 114, wij»rn. During the fourteen monttis mentioned in the text 27,399 cases were reported among the white tmoiw, with 1,5.'5
deaths, eiinalling .'1.79 per cent, of fntalitr; duriug tlie remainder of the jwriod covered Ity the statistics of the war 22,472 cases were reported with 2,471
dmhs, or U.Ol |)er cent.
t See page 212, mpra.
510 ETIOLOGY OF THE
felt uncertainty as to what really constituted the fever in c[uestion. A similar dearth of
cases in the medical journals after tlie war may be explained in like manner. Dr. WooD-
WAED held the whole matter in hand, and to him the profession looked for enlightenment.
This was given in a paper read in the section of medicine of the International Medical Con-
gress held at Philadelphia in 1876. This achieved a wide circulation, and, as might have
been expected, did much to clear away the mists of the typho-malarial atmosphere. But
inasmuch as this author failed to appreciate the influence of a continued malarial fever in
the evolution of typhoid symptoms, he was obliged to recognize a specific typhoid element
where there was no post-mortem evidence of its presence.* The group of febrile cases which
in this volume has, for reasons assigned, been set down as continued malarial, was regarded
by him as typho-malarial, and constituted his first group of typho-malarial cases, — fevers in
which the malarial element, without being the only pathological condition present, is the
predominant one. This complication of the typho-malarial series with cases which presented
neither clinical nor anatomical evidence of the presence of a specific typhoid fever has per-
mitted a continuance, even to the present time, of much of the obscurity in which typho-
malarial fever had been enveloped.
Before the introduction of the term the association of tyj^hoid symptoms with malarial
fever and of malarial symptoms wdth typhoid fever was well recognized.
Dr. W.L. Feldee, of Sumter District, S.C.,descrilieclt a form of fever which, originally intermittent or remittent,
lapsed into typhoid, this latter becoming complicated with swelling and suppuration of the parotid glands.
In the report of a committee on the diseases of Missouri and Iowa J we find:
The term typhoid is also sometimes applied to designate the terminal stage of an autumnal endemic fever of a
periodic type, in which the distinct paroxysmal type becomes ultimately absorbed or lost in the continued febrile
movements established by the supervention of acute or subacute inflammatory lesions, with nervous lesions terminating
the pathological r61e.
Dr. S. H. Dickson, § Charleston, S. C, considers it a matter of familiar remark that in long protracted cases of
the ordinary remittent of malarious regions there is a diminution or shading down of the palpable contrasts and alter-
nations of the periods of febrile exacerbation and remission ; a tendency in the former to contiuuousness, tlie latter
exliibiting less alleviation of symptoms, and the whole appearance approaching that met with in continued fever,
simple, nervous or typhoid. In common professional parlance such cases " take on the typhoid character."
Typhoid fever, says Elisha Bartlett,|| like all other continued affections, is sometimes more or less mixed up
with and influenced by the pathological element of periodicity. This will happen most frequently and will be most
strongly marked in malarious regions and during the prevalence of remittent and intermittent fever. He cites Dr.
WoOten, of Lowndesboro', Ala., as follows: "I may remark that I have often seen typhoid fever complicated with
regular remittence — that is, typhoid fever and remittent fever existing together; and I have cured the paroxysmal
exacerbations whilst the disease essential to typhoid fever continued ; and I have frequently found it necessary to do
this before the more formidable disease could be influenced by remedies. I have seen sucli cases iu the practice of
physicians who supposed them to be remittent or bilious fevers, in which the bowels had become diseased as a con-
sequence of the fever. I think this is a very common error. The malarial influence frequently so predominates in the
symptoms of inflammatory disease in our latitude as to obscure the real disease for many days; and in such cases it
is easy to look upon such influence as the cause of the structural lesion, whilst in fact the latter has acted as the
exciting cause to the manifestations of the former."
It is interesting to observe, as part of the history of this typho-malarial epoch of the
literature of the continued fevers, that in the early part of the war, before the term became
an ofiicial designation. Dr. Jas. J. Levick of the Pennsylvania hospital described, in one of
his clinical lectures, a series of cases identical with those afterward correctly regarded as
typho-malarial. •[[ These he called miasmatic typhoid fever, and to them he invited special .
attention, as he believed that this mixed fever was of frequent occurrence at that time among
• « See page 402, siijira. \ Tram. Amer. Med. Associalimi, Vol. V, 1852, p. 361. t W*'"'. "^'»'- '^IHi 1*55, p. 106.
§ Idem, Vol. V, 1852, p. 141. || Tke Hislonj, Diagnosis and Trealinenl of the Fevers of the Vailed Stales, Phila., 1S47. p. 127.
% Miasmatic Typhoid Fever, — Med. and Surg. Reporter, Phila., June 21, 1862, also American Jour. Med. Sciences, Vol. XLVII, 1S64, p. 404 et seq.
COXTIXUED FEVEKS. O 1 1
our troops ia the tielJ. He considered that the two complaints coexisted in their essential
natures and ran their course together without losing their individual characteristics. His
description of typho-malarial fever agrees very closely with that afterwards given bv Di-.
AVooDWARD in his volume on the Camp Diseases of the U. S. Army.
After the introduction of the terra its restriction to cases in which the poisons of both
malarial and typhoid fevers were present was insisted on by manj- observers.
Pr. ArsTix Flint s.iys • typho-ii\aIariaI fever is caused liy the comliined action of malaria and the special cause
of typhoid fever, rractitionevs in malarious situations have been aceustonK-d to say that remittent lieeomes con-
verted into typhoid fever. This mode of expression is not accurate: there is not a metamorphosis of the one disease
into the other, Imt a combination of both diseases, the phenomena of the ouje or the ntber disease predominating iu
ditterent cases.
Dr. Aloxzo Ci.AKKf has accepted the term typho-malarial as indicating tlie result in the human system of the
conjoint operation of the poisons of malarial and typhoid or typhus fevers. He gives as an example a ease of typhus
in which intermittiuf; coma was removed by the use of quinine. "Symptoms as severe as this do not commonly
appear in typho-malarial fever, but accessions of fever are very apt to correspond with the accessions in the intermit-
tent and remittent fevers — that is, the highest temperature is more apt to be present iu the morning than in the
evening.''
In a recent medical journal we find:
I have met with many cases this season which commenced with a chill every afternoon, followed by a temper-
ature of 1(U° and 105° in the evening. The next morning it would be normal. And with all the anti-malarial reme-
dies used the chills would continue for ten days or more, when they would gradually cease and the fever become
continuous, with all the symptoms of typhoid fever, even the rose-colored spots, bronchial trouble, tympanites and
diarrhoea. Some cases would start as remittents and end with all the typhoid symptoms. To call such cases per-
nicious intermittents or remittents is nonsense. When a case of intermittent or remittent fever does not yield to
full doses of quinia, repeated for three or four days, you generally have the typhoid combination.}
Similar ideas are found in recent Endish literature:
o
There seems no doubt that there occur epidemics of fevers partaking of the nature of typhoid and of truly
malarial intermittent or remittent fevers. This typho-malarial fever seems chielly to originate and spread in regions
where the poisons of both types of fever coexist — as in swampy regions in which the soil and water are largely impreg-
nated with decomposing organic matter of both vegetable and animal origin. In ill-drained marshy regions in
proximity to human habitations much animal refuse matter tends to accumulate and undergo decomposition simulta-
neously with the vegetable matter of the swamp. We tiud that iu such regions ague and typhoid are, ordinarily,
both prevalent.^
But various other views have been expressed, from a weak denial of the existence of a
typho-malarial fever to the recognition of a typho-malarial miasm, both as a hybrid from
typhoid and malarial factors and as sui generis or of telluric evolution independent of typhoid
or malarial causes.
Roberts Bakthoi-OW i| doubts the existence of a t.vphoid fever modified in its progress by a malarial fever. Tie
attributes the frequency of the typho-malarial diagnosis by the profession to errors arising from a want of apprecia-
tion of the remissions in the stages of accession and subsidence of ordinary typhoid and from a want of recognition
of the antipyretic influence of large doses of quinine in this disease. He believes that there exists such an antag-
onism between the two that iu the presence of the typhoid poison the malarial poison ceases to be active. He had
held that the thermal line of typhoid might receive an impression from a coexisting malarial complication, but in
the light of a wider experience he concludes that the modification iu the thennal line, supposed to be due to malarial
complication, has for the most part no real existence. In chronic malarial poisoning the malarial influence is insuffi-
cient to modify the'typhoid process to any appreciable extent; but where the malarial infection is active its mani-
festations cease during the typhoid progress, to become again prominent as an intermittent during the j)rogress of
convalescence.
J. S. CArLKlNS,ir of Thornville, Mich., argues that typho-malarial fever is a distinct disease, propagated by its
own special cause, and that this special cause is a hybrid or fertile cross between marsh miasm and the typhoid-fever
poison. He infers that these morbific agencies are nearly related saprophytes, probably varieties of one species, or
at the farthest species conforming closely to a common type, because the progeny of parents more remotely connected
is incapable of propagating the cross, which perishes with the first generation. Cases last usually about four weeks.
At first, in some instances, a reduess of the tip and edges of the tongue may be suggestive of the future progress of
• PrixcipUa and Praclict n/ .Ve.lici'ii<, Xew York, IST.!, p. <«-. t .Veidcal fffwrf, Vol. XIII, Xew York, 187S, p. 304.
{Dr. W. F. Smith, M'I. aii.l Snry. Reporter, Pliilad.lpl'ia, fa-, IfS'-^ Vol. XLVI, p. 167.
iSargeoD E. G. RrssELL, Bengal Med. Service,— .Wi/nnVi, iU I'mif nail KjTftl, Calcutta, 1880, p. 92.
I See bis paper On Typlvy-matarial Terer, Medical Seirt, Vol. XLV, Pliila., 1884, p. 281. 7 DttroU Lancet, Vol. 1, 1878, p. 403.
512 ETIOLOGY OF THE
the disease; iu others the tongue is pale ami coated with a bilious-looking fur. The intermissions may be so distinct
that the case is regarded as an ordinary ague; but the febrile action becomes continuous, and in the secoud week
enteric symptoms are developed. He gives notes of one case and briefly refers to five others. In the case noted there
were recurring chills with nausea and vomiting, fever and profuse sweats. In the second week the patient seemed
much improved and was able to be up and walk about, but his appetite did not return, his tongue continued smooth
and red and he perspired profusely at night. In the third week a relapse occurred with nausea, vomiting and chills
as at first. Diarrhcea followed the administration of castor oil. Improvement was gradual; even at the end of the
fifth week the evening temperature was 100° Fahr. and perspirations occurred nightly. Ko cerebral symptoms were
present : no rose-colored spots are mentioned as having been seen.
W. C. Jahn'agix," Macon, Miss., takes a chemical view of this subject. He considers that the specific poison
which produces typho-nuilarial fever is distiuct iu its individuality, and argues that since we are ignorant of the
nature of the typhoid or malarial poison there is nothing left for us but to approximate the truth "by reasoning
from the visible and tangible effects through the conditions requisite for the development of those jioisons to their
nature." He is thus led to believe them gaseous; but as he knows of nothing in nature that has not a chemical
existence and is not controlled by definite chemical laws, the separate and distinct septic poison which, under favor-
able anti-hygienic conditions gives rise to typho-malarial fever, must naturally be the product of the chemical com-
bination of the gaseous poisons of typhoid and malarial fevers.
J.H. CAR.STEN'S,t Detroit, Mich., holds that this fever is sui generis and to be distinguished from typhoid, inter-
mittent and remittent fevers. After a few days of malaise there is a chill followed by high fever, the temperature
remaining thereafter at 103° to 105° Fahr., and the evening observations being sometimes a little higher than those
taken in the morning. The sudden development of the febrile conditiou excludes typhoid fever; continuance of the
high temperature excludes remittent fever. Among other diagnostic signs are mentioned the pulse, which is rapid,
120 to 140, small and quick ; delirium present from the very first night, and the occasional appearance of purpuric
spots; rose-colored spots do not appear. The anatomical changes are said to be almost pathognomonic, consisting
of enlargement of the solitary follicles of the small intestine with deposit of pigment in them and sometimes ulcera-
tion of their apices, Peyer's patches being unaltered or merely congested.
All association or combination of the malarial miasm with a septic poison, not that of
typhoid, is invoked by some writers to account for the existence of typho-malarial fever.
Henry WORTHixGTON,t Los Angeles, Cal., says that the morbific principle Is not identical with the typhoid
material of the pythogenic disease, but rests upon a double animal and vegetable basis, a combination of septic and
malarial elements. He gives the following account of the symptoms. The patients suffered from the remittent type
of fever in the beginning, which gradually became continued. A characteristic group of symptoms was present
such as dry tongue, cough with expectoration, usually vomiting, inconsiderable iliac tenderness and tympany; in
one case diarrhcea, in one constipation and iu a third slight hemorrhage from the bowels. They sank into an
apathetic condition with delirious muttering and in one case extreme jactitation, involuntary evacuations and the
hiijpocratic expression. He gives as follows the results of j)Os(-mo)-ton examination iu three cases: Fii-st case. Brain
anaemic: lungs congested and splenified posteriorly: heart soft and flabby; mucous membrane of stomach red and
softened; spleen enlarged and easily torn; liver enlarged and brown; kidneys congested; mucous membrane of intes-
tines iutensel}' pigmented throughout, near ileo-eiecal valve several small ulcers with inverted edges ; Peyer's patches
and mesenteric glands unchanged; bladder softened and containing fetid urine. Second case. Brain normal; lungs
hypera-mic by hypostasis ; heart pale and easily torn , mucous membrane of stomach reddened ; spleen soft and enlarged ;
liver hypertrophied and brown: kidneys enlarged and hypera?mic; nuicous membrane of intestines engorged and
stained with pigmentary matter, mesenteric glands slightly swollen ; Peyer's patches unchanged ; bladder softened and
very pale. Third case. Brain healthy ; lungs congested, consolidated and pigmented; heart flaccid and pale; stomach
healthy; spleen enlarged, its trabecular easily broken down; liver congested* kidneys enlarged and the seat of small
infarctions; mucous membrane of intestines swollen and red; mesenteric glands swollen; Briinner's glands enlarged
and congested ; bladder normal.
L. A. SxiDER,§ Sacramento, Cal., in a paper on an epidemic in that city, announces that the disease is developed
from the combined influence of a malarial and septic ])oison arising from sewer gas and wholly independent of a
si)ecific typhoid germ or other morbific agent derived from a diseased organization; but he gives none of the experi-
ences or arguments on which his belief is formed.
A. L. LoOMis|| has systematized this idea of a septic poison, and suppressing the term
ti/pho-mala7'ial, has aggregated the cases supposed by him to be due to the septic and
malarial combination under the heading of Continued Malarial Fever. Here he places
those malarial fevers of continued type that have no claim to typho-malarial characteristics
except that clinically they present the typhoid signs attending a non-sj^ecific deterioration
of the blood. These are his cases in which the malarial element predominates. Here also
* St. Lonh Courier of Medkhie ami Cfltaleral Sciences, Vol. Ill, 1880, p. 335. f Delroil Clinic, Vul. I, 1SS2, p. 7.
t New York Medical Iteciml, Vol. XIV, 1S7S, p. S3. g Pacific Med. and Surg. Jour., Vol. XXIII, 1880-'S1, pp. 218 et aej.
II .1 TejrI-Book of Practical 3Ie(licine, New York, 1881, pp. 826 et seq.
CONTINTKn FEVERS. 513
111' places the true typlio-nialarial cases, they const ituting his septic group of the continued
malarial fevers. Having associated these essentially different sets of cases, lie apparently
assumes that what has been proved of one set is applicable to the other, arguing that because
in the one the glands of Peyer are not ulcerated and no suspicion of contagion, direct oi- indi-
rect, is apparent, there can be no typhoid in the other ; and that since there is no typhoid
in these, the ulcerations that look so like those of typhoid must be due to some other septic
cause. Dr. Loomis, indeed, points out that there is little to distinguish these intestinal
changes from those that are developed in typhoid fever except the tendency to tlie deposit
of black pigment in the enlarged follicles; but he considers that tliis pigment is enough in
itself to show that the disease depends on an essentially diflferent exciting cause. It has
already been shown in this discussion* that the presence of the pigment is susceptible of
satisfactory explanation without calling in the aid of peculiar and unknown poisons.
1\[. L^;oN Colin has expressed the opinion that a real affiliation exists between typhoid
and remittent fevers.f
Does the paludal t.vplioij lever of camps and marshy countries, arisinj; outside of cities, an<l, hence, outside
the principal t.vphogenic foci, depcnil on a coincidence of two niorhid influences? We might have adopted this
opinion if we had not extended our observations over :i greater period than a year; but during the three summers
that we have observed the disease of the Roman Campagna we have always seen the typhoid fever break out in the
mouth of July, together with remittent fever of i)aUulal origin, presenting from the first its maximum gravity, showing
neither increase nor decrease, and attacking in preference those in whom the phenomena of remittent fever were most
characteristic. If sueli associations periodically reappear at a time when telluric inlluences predominate, it follows
that something more is re(|uircd than coincidence of two ditiereut aftections, and that there exists between them a
Teal afiiliation.i
AUliougli Well versed in the characteristics of these fevers he found it impossible to
distinguish during life between a so-called adynamic remittent and a typhoid fever compli-
cated by an antecedent malarial influence. Often, when be believed the malady to be exclu-
sively malarial, the typical typhoid fever lesions were found oiv past-mortem examination,
and in other cases in which from the clinical appearances he regarded typhoid fever as cer-
tainly present, only the lesions of pernicious fever were discovered after death. He was
therefore led to suggest an intimate relationship between the two fevers. He considered
the typhoid fever in these instances due to the development of a predisposition in the human
system, under the influence of a prolonged febrile movement, gastric troubles and altered
secretions. In fact, he assumed that the malarial fever prepares the system for invasion by
the telluric miasms which are the cause of tj'phoid fever, the former being thus a determining
agent in the production of the latter. But he goes further. He believes that malarial fever
can induce true typhoid by auto-infection, and in this way he exjjlains the succession of
typhoid to remittents not only in individuals but in districts. When a malarious section
has been improved by drainage and made suitable for agriculture, immigration fills it with
.a class of people hitherto preserved from malarial and typhoid affections. Their predispo-
sition to these diseases is strong and there is required only the malarial cause of a remittent
fever to develop in them a true typhoid fever. Indeed his theory finds expression in the
phrase popular in some parts of this country — "the fever turned into typhoid." There is,
however, such essential differences between the natural history of the typhoid and the mala-
rial poisons, differences which led Boudin to adopt the doctrine of a vei'itable antagonism
between the diseases caused by them, that it is impossible to admit the development of the
one from the other. On Colin's hypothesis typhoid fever should be more common where
• Supra, page 45.-.. f See his TniU Oa fSerrej InUrmiUntilm, Paris, 1870, pp. 276 rf »«;.
I S«- to FUrre T^/phoide dam rArmie, Paris, 187S, p. 155.
Med. Hist., Pt. Ill— 65
514 • ETIOLOGY OF THE
remittents prevail; but it is well known, on the contrary, to increase with their diminution.
Typhoid symptoms are frequently associated with persisting remittents and continued mala-
rial fevers, but these are unconnected with the anatomical lesion which indicates the pres-
ence of a true typhoid fever. From the invariable presence of this lesion in typhoid fever
is inferred the action of a specific cause, — an inference sustained by our knowledge of its
incubation in the system and its infectious qualities, and this is inconsistent with the idea
of the development of the disease from a cause which ordinarily evolves a malady closely
associated with the simple intermittents.
Another French writer, CoRRE,'=' defines typho-malarial fevers as engendered under the
combined influence of malarial and typhous conditions and presenting phenomena suggestive
of the presence of both diseases. He divides them into three classes:
1. Typho-malarial by association, each of the tw5 elements being present and producing its effects.
2. True typho-malarial fevers resultiug from the operation of a single ageut, — tijijlw-mnlarin of external origin.
3. Typho-malarial fevers by transformation, in which in a malarial fever the typhoid condition is developed
under the influence of an infection engendered in the system of the patient.
His first class comprises the true typho-malarial cases of the civil war; his third clas.'<
the adynamic malarial cases. Our records give no evidence of the existence of cases such
as are comprehended in his second class.
The medical journals do not contain many cases illustrative of typho-malarial fever.
Nevertheless a few notes may be submitted to show the character of the cases reported
under this heading. Some of these no doubt were truly cases of the associated diseases;
others were remitting or continued malarial fever or other continued fever, not even excluding
specific typhoid with or without typhoid symptoms. In fact, the same aggregation of cases
of doubtful character ,that constituted the typho-malarial fevers of the war appear to have
constituted the typho-malarial cases that have been reported since the war.
J. p. CHESNEY,t New Market, Platte County, Mo., refers to the ambiguity of the term typho-malarial, and states
that in his part of the country its use is restricted to cases presenting "one or more symptoms common to each of the
two fevers."' This mixed form as well as uncomplicated typhoid is rare in his section. He gives a case to illustrate
the Platte county use of the term. A man who had been living for some months in a highly malarious locality was
seized July 10, 1869, with intermittent fever which was readily controlled. After this he was somewhat indisposed
but able to attend to business until towards the end of the month, when he took to bed August 2. Dr. Chesney
noted his condition as follows: " Dorsal decubitus, stupor, cutaneous surface presenting a sallow shriveled appear-
ance, night sweats, great tenderness in the ileo-colic junction, diarrhoea, tongue dry, red and 2>ecidiarly ci/lindrical in
form, cold extremities, dilated pupils and pulse 120 to the minute." On the 4th the patient was improving, but having
been left unattended he went out to stool, and becoming l)ewildered among the tall grass and corn, wandered from
miduiglit till day before he was found. He was completely exhausted, and died on the 6th.
Mr. C, a farmer; aged 42; married; came under the care of J. H. Van EMAN,t of Toganoxie, Kans., Oct.
23, 1872. Three weeks prior to this date he had been taken with chills and fever, the latter soon becoming subcon-
tmuous. Some medicine administered by his family physician set up violent catharsis .accompanied witli delirium,
but the diarrhoea was speedily controlled. Delirium and sleeplessness had continued for six days, when Van Eman
was called in. The patient's tongue was brown in the centre and red at the tip and edges ; his eyes congested and the
pupils somewhat contracted and sluggish; respiratory and percussion sounds normal; pulse, 118 and rather feeble;
bowels unmoved for twenty-four hours, tympanitic, tender and gurgling on pressure in the right iliac region ; every
few minutes the patient tried to get out of bed and out of the house, and when in a quieter mood worked his hands
and fingers, picking constantly at the clothing. To promote sleep and restrain delirium a solution of ten grains of
chloral and five of bromide of potassium was given occasionally: quinine in three-grain doses every two hours was
also prescribed, with milk and beef-essence as nutriment. The tongue became very dry on the 26tli; the quinine
was reduced to two grains every four hours with small doses of turpentine emulsion. Next day his passages were
involuntary, and during the following night he had an attack of violent delirium ; but on the 30th the t, ngue began
to clean, and on November 1 consciousness was restored. After this improvement was slow but uninterrupted. On
December 10 the p.atient was considered well.
The experience of H. K. Pusey,^ of Garnettsville, Ky., leads him to doubt the accuracy of the view that the
* A. CORBE — Trailc des figures bilieuses et ti/phiques despays chaud^j Paris, 1883, p. 255.
i Pacific Med. and Siirg. Jour., N. S., Vol. Ill, p. 310. % Leavenworth Mtdkal Herald, Vol. VI, 1872-7a, p. 85.
I LouisvOk Med. News, 1878, p. 104.
, CONTINUED FKVERS. 515
t.viiliu-in:il;tii:il lovi r whicli prcvail.s in that Ni'cticni of the country is tyi)lii>i(l tVvii iiunlilifd l)y a cD-cxiKtiiiK aoiili!
malarial attaik. Fiiiding tliut in many instaiiri's the disease is cut shoit l>y quinine, he considers himsell' justilied
in re;^ardiug it as beiuf; essentially malarial and having no speeilic typhoid element. He suggests the name of con-
tinued malarial fever as more approi)riati' and suggestive of correct principles of treatment.
K. H. MAfRY," Memphis, Teiiii., in describing ivhat he calls malarial continued fever, says: ''Cases of this
kind are liy others referred to as "neglected remittents," and as ' remittents with adynamic tendencies'; and for several
years pa.st, a.s far as I can learn, this is the form of fever denoniinateil in the mortality reports of this city 'typho-
nialarial.' • • • This term has l)ci'ii api)lied generally liy our i>hysicians to all the cases of continued fever
because they were recognized as not being tyi>lioid and were not looked upon as remittents." His description of the
disca.se is as follows: It.s invasion, instead of being abru)it, as is the case with remittent, is sometimes nuirked by
pr«>dronies. In nuiny cases the patient has been ailing for a week before going to bed; in others he has had a
lept'tition of chills for two or more weeks at irti-gular intervals, when finally the fever which follows the chill a.ssumcN
a continued form and goes on rising graduiiUy until the sixth or seventh day, when the temporaturo reaches 103i°
or 104°. This fever presents a stadium of increase of abont one week, a stadinin of height of five or si.\ days and a
-tadinm of decrease which terminates completely on the twenty-first day. Its thermometric range is decidedly lower
than that of typhoid; it seldom goes above 103i°. Vomiting of bile is a comnuju symptom during the first days of
the attack; bronchial catarrh is generally present; constipation and a concave abdomen are marked features;
appreciable splenic tenderness or eiilargenu'iit has been so rare in his observation that fnuu memory he can recall
but two cases in fifteen years. All the essential features of typhoid or enteric fever are absent : There is no diarrlnea,
no ilco-ca-cal tenderness or gurgling, no meteorism, no eruption of rose-colored spots, and as a rule tlu'te is an entire
absence of abilominal .symptoms; but in some cachectic instances in which the iiatient was unfavorably situated for
treatment or had no treatment he has seen diarrlm-a. dry, red and shining tongue, sordes and low delirium, with
picking at the bedclothes and a condition closely resembling typhoid.
Surgeon C. B. White, t U. S. Army, considers the disease a compound fever, typhoid in form and malarial in
jiharacter. He refers to an epidemic in the Sciot'i Valley beginning by distinct chills, with repealed perfect inter-
missions. Although in some eases the chills were broken by quinine a low form of continued fever c;nne on after
an interval of three to seven days, accompanied by modenitc delirium, loss of relish for food, little thiist but much
heat of skin and derangement of the digestive organs; diarrluea was not constantly present. * ' " "During the
past year 1 have noticed ulcerated jiatches as more usual and more fieiiuent in the colon; perhaps very few sixits in
tlie small intestine, and in the large intestine large and fre(|uent ulceration. I should not give this so important a
notice, but on consultation with Professor Loving of Columbus, a careful and conscientious observer of large experi-
ence, he states that he believes ulcerations of the large intestine to be a distinguishing mark of the disease, and
exhibited specimens illustrating this pathological view."'
J. M. Da Costa shows that he does not regard the presence of enteric fever as an e8senti:il of the fever which ho
designates by the term tyi>ho-maIarial.} On the contrary, it may bo inferred from his remarks that if the abdominal
lesion of typhoid had been indicated by the symptoms, his diagnosis would have been typhoid andiiot typho-malarial
fever. The patient was a girl about eighteen years of age. "\ week prior to her admission to the wards she was
seized with fever, headache and pain in the back, stomach and left side. Her face too was flushed. The thernu>nu!ter
marked 102i° on the evening of her admission. Her tongue was coated and dry. The pain in her neck and the back
of her head grew nuire intense. She also complained of cough and of pain in her left chest. Theie was no stiffness of
the neck and none of the symptoms of cerebro-spinal meningitis. There was a slight amount of nausea and gastric
uneasiness. As regards my diagnosis of the case, the intestinal pains, the fever apparently without cause, the head-
ache and the age <if the patient all pointed towards typhoid fever. On the second day after admission, however, I
decided positively that it was not a case of typhoid fever, and this conclusion has been verified by the resnlts. The
symptoms which led me to exclude the thought of typhoid fever was the extraordinary temperature record, — show-
ing snch marked remissions and exacerbations. In the corresponding stage of typhoid fever such a state of affairs
would be almost if not entirely unknown. On the evening of the second day of admission the temperature was 103°,
on the third morning it was 011°. in the evening it again rose to 103°. For several days following this time there was
a daily variati.)n of from 3° to 4° between morning and evening temperature. On the 9th of the month the morning
temperature was 00° and the evening temperatuie 101°. On the 11th the temperaturf was about normal, with but very
little difi'erence between morning and evening charts. On the 12th, yesterday, I ordered the quinine to be stopped,
as quinhiisiii was rapi<lly making its appearance. The patient had been taking a daily do.se of si.xteen grains of the
drug. Our treatment by (juinia had proved two things to our entire satisfaction — first, that our view of the naturi'
of the case was the only correct one. and, second, that the minute you discontinue the antiperiodic in a case of
malarial infection the temperature may run right up again, although you may have succeeded in reducing it almost
to the normal state. (On the evening of the 12th the temperature rose again to 101°.) This morning the paticnfs
pnlse is 74, her respiration 26 and her temperature 90^°; her face is somewhat flushed. She is again under the
influence of quinia, having taken eight grains this morning. There is no enteric tenderness and no eruption. The
spleen is somewhat .enlarged, extending, as it does, nearly an inch below the ribs. The area of liver dulness is but
• AmrHcan Jmimal Mrdical Srinuxt, S. S., Vol. LXXXI, 1881, p. 401. 1 3Iedical Record, Xew York, Vol. XV, 1870, p. 267.
J In a ilinkal lecture On Tijpho-malaruil Frier, in the I'liilmhtpliia iredtcal Times, I877-'78, p. 434. Dr. Da Costa, in a recent luttcr to tbp writor,
s his opinion— "Tlmt remittent fever not nnfre<)nentl.v runs into a continneil fever of low tyj)e to which the term malnrio-typhoid fever might
Mapplied. It is not, however, the specific enteric fever with it* characteristic lesions ; and what is called tj-pho-malarial fever is, I believe, generall)-
ftoD the oiuet typhoid fever, its feattires slightly blnired hy occurring in malarial subjects."
516 ETIOLOGY OF THE
Blightl.y increased below the margin of the ribs. There is a left liasic, systolic blood-murmur to be distinguished
over the heart."
Wji. H. Ve.'^tch,* of Pawnee, Sangamon County, 111., arranges the cases of the typho-malarial epidemic of 1864
in his county into three classes. The first cases that came nnder his observation Ijegau as common remittents, but
after three to seven days a typhoid character was assumed; death occurred or convalescence was established by
the end of the second week. In others the remittent attack continued for eight or nine days without the appearance
of typhoid symptoms, when, suddenly, a recurrence of chills would take place with an aggravation of the febrile
condition, petechia", delirium, heavy perspirations, diarrlioea, collapse and death about the fifteenth day, if at this
time a favorable change failed to make its appearance. In the third class the on.set was gradual, — general indispo-
sition, lasting from seven to fifteen days, was followed by chills, a febrile condition, diarrhoea, with a brown-coated
tongue, red at the tip and edges, and congestion, perhaps even ulceration of the fauces; wild delirium supervened,
followed by coma and speedy death, or, if stupor did not come on, the jjatient passed through a course of typhoid
fever lasting from fifteen to forty-two days. In this class the typhoid symptoms appeared at various periods of the
fever from the sixth to the twenty-sixth day, but in some cases it was not observed.
According to Dr. Cl.\iborne the cases in the epidemic at Petersburg, Va., in 1879, t were always distinctly
intermittent or remittent in their inception; but quinine did not exercise its ordinary antiperiodic effect. In three
cases there was a cleaner tongue, less thirst, nausea, anorexia, debility and fever, fewer nervous symptoms and less
delirium than in the typlio-malarial fevers of the war; they lasted six, eight and ten weeks. The tongue became
red and dry about the third week, but only in grave cases; diarrhoea was the exception, not the rule, and the
rose-colored spots of undoubted typhoid were not present. But on the typhoid side there was in all cases some
bleeding from the nose, sometimes only a few drops, sometimes more; and in most of the cases dulness of hearing,
tinnitus aurium, the russet flush on the cheeks and abdominal tympanism ; moreover, the disease occurred exclusively
among young people and manifested a certain limited or quasi infectiousness. It was characterized by a high tem-
perature, seldom less than 10.5° or 106° at 1 or 2 P. M.; the frequency of the pulse increased with the febrile exacerba-
tion, but not in the same proportion, seldom rising above 100 or 110 per minute. Fatal ca.ses usually terminated
during the third week with wild delirium, acute mania, insomnia and convulsions, yet with recurring consciousness
and without paralysis, showing the absence of organic lesions of the brain. No post-mortem observations were made.
P. W. Hand, St. Paul, Minn., gives a general description of typho-malarial fever as it is occasionally seen
in St. Paul during the autumn ahmg with ordinary remittent fevers, and as it occurred epidemically in the autumn
of 1870. t It was distinguished from typhoid by its marked remittent form, the mildness or ab.sence of delirium,
the moist white condition of the tongue, the slight amount of intestinal irritation and tympanites and the early
period at which convalescence frequently liegan ; nevertheless the symptoms at first were much like those of typhoid.
The chill was often unobserved and the attention first arrested by sudden loss of appetite and strength, violent
head-pain and decided fever in the afternoon and evening. In some cases a bilious diarrhoea was developed ; in others
constipation, which did not yield readily to cathartics. The tongue, which was pale and round, usually remained
coated with white fur throughout the disease. The stomach was generally irritable, and in many cases there was
distressing vomiting. The pulse was from 90 to 120 and not usually very feeble. In all cases the temperature was
largely increased, varying from 102° to 105A° Fahr.; indeed, most cases showed a temperature of 104° to 105° every
evening for a week or ten days; the morning temperature was usually 1° to 1\° lower than that of the evening.
During the first three or four days the throat was sore, sometimes showing a diphtheritic exudation; and in a few
cases a rash like that of measles appeared during the first week. Epistaxis sometimes occurred and the hearing
became impaired. During the second week a bronchitic cough was invariably developed. There was generally some
abdominal tenderness, but tymjiauites was rarely marked and diarrhcea, if present, was usually easily controlled.
Sordes seldom appeared and the tongue rarely became dry or rough. After the early headache passed otf the mind
usually romained clear, although the patient was frequently rather dull and the countenance heavy; delirium, if
present, was mild. Rose-colored spots were seen in very few cases, although carefully looked for; stidamina were
common. Convalescence often began in the first or second week, although the fever lasted three weeks. Profuse
night-sweats were common during convalescence. Dr. H.vnd saw at least one hundred cases during the epidemic
and only three of these died. The disease was widespread, but the reports of the citj' health officer showed only
five deaths attributed to it ; perhaps, however, many of those reported due to typhoid should have been placed to
the account of the typho-malarial epidemic. No post-mortem examinations were made.
J. A. Porter, $ Jackson, Mich., states that an endemic fever prevailed in the counties of Jackson and Lenawee
in the summer and autumn of 1873, and that while the disease was regarded difterently by various i)ractitioners, some
terming it cerebro-spinal meningitis, some remittent fever and some typhoid fever, he with others called it typho-
malarial fever. He gives two cases to illustrate his general description. The attack began in various ways. Some-
times the patient was seized with a severe pain in the left shoulder, extending up the back of the neck, or in the arm
or leg, with hypersesthesia and febrile action; in others the febrile attack was preceded by a jieriod of general indis-
position. Generally there was an initial chill. Occipital or frontal headache was rapidly followed by delirium, with
subsultus tendinum, some deafness and defective vision. Epistaxis was an early symptom and seemed to be a measure
in some degree of the severity of the attack, it being more frequent in the severe cases. The tongue for the first three
* Chicago Medical Examiner, Vol. YII, 1866, p. 666. f See page 502, gitpra.
XNoTlhwestmt Medical and Sur^Kal Jour., 1870-71, Vol. I, p. 367. § Detroit Review of Medkine atid Pharmacy, Vol. IX, 1874, p. 387,
CONTINUED FEVERS. 517
weeks was moist, deep scarlet in color, with elevated iiajiilhe al)oiit the tip and sides and 8li;;litly furred at f lie liase.
The stomach was sometimes irritahle. The abdomen was tympanitic; the bowels irregular, diarrluea and constipa-
tion alternating, and susceptible to the action of purgatives; the discharges fetid, at first dark-brown or black in
color and afterwards of a light yellow. Mucous r;\les were generally heard in the lungs. The fever was distinctly
and regularly remittent in character, and the skin at times bathed with perspiration without any diminution of the
bodily temperature, and at other times dry and harsh without any marked increase of surface heat. Moreover,
about the eighth or ninth day from the initial chill or pain a remission occurred of so marked a character that it
appeared as if the fever had subsided: but in about thirty-six hours the fever recurred and pursued a uniform
course, so that one day was an exact representation of another day, but fur the increasing prostration and coma
tending to death. If not fatal a slow convalescence similar to that from typhoid led to recovery, retechial spots,
appearing generally as early as the tenth day, were found in most of the cases, usually on tlie abdomen anil arms;
in some they were numerous, in others not more than five or six.
T. K. Powell,* Dyersburg, Tenn., under the title of ty pho-malarial fever, describes an epidemic that prevailed
in Haywood County in the autumn of 1881. By some it was called typhoid, by others typho-malarial and by others
again continued malarial fever. The prevailing diseases of the county are of a malarial character, but Dr. Powell
does not remember to have seen a case of intermittent fever during the height of the epidemic in tiuestion. In con-
nection with its causation he refers to the extrenudy hot and dry weather of the preceding suunner. In a certain
proportion of the cases hemorrhage from the bowels was present, not in the beginning or congestive stage as in inter-
mittent or remittent fever, but at the height of the disease. Some cases were characterized by a pointed tongue
with red tip and edges, rose-colored spots, tympanites, tenderness in the right iliac region, diarrhiva and low delirium.
Few cases were fatal. No post-morhm examinations were made. Dr. Fow ell regarded it as a mild form of typhoid,
intluenced to a great extent by the malarial poison, as shown by marked morning remissions or even intermissions in
the early days of the fever.
Jeff. D. WiLLL\MS,t Philadelphia, Miss., his i)ublished a case to illustrate his general description of t he disease
and his statement that it seems to be only a milder form of typhoid.
Dr. Daw} submitted to the Cincinnati Medical Society two illustrations of fever without rose-spots, which,
for want of a better name, he was in the habit of calling typho-malarial fever. '-A boy, aged ten years, had staid
at home from school on Thursday, but was first seen by the doi'tor on Saturday. His temperature was W.i°, his
pulse about 110 per minute, bowels slightly constipated and tongue white. He had consideral)le thirst and loss
of appetite, but he refused to go to bed. The case had appeared altogether similar to a slight attack of malarial
fever, and the speaker thought a mercurial purge and liberal doses of quinia would bring about convalescence in
a day or two. The day following, however, the patient was not improved, still having a temperature of 102.5°.
The ne.xt day ho went to bed complaining of a severe pain in the frontal region, while his tongue became heavily
lo.ided and his pulse beat 120 per niinnte. He went on growing worse for a few days. The day was passed in
mild, the night in wild delirium, with .jactitations, subsnltns tendinnm and picking at the bedclothes very well
marked. About this time slight diarrluea set in, accompanied by some abdominal pain. There was no gurgling of
the right iliac region and no rose-colored spots or sudamina at any time to be seen. The delirium subsided in about
a week and he made a gradual but complete recovery. The other case was that of a girl of fourteen on the verge of
the first catamenial period. She had been indisposed for several days but refused to go to bed. Her temperature
was not above 103°, her pulse about 100 per minute. On the second d.ay following she went to bed complaining of a
slight headache only. Front this time her condition became gradually aggravated, mental hebetude and slight
delirinm also appearing. About the bi-ginning of the attack she had had a spell of nose-bleeding, but it did not recur.
About the fifteenth day. when she was apparently convalescing, she discharged from the bowels about a pint and a
half of dark blood in three stools. For about a week previous to these bloody discharges she had pain in the abdomen
and diarrhft'a, but this was readily controlled by an o)iiate. The appetite was almost though not entirely lost. The
tongue once became clean and then recoated. Temperature remained about 102. .5° most of the time, falling to 100°
when convalescence was established; for a few days towards the end of the attack it was intermittent, showing a
dift'erence at one time of 2.5°."
W. Milliard^ gives a chart of the temperature curve of typho-malarial fever, reproduced on the next page. He
does not express his views on the etiology or pathology of the disease. " Its symptoms," he says, "are quite familiar
to those physicians who have resided in the malarious regions of the south and southwest. Above all the rest of the
essential fevers incident to this climate typho-malarial fever stands pre-eminent as to duration. While in a few mild
cases the mercury will recede to 98.5° Fahr. alter ranging above that point for fifteen days, yet in a large majority
of cases the preternatural heat will extend over a period of at least thirty days; in some instances the pathological
heat will last forty, fifty . even sixty days. Early in the career of this pyrexia the thermal waves are generally high;
for the first two or three days the lowest markings will bo 10S° Fahr.. the highest 104°, 10.5° or even lUfi.5° Fahr. The
thermal wave during this period is to all ajipearances the same as that of remittent fever. Gradually, however, these
high altitudes subside into a gentle undulating thermal wave only a few degrees in mild cases above the health-line.
Finally, when the mercury sinks to the health-line, it will suddenly rise a few degrees above, then fall to rise again,
displaying the thermometry of intermittent fever."
• IWtiM. Med. Six. Tmntaxe, 1882, p. 64. t ffrghiia Medical MonMy, Vol. Ill, ISTfr-TT, p. 869.
J Rtfon in Cmrimali LaonI and C/imV, 1880, p. 6.10.
'i On the MtdKot ThtrMutmrlrti o/ O-rfoiii W«.Mf« a« ihey prrrail In Hit .SiiiHi ami UnUliirctl.—Neiv OrleaM Medical and Surgical Jounial, 1877-78, p. 32.
518
ETIOLOCrY OF THK
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Two temperature charts of typho-iualarial fever, drawn by Surgeon F. L. Town, U. S.
Army, Fort Sill, Indian Territory, are on file in this office. The cases occurred in 1877.
Many remittents were treated at the post during the summer and fall of that year, l)ut only
in these two cases were typhoid or adynamic symptoms developed.
Case 1. — Private Geo. W. Barnes, Co. A, 4th U. S. Cav., was admitted to hospital September 13, presenting
symptoms similar to those of a tertian intermittent but with unusual depression. The exacerbations did not yield
to antipeiiodics, and after a few days the case assumed the character of a remittent with diarrluea, the abdominal
symptoms becoming gradually more prominent. Prostration was progressive and the fever slowly assumed the con-
tinued form, which was fully developed on the 18tli day after admission. Up to this time no record of temperature
was made, as the case had not ditfered materially from other severe remittents. There now appeared low deliriiuii
with increasing stupor, prostration and involuntary discharges, which were associated on the 23d day with a rapid
and abnormal lowering of the temperature. Tlie gravity of the symptoms appeared to indicate a speedy and unfavor-
able termination. On four consecutive mornings the temperature registered was one or two degrees below the normal.
On the 27th day it rose from 95.6° to 103.4°, after which it did not again fall below the normal. Soon after this the
patient began to mend, although convalescence was not established until the o7th day. Some degree of mental
aberration persisted until the patient began to sit up, and even until he was able to walk into the dining-room at
meal times. He was returned to duty December 10.
Case 2. — Private Charles Krull, Co. B, 16th U. S. Inf., was admitted to hospital October 12. This case was of
equal severity, although the abdominal symptoms were not prominent and there was no diarrha?a until the close of
the attack. The progress of the fever was characterized by a prolonged period of abnormally low temperature. On
admission the case pi-eseuted the appearance of a severe remittent with rapidly increasing prostration. By the Till
day the typhoid condition was unmistakably manifested, and a record of daily temperature was commenced. Cere-
bral symptoms appeared and the bodily heat fell to below the normal and continued below this point from the 9th
to the 22d day of the disease. During the continuance of this vital dejiression the skin was cool to the touch, and
the patient lay in a condition of partial stupor, moaning at intervals as he breathed and having involuntary passages;
the pulse was slow and weak — 50 per minute on the 11th day; by gentle shaking and questioning he could usually be
CONTINUED FEVERS.
■)19
partially aioiiseii, but his attempts at articulation were incuhcrcnt, if, imleini, thoy diil not fail altogether ou account
of the parched condition of tho month, tongue and fauces. After the temperature rose, on the 23d day, an ameliora-
tion of the symptoms was perceptible. From this time until about tho 28th or 2i)th day tho patient would at intervals
cry out as if alarmed, and continue this as loud and as long as his exhausted condition would permit. Subsequently
Day
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the case progressed slowly to convalescence, with occasional recurrences of moderately increased temperature and
accelerated pulse, due probably to intestinal lesions, as some diarrhiea occurred during this stage. Ho was not finall.y
returned to duty until JIarch 4, 1878, and even then he was somewhat amemic. 15y April 20, however, he had in a
great measure recovered his usual weight and strength. The temperature observations were made in the axilla.
These two cases show the coincidence ofthe typlioid condition and an abnormally low
temperature. Two other cases, filed in this office since the war, associate these low 'temper-
atures with the weakness of convalescence; they were reported from Fort Duncan, Texas
by Ass't Surgeon E. T. Comegys, U. S. Army.
Case 1. — Private Claudius Mansoz, Co. K, 8th Cav., a young French recruit ; robust and healthy; was admitted
June 7, 187ti, complaining of diarrha-a. The case remained under observation until the evening of the 7tii day, when
treatment by baths, quinine and stimulants was adopted. The record has few entries except as regards treatment.
On the K^tli day the patienX was restless and had a steady and dull pain over the liver. On the 28th d.iy profuse uoc-
tnrnal perspirations were noted. He was able to sit up in bed on the 30th day, and two days later he began to sit up
iu a chair. He is said to have recovered his strength slowly and to have l)een returned to duty August 28. In com-
paring the course of treatment with the chart it is found that a distinct impression was made in the curve of tempera-
ture by the administration of large doses of quinine. On the evenings of the 7th, 8th and 9th days ten grains were
given; this dose was doubled on the 10th and 11th days; thirty grains were given on the 12th, 13th and 14th days,
after which small doses were occasionally used until the 18th, 19th and 20th d.aye, when large doses were again admin-
istered. Two days after the temperature fell below the normal the patient was able to sit up in bed. When the
temperature again reached the normal line, at the end of the tliernu>metric record, he was on full diet and able to walk
alxMit. The temperature charts of this case and of that which follows are submitted on the next page.
C.^SE 2. — Private Edward R. Stafibril, Co. K, 8th Cav., a young, healthy but rather delicate-looking recruit,
reported June 8, 1876, as atl'ectcd with headache, weakness and dizziness. The case renuiined under ob.servation
until the evening of the Gth day. wlu-n quinine, the sponge-liath and stimulants were ordered. Epistaxis is the
only symptom mentioned; it occurred on the 9th, 10th and 27th days. On the last-mentioned day the temperature
fell below the normal; two days later the patient was able to sit up in bed; four days after this ho was walking
about the ward, and iu three more days he was permitted to go out. During this period of improveuu'iit the tem-
I>erature was generally considerably below tho normal.
Post-mortem records have been rarely published. In the few cases in which the ana-
tomical conditions are mentioned typhoid fever appears to have been absent. Carstens
of Detroit, speaks of enlargement, pigmentation and ulceration of the solitary follicles,
Peyer's patches being unaltered or merely congested; but there is nothing in his article to
show that his statements were founded on original researches.* C. B. White, U. S. Army.
announced as his personal experience and that of Dr. Loving of Columbus, Ohio, the exist-
ence of ulcerated patches in the colon rather than in the small intestine.f Worthington
of Los Angeles, Cal., reported three cases in which, with congestion, pigmentation and
ulceration of the intestinal mucous membrane there was no affeotion of the glands of Peyer.J
The term typho-malarial has also been given of late years to the fevers of the Rocky
•Siij>ra.D. 512.
f Supra^ p. 515.
I Supra, p. 512.
520
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CONTINUED FEVERS. 521
^lountain region, — the raountaiu fever of the froutiersmeu.* At first these fevers were
supposed to be something new, dependent on the rarefaction of the air or some obscure
atmosplieric causes ;f by some, however, they were regarded as malarial J Bartholow,
wliile serving with the expedition to Utah, saw two forms of fever: Malarial fevers first
afl'ected the troops, and two months later typhoid became aissociated with remittent fever not
only in tlie camp but in the individual; rose-colored spots were present in some of the cases,
and all those that were fatal showed the intestinal ulcerations of enteric fever. Probably
the aggregation of troops constituting the army of Utah had an influence in determining
the occurrence of typhoid in Bartholow's experience. Certainly this disease became less
frequent in the service of officers who were on duty in that part of the country at later dates
and with smaller commands. Moreover, when typhoid fever was recognized it was so
reported and its cases ceased to form a constituent part of the totality of the records of moun-
tain fever. The former was rare, the latter common. At Fort Bridger, Wyoming Territory,
for instance, in a mean strength of 153 men there were recorded during the eight years,
1866-73, fifty-nine cases of mountain fever expressed as malarial remittent and but one
case of typhoid fever. Among medical men tiie name mountain fever came, therefore, to be
synonymous with remittent or continued malarial fever.
A species of remittent fever, called by the citizens moutitain fever, is the prevailing disease. It is easily con-
trolled by quinine. $
F. Rice W.\ggoxek|| gives the record of three cases illustrative of this disease. From a consideration of the
snrroundinss of Fort Lyou, at which his cases occurred, .and from the prevalence of severe intermittcuts and remit-
tents in the same garrison at the same time, he believed tlii^ continued fever to be of malarial origin, and the efficacy
of large doses, sixty to seventy-five grains of quinine daily, gave therapeutic support to this view. The absence of
enteric symptoms appeared to indicate that the fever was not due to the typhoid poison.
Ass't Surgeon J. H. Patzki, U. S. Army, reports from Fort Steele, Wyoming Territory,1[ that : A remittent fever,
occasionally very severe, is met with, by the mountaineers called mountain fever and much dreaded by them. The
most ]iromineut symptoms are headache, severe aching through tlie whole body, insomnia, furred tongue, frequent,
full ]>nlse, constipation. Chills are frequent. The efficacy of large doses of quinine proves the malarial origin. The
mountaineers treat it with their panacea, sage tea, and, as they assert, quite successfully. Men cutting timber along
the streams, mostly Iianes and Swedes, suffer most from this fever.
Surgeon Chahles K. (Jkeknleak, U. S. Army, in a letter from Fort Benton, Montana,"* says: The subject of
iiiiiuiiniin fever is one in which 1 have taken a great interest, having met the disease during my tour of duty on the
ir(«/ side of the Rocky Mountains in Idaho, in 1869-73, and again during my present tour on the eaxt side of the same
range. I was much struck with the similarity of its features in both localities, but more particularly with its close
resemblance to the malarial fevers I had treated in the South during the intervening four years 1873-77. Recently
I have treated, among the citizens in and about Helena, a great many ca.ses recognized by the local physicians as
mountain fever, which I regarded as pure malarial fever, and succc-ssfully treated accordingly; I kej)t careful notes
of all my cases iu civil and military practice and am thoroughly satisfied that the disease is malarial remittent.
The name of mountain fever is simxily a local one, the use of which shoulil be discouraged in the profession as causing
confusion and misleading new comers to the country. The disease runs a course precisely similar to those of our
Southern and Western remittents, assuming a typhoid type in severe and long-continued cases and yielding readily
to vigorous doses of quinine. I think your term typho-malarial is admirably descriptive of its later stages so far as
tiliHiiloms go; a.s to the pathological significance of the term I cannot say, never having made a post-mortem examina-
liiiu nor in fact had a fatal case.
But in the meantime the term typho-malarial, imported into these regions and applied
without a reference to pathological restrictions, became to many practitioners a generic title
1 ! may be mentioned that the ifamlam Ferer described Uy Altbed Wise— BriluA Mtdical Joumat, Vol. II, tSSO, p. 809— is not the mountain ferer
■ 'I Am. rn-An writers, Itut a low fehriie or rather irritiittle comlitiuu due to tunldtMi cX|>o«tnrc to diminislied atmosplieric pressure and corresponding nire-
factiun ..f til.- air. The attack lasted ahout a week, the tcmperaliire varjing from 1)9° to 101° Fahr.; but its chief feature wiis cardiac irritability,— the
jrulse and nspiratioii on the slightest ninreiiitnt were increased out of all proportion to the exercise taken.
t Pr. EwiM.-, ill the Sr. Lotiin Mf.llcal ami Surgical Jonnml, Vol. XIII, IS-'w, pp. lOO-llC.
t .1. E. 0\l>i.\x,—3lomilain and .Vii^n'uiui Ft r<T» frojucat bij Uie tame cauit,—Xorl}ivtat iledical aud Surgical Journal, Vol. VIII, 1851, pp. 105-108, and
Bottom ilnliral aud Stirijical Jounud, Vol. XLIV, pp. .'il J-oI2.
\ Letter of Joitx H. FrsraocK, Ass't Surg. 11th Ohio Car., Fort Halleck, Idaho.— Bosfoa Med. and Surg. Jour., Vol. 69, 18G3-64, p. 527.
I AatTicm J,mr. Med. Sciaic€t, Vol. L, 1865, p. 50. V Il'V<"'' <"' "'« Uygimc of Ok V. S. Army, 1875, p.38o.
*• Sated July 7, 1878, to Snrgeon J. J. Woodward, U. S. Army.
Med. Hi.sT., Pt. Ill— 66
522 ETIOLOOY OF THR
equivalent to mountain fever, in wliicli the lines of separation into typhoid, typhoid with
malarial complications and malarial fevers with typhoid symptoms were more or less oblit-
erated. For instance:
Surgeon F. L. Town, U. S. Army,* states that remittent and typbo-malarial, auil probably enteric fevers, are
not infrequent in the spring and fall, especially amour; miners and hunters, or persons who are generally without
shelter: these, in the parlance of the country, are called mountain fevers indiscriminately.
Ass't Surgeon Geo. P. Jaquette, U. S. Army, reported from Fort Bowie, Idaho, the occurrence of an occasional
case of fever, either remittent or intermittent, commouly called in this country mountain or typho-malarial fever.
One of the most recent papers on mountain fever,"}" or as the writer calls it, typho-
malarial fever, gives a history of five cases aggregated under this generic title. One case
proved fatal, and on post-mortem examination the lesions of typhoid fever were discovered.
This case is of particular interest as showing tlie development of that fever in one of five
hundred men, all of whom had been on scouting duty in an unsettled country for four months
before the disease made its appearance in his person, — in fact, the spontaneoua or miasmatic
origin of typhoid does not require a stronger illustration to establish its existence. But it
is not on this account that Dr. Hoff, the writer of the article in question, describes the case:
He makes use of its typhoid lesions to infer the existence of similar lesions in all the cases
that have been described and treated as mountain fever.
The five cases were turned over to Dr. Hoff at Fort Fetterman, Wyo. Ty., by Acting Ass't Surgeon A. J. Gray,
U. S. Army, chief medical officer of the expeditionary colunm. This command, consisting of about five hundred meu,
took the field May 24, 1878. It was well equipped, having ample and suitable clothing, tentage and rations; and,
moreover, its morale was excellent. Its first permanent camp was on the Clear Fork of Powder River, three miles
from the eastern base of the Rig Horn Mountains. The only feature of this oaiup to which exception might be taken
was the water-supply, whicli, although at first soft, clear and pleasant to the taste, had, later in the season, a sus-
picion of vegetable infusion. From this camp the conunand moved July l."> to a similarly good site on Rock Creek, a
few miles to the northward. The duties of the men were light ; the temperature equalde and never oppressive. The
only sickness recorded consisted of a few cases of intermittent fever, in all of which there was a history of previous
malarial toxa;mia. On September 5 the troops broke camp to cross the mountains to Camp Brown (now Fort Washaki)
which was reached on the 14th. During this march they encountered a rain- and snow-storm which covered the country
to a depth of twelve or more inches and flooded the streams with turbid water. The water-supply during this time
was obtained from the melting snow. The health of the meu continued good until the 12th, wlien a strong young
soldier of good habits, who afterwards became one of Dr. Hoff's five cases, was seized with intermittent fever, which
yielded to large doses of quinine. He resumed duty on the 16th. On the 19th the command left Camp Brown, but
meanwhile three men bad been taken sick with symptoms of jiaroxysmal fever and Avere left under treatment at that
post. On arriving at Fort Fetterman on the 28th five patients were turned over to Dr. Hoff, two as cases of quotidian,
two as tertian and one as remittent fever. ■' That these eases,'' Dr. Gray says, " were malarial there is in my opinion
no room for doubt, but whence came the toxic germs? Reasoning by exclusion I am compelled to attribute their
source to the water formed by the melting snow."' But although presenting these characteristics at their inception
and during the early period of the attack, when transferred for treatment at Fort Fetterman the febrile action was
of a continued or subcontinued type.
In case I the morning temperature was about the normal, but a diurnal elevation averaging two degrees of
Fahrenheit's scale was manifest for ten days after the patient's arrival at Fetterman. From the history and temper-
ature chart, constructed after his admission into hospital, this man was apparently recovering from an attack of
malarial fever which had been in part controlled by (luiuine.
In case II the temperature oscillated from 102° to lO.'t" Fabr. for six days after admission into hospital, when
fifteen grains of quinine, administered on the morning of October 4 and repeated on the evening of that day, sent
the temperature down to 97.4° on the following morning. Similar doses thereafter jjrevented the recurrence of the
former high temperatures. Quinine was continued until the 22d, at which date convalescence was progressing rapidly.
The temperature charts of these two cases are given on the opposite page.
In case III the subcontinued fever persisted for a long time. A careful study of this case shows that thirty
grains of quinine daily, usually given in morning and evening doses of fifteen grains each, exercised a beneficial
influence. Occasionally, when a day was permitted to pass without the exhibition of the specific, the temperature
immediately ran up to 104° Fahr. During a considerable portion of the time the daily dose amounted only to ten
grains; but when, on November 14, more than six weeks after admission, large doses were administered, the disease
was immediately controlled and convalescence established. The accompanying chart, constructed from Dr. Hoff'.s
« Report oil the Hi/giene of the U. S. Army, 1875, p. 434.
f Tyyho-malarUil Fever, the sv-ciUled Mowntain Fever of tite Rocky Mountain Retjion. — By J. Van R. Hoff, Ass't Surtj. U, S. A,, Amerkan Jour, Med, ,Scienees,
N. S., Vol. LXXIX, 1880, p. .'iS ct ««y.
CX)NTINDED FEVERS.
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524
ETIOLOGY OF THE
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record, illustrates the effect of four closes given
between the 14tli and 19th. After this the case
was completed with hardly a symptom worthy of
remark. The periods of administration and the
quantity, in grains, of the quinine which pro-
duced the defervescence are indicated on the face
of the chart.
In case IV, also, the febrile action was
markedly under tlie control of the quinine ad-
ministered.
Case V was the only one in which there
was a distinct approximation to the status tt/pho-
sus. The i^atient was much emaciated, and delir-
ious on admission on the 20th day of the attack,
the tongue slightly coated in the centre, clean
and pink at the tip and edges. During lucid
intervals he complained much of headache; his
Temperature Chart of Dr. Hoff's 3d Case. aljdomen was tender but the bowels were not
relaxed. While improving somewhat in his general condition he was seized with symptoms of peritonitis and died
November 11, the 32d day of the disease, from perforation in the site of an ulcerated patch of the intestinal glands.
In all these cases excepting the first, the convalescent case, there were chills, fever and
perspirations recurring with greater or less regularity, and these were of such a character
that they could not be regarded as recrudescences or relapses of typhoid. In no case was
the ultimate defervescence effected by the oscillations of decline considered characteristic of
typhoid fever. There was much headache in all, with some delirium in two of the cases;
diarrhoea in none, — on the contrary, the patients were all more or less constipated; nor did
meteorism exist in any of the cases, although there was some abdominal tenderness; the
tongue was thick, flabby, coated at the base but clean at the tip and edges; the breath was
offensive. In one case the patient said he had noticed some red pimples on his chest and
abdomen about the sixtli day of his sickness, and in this case Dr. Hoff observed, about the
thirty-sixth day, on the chest and abdomen a papular eruption which remained for many
days, the papules meanwhile increasing in number; they were of a bright-red color, pain-
less and disappeared on pressure. In two of the cases there was acute nasal catarrh and in
three herpes labialis; convalescence was rapid; the hair did not fall; moreover, quinine
seemed to exert a specific rather than an antipyretic influence. Here are none of the char-
acteristic signs of typhoid fever; on the contrary several are inconsistent with the generally
accepted clinical history of that fever. All, however, agree with the records of a subcon-
tinued malarial fever modified by inefficient specific medication.
The malarial element in all may be granted; but Dr. Hoff claims that since a specific
typhoid was present in the fatal case, it must have been present likewise not only in the
other cases that occurred in this command but in all other cases of so-called mountain fever.
He considers it reasonable to assume that the external causes of disease are identical when
the outward conditions of the patients are similar. Believing that this will be conceded he
argues that the diseases known under the name of mountain fever have no essential differ-
ences, and since, in his fifth case, the disease was truly typho-malarial, all mountain fever
cases must, therefore, be typho-malarial. But, as we know by our war experience, the out-
ward conditions of the patients in cases of adynamic remittent and continued fevers were
frequently so similar to those of typhoid fever as to be indistinguishable from them. To
concede that these cases were due to the same external causes is impossible without allowing
the identity of the malarial and typhoid poisons ; and, in view of our present knowledge of
these poisons, this would be absurd. The same argument, rallying on the post-mortem appear-
I
oontinup:d fevers. 525
aiioes reported by Carstens, White and Wokthington, as pertaining to the typlio-malarial
fever of civil life, would lead to the equally false conclusion that there is no typhoid element
in this fever. In both instances the erroneous conclusion is the result of tlie inudinissililc
assumption introduced into the arsjument.
The clinical experience of our medical officers in the Western Territories from the time
of the overland invasion of the gold fields of California cannot be offset by a. case of death
from typhoid perforation of the intestine. Twenty years before Dr. Hoff recorded this case
Bartholow reported similar cases with the post-mo7-te7n appearances in every instance indi-
cating the presence of specific typhoid fever, — indeed, there are few Western posts from
which typhoid fever has not been reported; but this does not appear to have led our medical
officers or the civilian practitioners in that part of the country to believe that all tlie febrile
caSes coming under their observation are cases of specific typhoid, — on the contrary they
recognize the prevailing fever to be a malarial remittent on account of its amenability to
quinine and its persistence in the absence of antiperiodics. The rarity of fatal cases at
present, when medical attendance and quinine can be had in almost all parts of the country,
as compared with the fatality, of the disease in the early days of settlement and overland
emigration, when the means of treatment were unattainable or misunderstood, points to the
absence of the typhoid element in the majority of the cases; in fact, the present death-rate
is alone sufficient to show the absence, as a general rule, of a specific typhoid fever.
Nevertheless, it is probable that in most of the fatal cases of fever in the Rocky i^biun-
tain region typhoid ulcerations will bo discovered notwithstanding the greater prevalence of
malarial remittents in the locality. It has been already pointed out that although malarial
remittents during the war predominated over typhoid in the proportion of 3.7 to 1, the
chances in favor of discovering typhoid lesions in a fatal case of low fever were as high as
7 to 1, and that in the third year of the war, when the great typhoid epidemics had subsided
and the remittents outnumbered the typhoid cases more than sixfold, the chances were still
5.4 to 1 in favor of the discovery of specific lesions after death from a low form of fever.'-''
The fatal cases do not therefore indicate the nature of the prevailing disease in the febrile
cases under discussion.
Where facilities for post-mortem observation are to be found there are usually also
facilities for treatment that give the malarial case a more desirable termination. It is among
the hunters, herders and prospectors who fall victims at a distance from medical aid th&t post-
inortem illustrations of the formerly fatal malarial remittents are to be expected, but in such
cases the investigation can seldom be made. Moreover, it must be remembered that the
negative character of the post-mortem testimony — in cases where typhoid fever is not pres-
ent— deprives it of one of the methods of record, that by preservation of the specimen.^
The sanitary environment of the miners, lumbermen, prospectors, surveyors, herders,
settlers and soldiers on scouting duty, who are the chief sufferers from this mountain fever
of the West, has been and even now is similar to that of our troops during the war. They
are subject to great fatigue, exposures by night, climatic and weather changes, with imper-
fect, badly constructed and oftentimes overcrowded shelters, deficient clothing and bedding,
monotonous and sometimes scanty diet ami impure water supplies. Naturally we should
expect to find the same diseases developed in both classes of men, and it is contended here
• S«J?ra, page 375.
t Proltably few niMical loeu wouM mount and jirpsf rvo a piece of apparently souu<l ileum hy way yf illustrating its condition in a case of so-called
typbo-maUrial fever as was done by Dr. G. B. Balch, of Tonkers, S. Y,
526 ETIOLOGY OF THE
that this expectation is realized ; that there is aggregated under the term mountain fever the
malarial and typhoid fevers and the association of both that constituted the camp fevers of
the war. The application of the term typho-malarial to them is in principle as much to be
deprecated as its original introduction in 1862, when, as has been seen, it gave official license
to confound together febrile conditions which, to be studied with satisfaction, should have
been left a})art.
Important practical results hinge upon the- application or disuse of this terra. To
authorize its application is to acknowledge the inability of quinine to remove the disease,
and cases which might have been cured in a few days will terminate fatally, as in the first
of those reported by Surgeon Geo. A. Otis, U. S. Army;'=' or the unnecessary prolongation
of the attack will exert a dangerous strain on the constitution of the individual, as is plainly
illustrated by the third of Dr. Hoff's own cases.
Prom this brief survey of the use of the term typho-malarial since the war, it is seen
that although a more accurate knowledge of the restrictions on its application has been
acquired by the profession than was possible during the war, it is still capable of involving
in uncertainties the cases to which it is applied unless associated in every instance with an
explanation of the views that dictated its use. If the term be retained in our medical nomen-
clature it should be restricted to typhoid fever modified by acute malarial manifestations.
Preferably it should be abandoned. Its use during the past twenty years has tended to the
detriment of individual cases and the retardation of medical progress. At the present day
we are ready to fall back to the position occupied before the war, arranging these continued
fevers for clinical as well as scholastic jiurposes into the three classes:
Ephemeral and continued fevers, the causes of which are oliscure, some beiug ajiparently due to overfatigue and
exposure, otliers to euianations into air and percolations into water from cesspools, sewers and other hotheds of
fermentative action ;
Typhoid fever, a specific fever of miasmatic origin, propagated, especially in older settlements, by various modes
of indirect infection,
And malarial fevers, due to a specific and extensively diff'used miasm practically free from infectious qualities.
Eventually medical men will, no doubt, become able to discriminate between an obscure
case of typhoid, a cesspool fever, complicated or not with malarial manifestations, and a con-
tinued or remittent malarial fever which has assumed a typhoid type; but this assuredly
will not be hastened by confounding all such cases in the meantime under the title of typho-
malarial.
v.— TYPHUS FEVER.
Although most of the cases reported under this heading by medical officers serving with
troops in the field were probably typhoid fevers aggravated by malarial complications and
an insanitary environment, it is impossible to dispose in this manner of the epidemic that
aflPected the Salisbury prisoners at Wilmington. N. C. This disease must have been typhoid,
malarial, typhus or some unknown malignant fever of unusual character and peculiar origin.
The last supposition cannot be entertained in the absence of positive and affirmative testi-
mony to some at least of its unusual characteristics. The raj^id spread of the disease to the
garrison and citizens of Wilmington is inconsistent with our experience of typhoid except
as suddenly propagated by the contamination of a general water-supply; liut we are led
to understand that the main factor in the extension of this epidemic was a direct contagion
from the sick to the well. Medical officers in attendance were taken sick and died; most
* See suyra, page 1^73,
CONTINUED FEVERS. 527
of the inc'ii fiujiluyeil on the stcunifrts used in tlie transportation of the prisoners Ui Wil-
mington suflered from the fev.er; even isohited settlements in the surrounding country
were invaded by the disease through the medium of negroes seeking safety by flight from
the contagion of the camps and city. J\Ioreover, the infection of so large a proportion of
the prisoners, 3,400 out of 8,600, with typhoid is inconceivable, for most of tliese men must
have been insusceptible to tlie disease by virtue of the exposures incidental to their service
before capture together with the even greater exposures to the typhoid miasm that attended
their period of confinement. Remittent fevers were common in that department, and More-
iiK.vp refers to an adynamic remittent fever of suspected infectious character;* but had the
fever that affected and spread from the prisoners been of a malarial nature the niilder of the
epidemic cases, by their amenability to quinine, would have thrown light upon the more
serious cases. Medical officers who had served for four years in malarious localities would
ixssuredly have demonstrated the character of this fever if it had been a malarial remittent.
It must, therefore, have been a true typhus, as diagnosticated by Dr. Hand and the medical
officers serving with him during the epidemic. Moreover, this view appears to have the
support of the few post-mortem investigations that were made.
It may be well, before proceeding further, to submit what is known with regard to the
history of these men prior to their appearance at Wilmington. The records of this office
are silent on the subject; but fortunately the Report of the Committee of the 40th Congress
on the treatment of Prisoners of War by the Rebel Authorities gives much information con-
cerning their condition, containing among other papers a report of an inspection made by
Captain T. G. Hall, under orders from the Confederate War Department and at the instance
of Governor Vance, of North Carolina, on February 17, 1865, a few days before the pris-
oners were exclianged.
The prison at Salisbury, N. C consisted of a brick factory four stories high, forty by one liundred feet, with
five buildings formerly used as boarding houses for the operatives. A l)oard fence surrounded the buildings, enclosing
at tirst five acres of ground, a space afterwards enlarged to eleven acres. In October, l>*t>l, ten thousand men were
sent to this depot, crowding the enclosure to its utmost capacity. The buildings were soon filled with the sick and
dying. Those who were unable to obtain admission remained without shelter other than one Sibley tent for each
hundred men, and were exposed to the rigors of the following winter. After a little while they went to digging holes
and tunnels in the ground with any tools they could procure, such as case-knives and broken canteens. In these
holes they slept at night and staid most of the daytime. The soil was a stift' tenacious clay which, after a rain or
snowfall, became converted into a perfect bog and remained wet for a long time. No efficient details were made for
the purpose of policing the grounds: filth of every kind was allowed to be deposited and to remain anywhere and
everywhere around the ([uarters, unsightly to the eye and generating offensive and no doubt dangerous odors. It
was considered that in warm weather the sinks would not fail to prove a source of great annoyance and ])ossibly of
pestilence not only in the prison but in the town of Salisbury. The regular ration, according to one of the prisoners
who testified before the committee, was bread, rice and soup, the bread being sometimes made of coinmeal, sonu'-
timesof cornmeal ground from the cobs as well as the grain; wheaten and mixed breads were also issued. The ration
of bread was from four to eight ounces ; of son]) about half a pint. Occasionally a few spoonfuls of molasses and now
and then sonte small potatoes were added to tli(^ ration. About two ounces of meat were issued once in six or ten
days. Inspector (feneral Hall's account of the ration, derived from a statement on paper of the amounts issued between
February 1 and 15, is somewhat different in its tenor. "Compared," he says, "in quantity and kind with the
rations issued to our own troops in the field, it will be seen that on this score the prisoners have no cause to complain.
The rations are cooked before they are issued, and pains have been taken by General Johnson to see that no frauds
ate committed in this department to the injury of the prisoners. Bread and meat (or sorghum in lieu of meat) are
• JhteoTcht* on [tuu-tve ni Twtia, by Charles Morekead, London, 1860, p. l.'i.'i. He is of opinion that malarial fevers are susceptible of a^tsuming an
adynamic type fruin the slate of tlie constitution of the individual attacked and infectious properties from flith, crowding antl IkkI ventilation in liouws
and Tillajres. Clark and Lixn held tlio same views, .\hhuugh tlic greater attention piid to cleanliness and vcniilation in recent times bus generally
prevent*'*! any development of infection in connection with n*ntittent fever*, o<-ca.*iional instances have been reconled : From 181.5 to 1S20 an a*lynaniic
febrile disease prevailed at Kattywar, Kutch and parts of Guzerat. A similar atfectioii at P»li in Marwar in July, 18.36, extenried to the towns in the
adjacent districtit up to the middle of 1838. Dr. Forbes describes the disease as seen by him at Pali in 1848. — Traiif. Medicaland Pliyifirat S^tcietrf of lioutltttij,
Jw. 2, p. 14. His dcMTiption bears much resemblance to that given by Pringlr of jail or hospital fever. The fever was regarded as infections, but in no
great degri^' unless there bad been coutioued exposure to the euanatioDs. Tbia infectious remittent was observed in X84t» in Gurhwal, in Kumaou and
ia 18o3 in BobilcuDd.
528 ETIOLOGY OF THE
Issued every morning, rice or pea-soup in tlie afternoon. The bread wliich I inspected in the bakery was of average
quality and of the average weiglit of five pounds to tlie double loaf. A half loaf, tlierefore, the, daily allowance of
each prisoner, will average twenty ounces of bread, the eiiuivale.nt of sixteen ounces of Hour." The water-supply was
limited and not more than sufficient for cooking and drinking purposes. It was derived from wells in the yard and
from a creek about half a mile distant, to which the prisoners were permitted to go, a certain number at a time, under
guard, with buckets and barrels. The want of a running stream within the jirison enclosure for purposes of washing
and general sewerage was greatly felt. The persons of the men were dirty, their clothing filthy and ragged. Tliey
suffered more than from any other cause from the want of sufficient and suitable clothing. They were generally desti-
tute of blankets and had no other clothing than that which they had on at the time of their capture. Shortly before
Hall's inspection three thousand blankets and one thousand pairs of trousers had been received from the United
States for distribution among them; further supplies were expected. One of the most painful features connected
with the prison was the absence of adequate provision or accommodation for the sick. With few exceptions all
the buildings in the prison yard were used as hospitals. There was an entire absence of hospital comforts, bedding
and necessary utensils. The reason assigned for this was that the articles if supplied would be inevitably stolen,
since no guard was kept inside the prison enclosure. The number of sick in hospital on February 15 was 546.
There were bunks for not more than one-half of tliis number; the rest lay on the floor or ground witli nothing over
them but a little straw which had not been changed in four weeks. For a period of nearly one month in December
and January the hospitals were without straw, although the county (Rowan) was one of the largest wheat-growing
counties of the State and thirty horses were standing idle in the prison quartermaster's stable. The supply of fire-
wood was also needlessly limited. From Oct. 5, 18(54, to the date of Captain Hall's inspection there died, according
to the surgeon's report, 2,918 of 10,321 prisoners; but, according to the burial report, since Oct. 5l, 18G4, a less period
by sixteen days, 8,479 bodies had been buried. This discrepancy was explained by the fact that, in addition to the
deaths in hospital, six or eight men died daily in quarters without the knowledge of the surgeons and, of course,
without medical treatment. Pneumonia and bowel aft'ections were the prevailing diseases; but the prisoners appeared
to die more from exposure and exhaustion than from actual disease.
The experience of many years and many epidemics has demonstrated the connection
between poverty, famine and their attending conditions on the one hand and tlie prevalence
of typhus fever on the other. In Ireland the worst developments of this fever have always
occurred as a sequence to failures of the food-supply. AVithin the enclosure at Salisbury
there was an accidental or artificially induced poverty, which, however, was attended with
all the exposures and hardships that belong to the condition when resulting from natural
famine causes. Whether the ration of bread was twenty ounces, as reported by the con-
federate inspector from the official ration returns of the prison, or. six to eight ounces, according
to the evidence of some of the consumers, it is certain that the men confined in this prison
bore the impress of semi-starvation on their arrival in New York, although in the meantime
every effort at recuperation had been made by the United States authorities and the U. S.
Sanitary Commission. The}' liad thus been exposed to one of the most powerful influences
that predispose to typhus fever, — but not more so, indeed not so much so, as the unfortunates
at Andersonville, among whom 'typhus did not make its appearance. Famine, therefore,
while strongly predisposing to the development of the fever was not the essential element
in its causation.
But some of the conditions associated with famine, as filth, personal, domestic and civic,
from want of facilities and energy, overcrowding from deficiency of shelter, and in cold
weather the inhibition of ventilation consequent on insufficient clothing and fuel, have been
•shown to be more intimately connected with the develojiment of the disease than the famine
itself, inasmuch as in its absence they alone have appeared sufficient in some instances to
determine an outbreak of the disease. Indeed, many writers of the past considered the
fever to originate in a human miasm generated under the conditions mentioned. Thus, they
explained its appearance in crowded jails before the assizes which were to dispose of their
inmates; in slave, emigrant and troop-ships; m barracks and in the overcrowded and filthy
slums of large cities before air-space, ventilation and cleanliness were recognized as efficient
against what was popularly regarded as a visitation of Providence. Many medical men,
however, at the present day, although regarding these conditions as favorable to the devel-
CONTINUED FEVER?. 529
opment and spread of the disease, consider them incompetent to generate it in the absence
of the contagion from a previous case. One of our hitest writers* states that there are cer-
tain endeniii- centres, such as Irehxnd, Italy and Russia, and that whenever the disease occurs
ill other localities it is due to importation; but this conclusion is derived from the investi-
gation of one epidemic in New York City, which was traced back to Ireland from Bellevue
hospital by way of a Mulberry street tenement house and a transatlantic immigrant.
On the other hand, medical literature is full of illustrations of the outbreak of the dis-
ease, under the conditions mentioned, where the previous case can only be admitted upon the
most absurd assumptions. The germ theory has, during recent years, done much to clear
away obscurities surrounding the causes of certain diseases, and the results have been inval-
uable to preventive medicine; but there is a danger that the enthusiastic adoption of this
theory in all cases of specific disease may lead to error. The facts in the case of typhus
fever are such that at one time Lebeet believed in its spontaneous origin. f He explained
in this way certain facts observed in the Crimean war, as its rapid and unexpected origin
before Sebastopol with the occurrence of the cold damp season, its breaking out in a war
vessel fifty days after her departure from Kamiesch, and many other sudden and unexpected
outbreaks unconnected with any probable mode of importation or transmission from a pre-
vious case. Recently, however, he has changed his opinion, considering that these facts
admit of anotlier explanation : "Small quantities of typhus germs may have remained latent
in these places, or their importation may have taken place from t3^phus regions by infected
articles, which may have escaped the closest scrutiny." This change of opinion is not based
upon any new information affecting the observed facts, but on a consideration of the incon-
sistency of a spontaneous origin with the doctrine of the germ theory. Will knuwledge and
lingering wisdom be reached in this way, — by assorting facts to secure uniformity to precon-
ceived ideas, — or must we accept them as they are? Wliere, for instance, are we to look for
the previous case that gave birth to the epidemic among the Salisbury prisoners on their
liberation from the prison enclosure? If typhus fever existed at that time in the United
States of America, the cases were few in number and confined to northern cities hundreds of
miles from the place of captivity of these men, and separated from it by the lines of hostile
armies. The confederacy itself was in fact at that time cut off from communication with
the outer world as effectually as were its prisoners at Salisbury. These untbrtunates were
so thoroughly guarded against the intrusii^i of typhus fever that if the disease appeared
among them, and there seems no doubt of the fact, it originated from causes that were in
operation within the limits of their stockade.
At first sight it is difficult to say why the Sahsbury prisoners should have been taken
with typhus while those at Andersonville were spared. The condition and environment of
both bodies of men were similar in character: Both were exposed to the inclemencies of the
weather with scanty and ragged clothing, insufficient shelter and food; and both suffered in
consequence. Both were filthy in the extreme and closely packed within their stockades.
Both were similarly deficient in hospital accommodations. Patients died in camp in holes
m the ground and were buried unknown to the hospital surgeons. Admission to hospital
iTought with it but little improvement in their mode of life; many of them had to lie on the
floor or ground without blankets and without straw. But there was one important difference
* A rert-*.«»t nf /VurfiViil Meilicitit, Ijy \. L. Loows, New York, 18M, p. 71 1. S<r also liis Leclureg nn Fcrerg, New York, 1877, y. 212.
t See Liii article on (he disease in the Firtt Volume of the Amerkait TraiuslaUim of Ziemsten's C'l/dopedia, p. 300.
Med. Hist., Pt. Ill— 67
530 ETIOLOGY OF THE
in the hospitals of the two camps: At Anclersonville tlie liospitals consisted of some tattered
tents and unfinished barrack sheds, roofed and floored, but open at the sides, — practically,
the patients were in the open air. At Salisbury the hospital building consisted of a four-
story Ijrick factory and some smaller buildings formerly used as boarding-houses for the
factory operatives, — practically, patients crowded into the rooms of these buildings were
under the precise conditions that have so often been recognized as productive of typhus fever.
What the amount of crowding may have been if expressed in air-space per patient is
unknown, and probably if known would be of little value, as the foulness of t!ie air in a room
occupied by a number of inmates depends more upon deficient ventilation than upon a few
hundred feet of air-space more or less per man. In accordance with what is known of the
management of these prison hospitals we may suppose that the floors of the rooms occupied
by the sick were well covered. ' The point to be considered is, that during the cold winter
weather of the occupation of the prison the shivering j)atients, without blankets, without
even straw and with a deficient supply of fuel, would be more likely to stifle in the vitiated
atmosphere that had been wanned by their own bodies than to throw open the windows and
effect such a ventilation of the room as was possible. During the typhus epidemic of the
Crimea the months of prevalence were those in which the soldiers shut themselves up in
their quarters in seeking protection from the external cold; the months of decadence of the
disease were those in which the weather conduced to free ventilation and an open-air life.
Whether the disease was generated in some of the prison-wards at Salisbury is of course
unknown, liut on this theory only can its subsequent epidemic "development be explained.
The fever might have caused frequent deaths among the inmates of an infected ward without
attracting special notice, so great was the indifference of the Confederate authorities at these
prison-pens to loss of life among their prisoners, and without spreading to the occupants of
the enclosure, protected as they were from contagion by their open-air life; but when the
prisoners were packed with these typhus foci on the trains which were to convey them to
North East on the Cape Fear River, and were subsequently repacked on the small river
boats for transmission to Wilmington, every facility was afforded the disease to spread from
man to man and appear as a generally diffused epidemic on their arrival. Their subsequent
distribution among the hospitals and barracks of Wilmington sufficiently accounts for the
extension of the disease to the citizens and local garrison. Cases occurred among men who
were considered fit to travel northwards to their homes; but as these made the journey in
well-ventilated and thoroughly appointed hospital transports the disease did not spread,
although those primarily affected were delivered at David's Island, New York Harbor, suf-
fering, according to Medical Inspector George H. Lyman, U. S. A., from a disease which in
its essential features resembled true typhus more than any other fever he had ever met with/^
On this view, not famine, filth nor overcrowding is the essential element in determin-
ing the evolution of typhus fever, but the concentration of the human emanations developed
■by those in confined and un ventilated spaces.f There Avas no typhus in our Northern prisons
* See ewproj page 333.
t Jacquot, from his experience of the Crimean epidemic, was so strongly imprcssod with the sjioutaiieoiis origin of typhus from a human miasDi
under such conditions as have heen meutioned in the text that he wrote of the disease : We can genertUe it ai icill. "Ou peut faire naitre le typhus k
volonte, pour ainsi dire ; riou de pareil pour la fievre typhoide." — Dit Tijphm deVArnu'e tV Orient, Paris, 1858, p. 305. Guillemin states that, cootraiy
to the opinion commonly entertained, typhus occurred in the city of Metz during the siege of 1870. Physicians practicing there were almost unanimous
ujtoii this question ; and some of them, who had formerly been in the army, had studied the disease during the Crimean war. It never became general nor
Hjssumed the gravity observed in the Crimea or Algeria for the sufficient reason that its causes had not been either so long in action or so intense.
M£ry is cited as saying: *'I saw there (in Metz) the disease pursuing the same course that it followed on its apparition in the Crimea in 1854-5r», and if
the blockade had continued longer we should have had a second edition of the Crimean disaster." — See The PractUioyiei; London, Vol. XII, 1874, p. 'Sil.
CONTINUED FEVERS. 531
undoulitedlv because the needful concentratiou was not effected. Our jiavilion barrack-
buildings, although generally provided with three tiers of beds and frequently affording only
200 cubic feet of space per man, had always some attempt at ventilation, usually by the
ridge; and were, moreover, oftentimes satisfactorily ventilated by the very imperfections of
their construction. Nevertheless, in many such overcrowded quarters a malignant character
was assumed, especially by typhoid fever and acute malarial and pulmonary diseases, which
obscured their clinical features and rendered their diagnosis from true typhus a matter of
ilifficulty.* And in certain of these instances even the suggestion of a contagious quality was
not wanting. It may, therefore, be claimed with some degree of plausibility that our typlius
cases, or those that seemed to our medical officers to be typhus, did not require for their
development the introduction of a specific ferment, poison or germ elaborated in the system
of a pre-existing case of the disease, but were generated by a coalition of favorable condi-
tions, of which the chief was overcrowding with deficient ventilation.
On this view, tyjihus as affecting the soldier should become an unknown disease. The
measures to effect this are so obvious that their formal presentation is unnecessary.
VII.— TREATMENT OF THE CONTINUED FEVERS.
The functions of the Army Medical Officer are twofold. He is the Health or Sanitary
Officer of his command charged with the duty of preserving the men in their best condition,
that their aggregate, the military machine, may be enabled to exercise its maximum of
power. From the governmental point of view this is the raison d' etre of the military medical
man. His duty as Sanitary Officer requires a careful supervision of the clothing, diet, shelter
and labors of the men, that they may be protected from all avoidable influences of a per-
nicious character, including invasion by endemic or infectious diseases. But if, notwith-
standing his efforts in this direction, disease should attack the command, ho then becomes
the physician in attendance on the individual case.
These functions, although distinct, are so intimately co-related that, as regards the con-
tinued fevers, the measures adopted for the protection of the command are oftentimes those
best calculated to lessen the danger in individual cases; the prevalence and the fatality
of an ej)idemic are frequently direct and proportionate results of the same insanitary condi-
tions. The treatment of the continued fevers resolves itself therelbre into a consideration of:
Ist. Jlcasiires for the protection of the coiniii;in<l against their introduction;
2d. McaHnre.s to restrict their sjiread and free tlie command from tlieir presence;
3d. Measures for the relief and recovery of individuals attacked.
1st. — Preventive measures have already been indicated in discussing the etiology of
these fevers. As protective against common continued fevers all unnecessary overfatigue
and deprivation of sleep, exposure to excessive heat or chill, to contaminated soil or foul
neighborhoods, the use of tainted articles of food and of impure water-supplies, should be
especially avoided. Exposure to such influences is oftentimes inseparably connected with
•A simiUrnialif^naiK > u.t^ i.l.fttTviM! in the hospitals of Paris during the giego in 1870. Patients fell into a condition in many respects rescmblins:
that pnMlurod I»y typhiirt fi-V4T, :iii<l to this was due a cfmsidcrattle amount of the mortiility anions tln-ni. Tin- piihlished statistics of tlie siege contained
no raw of pure typhus* ; nevertlieless— "There is indeed much reason to Iwdieve that cases of pure typliiis wiiicli did ttccur, instead of being shown sei«a-
laCely in the returns have t>een includi-d among the typhoid ; and it may t»e fairly doulded if, iluring tlie continuance of tlie siege, the strict line of diagnosis
iH'lween tliejie forms of disease was drawn, as it usually is in Knglaud and doubtless would have bccu in Paris under normal conditions," — C. A. Gordon,
i^mmt <m Htfyiene and Svryeri/ /rcnn the f>anot>-Prttesian War^ London, 1873, p. 235.
532 TREATMENT OF THE
the duty on which the troops are engaged, in which case continued fevers and other diseases
thus originating must be accepted as part of the price paid for the achievement of the rniH-
tary result. Usually the lists of killed and wounded pass current under this title, but these
fail to give full expression to the price if sickness and mortality from disease be not incor-
porated. Nevertheless, with earnest medical officers and intelligent commanders, much
unnecessary loss to the command may be avoided even in the most active of campaigns.
Just as hastily constructed breastworks or rifle-pits are used to lessen danger from a hostile
fire, so certain sanitary precautions should, even in the face of an enemy, be used for the pro-
tection of the men from diseases incidental to a campaign, whenever they can be applied
without hazard to the military issues.
As has been seen, no exercise of sanitary supervision will be efficient at all times in
preventing attack from tvphoid fever; but much may be done in the way of protection by
the avoidance of all communication with suspected foci or contaminated materials.
Nor can protective measures be in all cases efficient against the development of con-
tinued malarial fevers, although their frequency and gravity may be materially lessened by
preventing unnecessary exposure at night, by filtering the supplies of water for drinking,
and by using quinine as a prophylactic in movements involving conditions known to be
specially dangerous.
Typhus fever, on the other hand, may be blotted from the list of camp diseases by
excluding contagion and preventing the spontaneous origination of the disease. In camps
and garrisons, and during service in the open field, the ordinary sanitary measures for the
preservation of health will prevail against it, but during long-continued sieges troops in bomb-
proofs and the civil population occupying basements and cellars will require active sanitary
supervision to prevent an unnecessary disaster.
2d. — Measures to restrict the spread of febrile diseases and free the'command from tlieir
presence have in view, under our present heading, only the typhoid and tophus infections.
In the case of typhoid, removal from the miasmatic locality is needful if the outbreak
seems due to purely miasmatic influences. Removal is also required if the outbreak is due
to a contaminated soil, as from a prior occupation by infected troops. If the place must be
held, veteran regiments that have undergone their typhoid seasoning should be sent to
occupy it. If the disease is attributed to an infected water-supply, a new source should be
obtained, and until this is accomplished the suspected water sliould be used only after having
been boiled ; — filtration is untrustworthy as against typhoid fever. When the onset is less
sudden, pointing to an accidental intrusion from other commands or localities, every new
case as soon as detected should be removed from quarters to hospital, where its infectious
material may be under medical control. Meanwhile obnoxious features in the sanitary
arrangements of the camp should be obliterated. Its area should, if j^ossible, be extended;
any tendency to overcrowding in particular tents or huts should be obviated; tent floors
should be exposed daily; infected sinks disused, and those in use disinfected daily lest they
become contaminated by some new and as yet undiscovered case.
The typhous malignancy assumed by other diseases should undoubtedly have led to the
removal of the insanitary conditions which evoked it long before the continuance of those
conditions could evolve a true contagious typhus fever. But in the event of the occurrence
of such cases their removal to hospital, the abandonment of the infected site, or failing that,
its thorough purification by feration and an efficient system of personal and camp police,
CONTINUED FEVERS. 533
together with strict attention to general hygienic laws, would certainly suppress the epidemic
before it attained disastrous proportions.
3d. — Tt is well that so much can be accomplished from the sanitary or preventive
stand-point. It oflTsets the incompetency of professional methods applied for the cure of the
individual case. The clinical records and medical descriptive lists of the war are filled with
notes of the treatment employed in cases of continued fever, but it does not appear that any
systematic effort was made to determine the relative value of diflerent methods. Patients
'lied from exhaustion, diarrhtea, coma, peritonitis, hemorrhage, pneumonia, etc., while others
submitted to the same remedial methods made a rapid recovery. Some progressed unfavor-
ably for several weeks, but ultimately rallied from the most profound typhoid state and con-
valesced satisfactorily under treatment which, in other cases, did not prevent a suddenly
fatal issue notwithstanding the seeming absence of all grave symptoms until the closing
hours. Others recovered with no other treatment save that which protected them from
harmful influences. In fact, the closest study of the records fails to show that the disease
was influenced beneficially by any system of medication, or even that individual remedies
had a notable effect on the result in individual cases. In many instances the administra-
tion of a certain medicine, a laxative, astringent, diaphoretic, calmative, refrigerant, antipy-
retic, etc., modified favorably for the time being the svmptoms which called for its exhibition,
but it cannot be shown that the ultimate issue of these cases was in any wise affected.
It must not be supposed, however, that professional care was valueless in the treatment
of the continued fevers. Regulation of the diet in the late as well as in the earlv stages of
the disease no doubt saved many lives by lessening intestinal irritation and promoting the
cicatrization of ulcerated patches. The administration of suitable nourishment at regular
times saved the strength of the patient. Watchful care and control during the period of
delirium not only preserved the patient from direct and immediate accidental death, but pre-
vented that involuntaiy violence of action and those unconscious exposures which would
have tended to death by subsequent exhaustion or local congestive processes. The removal
of retained urine by catheterization sometimes quieted delirium, relieved hypogastric pain
and prevented local injury. Careful nursing economized the patient's strength by affording
assistance in all his desired and permitted movements. The use of the bedpan certainh'
decreased the fatality of continued fever: Exhaustion was rapid in cases associated with
active diarrlioea when, from want of facilities, the patient had to leave his bed on every
alvine movement; moreover, sudden death was not uncommon among asthenic patients who
made the effort to attend to their own necessities in this regard. Careful nursing also pro-
tected the fevered soldier during the night, when a pneumonic complication might have
resulted from a continued dispilacement of the bedclothes; and by constant attention and
frequent change of position and pressure, it prevented the development of exhausting and
distressing bedsores, keeping the skin of the patient clean, his bedding fresh and the aii- in
his vicinity comparatively pure.
^luoh was possible, therefore, independent of medication. Much, also, was accomplished.
But it may be readily gathered from a perusal of the records that on account of crowded
hospitals, overworked nurses and, in rare cases, defective discipline, everything that should
have been done, and, indeed, in exceptional cases, everything that might have been done on
behalf of the patient was not always effected.
In the field, facilities for the proper care of continued fever patients were not always at
534 TREATMEKT OF THE
hand. Nevertheless, it is believed that cases treated in the field hospitals, as when the
army was in winter-quarters, did better than their comrades who were sent to well-equipped
hospitals at the base of operations or in ISTorthern cities. The superior comforts which sur-
rounded the patient on his arrival at the general hospital failed to offset the injuries inflicted
on him during the journey. This will readily be understood by those who have seen a
wagon-train of sick soldiers en route to the rear. Suffering and danger assailed the patient
on every hand. The hot sun and stifling dust of the summer were as dangerous as the cold
rains or snows of winter. The irregular jolting over deeply-rutted country roads, and the
continuous and intolerable agony caused by the passage of those that had been corduroyed,
were enough of themselves to have transformed the headache of fever into its delirium. The
innumerable occasions when the utmost strength of the patient was taxed to enable him to
fulfil the necessities of existence under these conditions rendered liim less able to withstand
the hardships that had yet to be borne. Dietetic arrangements were generally imperfect;
perhaps the only refreshment whicli the fever-stricken soldier was able to take during the
journey was an occasional swallow of coffee from his canteen.* The transfer to rail or boat
involved further efforts that increased his prostration. The tedium and exposures of this
second journey, and the want of proper attention during the whole route, often brought him
to his destination in a state of exhaustion, delirium or unconsciousness. Hence the inqier-
fection of so many of the records of cases treated in the general hospitals; the previous his-
tory of the patient was unknown or received at second hand from some of his travelling
companions.
From the mass of records relating to the treatment adopted in individual cases of con-
tinued fever there is little to be learned that may not be gathered from the articles on the
treatment of typhoid fever by Wood, Watson and BENNETT.f The works of these authors
were, at the beginning of the war, on the Supply List of the Army Medical Department.
Their doctrines were thus invested with official sanction, so far as this migiit with propriety
be conceded in unsettled matters of a professional nature, and there is no doubt that they
exercised the \ery strongest influence. on the manner in which our soldiers were treated.
Wood was precise in his stateraeut of the method of treatment to be adopted : Irritating matter must be removed
from the bowels, but tliis must be effected by the gentlest of laxatives on account of the existence of a high degree
of susceptibility to the influence of cathartic medicines. Bleeding was doubtfully suggested to prevent local and
disorganizing inflammations, but the danger of injury to the system by induced debility was strongly set forth.
Refrigerating diaphoretics were recommended as useful from the earliest period of the disease; citrate of potassa
as a neutral or efl'ervescing mixture was preferred, in conjunction with tartar emetic if the stomach and bowels
were quiet, with some preparation of opium if these organs were irritable and with spirit of nitric ether if nervous
symptoms began to appear; Dover's powder was approved for use at bedtime; sponging the surface with cold water
or with alcohol and water was also recommended as a refrigerant. In addition local manifestations required treat-
ment : Headache by cold applications or leeches ; abdominal paiu and tlatuleut distention by cupping, warm fomenta-
* If M. le Docteiir Gvillasse, Ancien M^deciD principal de la Marine, fails to contribnte much to our knowledge in his Essay De ia Fievre Tiipho'^'h.
Etmle PlKittwlogique. Sa Sature — son Ttaitenient, Paris, 187S, he certainly furnialies some amusement to those who chance upon his pages in the progl>essof
tln-ir study of the literature of the subject. He tells us that in the absence of other means of investigation he had recourse to methods which every
til inking man may employ — analysis and induction — and he modestly submits his results that mankind may be the better for them if they are correct, or
leave them in obscurity if they are erroneous. An erethism of the nervous system of animal life, occasioned and sustained by a certain congested state
of the brain due to a stasis of venous blood in the capillaries of the organ, produces a spasmodic interference with the organic functions. This is all there
is' in typhoid fever, or, indeed, in any of the other essential fevers. In typhoid the spasm is manifested on the part of the liver by the secretion of an
acrid bile, which occasions irritation, inflammation and perforation of the parts of the intestine with which it remains in contact for some length of.
time, as in the lower part of the ileum, where it finds an obstacle to its passage in the ileo ca'cal valve. The pathology having been determined to M.
Gvillasse's satisfaction, it remained for him to find an agent which, by removing this erethism of the brain and its consequent spasm of the nervous
system of organic life, would permit the functions to resume their natural and healthy .action. This he discovered in coffee. To cure typhiiid fever it is
only needful that "On donne deux on trois cuillerees de fort cafe noir (je dis cafe et nou pas chicoree), toutes les deux heures." After having adminis-
tered the cofTee he found to his great surprise that its action w.as as prompt as it was decisive. "En effet, a peine uos malades en eurent-ils pris qnelques
cuillerees que leurs traits se detendirent et quils reprirent connaissance," etc. Our suffering soldiers en route to the general hospitals in the rear failed
to realize the benefits, although certainly their coffee was the real article and not a chicory mixture. ,
■f- Geokoe B. Wood — .-1 Treatise oh Uie Practice of Medicine; Tuom.as W'atsox — Lectures on the P}-inciples and Practice of Medicine ; John Ilrc.HES Ben-
nett— Clinical Lectures on the Principles and Practice of Medicine.
CONTINUB^D FFA'ERS. 535
tioiis, emollient cataplasms, rubofacieiits or blisters; iliarrluva by opium ami ipceaciianlia with or without acetate of
lead, kiuo, extract of rhatany or tannin; nervous symptoms by sweet spirit of nitre, Hoftmanii'>s anodyne, camphor-
water or opiates. In mild cases no other remedy than those mentioned was considered necessary; but in less
favorable cases, when about the ninth day there was a loss of vital energy with no diminution in the violence of
the disease, which was characterized by defective secretions and some degree of delirium, stupor and tyuipaiiites,
mercury in small doses to affect the gums slightly was highly approved. Under its influence it was said that the
tongue not unfrei|neutly became moist, the skin relaxed and the symptoms generally ameliorated, the )>atieiit recov-
ering without further treatment. The value of turpentine was also highly lauded. It was considered useful in all
cases in the advanced stage of the disea.se, when the tongue was dry and the ])ul.se not strong. In cases having tlie
tongue red, dry and smooth, after or during the process of parting with its fur, and in which this was associated with
an aggravation of the symptoms, notably of the tympanites, an amelioration of the patient's condition within twenty-
four or forty-eight hours after a resort to the oil of turpentine was coulidently predicted. Under its inllueiiee the
tongue was said to become gradually nuiister, covering itself with a whitish fur; rlie tympanitic distention ceased
to augment and after a time diminished ; the pulse became less frequent ; the skin h'ss dry and harsh and the patient
entered slowly but regularly into convalescence. Stimulants were recommended in the debility of the later stages
and also in the earlier periods, when they were found on cautions administration to lessen the frequency and increase
the fulness of the pulse, to relax the skin, moderate delirium, relieve nervous di.sorder and promote refreshing sleep.
Wine-whey and carbonate of ammonia were suggested when a more diffusible impression was desirable. Quinine
w.is recommended in small doses as a tonic. When collapse was imminent, x'owerful rubefacients, as hot oil of tur-
pentine, cayenne pepper in brandy, diluted solution of ammonia, sinapisms and blisters were approved in connection
with internal stimulation.
The treatment suitable to local affections or incidental complications was also indicated: Shaving and blister-
ing the scalp in ol)stinate delirium and coma; musk, assafiBtida and camphor in 8ul)sultus and jactitation ; musk in
singultus; acetate of lead, kino and extract of rhatany with opium in hemorrhage from the bowels; plugging the
uares after the failure of astringent solutions or other measures in epistaxis; mucilaginous applications or the local
use of silver nitrate or iodine in erysipelas : opium in peritonitis ; the catheter in retention of urine ; the mineral acids
and vegetable bitters in exhausting night-sweats; and change of position, sponging with alcohol and water, and pro-
tection from pressure by pillows and lead plaster in threatening bedsores. Strict attention to diet was enjoined. At
first all nourishment was re<|uired to be in the liquid form, as barley-water, rice-water, etc.; during the second week
farinaceous preparations of gelatinous consistence were allowed; subsequently milk was permitted, and in the stage
of prostration animal broths, eggnog, &c.
Watsox discountenanced efforts to cure the fever by medication or powerful impressions on the system. His
practice was to guide the fever and obviate the teiulency to death, and the means he adojited to effect these objects
were in general similar to those indicated by Dr. Wood. Among the remedies which in his opinion formed the staple
of the treatment were: Cold to the shaven head; the local abstraction of blood whenever there existed unecinivocal
evidence of local inflammation; an active purge at tirst, and mild aperients afterwards, if the bowels were confined or
sluggish; moderate astringents, as extract of catechu or Dover's powder, to control diarrluea; opium in more efficient
doses when nervous symptoms were prominent, particularly sleepless delirium and restlessness ; in certain ca.se8 small
and repeated do.ses of some mercurial, and in certain others larly support by animal broths and even by wine. "The
rational objects of treatment are to mitigate the urgency of symptoms that cannot be wholly subdued; to redress (.so
far as art may redress) those dangerous complications which are incidental but not essential to the ili.scase; and to aid
the conservative efforts of nature when these manifestly languish and fail."' The tendency to death by asthenia was
strongly imjiressed, and the danger of beginning thesupjuirting treatment a little too early was set down as infinitely
less than the risk of beginning it a little too late.
Bexxett recommended the use of mild laxatives when re<iuired, cold to the head, salines, such as the acetate
of ammouia with tartar emetic, and beef-tea and stimulants when the pulse became soft and weak although retaining
its frei|Uency. He considered active depleting measures as never useful and as seldom failing to increase the danger
by lowering the vital powers. He believed that the disease might be aborted by the early use of emetics; and con-
sidered quinine incompetent in large doses to establish a cure and of doubtful value in small doses as a tonic.
One only of these authors, Professor G. B. Wood, adverted to the possible complica-
tion of the typhoid case by specific malarial causes, and suggested the treatment appropriate
to this condition. His reference to this appears at the close of a paragraph devoted to a
brief mention of certain special plans of treatment, as by emetics or bloodletting in the early
stages, the use of nitrate of silver, alum, chloride of sodium, etc. He says:
When there is reason to believe that the disea.se is complicated with remittent or bilious fever, and especially
when, under such circumstances, it terminates iu intermittent fever, sulphate of <iuinia should be used withiHit hesi-
tation and with a freedom proportioned to the urgency of the symptoms.
From this casual reference it may be inferred that in civil practice before the war
typhoid fever, notably complicated by the malarial poison, was of infrequent occurrence.
But, as a rule for the guidance of our medical officers during the war, a paragraph similar
536 TREATMENT OF THE
to that just quoted should have been placed at the beginning of every article on the treat-
ment of the continued fevers. Typhoid, n:odified by malarial influences, instead of being
the occasional or exceptional case, was the rule in our regimental epidemics, and among these
modified enteric cases were plentifully scattered cases of pseudo-typhoid in whicli the clinical
features of enteric fever were impressed on a purely malarial disease. Quinine, used without
hesitation and with a freedom proportioned to the urgency of the symptoms, removed one
of the febrile factors, after which the typhoid disease not unfrequently ran a mild course.
The free use of tliis remedy was especially required where paroxysmal fevers were endemic,
for in the early stages it was often impossible to say whether an individual case would
ultimately prove to be enteric fever complicated by co-existing malaria, the latter susceptible
of cure by quinine, or a remittent which, in the absence of specific treatment, would speedily
fall into a dangerous condition characterized by typhoid symptoms.
Tlie uncertainty attaching to tlie real nature of a case in which typhoid symptoms were
developed led at first in some instances to a hesitancy in the treatment. Brigade Surgeon
Jas. Beyan gives expression to this where lie says that in North Carolina no two medical
officers appeared to agree upon any plan of treatment for the continued fevers.* Surgeon
Samuel Kneeland, 45th Mass., also 'referring to the fevers of North Carolina, stated that
they were usually treated from the commencement with quinine, whiskey and beef-tea, but
as the results of this method of practice were not satisfactory he pursued an expectant plan,
employing refrigerants, diaphoretics, camphor and carbonate of ammonia.f At Fortress
Monroe, Va., quinine was found inefficient in all the stages of the disease, and the treatment
by emetics in the early period was instituted.! According to Dr. Thomas T. Smiley, a stim-
ulant treatment was followed in the hospital at Hilton Head, S. C; but the patients when
received were already in the later stages of the disease, with the tongue dry, brown and
cracked, and the pulse feeble. § In tlie New York Hospital for Volunteers stimulants were
freely given regardless of inflammatory complications. ||
But it would be unjust to the jirofessiou to assert that this uncertainty as to tlie proper
treatment of the continued fevers was at all general or long continued. Indeed, at a very
early period of the war the malarial complication of typhoid fever was recognized and appro-
priately treated by quinine. In December, 1861, Surgeon Rohrer, 10th Pa. Reserves,
described a fever with rose-colored spots, which, in view of a malarial influence, he treated
successfully with a mild purge of calomel, a large dose of quinine, fifteen to forty grains,
during a morning remission, with calomel and ipecacuanha at intervals of four hours and
turpentine when the tongue became dry.^ In March, 1862, Surgeon C J. Walton, 21st
K}'., had already given expression to the principle on wliicli was afterwards based the
systemalic treatment of the continued fevers of the army: As it is often impossible to
determine at the beginning to what extent the case is influenced by malaria, it is well to
begin with a few doses of quinine, when, if the fever be a malarial remittent, it will be con-
trolled; but if it be enteric, — or, he might have added, a continued malarial fever in which
secondary lesions are already established, — no specific action will be manifested.**
The Seminary hospital records, which have been presented as giving a full A'iew of the
clinical characters of the febrile cases sent to Washington from the army in the winter of
* Obfei-val toils o» the Diseases of the Arttnj in the Department of North Carotina. — Boston Med. and Sim/. Jour., Vol. LXVI, 1SG2, p. 3S4.
■(-Bos/oK Med. audSnry. Juiir., Vol. LXVI, 1S02, p. 280. J^wienVui* Med. Times, Ni-w York, Vol. Ill, ISGl, p. 3S0.
^Boston Med. and Surg. Jour., Vol. LXVII, 1862, p. 270. \\ American Med. Times, New Yurk, Vol. IV, 1862, p. 303.
^See bis report, supra, page 318. **Supia, page 316.
<_>
CONTINUED FEVERS. 537
18G1-62, subserve anotlier purpose in illustrating the methods of treatment adopted. j\Iore-
vor, as the records of this hospital do not differ in their general tenor from those of other
large establislnnents of the same kind, the methods which they indicate may be accepted as
illustrative of tho.se in general use ]>y our medical officers.
Although these cases were treated in the early period of the war, several months before
the term typho-inalarial was introduced to direct the attention of the profession to the com-
plication of typlioid fever by the malarial poison, it is evident, from the frequent use of qui-
nine, that this complication was already recognized. Certain cases that were brought in
from the front along with the prevailing typhoid were recognized as remittent fever, cases
52-58 for instance, and treated successfully with mercurials, saline purges and quinine.*
Certain cases, 113-120, regarded as remittent, but which presented more or less evidence
of the co-existence of tyiihoid fever, were treated with antiperiodics in addition to the meas-
ures ado]>ted in view of a possible typhoid. "|' Thus, in case 116, fifteen grains of quinine, six
of blue-pill and two of opium were given in two doses separated bv an interval of two hours,
and were followed by four grains of quinine every two hours, while in 119 and 120 Fowler's
solution was employed. Certain cases of typhoid fever, 59-112, in whicli intermittent or
remittent paroxysms preceded or accompanied the symptoms of typhoid, or in which there
was more or less evidence of the complication of the enteric fever by malarial influences,
were treated with quinine before, during or after the exhibition of the remedies specially
directed to the continued fever and its intestinal lesions. Thus, in 64, 94, 99 and 105,
amouii others, quinine was <£iven before the use of the remedial auents called for hv tlie
typhoid disease; in 78 and 79 it was given along with the remedies for tvphoid, and in 74
and 75 it was tried after they had been in use for some time. Indeed, in some of the cases,
1-51, in which the evidence of a malarial complication was by no means strong, specific
medication was employed in the effort to lienetit the patient. Quuiine was thus given in
8, 14, 17, 29, 38 and others in unstatfd ([Uantities: in case 9 eight-grain doses were given
three times a da\-; in 26 two grains everv hour; in 44 twelve oi-ains dailv ior several davs,
and in 49 five grains every two hours. In 30 the exhibition of tiiis reme<lv was followed
by a manifest but probabl)- inconsequent improvement; in 41, on the contrarv, an active
delirium, which led to accidental death, supervened on the administration of t went v lour
grains in twelve hours.
Surgeon S. K. Towle, oOth Mass., in his extensive experience of the fevers afl'ect-
ing the troops in the Mississippi Valley, recognized that many of the cases I'egistered as
typhoid were of malarial origin. The.se had not the rose-colored eruption, and, on admission
to hospital, had already lost the early diagnostic features, retaining onlv the prostrated,
semi-con.scious condition of the last third of severe typhoid fever. Enteric fever itself was
seldom seen in an unmodified form except in recruits recentlj' arrived from New England.
He considered it indisputable that all cases did better after the introduction of full doses of
quinine into the treatment in the early stages, and that cases in which this remedy had not
been employed at first were often benefited by its use in smaller doses at a later date. J
A failure to recognize the malarial element in the typhoid case — no matter whether
the case in question was a true enteric development or an adynamic sequence of a remittent
or continued malarial fever — would have handicapped the physician in conducting the con-
tinued fever to a successful issue ; but this was a fault in tlie method of treatment that was
Si*>ir,i, \>nicf 22;>. ■ t Supra, page 246. X See ntprOf page 313.
JIjEi). Hist., Pt. 111—68
538 TREATMENT OF THE
rarely observed altliougli noted, as has already been seen, by Surgeon George A. Otis, U. S.
Army.* A failure, on tlie other hand, to recognize the tj^phoid element led sometimes to a
persistence in the use of large doses of quinine which, while incompetent to effect a cure,
may not have been in all instances free from injurious effects. As already explained, the
febrile cases of the general hospitals were mostly enteric, while those that did not reach
these hospitals, but terminated speedily in recovery or in coma and death in the regimental
establishments, were in general due to malarial influences.-]- Quinine freely administered was
regarded as essential to recovery in these cases. When a typhoid outbreak occurred in a
regimental camp where the malarial factor was recognized as potent, some time usually
elapsed before the enteric essential of the camp fever was distinguished, and during this
period a failure to control the disease was attributed to inefficient sj^eeific medication in the
early stages. Quinine under these circumstances was occasionally used with a freedom which
was not continued after the presence of the unimpressionable typhoid element was appreci-
ated. For instance, in the service of the 27th Conn, during the months of February, Marcli
and April, 1863, J cases 1-6, four of which terminated in death, were treated with fifty or
sixty grains dailv in repeated ten-grain doses; in case 2, two hundred grains were consumed
in four dnys; in "i, two hundred and forty grains in five days; in 6, three twenty-five-grain
doses in one day. But the intestinal lesion of typhoid fever discovered in the body of Dolph
(case 330 of tlie post' m or fern records) on March 20 put an end to this lavish administration
of quinine.
Typhoid fever, whether in its pure or )nodified form, was almost invariably treated by
what has been called the rational method. Efforts were made to restrain the violence of
abnormal actions, to protect tlie patient against harmful influences, to support his failing
energies until the febrile course had ended, and to rehabilitate his system after the attack.
A few extracts from sanitary reports are herewith submitted :
Siirgeoii M. R. Gage, 25th JT'is., Coliimhiis, Ki/., March 31, 18G.3. — At the outset the intestines should lie cleared by
an active purgative, and laxatives prescribed from day to day to keep tlieni ojien if they do not act unaided; but when
the vital forces are much depressed or the symptoms indicate ulceration of the intestinal glands, purgatives should be
avoided, and if anything is required only the mildest laxatives should be used. Cold water is applied to the head by
means of a linen rag frequently renewed. If there seem to be hejiatic derangement, mercury is administered in altera-
tive doses and with caution affecting the gums, but not jiushing the remedy to salivation. If diarrluea ensue or there
be much nervous manifestation, Dover's jiowdermay be ))rescribed with lienefit; and if intestinal uheration be diag-
nosticated fomentations to the abdomen and clipping are fre(inently beneficial, as also the internal use of spirit of
turpentine. Effervescing draughts may lie prescribed from time to time in this disease with good effect, allaying
thirst and dissipating fever, except in cases troubled with diarrhoea, — and even in these, if a little Dover's powder be
given to control t!ie relaxed bowels, they may still be resorted to; solution of acetate of ammonia, weak lemonade
and an occasional slice of orange do much to gratify the patient and no doubt prove serviceable by allaying excessive
heat and that unpleasant dryness and parched condition of the month and throat so distressing to sufferers from fever.
Bathing or sponging once or twice in twenty-four hours with water of a temperature which feels comfortable to the
surface, and to which a small quantity of carbonate of soda has been added, is very grateful to the feelings and of
some value in keeiiing the skin in a proper condition to exhale the poisonous matters so constantly and rapidly gen-
erated within the body. When the case is protracted and manifests increasing prostration of the vital forces resort
may be had to beef-tea, wine, carbonate of ammonia, etc., to sustain the enervated and sinking powers.
Jas'l Surgeon O. Peahody, 23d Iowa, HoUa, Mo., Nov. 30, 1862. — None of our purely typhoid fevers have spent
their entire force upon the bowels, and we believe that we have diverted it from them by the avoidance of all active
purgation in the progress of the disease. We have depended almost wholly on the very mildest of purgatives, sponging
of the surface daily, citrate of potassa as a diuretic and diaphoretic, veratrum viride to control vascular action when
necessary and, in the later stages, turpentine emulsion and wine freely with beef-tea. No case has been protracted
beyond five weeks, three weeks being probably the average duration.
Surgenn Philip Harvey, \Wi Iowa, Springfifld, Mo., Dec. 1, 18(i2. — Fevers of a typhoid character have presented
the usual symptoms, as dry tongue, sordes, tendency to stupor and diarrhoja with asthenia. In their treatment but
little medication was employed: Saline effervescing draughts in the early stages, guarding against diarrhu-a in the
*Sicjw-o, page 373. fSiipra, page 249. J See si(j)ra, page 250.
rONTTNURT) FEVERS. 539
progress, and moderate venous stimulaiiim in the decline constituted the method of cure; and its results were satis
factory.
Suri/eon C. \V. Steahxs, Ml X. )'., Fort Mcllinnj, Mil., Jan. 1, 1862. — Experieuce in the course and treatment ol
typhoid fever in this region has been very instructive. Eliminating remedies, all of which lielong to the class of
depressents, if used at all, must not he continued beyond the first or second day, after which a tonic au<l stimulant
course must be begun and continued with little regard to local symptoms or complications. The truth of this has
been illustrated in the opposite results of two recent cases of typhoid pneumonia: In the fust, that of Corporal
Kcssler, I could not resist the temptation to employ some simple and not very depressing remedies to relieve cough,
pain and other pulmonary symptoms. The ]>atient died. In the second, that of Private Martin, the chest symptoms
were even more urgent and distressing, hut I resolutely abstained from prescribing any of the so-called iipprnpyiiilc
remedies, continuing instead the fre<iuent use of stimulants and tonics. He is now recovering. Two other cases
may be mentioned as of interest: Private Morgan, with tyjihoid fever characterized by all the worst sym|itoms, as
coma, subsultus, involuntary discharges, a dark cold surface and some rigidity of the muscles, is now, under slimu-
!aut treatment, nearly well enough for duty. Corporal Ilagedore had. as a sequel of remittent fever, an enormous
u-ilema of the scrotum and ]>re]>uce, which terminated in sloughing of the integuments so that the testicle and body
of the penis were left wholly bare. Hectic, with numerous small abscesses, supervened. Yeast poultices, with char-
coal, tincture of iron, porter and good diet were employed in due course, ami the patient is now regaining Hesh and
strength, whi'e nature is rapidly replacing the lost integument.
Siinjeon R. \V. Hazlett, ,5(/i IFesi Va. Cav., Elkwatey, T'a., Oct. 1, 1861. — Typhoid fever predominated in September.
Our success in its treatment is attributable to careful nursing rather than to medication. Supporting iliet with
jndii'ious stimulation has restored many tmfavorable cases.
SiiiuitOH W. H. TllAYEU, II//1 .V. //., (IrfutVs Crogs liotuh, Md., Janiiar;/, 18t!:?. — The i)roiiortion of fatal ca.ses of
typhoid fever was large although the general character of the fever was mild. Death occurred in one case from profuse
intestinal henu)rrliage and in another from exhausting diarrhcea; in neither of these was there any cerebral disturb-
ance. In three delirium was the principal symptom, continuing until death in the'second week. Rose spots have
uot been found in all cases and only in a few instances have they been abundant. (Edema of the extremities followed
the fever iu four cases. Sulphate of qiiinia or of cinchonia has been employed in every ca.se, — in mild cases the former
ill three-grain dose.s daily, or the latter in twelve-grain doses, has been the sole medical treatment. The quantity
ailministered has depended upon the severity of the ca-se; sulphate of quinia having sometimes been given to the
amount of twelve, twenty or even sixty grains daily. When there was great debility whiskey was employed, or
brandy if urgent diarrluea was present. When, in addition to debility, there was much pulmonary congestion or
extensive bronchitis, carbonate of ammonia was also exhibited in fretiueutly repeated doses. licef-juico and milk were
given as nourishment. Convalescents were fed on beef, eggs, milk and bread. Diarrho-a was met with opiate injec-
tions; a drachm or a drachm anil a half of laudanum usually checked the evacuations for about twelve hours, and in
some ca.ses after two or three administrations tin- intestinal condition became apparently much improved. Sinapisms
were employed for the relief of abdominal pain. Roasted a)))ile was allowed to every patient. Latterly cold tea has
been used instead of water as a drink, on the sn.spiciou that the water of this region j)r<)dnced a tendency to dfarrhnea.
One ca.se deserves particular mention: .T. M., age 20, in the third week of typhoid began to fail on account of the
severity of the diarrlnea. About the eighteenth day he vomited everything and appeared moribuud, his eyes sunken
and surrounded with dark areola- and his extremities cold. .\11 attempts to administer food or medicine were discon-
tinued. After some hours fasting the vomiting ceased and the patient began to take champagne in half-ounce doses.
This was contiuued three or four times an hour until the one small bottle that had been procnreil was finished ; after
this cider was given, two or three ounces every hour for thirty-six hours. Then we ventured on beef-tea in small
quantities, and cm the fourth day gave milk, with a little hard bread on the following day. There was no subsequent
voinitiug; the patient improved slowly from the day after the change took place. After five days of constipation an
enema bronght away an abundant and well formed dejection. Thirteen days have now elapsed since he began to
improve and no untoward symptom has appeared. He sits up a little daily; his food consists of eggs, beefsteak,
milk, apples and l>read and tea. No medicine has been employed during his convalescence, and the cider has l)een
discontinued for several days.
Surgeon J. T. Calhoux, 74(A .V. Y., Camp Kearny, Alexandria, Va., Oct. 10, 1862.— The treatment consisted of a
mild cathartic at the outset, followed by diaphoretics; as soon as the debility characteristic of the disease showed
itself stimulants were given freely, — quinine, whiskey and oil of turpentine were used with turpentine frictions to the
abdomen. When cerebral disturbance was troublesome llotl'mann's anodyne was mostly relied upon. With the stimu-
lants a rich diet was allowed: beef-tea, eggnog, milk-punch and oyster or chicken soup. — but, although we had a
large hospital fund, it was often ditticult to follow out this line of treatment. The unfriendly inhabitants refused to
•ell to us, and communication with the outside world was indirect and uncertain. The scanty allowance of alcoholic
stimulants permitted in the field fell a prey to the teamsters during its transit from Washington, and we had to
depend for our supply upon li(|uor confiscated from trading sloops which carried on an illicit trade with the soldiers.
Oysters we could generally procure and oyster soup was a stand-by. Eggs were bought at fabulous prices when
obtainable. Xo less than three of my patients died after the establishment of convalescence bi-cansr jircjiier food could
not be provided for them daring a temporary suspension of fresh-meat issues.
Surgeon R. N. Barr, 36(A Ohio, Sumtnerrille, r«., Xor. 1, 1861. — There has been a comparatively large number of
fever cases, and what is peculiar, every ca.se of illness of whatever character speedily assumed a typhoid form and
yielded slowly to treatment. In most cases my reliance is on quinine, whiskey or brandy in large ;ind repeated doses.
540 TREATMENT OF THE
When I diminisb or omit these remedies my patients rapidly siuk exhausted. The epidemic, for such it is, does not
appear to have reached its climax, nor is it confined to the soldiery, but aft'ects also the inhabitants of the surround-
ing country. * * * The season has been unusually wet; drenching rains have fallen for days together. Resident
physicians ascribe the epidemic to this cause and look confidently for its disappearance when cold weather sets in.*
Attempts to suppress or favorably modiiy the disease by emetics in the early period
were rarely made. A few instances of this kind may be found in the service of the 19th
Mass., cases 3, 4, 10 and 12.f The plan appears to have been tried also at Fort Monroe, Va,
Usually, however, on the arrival of a fever patient at a general hospital the first means
adopted to promote liis well-being were, in the absence of peremptory indications for other
measures, a much-needed bath and a full dose of Dover's powder. These, with a few hours
of rest and quiet, perhaps of sleep, tended to free the case from much of the temporary
excitement or exhaustion due specially to the fatiguing journey from the front.
The relaxed condition of the bowels, so intimately associated with the essential lesion
of typhoid fever, was frequently held in check by the Dover's powder or other opiate admin-
istered as an anodvne, calmative, sudorific or hypnotic. Enemata of starch and laudanum
and pills of acetate of lead, tannin and opium were favorite remedies when diarrhoea was
active and threatening. The use of the former may be noted in cases 27, 62 and 97 among
others of the Seminary series; of the latter in 18, 45, 47 and S6 of the same series, and in
51 of the post-mortem records; chalk mixture was employed in case 11 of these records,
nitrate of silver and opium in 35 and subnitrate of bismuth in 85; catechu in 32 and 46 of
the Seminar)' series.
But although the pathological tendency was to diarrhoea few of the cases ran their course
without being subjected at some period to the action of laxative or active purgative medi-
cines. In case 38 of tlie Seminary records the object of the cathartic was apparently to
allay cerebral congestion, and in 13 repeated doses of castor oil and extract of senna were
administered on account of headache and dizziness towards the. favorable close of the case;
l)iit ill 'most instances the movement of the bowels was the primary object in the exhibition
of laxative or cathartic medicaments. Sometimes this was effected by enemata, as of soap-
suds in 36, 46 and 85. ■ In 29 no stool was obtained without the aid of castor oil except on
the day of admission. In 8, 9, 13, 15, 38, 39, 62, 63, 67, 73, 75 and 108 such cathartics
as calomel, jalap, compound cathartic mass, blue-pill and sulphate of magnesia produced no
undue effects, although in some of these, as 73, increased tenderness of the bowels was noted
after the administration; but, on tlie other hand, the benefits derived or expected to be
derived from their use are not clearly indicated. Moreover, in case 6 tliere was no promi-
nent abdominal affection until after the administration of castor oil; in 79, also, an exhaust-
ing diarrhoea followed the use of tliis laxative agent. In 21 two six-grain doses of calomel
were followed Ijy diarrhceal stools, with much abdominal tenderness and tympanitic disten-
tion; in 103 calomel and jalap induced frequent evacuations which were associated with
acute abdominal tenderness. In case 8 of the record of the 27th Conn, three compound
cathartic pills gave rise to eight small bloody passages, with pain in the right iliac and epi-
gastric regions, and an ounce and a half of sulphate of magnesia, subsequently administered,
induced six copious watery evacuations. The patient recovered; but it is difficult to con-
ceive in what manner this irritant action on the already inflamed and ulcerated mucous
membrane of the intestine contributed to the favorable result. In fact, the claims of activi'
cathartics to a place in the rational mode of treatment of typhoid fever do not appear from
the records to be well grounded.
* See Iteport, supra^ page ?.27. f See supra, pp. 255-257.
CONTINUED FEVERS. 541
As directed against the cornplexus of syinptoms constituting the febrile condition ipe-
cacuanha and opium, in tlie form of Dover's powder, was generally employed. Usually it
was given at bedtime to induce a restful night. Sometimes in mild cases no other treat-
ment was prescribed, as in the typhoid left after the suppression of the malarial element in
case 109. Occasionally, as in 86 and 110, sweet spirit of nitre was used to supplement the
effects of the Dover's powder. To these a saline solution was sometimes added — the acetate
of potassa, as in 107, or the corresponding ammonia salt, as in 38, 99 and 119. Camphor
was used with the ethereal spirit in 25; digitalis in 49, and veratrum viride in 105, in
which the pulse war, frequent, quick and strong, with pulmonary inilainmation threatening.
Nitrate of potash was used to control the febrile action in some of the cases that occurred in
the 19th Mass.; tincture of aconite in 65 and 6S of ilm post-mortem records.
v^mall doses of mercurials, usually calomel or blue-pill in conjunction with opium, were
given in many cases, as 82, 83 and 85, for a few days at a time, evidently with the view of
controlling the deposits in the intestinal and mesenteric glands; in 99, 100 and 105 these
were combined with quinine, and in 84, 90 and 101 with antimony; but so far as shown liy
the records the constitutional effects of the remedy wore not produced in an)' of these cases.
In 123 liquid eff'nsion in the pericardium or pleura was promptly absorbed on the occurrence
of salivation. Ptyalism in case 17 of the post-mortem records did not prevent death from
perforation of the ulcerated patches. In some cases in which jaundice appeared as a symp-
tom, as in 121 of the Seminary series, small doses of calomel and opium wen; aJiuinistcred;
in others, as in 67 and 112, blue pill and quinine constituted the treatment.
Cold was applied to the head by means of wet cloths when headache was violent or in
the presence of cerebral hypersemia, as in cases 36 and 38. Sometimes, as in 257 of the
post-mortem records, blisters were applied to the back of the neck to counteract the eflPects
of intra-cranial congestion. Sponging the body with tepid or cold water was frequently
employed as a means of reducing febrile heat and conducing to the comfort of the patient.
The reports of Surgeons Walton,* GRANGERf and Rkad J refer to the beneficial results of
this practice. In case 46 muscular pains in the limbs are said to have been relieved by
sponging the surface with alcohol.
Turpentine was as extensively used as if it had lieen considered a specific in typhoid
fever. Generally it was given when the tongue became dry and brown, and particularly
wlien this organ was dry, red and glossv, or when the abdomen was t3'mpanitic and tender.
It was administered in doses of ten or fifteen drops, repeated every throe or four hours; an
emulsion made with gum arable, sugar and cinnamon-water was frequently prescribed. Its
use was continued only for a day or two at a time ; but in case 268 of the post- moi'tem recoi'ds
it was employed for eight consecutive days.
Some medical officers have expressed much satisfaction at the favoi'able results obtained
by the administration of this remedv.§ The frequency of its use also testifies to a high
estimation of its virtues. But when the individual cases that have been presented in this
chapter are examined with reference to this point the beneficial effects of the remedy do not
appear to be so definitely established. Notes of the administration of tui'pentine are found in
seventy-two of the cases already presented from the clinical records of the Seminary hospital.
the 19th Mass. and 27th Conn.; but the records of some of these are so imperfect in their
• S>j>ra, page 316. f Supra, page 317. J /ii/ni, pego M7.
i Sw, for instance, the report of Aes't Surg. J. C. McKee, I". S. .\rDiy, stiprti, p. 60.
542 TEEATMENT OF THE
details of progress tliat, although the cases terminated favorably, they cannot be admitted
as evidence of tlio value of the remedy. On account of similar imperfections the records of
fatal cases cannot be used to testify to the inefficacy of the remedy, — the treatment by tur-
pentine was in some instances begun such a short time before the fatal termination that their
records cannot with propriety be considered in an investigation of this nature. It seems
proper, also, to exclude cases in which the mildness of the attack gave no opportunity to
emphasize the action of the medicine, as well as those which, although grave in their gen-
eral aspect, did not present a high development of the symptoms which the oil of turpentine
was assumed to control. On these grounds twenty of the seventy-two cases may be dropped
from consitleration.
Some improvement was observed to follow the use of turpentine in nineteen of the
remaining fifty-two cases; no improvement in thirty-three. But it is questionable if the
alteration in the condition of the patient can be with propriety attributed to this particular
medicine in all the cases in which the symptoms were favorably modified subsequent to its
use. When the imjjrovement in a febrile case is general and not confined to the condition
of a particular organ or set of symptoms its cause must be ascribed to influences affecting the
system as a whole. A remedy directed to a specific object may not be credited with a local
beneficial result which would have happened irrespective of it as a part of a general effect.
It will be shown hereafter that turpentine had no influence on the cerebral symptoms of
typhoid fever. When, therefore, in a ease of this fever the administration of turpentine for
a dry glazed tongue and tympanitic abdomen was followed by relief not only to these condi-
tions but to all the other symptoms of the complex febrile state, the local im])rovement must
be regarded less as the effect of the remedy than as a part of a larger effect produced by some
general influence, as a crisis or lysis at the natural termination of the febrile attack. Probably
in at least seven of the nineteen cases in whicli favorable results followed the use of turpen-
tine a doubt may be reasonaljly entertained as to the cause of the improved condition ; these
are 15, 19, 38, 40, 68, 71 and 86 of the Seminary series.
There remain, therefore, but twelve cases, 22, 27, 31, 36, 44, 45, 51, 93, 99, 113, 114
and 119 in which an improved condition of tlie tongue or an amelioration of the intestinal
symptoms may be attributed to the internal administration of the oil of turpentine; and
even these are not without qualification: In some, as 27, 45 and 119, the improvement
may have been in a measure due to the astringent remedies given at the same time; in
some, as 36 and 93, tlie relief was but temporary, the intestinal symptoms recurring at a
later date; and in one, 113, the connection between the condition of the skin and the presence
or absence of diarrhcea ai^pears to have been decidedly more intimate than that between
the intestinal symptoms and the administration of turpentine.
To oflfset these there are among the fifty-two cases thirty-three in wliich the details,
given with precision, discountenance the idea of a beneficial effect from the turpentine
treatment. In twenty-four of these the abdominal symptoms persisted or became aggravated
after the administration of the remedy, and in nine they were actually developed shortly
after its use. These are particularized in the subjoined analysis.
Similar results are obtained from a study of the cases submitted as the post-mortem
records of the continued fevers. In seven only of this large number of cases was some
improvement noted after the use of turpentine. In one, case 96, the remedy is said to have
disagreed with the patient. In thirteen cases in which a reference to turpentine has been
CONTINUED FEVERS. M^
preserved in the published records, by way of keeping in view tlie nature of the medication
adopted in these cases, no intimation of a favorable change can be drawn from the state-
ments given. In many others in which references to the treatment have been suppressed
in the published reconls as valueless by reason of their isolation from unrecorded correlated
facts, nothing is shown by tiie original papers except that although turpentine was used at
some stage of the malady the ultimate result was death.
The absence of any restraining influence exercised by this remedy on symptoms uncon-
nected with the intestinal canal may be readily gathered from an examination of the cases:
In 22 delirium continued for six days after diarrheeal symptoms had subsided subsequent to
the use of turpciitiui'. In 23 delirium supervened on the day after turpentine was admin-
istered, and persisted for eight days thereafter. In 21 all the symptoms that are usually
regarded as unfavorable prognostics, excepting those connected with the local lesion — as
exliausting diarrhoea, intestinal hemorrhages and indications of peritonitis from perforation
of the gut — were present for nearly two weeks after turpentine was used. Among other
instances of the coutinuance of cerebral symptoms cases 28, 32, 84, 87 and 97 may be
specially mentioned.
Analysis ok Cases ok Continiiek Fk\ kk in which TuitrKNTixE was used to modify the condition ok the
TONCl'E OK MITKiATK THE CUCENCY OK INTESTINAL SYMPTOMS.
C<M<'» ill tilihh III! improred condilion of Ihv tniuiuc or un amclionilion of the intestinal siimj>loms mai/ be attributed to the ittlcrnal
line of the rtiiicdji."
Cask 22. — The tongue cleaned ami iliai ilid-a snlpsided within t'diii' days after tlie reniedj was nsed, liat li-liiiii^
delirium continued I'nr six da.vs Idnjiei'.
Case 27. — When turpentine was jjiveii in this cuse the jialient was muttering in thedelirinui of I yptioid, his
tongue lirownish gray in the centre, red at tlie tip and margins and his bowels loose and tender. Two days later the
tongue was cleaning as part of a iierniani'iil improvement: hut opiate eiiemata were used in conjunction with the
emulsion on behalf of the intestinal symptoms.
Case 'M. — Tnri>entiue given late in the disease, when the tongue was dry from i>Mlnionary complications, was
followed by an im]irovement in the jialient's comlition.
Case 3t>. — The tongue became moist ami the tympaniteKiliniiiiislied after the admin isl rat ion of the ri'iuedy on the
twentieth day; but diarrhcea, involuntary stools and ahilominal tendeine.ss were noted at a later date.
Case 44. — A moistening of the dark-colored tongue followed the use of turpentine, but otherwise the symptoms
appeared unchanged.
Case 45. — Diarrhoea and meteorism, treated with turpentine on the ninth day, became relieved in a few days,
and the bowels thereafter remained quiet or with not more than one movement daily; but acetate of lead, tannin and
opinm were used coincidently.
Case .51. — Treatment by turpentine, support and slimiilation was followed by a subsidence of diarrho'a and
return of appetite.
Case S'S. — A temporary improvement , involving the disappearance of meteorism and of the fur from the tongue,
followed the use of the remedy: but diarrh<ea continued, and the case terminated fatally witli hemorrhage from the
bowels and laryngeal and pulmonary intlannnatory complications.
Case 99. — In this <:aKe the tongue was dry, and although the bowels were (|uiet there was some tenderness and
meteorism. After the use of turpentine the condition of the tongue remained unchanged, but an improvement was
manifest in the cerebral and abdominal symptoms.
Ca.se 113. — Diarrhoea subsided temporarily after the use of turpentine, l)ut al)dominal tenderness and distention
persisted. In this case the connection between the condition of the skin and the presence or absence of diarrhroa
appears to have been more intimate than that between the intestinal symptoms and the administration of turpentine.
C.VSE 114. — Relaxation and tenderness of the bowels, which ajipearcd in the list of symiitoms before the use of
turpentine, were not noted after its employment, although the general symptoms continued grave for some time.
Case 119. — I»iarrha>a was controlled but tenderness and distention continued. Acetate of lead, tannin and
opium were given at the same time.
Cawn in irhiih n favorable modifieation of the symptoms foUoaintj the use of turpentine may with propriety be suggested as due
to other coincident conditions.
Case 1.">. — Two days after the institution of the treatment by turpentine the tongue was cleaning and the bowels,
although slightly tympanitic, were cjuiet and free from tenderness: but as this occurred at a somewhat late period
of the attack and was gradually followed by convalescence, the probability of a natural lysis is suggested.
* ^\'hen not otlienvise stated the cases cited are from tlie Seminary hospital nerieci.
54:4 TREATMENT OF THE
Case 19. — The defervescence which took place two days after the use of turpentine was probably a natural
crisis by perspiration.
Case 38. — Tlus dry, liard and fissured tongue became moist and clean after turpentine was administered, but
the general character of the improvement suggests a natural defervescence.
Ca.se 10. — The improvement following the use of the remedy may be attributed to the subsidence of the pul-
monary inllammation which preceded the attack of typhoid. The tongue became dry and brown and the bowels
tender though not very loose in the subse(|uent febrile course.
Cases 6S, 71 and 86. — The general character of the improvement, and the period at which it took place, raise
a doubt as to its causative agency.
Coses ill which the rtcords do not show that any beneficial effect resulted.
In cases 78, 82, 95, 100 and 117 the want of precise details of the progress of the disease prevents the beneficial
eifects of turpentine, if any were exercised, from being known.
In cases 42, 48 and 91 of the Seminary series, and in 13 of the 19th Mass., the institution of the treatment by
turpentine was so delayed that the speedy approach of death iirevented any manifestation of its assumed remedial
powers.
Case 18. — When turpentine was given, on the eighteenth day of the attack, the patient was much exhausted by
night-sweats; his tongue was dry and brown, but he had no diarrho'a. The record does not show that any improve-
ment resulted.
Case 32. — Turpentine certainly did not exercise any favorable influence on the cerebral symptoms in this case;
nor is it clear from the record that the diarrhica, borborygmus, tenderness and tympanites were immediately relieved.
Case 80. — The remedy was administered after the abdominal symptoms had ceased to be distressing.
Case 104. — No special action of the turpentine can be inferred from the record. Perhaps the large quantity of
urine passed during the twenty-four hours immediately succeeding its administration may have been due to its diuretic
action; but that any favorable impression was made on the intestinal symptoms is doubtful, as a blister was applied
to the abdomen on the seventh day after the emulsion was prescribed.
Cases in which it is difficult to assign a favorable action to the lurpentine on account of the want of ijravitij in the abdominal
siiiiijjtomsfor which its use is recommended.
C.\se 7. — The tongue was red, smooth and glossy; the teeth blackened ; some abdominal tenderness and gurgling
was present but no meteorism. Turpentine was given on the ninth day and convalescence established on the fifteenth.
Case 13. — The abdominal symptoms were prominent neither before nor after the use of turpentine in the third
week of the attack.
Case 14. — A light febrile case which, though of some duration, did not present any of the indications men-
tioned by Professor Wood as calling for the use of turpentine.
Case 23. — Deliriuui supervening on the day after the turpentine treatment was commenced continued for eight
days, but the abdominal symptoms were not prominent.
Case 24. — This case, after admission on the twenty-second day of the disease and the institution of the turpen-
tine treatment on the following day, presented a series of grave symptoms — including delirium, unconsciousness, sordes,
dilation of the pupils, floccitatio, subsultus, inability to articulate, otorrhrea, bedsores and vibices — that did not sub-
side until the thirty-fiffch day, when a less frequent pulse, cleaning tongue, returning intelligence and moist skin
indicated the commencement of convalescence.
In 60 and llo the abdominal symptoms were so mild that the influence of turpentine as a remedial agent cannot
be determined from the records.
Cases in which diiirrhoa or other nbdominnl f^i/iiiptoms jiersisted or became aggrarated afterthe use of turpentine.
Ca.se 25. — Frequent stools, sometimes passed involuntarily, delirium, sordes, etc., persisted for many days after
the use of the emulsion.
Case 26. — This case presented a red, dry and glossy tongue, diarrha?a of some frequency, much meteorism, but
no tenderness. These symptoms persisted for a week notwithstanding the administration of turpentine, stupor and
delirium meanwhile supervening, the tongue beconnng dry and dark and the teeth covered with sordes.
Case 28. — Diarrho'a, abdominal tendernesa, gurgling and meteorism appear to have been as distressing after
as before the use of the remedy. Not until three weeks afterward did the cerebral symptoms subside, and with them
the manifestations of the intestinal lesions.
Case 29. — Tenderness and tympanites in this case do not seem to have been favorably modified.
Case 34. — The tongue was dry, fissured and brown-coated, the teeth covered with sordes and the abdomen
tympanitic when tur]ientine was given. No notable change followed until eight days later, when the tongue cleaned
and delirium subsided.
Case 37. — This was characterized by two passages daily, with slight tenderness and gurgling; tongue brown
in the centre, its margins red. Turpentine did not effect any change in these conditions.
Case 43. — There was much tenderness, some tympanites, little diarrhiea and a moist tongue, coated except at
the edges. After the use of turpentine the tongue became dry and the intestinal symptoms persisted, if, indeed, they
did not become aggravated.
Case 46. — Turpentine was used on the seventeenth day, the bowels at the time being loose and tender, the tongue
smooth and dry in the middle and moist at the edges. Next day the bowels were quiet but meteorized and acutely
i i
continuf:d fevers. 545
tender. The tenderness persisted on the ninoteentli day, but the tympanites was reduced and the bowels relaxed,
an enema of soapsuds liavinj; been administered meanwhile. On the twenty-first day the ton;;ue was smooth, glossy
and dry, and the bowels loose, tender and meteori/ed. The tongue did not become clean until the twenty-sixth day.
Case 47. — Xo improvement resulted from turpentine administered ou the seventh day; for the grave symptoms,
including diarrhoea, were not relieved until five days later, when the tongue became moist and began to clean in
patches,
C.\SE 50, — Turpentine was not beneficial in this case, for from the time of admission the condition of the jiatient
gradually changed for the worse, the stools becoming involuntary and the prostration extremo.
Case G4. — When remitting fever gave place to a continued form in this case turpentine was substituted for
quinine, the patient having a dry tongue and fn-cincnt stools. Its further progress was marked by abdominal symp-
toms, whieli appeared rather to alternate with pers]>irati(nis than to indieate the iiilluence of any s])eci,il uuMtication.
Case 70, — .Severe diarrhu-a and abdominal pain i)ersisted for ten days after turpentine was prescribed on the
seventeenth day,
Ca.sk 74. — Turpentine was given on the eleventh day for intense abdominal tendi'rness. From this time to the
end of the fourth week the patient's general condition remained unelianged; his tongue tlabby and y<'llow-furred ;
bowels moved from one to seven times daily, with general and oeeasionally umbilical and left iliac tenderness, and
with sometimes slight tympanitic distention.
Case 75. — Turpentine was given on the eighth day: but for several weeks after this there was a notable relaxa-
tion of the bowels, with more or less tenderness, chietly in the umbilical and left iliac regions.
Case 77, — Involuntary diarrhceal stools, abdominal tenderness .and distention, with a dry, brown tongue and
sordes, persisted for a week after the use of turpentine.
Case 81. — The benelicial effects are not manifest in this case, as subse(iuent to tln^ use of the remedy sordes
appeared on the gums, the stools were pas.sed involuntarily, and eight days afterward the tongue was dry and tremu-
lous and the bowels loose.
Case 84. — After turpentine was given cerebral symptoms were manifested, while diarrluea and tympanites
appear to have beenuggravated. Treatment was complicated by the administration of calomel, opium and antimony.
Case 87. — For three days after turpentine was used there was luit little improvement: diarrhoea continued,
cerebral symptoms were developed and afterward pulmonary inllaniniation.
Case 90. — Intestinal and cerebral sym|)toms persisted for nine days after the use of turpentine.
Case 97. — Diarrha'a was aggravated and cerebral symptoms developed after the u.se of turpentine, all leading
to a fatal result thirteen days later.
Case 111. — The intestinal symptoms do not appear to have been favorably modified by turpentine; tenderness
or looseness of the bowels was noted on the days following the use of the remedy.
Case 118. — On the third day after the administration of turpentine the condition of the patient remained
nnchanged. At this time an enema of castor oil and turpentine relieved the tymp.anites.
Case 7, 19tli JIass,— The freiiuent but bloody and scanty stools which characterized this case were not favorably
modified nor were the general symptoms alleviated.
Case 4,27th Conn. — Following the aduiinistnition of turpentine for abdominal distention the tongue, which
had been somewhat moist, became dry, cracked, dark and bloody; tympanites was not relieved until six days later,
Case8 in u-hich intestinal si/nqytoms iccre developed strikinghj after the administration of turpentine.
Case 6, — The remedy was given as the eruption appeared, the tongue being dry in the centre but moist at its
edges, and the patient having had no diarrhtea, tenderness or tympanites. Two days later the tongue became red, dry
and glossy, and diarrhoea w ith umbilical pain was developed, castor oil having been administered in the meautime,
C.\SE 16. — The tongue was dry, red and glazed, and the bowels quiet when turpentine was given, but the further
somewhat prolonged progress of the case was characterized by diarrhoea of three to five stools daily, nieteorism, and
right iliac, umbilical and general abdominal tenderness.
Case 21, — Turpentine did not prevent the occurrence of three or four stools daily, with much abdominal ten-
derness and tympanites, which, however, may have been due to medication by calomel and not alone to the morbid
processes induced by the febrile poison.
Case 69. — Four days after t be use of turpentine diarrhiea appeared as a prominent symptom, speedily associated
with tenderness, especially acute in the right iliac region.
Case 79. — In this case, as in 6 and 21, the effects of turpentine were complicated by the use of purgative remedies.
Case 94, — A fatal issue, with much diarrho-a and nieteorism, was not prevented.
Case 96. — M\ the grave symptoms in this fatal case were developed after the administration of turpentine; but
the intestinal symptoms were not prominent.
Case 101. — A few days after turpentine was administered for intestinal distention diarrhoea was developed,
which continued for more than a week, associated with pain in the epigastric region and gurgling in the right iliac
fossa and along the track of the colon.
Case 116, — Two days after the use of tur]ientim> the bowels, w hieh had been (juiet, became loose.
Turpentine in the Casks oi' the I'ost-mohte.m Kkcokds, — The notes of treatment in many of the cases sub-
mitted aa post-mortem records were omitted in preparing the cases for publication; but they were retained in every
instance in which they were recorded with precision and also in several in which they merely indicated the method
adopted,
Xo intimation of even a temporary improvement from the use of turpentine is found in the records of 10, 11,
Med, Hist,, Pt. Ill— 69
546 TREATMENT OF THE
35, 40, 78, 83, 89, 95, 111, 247, 248. 258 and 264, or in any of those in whicli the references to treatment have heen.
suppressed as valueless.
In 96 turpentine is said to have been tried, .and discontinued on account of disagreeing with the patient.
In seven cases some improvement \vas noted, as follows: 17. — The dry, red and glazed tongue became moist and
sordes disappeared, but death was precipitated by perforation of the intestine. 43. — The dry, dark, cracked and glazed
tongue, sordes, diarrho-a, abdominal tenderness and tympanites were favorably modified by the use of turpentine
for about three days, when fatal pneumonia supervened. 79. — The patient suffered from typhoid delirium; tongue
dry, red and gashed; bowels loose and tympanitic. After the use of turpentine the tongue became moist and the
bowels checked, but diarrhoea suddenly recurred and death took place in a short time. 88. — Progress was favorable
under turpentine until abdominal pains set in a few hours before death by coma. 105. — A temporary improvement,
the nature of which is not precisely stated, resulted from the use of quinine, turpentine and stimulants. 117. — Under
the influence of small doses of emulsion of turpentine and laudanum delirium subsided, the tongue became somewhat
moist and the pulse less rapid, but diarrhoea was subsequently established. 268. — Under the use of turjjentine, con-
tinued for eight days, tympanites subsided and the tongue began to clean, but a fatal stupor came on at a later date.
In case 300 the tongue, notwithstanding turpentine, continued red and dry for several weeks.
The testimony on behalf of turpentine is not encouraging; nor is this unexpected when
the pathological conditions are held in view. The tenderness and tympanitic distention of
the intestine and that dry and dark or scaling and glazed tongue which, in accordance with
army practice, suggested the use of the remedy, were generally associated with extensive
ulcerations that admitted of no sudden'reparation and return of the affected parts to a healthy
state. A mitigation of the urgency of distressing or dangerous symptoms was all that could
be hoped for under the conditions. This was sometimes obtained. Hence it is probable
that, were these cases to come up anew for treatment at the present time, turpentine would
be as generally used as in the past, in the absence of any more trustworthy method of exer-
cising a salutary influence on the sloughing or granulating patches of the affected mucous
membrane.
That part of the rational method of treatment which looked to the support of the failing
energies of the system became, in many cases, of so much importance that in practice it ceased
to be known as a part of the expectant plan. It became the supporting or stimulant method
of treatment. In some mild cases its use was unnecessary. Few, however, of the serious
or protracted cases reached their termination without undergoing systematic treatment by
quinine, iron, alcohol and nutritives. The so-called typhoid symptoms — ^increasing prostra-
tion and tremulousness, muttering delirium, dark tongue, sordes, subsultus, etc. — -were inva-
riably met by support and stimulants; but these were often employed long before the devel-
opment of such dangerous symptoms. In many cases as soon as the pulse lost its fulness
tincture of iron was prescribed in doses of twenty drops three times a day, with alcoholic
stimulants, small doses of quinine and the use of beef-essence at short and stated intervals.
This was continued to the end of the attack and in favorable cases well into the period of
convalescence. Citrate of iron and quinine were employed in some cases. Quinine was
generally given in one-grain doses three times a day. Whiskey, in the form of milk-punch,
was the stimulant in common use; but wine, wine-whey and brandy-punch were also largely
employed. The quantity of stimulants varied with the necessities of the case as recognized
by the prescribing physicians. Some medical officers dispensed them with a liberal hand.
In case 2 of the post-mortem records, whiskey to the amount of six ounces was given daily,
and this quantity was afterwards increased to sixteen ounces on account of prostration.
Practically, in such cases, the patient took all that he could from time to time be prevailed
upon to swallow. As a contrast to this, the patient in case 249 used only half an ounce
of brandy three times a day. Suggestions of pulmonary and peritoneal inflammation prob-
ably kept the quantity at a minimum in this case; but in other instances stimulants were
given freely irrespective of inflammatory complications. In some cases, when the patient
I i
CONTINUED FEVERS. 547
was unable to swallow, stimulants were given, as in 84 of the Seminary series, by enemata.
The beneficial effects of this plan of treatment are not evidenced by the records, for cer-
tainly a larger quantity of alcohol was given to the average protracted, serious or fatal
case than to the typical mild case ending in speedy recovery. Nor can the fatality of the
disease as thus treated be compared favorably with the results of other treatment in civil
practice before or since the war. But as tjiis system of treatment aimed with all the power
of the therapeutics of the period at obviating the pronounced tendency to death from exhaus-
tion, it seems probable that had suitable comparisons been available a favorable exhibit
would have been presented.
In a few cases chlorate of potash was used as a remedial agent when typhoid symptoms
were present, as in 95 of the post-mortem records; in 111 of the same series it was given in
a more active stage of the fever without producing any apparent benehcial effects. The
following extracts relate to the use of this salt in the continued fevers:
Surgeon Ezra Rkad, 21st Ind., Fort Marshall, Baltimore, Md., Jan. 14, 1862. — In the treatmeut of typhoid fever I
haverelieil upon a liberal iiseof quiuineaiul a supporting diet. Where the tongue hecanie red and very dry I admin-
istered chlorate of potash in five-grain doses every three or four hours with great benefit. For several years I have
used it in like cases, and can recommend it with much confidence. It diminishes the redness and restores the natural
moisture more readily than any other remedy which I have used. For a like purpose I have not omitted the use of
turpentine in ten-drop doses every three or four hours where it seemed indicated. Well-ventilated rooms, scrupulous
attention to cleanliness and frequent sponging the body with tepid water, alone or mixed with vinegar or whiskey,
are absolute essentials in the successful nukiiagement of the disease.
Surgeon Robeut Hubisard, nth Conn., Jirool''s Station, Va., March, 1863. — The treatment of this disease by nutri-
tious diet and stimulants, of which milk-punch has seemed to operate the best, and when the tongue and mouth are
dry and sore the exhibition of iiuinine with turpentine emulsion or chlorate of potassa has been successful except in
one instance associated with an intractable and exhausting diarrhoea. Nearly all the cases of fever have had diar-
rhtra as a prominent symptom; but it has usually yielded to stimulants and farinaceous diet, with condensed milk.
Opiates and astringents have been used only when there was much sleeplessness and persisting diarrhrea.
Chlorate of potash was used as a local application in many cases in wUich the tongue,
mouth or throat was abraded or ulcerated. It may be noted also, with reference to the con-
dition of the tongue, that in 249 of the post-mortem records an effort was made to prevent
an excessive dryness of its surface by the local use of glycerine.
Opium, which was usgd so frequently in the form of Dover's powder in the early stages
to control fever and allay cerebral excitement, and at a later date with astringents to restain
diarrhoea, was also largely used when an aggravation of the abdominal pain suggested a
possibility of peritoneal inflammation. The frequent occurrence, in the course of the fever,
of therapeutic indications which could be best fulfilled by means of this drug rendered it
an important agent. In fact, it may be said of some hospitals that opium and brandy con-
stituted the essentials of treatment. In cases 13 and 14 of the post-mortem series, from the
ladies' Home hospital, New York, the treatment is said to have been effected in the one case
by laudanum, brandy, beef-extract and milk, and in the other by anodynes, alcoholic stim-
ulants and sustaining diet. Cases 19, 20, 82 and 226 of the same series may be noted as
illustrations of the use of opium to alleviate the intense pain of peritoneal inflammation;
in 50, the drug was given by enema on account, of gastric irritability. The hypodermic
syringe had not yet found its way into the hands of our officers.*
• It was not until after the close of the war that hj-iiodermatic medication began to be discus.«cd in our medical journals. Ruppaner's treatise
on HjfjHMUmic IiijfKtiotiti waj< nut publi.ihe<l until 186.S, altliough in 1860, in the Boslou Medirjii and Siinjicat Journal, its author called the attention of the
pnlenion to the value of the syringe in the treatment of neuralgia. Bartholow, in his Manual of Hypodermu: ^Indication, Phil»del|>hia, 18C9, ascritMiS
the new art to the discover}- of the |inicticahility and utility of introducing medicines under the skin for the relief of local pain, by Alexander Wood
of Edinburgh in 1*13, and the demonstration by Mr. Charles HrMER of London in 1859 of the important fact that the application of the injection to
the iiuafui points, k9 contended for by Woob, was ie»lly unnccessarj-, as equally good effects followed the introduction of the l^jcctloD into a distant part.
548 TREATMENT OF THE
For the relief of abdominal pain local applications were frequently employed. Warm
fomentations, poultices, cupping, turpentine stupes and blisters were used according to the
urgency of the symptoms. In case 300 of the post-mortem records woolen packing of the
abdomen was substituted for the poultice. A blister was applied to the abdomen in 85 of
the Seminary series on account of pain along the track of the colon and the passage of blood
from the bowels. Blisters were applied in 94, 96, 98 and 119 of the same series on account
of excessive tenderness and tympanites; in 50 and 93 of the pod-viortem records the resort
to cantharides was occasioned by pain following perforation of the bowel. In the last-men-
tioned case gray spots appeared on the blistered surface, and three days later an erysipela-
tous redness extended downward to the thigh;* liquor sodte chlorinatge and a strong solu-
tion of nitrate of silver were applied, without benefit, as a dressing to the sloughing surface.
Blisters and other counter-irritants were also used on account of pain in the chest con-
nected with pneumonic complications, as in 36, 38 and 41 of the Seminary series. In such
cases the local applications were often associated with general medication, as by small doses
of sulphate of magnesia and tartar emetic, calomel and opium, stimulants, expectorants, etc
Tympanites, which was frequently the cause of abdominal pain, was relieved in some
instances, as in 88 and 118 of the Seminary series, by enema, and in one, 96, by the passage
of a tube into the intestinal canal. Occasionally, also, the removal of retained urine was
followed by relief to abdominal pain; the catheter is reported to have been used in 121 of
the Seminary series, and in 6, 83 and 268 of the post-mortem records; retention was some-
times treated by extract of buchu, as in 28, 110 and 119 of the former and 65 of the latter
series of cases.
Hemorrhage from the bowels appears to have called for the use of persulphate of iron
in 109 and 335 of the post-mortem series.
Aromatic sulphuric acid was generally employed to control the exhausting perspirations
which recurred nightly in many cases at a late period of the disease, although in 18, 19 and
112 of tlie Seminary series it does not appear to have been very successful in checking them;
in the first-mentioned of these the surface was sponged with alcohol and dilated nitro-mu-
riatic acid, and in 83 with alcohol alone, as a means of lessening the perspiratory action.
When collapse was imminent warmth, frictions and rubefacients were applied exter-
nally, while capsicum, ammonia and brandy were freely prescribed.
Bedsores were prevented and treated by cleanliness, change of position, special padding
and sponging with alcohol. In 113 of the Seminary series a water-bed was used. Keen
speaks of the valuable results produced on bedsores by applying ice for fifteen minutes and
following this with a hot flaxseed poultice for two or three hours."j" One of the few reports
relating to the treatment of typhoid fever on file in this office urges the advantages to be
derived from change of position during the course of the fever.
Surgeon Charles Abbott, 26ih Me., Baton Souge, La.. January, 1863. — Typhoid fever .ijipears to be endemic, and
in its treatment we find it necessary to nse stimulants freely and easily digested animal food; also to change fre-
quently the position of the patient. This last point we consider of great importance, l>eing satisfied that the loss of
one of our cases was wholly the result of persistence in lying on the right side, thus producing passive congestion of
the lung.
During the war Mr. Hunter was engaged in extending the use of the hypodermic method from Edinburgh and Dublin, where it was first employed.
It was tried anil reported upon favorably by Covrty of Monti>elIier, Bl-heir of Paris, Scaszo.ni of Wurtzburg, Oppolzer of Vienna, Gr^fe of Berlin and
many others who established its use in Europe ; and very shortly afterwards the hypodermic syringe became naturalized in this country.
* Dr. Jas. L. Cabell reported two fatal cases of sloughing from the same cause in the Confederate hospital at Charlottesrille, Va. — Sichmond Mfd.
Jmr., Vol. I, 186G, p. 453.
t See his pamphlet, cited supra, page 207, where he says, page 32 : " The treatment, first proposed, I believe, by BnowN-St-QUARP, of ice poulticea
for fifteen minutes, followed by hot flaxseed poultices for two or three hours, often stimulates the rooaf indolent bedsores to heal with surprising rapidity.
Puring and since the war I have repeatedly and successfully tried this plan of treatment,"
CONTINUED fe\t:rs. 549
A communication filed by Surgeon A. L. Cox, U. S. V., advocates the use of arsenious
acid in typhoid fever. He claims value for it as exercising a specific influence on the intes-
tinal glands, preventing their ulceration wlien administered in the early stages, and promoting
granulation and cicatrization when given at a later period. Fowler's solution was inadmis-
sible on account of the gastric disturbance which it excited, but the solid acid, taken after a
small quantity of prepared arrowroot, rice, custard or other suitable food, acted with an almost
magical curative power. One-tenth of a grain was administered three times a day coaibined
in the form of pill with an equal quantity of opium. It is claimed that two days of this
treatment induced a marked improvement in the symptoms, five days sufficed to suppress
the febrile action and ten days effected a thorough cure. Two cases given as illustrations
of its use are briefly as follows :
1. — Captain Palmer, 26th N. Y., was attacked at Sliaii>sl)uif;, soon after the battle of Autietam, with lo.s.s of
spirits and appetite, sliglit headache and a disposition to avoid all exertion. At the end of ten d.aya, when Sui'gcon
Cox was called in consultation by W. B. Coventry, the regimental surgeon, the patient had duskiness of counte-
nance, epistaxis, right iliac tenderness, some tympanites, temporal headache, pungent heat of skin and accelerated
pulse, 110, which led to a diagnosis of typhoid fever. Pills of arsenious acid and opium were administered, and an
application was lodged for leave of absence that the benefit of home treatment might be obtained. Ten days elapsed
before the leave of absence was obtained, but by this time' the fever had been subdued and the patient was so well
that the propriety of accepting the leave seemed doubtful.
2. — A teamster attached to brigade headnuarters was taken seriously sick on a certain Friday. Within a day
or two he became irrational, continually attempting to get up; and in one of these efforts he had fallen from his
wagon to the ground, where he was found at night helpless and unconscious. Dr. Ciiapelle, medical oflicer of the
battery on duty with the brigade, saw him on Sunday and learned that some of his comrades, recognizing typhoid
Bj-mptoms, had given him whiskey and quinine. The quantity was not known but was supposed to have been large,
as on Monday, when seen by Dr. Cox, the patient had symptoms which were recognized as indicative of meningitis.
His pulse. 110, was hard and strong, his countenance flushed and eyes bloodshot, but the delirium was low and mut-
tering, lie could be roused from his almost comatose condition by speaking in a sharp tone, and he made ineffectual
efforts to protrude his tongue when directed to do so. The tongue had a white streak in its centre, its edges were
scarlet; sordes appeared on the lips and teeth; the abdomen was hard, tympanitic and tender, and there was a tend-
ency to diarrlnea. The patient was considered to be suft'ering from t lie effects of injudicious st imulation. Ten grains
of calomel were administered. Xext day the vi<dent symptoms had subsided; the pulse had lost its hardness, the
eyes their preternatural redness; the face had assumed its natural color, fair and fresh as that of a well-nourished
Englishman: but the semi-comatose condition persisted, with inability to protrude the tongue or .speak coherently;
the abdominal symptoms and the frequency of the pulse also continued. Pills of arsenious acid and opium were
prescribed for administration three times a day; nothing else was given Imt water as a drink and suuill (luantities of
farinaceous food. On Wednesday the patient answered questions intelligently. On Thursday he was greatly improved.
His condition on Friday is not stated. On Saturday he was despatched to Washington as a convalescent. On the
afternoon of that day Dr. Cox saw him at the railway station, Warrenton, Va., and loosening his clothing, made an
examination of the abdomen, on which some roseate spots were to be seen. Dr. Moseley, Surgeon-in-Chief of the
.division, passed at the moment, and noting these said — "That is perfectly conclusive as to the nature of the case."
The record closes with an. account of an accidental meeting between Dr. Cox and "a stalwart pedestrian crushing
under him the brush and brii^rs which were in his way, — a man of brilliant countenance and fine proportions with
every expression of health and strength," who proved to be the recently sick teamster. This meeting took place
on the eighteenth day after the patient had been obliged to give up his duties on account of sickness.
Surgeon Cox's favorable experience of the use of arsenious acid in typhoid fever does
not appear to have led other medical officers to report similar results, although the field
hospitals at all times afforded facilities for testing a question of this nature.'-'
Acting Assistant Surgeon B. Brandies thus describes the treatment adopted by him in
the wards of Hospital No. 1, Xashville, Tennessee:
• L. DiTTEKlcH, Blu«<r/5r UeiticiaeHK'uafI, Munich, Jan. :!1, ISVl, in recorjing the reeutts of an experience of twenty-six years in the arsenical
tTMlinint of tyjihoid fever sa.vs, that after the use of llie n'Micily for two or three days moisture returns to the dry and cracked lips and tongue and
the dark coating of the hitter di!Oip|»ears ; hemorrhage, from whatever source it may proceed, becomes less aud in five or si.x days ceaws entirely; at
the sntne time delirium and subsultus subside, petechia? fade, the small tremulous pulse improves iu character, the eyes Ix-come brighter and the counte-
nance regains its natural expression. Diarrheal, meteorism and splenic swelling subside more slowly and disappear only in the period of convalescence-
BedM>n-!* seldom f.inu ; and the di.srase runs a shorter aud milder cour^. Arsenic is of uo advantage, aud indeed may do harm so long :o* there is only
a catarrhal state of the mucous membranes, whether of the respiratory passages or alimentary tract : but when nervous disorder Vconies decided and
the secretions dry up. the tongue becoming dark and cracked and the abdomen tympanitic, the remedy proves of value. It is given in the form of Fow-
ler's s<ilntion of which live drops <mly are usi^l in the ftrst twenty-four hours ; on the second day ten drops are administered. The patient can seldom
take fifteen drops without distressing the stomach.
550 TREATMENT OP THE
I constantly abstain from three things — mercury, purgative medicines generally and emetics. My treatment
may be divided into that of the disease itself and that of its complications. Assuming that the disease is dependent
on a poisoned condition of the blood, I direct medication against that condition by administering chlorine or muri-
atic acid. I regard these as equally powerful. The former is contraindicated by cough and extensive broncliial
catarrh ; the latter by diarrhoeal tendencies. I pay particular attention to purity of air and cleanliness of the penson
and bedclothes, frequently sponging the surface with aromatic vinegar and water. A liglit, nourishing diet is
enjoined, as of beef soups, milk, good strong coft'ee, and as a drink water or lemonade. I meet hcodnche with appli-
cations of cold water; active delirium with hyoscyamus and camphor; and ojnstholonos , which I regard as a localization
of typhoid material on the medulla or i(s membranes, with cujipiug on the nape of the neek and camphor or musk.
S-welling of the purotid gland is treated by the application of a camphorated iodine ointment with flannel, and when
suppuration is manifest poultices and the lancet. Senega or squill with carbonate of ammonia, or camphor with
opium or hyoscyamus, relieves tronchitic compVicaliiinn. Pulmonary congestion is treated by frequeut changes of position,
quinine, brandy and muriate of ammonia. For nausea or vomiting neutral mixture is prescribed, with blisters over the
stomach; aqua lauro-cerasi or acetic ether, in five- or ten-drop doses on sugar every hour, is sometimes beneficial.
I have often permitted constipation to go on for five or six days with great benefit to the patient. Instead of purgatives
I use an enema of turpentine and olive oil, or of equal parts of vinegar and water; the latter acts promptly. In
diarrhoea I do not interfere, if there are not more than four or five characteristic typhoid dejections in the twenty-four
hours, but if the stools be in excess of this I endeavor to control them with alum and opium in gum arabic mixture;
when they are sanguinoleut, the same prescription or diluted sulphuric acid, sometimes with alum or sulphate of
iron, is successfully used; when they assume a chocolate color and very oftensive odor, I prescribe charcoal with
aromatic powder. The latter remedy is also useful in tijmpanites. Indications of peritonitis or perforation are met with
large and repeated doses of opium and the application of ice-water to the abdomen. Hetention of urine is treated by
systematic catheterization, a practice which is needful in all cases of coma, as well to prevent invohintary defilement
of the bed as to relieve distention. One case which presented a 2)aralysis of the bladder, even after convalescence,
was treated successfully with ergot in five-grain doses every four hours; in another, complicated during convales-
cence with catarrh of the bladder, injection of a solution of nitrate of silver removed the trouble. Bedsores were
prevented by frequently changing the position of the patient, by the use of clean sheets, and particularly by India-
rubber water cushions; an ointment of lead, tannin and camphor or the charcoal poultice was used when sloughing
had already commenced.
The oiil}' other jDaper relating to the treatment of typhoid fever on file in this office is a
communication recently received from Dr. George M. Ramsay, formerly Surgeon 95th N. Y.
The following abstract and quotation are submitted:
Typhoid fever is emphatically a low and slowly progressive fever. Its diagnostic symptoms are low fever and
restlessness, furred tongue, slight constipation and scanty urine. In its treatment we must abate the fever, calm the
nervous system and restore the secretions and excretions to their normal condition. Scanty urine and constipation
arc always ass<iciated with fever. They result from it and require treatment. The diarrhcea that follows is a reaction
of the system — an eftbrt of nature at recovery. To allay the fever give one grain of quinine in half a drachm of sweet
spirit of nitre three or four times in twenty-four hours. To restore the secretions and excretions use the following
pill, one or more, or less than one daily, so as to obtain one movement of the bowels every twenty-four hours: A half-
grain each of iodide of mercury, ipecacuanha and extract of hyoscyamus, and one grain each of camphor and com-
pound extract of colocynth, with syrup as an excipient. The fever will abate, the tongue clean oft' and the appetite
return within forty-eight hours after this treatment has been commenced. Dry toast and tea with milk may be given
as uourishnieut.
" I adopted this method of treatment at Belle Plain, Va., in 1862-63, but before I had become fully satisfied of
its potency I i>eruiitted a patient to sink into the typhoid condition: Pulse 100; tongue dry as a chip, much swollen,
black-brown in the centre, concave on its dorsum and curled up at the edges. I gave him a dose of the solution of
(luinine in nitrous spirit and repeated it in fifteen minutes. In ten minutes more I gave him a third dose, and in
five minutes after this last dose the tongue had become moist and rounded. Then I ordered tea and toast, of wliicli
he ate sparingly. Under the continued use of the quinine and nitre-drops three or four times daily, and the pill as
described, this patient steadily improved and was returned to duty in ten days. Several cases of typhoid fever were
treated in shelter-tents at Sharpsburg, Md., during very inclement rainy and cold weather. Under the treatment as
specified the cases terminated favorably In ten days. Again, in the winter of 1863, a most aggravated case was treated
in the regimental hospital. The command had marched to Raccoon ford, ten or twelve miles distant, and returned to
its old camp next day, where I found that this fever case had been without shelter from the rain and cold for twenty-
four hours, the quartermaster having taken down and carried away the hospital tent. As a result the patient had
become much worse ; he muttered and was incoherent ; pulse 100 and weak. It was feared that he was beyond recovery;
bnt, under the treatment described, his tongue became moist and clean in forty-eight hours, and convalescence pro-
gressed rapidly. After twenty years of civil practice I continue to place implicit reliance on this mode of treatment.
Great stress was laid on the alkalinity of the urine as a therapeutic indication by Surgeon
George D. Winch, 42d Wis., who directed special treatment to this condition.* He reported
that of thirty-three cases treated at Cairo, 111., only one terminated fatally. In most of these
* Chicago MedicalJouriml, Vol. XXII, ISe.l, p. 15.
OOUTIISLEiJ IKVERS. 551
an alkaline state of the urine was present throughout the attack unless corrected by a^ids.
In cases of relapse this alkalinity persisted after convalescence from the primary attack, even
after return to duty, and was found when the patient was readmitted to hospital. The gravity
and duration of the case were in direct proportion to the intensity of the alkaline condition.
In mild cases Surgeon Winch gave fifteen drops of diluted hydrochloric acid three times a
day, beef-tea every three or four hours, small doses of some alcoholic stimulant, opium if
necessary to quiet wakefulness, and stimulating expectorants for pulmonary affections. In
cases of a more aggravated character tincture of opium was u.sed in conjunction with the
acid, and one or two grains of quinine were given four or five times a day, or, when there
was much anaemia, tincture of iron with compound tincture of gentian.
The diet of the continued fever cases of the war was usually precisely indicated. Our
medical officers recognized the necessity for a constant reparative supply- in a prolonged disease
characterized by rapid waste and progressive asthenia; but at the same time they exercised
a judicious care in the management of the dietary in view of the implication of the alimentary
canal in the diseased action produced by the fever-poison. Liquid preparations and concen-
trations were employed during the progress of the attack, and in many instances the return
to a normal dietary was not permitted until convalescence was well advanced. Patients
treated in the regimental hospitals of stationary camps, as during the occupation of winter
quarters, were usually well cared for in this respect. Thev were under the observation of
their own medical and company officers, personal friends and perhaps relatives in the ranks,
who made special efforts to procure for them whatever was recommended outside of the
limited resoiu-ces of the hospital. In the field division hospitals, which were practically a
consolidation of the regimental establishments, large hospital funds enabled the surgeon in
charge to purvey through his subsistence officer occasional supplies of milk, eggs and chickens,
and a constant supply of fresh meat for the preparation of animal broths. These, with the
beef-extract, condensed milk and farinas of the regulation supply list, furnished materials for
a dietary the real value of which depended on the competence of the culinary knowledge
which superintended its preparation. The general hospitals in northern cities, with large
funds and open markets, found no difficulty in perfecting the dietetic arrangements of their
special diet kitchens. As a rule, but few cases of fever suffered at any time from the want
of appropriate food. These exceptional cases were taken sick while their commands were
in active service, when the fatigues and privations of the march, the arrangements for antici-
pated battle, and the primary disposition of large numbers of wounded men often prevented
that assiduous attention to their wants which would have been accorded them in the general
hospitals or in quieter times at the front.
CHAPTER v.— ON THE DISEASES ALLIED TO OR ASSOCIATED WITH THE
PAROXYSMAL AND CONTINUED FEVERS.
The fevers which prevailed in our camps were readily divisible into two groups, the
paroxysmal and continued. Each of these was as readily susceptible of subdivision into
groups of lesser magnitude, the one into intermittent, congestive, remittent and sub-continued
malarial fevers with adynamic tendencies; the other into common continued, typhoid, typho-
552 DISEASES ALLIED TO OR ASSOCIATED WITH
malarial and typhus fevers: Large numbers of what may be regarded as typical cases of
each of these were no doubt observed, but it must be acknowledged, from the records that
have been presented, that clinically there were no definite boundaries to the groups. Each
was overlapped by the other. Even the two grand groups had a common territory where
the malarial fevers became continued. Looking at the paroxysmal cases as a whole, there
may be said to have been no break or missing link between the well-defined simple inter-"
mittent on the one hand, and the pernicious congestive case or the sub-continued malarial
fever with its typhoid tendencies on the other. Looking at the continued fevers as a whole,
there may be said to have been no 'break between the ephemeral fever simulating a single
paroxysm of the intermittent, the prolonged typhoid case with intestinal, pulmonary or cere-
bral developments, and the more rapidly fatal cases that were clinically undistinguishable
from those usually ascribed to the powerful operation of the cause of typhus, cerebro-spinal
fever or pneumonic consolidation. Moreover, the two grand groups were interlocked as
well in their pernicious phases as in their protracted course; for while in the former they
bore a strong general resemblance to each other, in the latter they were attended with intes-
tinal, lung and brain symptoms that connected them clinically with each other and with
diarrhoea and dysentery, pneumonia and cerebro-spinal meningitis.
Having considered the mutual relations of malarial and typhoid fevers, it seems advisable
now to refer to the relations that existed between these fevers and those diseases that seemed
so closely allied to them as to be in some instances undistinguishable from them clinically,
and in others to arise as a direct result of hyperasmic conditions determined by their mor-
bific causes.
I.— CEREBRO-SPINAL FEVER.
L— CLINICAL AND POST-MORTEM RECORDS.
The number of cases of cerebro-spinal fever that occurred among the troops is not known.
The official reports of sick and wounded did not provide a specific heading for the segrega-
tion of cases of this disease; hence no statistics can be submitted bearing on- the absolute or
relative sickness and mortality caused by it. A few of the cases were perhaps reported as
inflanmiation of the membranes of the brain; the proportion of deaths reported from this
cause in every thousand men — viz., .36 in the first year of the war, when cerebro-spinal
fever was unobserved — was slightly greater than the corresponding ratios of the subsequent
years, .32, .33, .28 and .19 respectively, when this fever assumed some degree of promi-
nence. Probably some of the cases were returned among the non-specified diseases of the
miasmatic order, as the percentage of fatality of these rose considerably after the first year.
Most of the cases, however, appear to have been entered on the reports as congestive, typhus,
typhoid or typho-malarial fever.
The case-books of the general hospitals testify to the occasional occurrence- of the dis-
ease, and even to its epidemic prevalence in certain commands; hut from these records no
estiniate can be formed of the number of cases that occurred in the field. The suddenness
of the attack and the rapidly fatal issue usually prevented those struck down in camp from
reaching the hospitals. It is certain, however, that at no time were the cases numerous:
THE PAROXYSMAL AND CONTINUED PEVEKS. 553
When prevailing as an epidemic in the camps around New Berne, N. C, only a few men
became affected in each regiment.
One hundred and five cases are presented below. None of these occurred during the year
ending June 30, 1S62, when typhoid fever was at the height of its prevalence; neverthe-
less there is every reason to believe that the disease was present, althougli, on account of
the absence of a proper designation for it in the reports, but httle record of its existence has
been left. The following extract from a letter* of Surgeon R. B. Bontecou, U. S. Vols.,
sliows that it occurred as early as January, 1862, in the hospital at Fort Monroe, Va.:
Seven cases of a very interesting character, namely, cerebro-spinal meningitis, were treated, bnt all died, with
the exception of one, soon after admission. This one lingered for some weeks, and linally sauk from sudden increase
of elfusion in the ventricles. All these were examined after death, and extensive deposits of lymph or pus were found
ill the cavity of the spinal arachnoid and over the medulla oblongata: and in one case over the entire cerebrum and
cerebellum, on the visccial and peripheral surfaces of the pericardium and in all the joints, but without iiitlamniatory
indications in theperitoneuuuir tunica vaginalis testis. In one the lateral ventricles were greatly enlarged and dis-
tended with sero-purulent liuid, but the other cases presented no unusual enlargement of these cavities.
During the same winter the disease appears to have been observed in the 44th N. Y.,
encamped at Hall's Hill, Va., near Washingtou, D. C. Medical Inspector Vollum, U. S.
Armv. reported of this regiment as follows:
There has been considerable typhoid fever and four cases of typhoid-pneumonia; four cases of cerebro-spinal
meningitis have also occurred. These proved fatal in from six hours to four days, the patients without exception
becoming delirious and remaining so until death. An autopsy in two of the cases showed large eifusiou on the brain
and spinal cord.
Some details of these cases have been made public by the Regimental Surgeon, W.
FROTHiXGHAM.f Measles, typhoid and malarial fevers were prevailing in this command at
the time of the outbreak of .cerebro-spinal fever.
The winter was mild and damp. The soldier's quarters were about seven feet square, the walls two or three
feet high, built of logs plastered with mud and roofed in by a wedge-tent. Each of these canvas-roofed huts was occu-
pied by six or seven men. Xo attention was paid to ventilation at night, notwithstanding the efforts of the medical
officers in this behalf. There had been during the winter some two or three hundred cases of measles in the regiment,
and intermittent, remittent and typhoid fevers prevailed. Four cases, all in young and robust men, were reported;
in none of them were any petechitc present to constitute spotted fever.
1. — The patient complained in the night of severe pain in the head, and at daylight was found with his
bands pressed upon his abdomen, groaning and insensible. One arm and leg werfe paralysed, and there were occa-
sion.il convulsive movements of the rest of the body except the face. The pupils were insensible and somewhat
dilated, the conjunct iv:e dull-red, the face darkly taished, the tongue and te^tli coated with sordcs, the pulse frequent
and feeble and the breathing stertorous. He died in the afternoon. The treatment consisted of blisters to the tem-
ples and back of the neck and croton oil internally.
2.— The patient was attacked one morning with a chill followed by fever and severe headache. In the
•fteroouu he felt better and the disease seemed to be au ordinary malarial fever. Sulphate of quinine was ordered,
and the patient was quiet during the night ; but next morning he was attacked with frequent and violent opistho-
tonic convulsions. The face was pale and free from convulsive movements; the eyes suffused and dull, the pupils
insensible and somewhat dilated. Consciousness was lost and the evacuations were passed involuntarily. He died
at noon. Chloroform, given to control the sp.tsm, and mustard along the spine, constituted the treatment. Post-
aiortrm examination revealed some congestion of the dura mater, and a layer of exudation beneath the arachnoid,
slight over the cerebellum and anterior lobes of the cerebrum but more abundant over the posterior lobes of the hitter,
the base of the brain and the medulla oblongata. The spinal cord was not examined. The pericardium was highly
Congested and contained three or four ounces of turbid serum. All the other organs were normal.
3. — The patient complained of pain in the head and chilliness followed by fever. Next day pain in the head
ftnd neck was intense: the pulse was rapid and feeble. Cups and counter-irritants were applied. Meanwhile the
pain increased, and towards the close of the second day the patient became dull and soon after sank into a stupor
firom which he could with ditticulty be roused. He died comatose on the third day. No convulsions were observed
in this case. At the autopsy of a similar case in a regiment near by. the brain lesions were similar in character to
those of case 2. but the effusion was of a greenish-yellow color and not so diffluent. The spinal cord was abundantly
coaled with a greenish, semi-diftlueut plastic exudation. This patient had been bled freely, but died after thre<
or four days illness.
•Published in the Mnli,,,! ,i»,; Surgical Beporter, I'hiiu., Pa., A'ol. VI, lS61-«2, |.. 4Uli. f Jwcriam ilcdicai 7ira.<, \ ol. VIll, ieiA, p. 207.
Med. Hist., Pt. Ill— 70
554 Diseases allied to or associated with
4. — The patient had chills, a rapid but feeble pulse, dull and injected eyes, furred tongne and constipation.
He suffered from excruciating pain in the back of the head. Some relief was obtained by the application of leeches
to the temples and neck — a remedy renewed four or five times during the day. The symptoms gradually disappeared
leaving only great debility, from which he recovered.
E. Y. Yagee of Chillicotlie, Mo-., states that four cases were witnessed by him in April,
1862, in the 3d Mo. Cav.,* then stationed in the town mentioned. An .extensive epidemic
of measles was prevailing at the time.
The symptoms were chills, severe headache, high fever, soreness and pain in the muscles of the neck and jaws
and tenderness along the spine, delirium and retraction of the head. Two of the cases recovered and two terminated
fatally in less than sixty hours. In one of the latter several paroxysms of convulsions came on within a few hours
after the attack. The survivors, a few days after the commencement of the complaint, fell into a typhoid condition
from which they did not recover for weeks. Recovery in one case was perfect.
The epidemic which produced these and other cases at Chillicothe and its vicinity made its appearance in
February and continued until May. It prevailed to some extent among the population at large, but particularly
among those civilians who, as political oftenders, were confined in the guard-house. Among these no case of recovery
was noted; as many as five deaths a month occurred among a number of men never greater than twelve or fifteen.
Dr. Yager also reports that in February five cases appeared in the 23d Mo., also stationed at Chillicothe. He
did not see these, but was informed that three ended fatally by coma in less than forty-eight hours and two recovered
after a protracted convalescence. These men, on the night preceding their attack, had been exposed while on guard
to a snow-storm which had been ushered in by a dense fog and chilly east wind.
The disease was terribly fatal. In many localized epidemics no patient was known to
have recovered. Of the one hundred and five cases recorded below only seven evaded the
fatal issue ; but this statement exaggerates the deadly nature of the disease, for in some of
the hospitals only those cases that came to the post-mortem tables were recorded. At New
Berne, N. C, four of twenty-seven patients whose cases are recorded survived the attack;
but fifty-two cases were believed to have been under treatment, and of this number thirty-
six died and sixteen recovered.
The New Berne epidemic occurred during January and February, 1863. The regiments
that suffered most were the 44th, 45th and 51st Mass. nine-months men, who had seen
but little service. They were quartered on the banks of the Neuse and Trent in huts built
of green lumber. The barrack of each company was fitted with bunks, in three tiers, for
one hundred men, and gave 180 feet of air-space per bunk; but as the companies did not
average more than sixty men the air-space per man at the time of the outbreak was about
300 cubic feet. Ventilation was effected by shafts through the ridge and apertures near
the floor between the bunks. The site was a sandy and sterile plain, broken occasionally
by stagnant pools and marshy spots; it was elevated only a few feet above the level of the
water of the rivers. Beyond this plain the country was covered with pine forests, swamps
and tangled undergrowth.
The regimental records do not show how many cases occurred, as the disease can be
identified on the monthly reports of sick and wounded of but one medical officer. Surgeon
Samuel Kneeland, 45th Mass. In January this officer reported 1 case of typhoid fever
and 5 of malarial cerebral disease. In February his command was free from miasmatic
diseases, which he attributed to a change of station, the regiment having been removed to
New Berne for guard duty. Surgeon Geoege Jewett, 51st Mass., reported in January
21 cases of typhoid, 7 of typho-malarial, 12 of remittent fever and 1 of inflammation of the
membranes of the brain, with two deaths, 1 from congestive chill and 1 from typho-mala-
rial fever. In February he reported 17 cases of typhoid, 9 of typho-malarial fever and 13
remittents, but no other cases which might be conceived to represent the disease then con-
» Chiaxgo Med. JExaminer, Vol. V, 1864, p. 396.
THE PAROXYSMAL AND CONTINUED FEVERS. 555
sidered epidemic in his camp ; the only death returned during this month was said to have
been caused by typho-malarial fever. In March the report shows 1 case of typhoid, 12 of
remittent fever and 1 of inflammation of the membranes of tlie brain ; no death occurred, —
tlie regiment meanwhile had changed camp to Beaufort, N. C. Surgeon R. Ware, 44th
Mass., reported in January 2 cases of typhoid and 19 of typho-malarial fever, 3 of the latter
having proved fatal. In February no case of typhoid, typho-malarial or congestive fever
was reported, nor in fact of any disease which might be supposed to represent on paper tlie
cases received into the New Berne hospitals. Nevertheless Ass't Surgeon Theo. W. Fisher,
who was in charge of the regiment when the report for March was furnished, remarked on
the report that the epidemic of cerebro-spinal meningitis which prevailed in the command
in January and February was now abating as only one case had occurred during the month,
and yet the body of his report shows no case that could be regarded as the one in question,
if those entered under the headings typhoid and typho-malarial fevers are excluded from
consideration. Manifestly the cerebro-spinal cases of the Stanley and Academy hospitals
were the typhoid and typlio-malarial fevers of the regimental reports, and in view of the
small number of deaths in the regimental camps those hospitals may be supposed to have
received most of the cases.
Dr. Upham in his Hospital Notes and Memoranda'^ refers to a clear and able report
of the disease, for which he was indebted to Surgeon George Jewett, 51st Mass. He quotes
from this report and states that of the fourteen cases communicated by that officer all were
fatal. The inference from this, that fourteen men perished in the regimental camp of
the 51st Mass., in addition to those that died in the New Berne hospitals, is inconsistent
with the facts. Surgeon Jewett joined the regiment in December, 1862, during which
month no fatal case of disease occurred in his camp, and the substance of his reports of sick-
ness for the epidemic months, so far as relates to the subject in question, has already been
submitted. The following probably formed the basis of the report to Dr. Upham :
Surgeon George Jewett, 51sJ Mass., New Berne, X. C, Feb. 14, 1863. — In January, a fearful epidemic broke out
in our regiment which was at first supposed to be congestive or typho-malarial fever. After se\'eral deaths had
occurred au autopsy revealed the true character of the di.sease, which proved to be cerebro-spinal meningitis.
The firet case occurred on the 10th. A drummer boy was taken with nausea, vomiting and general febrile symp-
toms; pain in the head and back; face and eyes suffused, pupils dilated; skin moist and warm; retention of urine;
tongue slightly covered with a thin white coat; pulse rapid and at first feeble. These symptoms soon became aggra-
vated ; the pulse increased in force and frocjuency ; great restlessness came on with jactit ation and delirium ; a copious
viscid secretion filled the throat and nares. The patient died by apn<ta in tliirty-six hours. No autopsy was held.
From Jauuary 11 to this date fifteen ileaths have occurred in the regiment, all but one from inllammation of the
brain aud spinal cord. The single exception was a case of typhoid fever with prominent cerebral sym])toms.
There has been a remarkable uniformity of notable symptoms. The disease attacked the young, active and
vigorous and those of apparently the greatest vital power. The eldest was thirty years of age, the youngest sixteen ;
the average age twenty years. The greatest duration of the disease was twenty-three days — the least one day. It
generally came on nnich like malarial fever, with pain in the head and back aud fugitive pains in various partj of
the body. Often it was ushered in by a rigor followed by nausea and vomiting. In a few, and these the most severe
cases, no moan or sound of any kind escaped the patients: but there was manifested a fearful restlessness, which
ceased only with death. In others there Avas much moaning; in a single case pleasing delirium was noticed with
mnch loiiuacity. Erotic desires were observed in about one-third of the cases. In about a third, also, there was
more or less stiffness of the muscles of the back aud neck, with opisthotonos; in one there wae paralysis of the
glosso-pharyngeal nerve. The skin was uniformly moist^ the tongue generally moist, but in a few instances the
disease assumed a typhoid character, with the tongue dry and brown. The face was often suffused aud the eonjunc-
tivsB congested. In two or three cases there was occasionally S(iuinting. In all the violent cases the urine was
retained The bowels were often loose and the discharges ofiensive, but constipation was occasionally present.
Decubitus was dorsal in but a sii gle case; in the others the patient lay upon the side until the close of life. No
petechial spots were noticed in any of the fourteen cases, although such were frequently observed in cases occurring
in other regiments. The pathognomonic symptom was a vioient pain in the back of the head.
» Boston Med. aad Surg. Jmu-., Vol. XLVni, p. 316.
656 DISEASES ALLIED TO OR ASSOCIATED WITH
Post-Mortem observations were made in five cases. Of these I select two for illustration; one terminated in
twenty-four hours, the other was protracted for twenty -three days: In the first the arachnoid -and pia mater were
firmly adherent, particularly on the right side ; the subarachnoid space was filled with straw-colored serum. There
was more fluid in the right ventricle than in the left; the surface of the brain was highly congested, and small patches
of lymph were found at the base of the cerebellum. The cerebro-spinal fluid was greatly increased in quantity, of a
milky appearance and yellowish color; the membranes were congested and the cord softened. lu the second the
lateral ventricles were filled with straw-colored fluid, the vessels of the choroid plexus strongly injected, and the
fourth ventricle filled with serum and pus; deposits of lymph, three lines in thickness, were observed about the pons
Varolii aud inferior surface of the medulla oblongata. The membranes of the cord were much congested; one and a
half ounces of sero-jiurulent matter drained from the spinal canal; the cord was enveloped in a layer of lymi)h from
two to three lines in thickness ; its substance was softened in the lower dorsal region and the cauda equina and sacral
nerves were coated with lymph. In all the cases which I have thus far examined the organs of thetiiorax aud abdo-
men were in a normal condition but for an increase of fluid in the pericardium in one instance to the amount of two
and a half ounces.
The causes of this peculiar form of disease are various — and, firstly, as a predisposing cause climatic influences;
secondly and mainly, the condition and character of the barracks. These had been recently constructed of green,
hard pine boards, and the logs having lain long in water were saturated with sap and moisture. When first occupied
they were almost without windows and poojly ventilated. The air-space per man was about 180 cubic feet. One
important fact bearing on this point is that a large proportion of those that died occupied the highest tier of bunks;
eight cases were taken from this row; three occurred among the men in each of the other rows. The facilities for
warming are slight. There is a fire-place and chimney in each room, but so badly constructed as to prevent the radia-
tion of lieat; hence the barracks are cold, dark, damp and poorly ventilated. The food of the men has been of good
quality and well prepared.
As to treatment little can be said. In the first cases the attack was supposed to be of a malarial character, and
quinine and stinmlants were given in large quantities; but after recognizing the true character of the disease cups,
both wet and dry, were applied along the spine, with blisters to the nape of the neck and along the spiual colunm,
while internally mercurials with opium were freely given and four grains of iodide of potassium every three hours.
But a single case has recovered under my treatment after the disease had become fully established. In this mercurial
ointment was rubbed along the spine twice daily, while tincture of iron in twenty-drop doses was given every three
hours, with opiates as required; the patient remained in a low condition for some days and convalescence was tardy.
A number of men, apparently in the incipient stage, were successfully treated by large doses of oinum repeated
until convalescence was fully established.
The following is the account given February, I860, by Surgeon R. Ware, 44th Mass.:
The regiment was recruited at Boston and mustered Sept. 12, 1862, numbering nine hundred and seventy-one
men. It embarked October 22 on the transport Merrimac for New Berne, N. C. On this steamer was also placed one
battalion of the 3d Mass. Over fifteen hundred men were thus crowded into the vessel. The space between decks
was dark aud ill ventilated ; if inclement weather had compelled the men to remain below serious injury to their health
would haveresulted; but fine weather enabled us, by keeping the main deck always crowded, to give all the men in
turn the benefit of light and fresh air. The accommodations for cooking were very limited in view of the number of
men to be fed; there were no facilities for washing, and the privies were miserably inadequate.
The regiment disembarked at Morehead City October 26, aud reached New Berne by rail the same day. Next
day they occupied their present camp-ground, two companies housed in barracks which had just been closed in and
the others in Sibley tents. But on the 30th the reginieut, in light marching order, went on board transports for
Washington, N. C, which was reached next day. During the following week an expeditionary march of 125 miles
was made, in part through rain and snow. The command returned from Plymouth to New Berue November 15, and
occupied the barracks which had been completed during its absence. These are situated on the Neuse, about half a
mile from the town, and just beyond a small swampy stream which empties into the river. They are so near the edge
of this swamp that the space allotted for the sinks, refuse pools, etc., is much too small for a permanent camp and
too near the barracks. The quarters are built of green pine, the sills laid directly upon the ground. Each is 58x24x
8i feet to the top of the plate. They are very inadeciuately lighted and are warmed both by open fire-places and
by stoves. On December 11 the regiment, equipped with blankets aud overcoats, started on an expedition towards
Goldsborough, and returned to New Berne on the 20th, having in ten days marched one hundred and fifty miles,
bivouacking at night. It participated in the actions at Kingston, Whitehall and Goldsborough bridge. The weather
during this march was clear with hot days and frosty nights. On the first day three men were sunstruck. Every
day a number of men fell out of the column because of sore feet, but rejoined at night. The command embarked
February 1 for Plymouth, where it remained seven days. It returned to New Berne on the 10th, having been two
days on the transport. Since then it has remained in camp.
Camp-fever in the form of cerebro-.spinal meningitis has been the most serious epidemic. This, and measles,
from which the regiment is at present sufieriug, have been the only fatal diseases; catarrhal bronchitis, diarrha'a
and tonsillitis have been prevalent at various times but have never as.sumed a serious form; six cases of pneumonia
occurred, none of which were fatal. Cerebro-spinal meningitis first appeared Dec. 25, and up to the present date
nineteen cases have been developed, twelve of which hare ended fatally. No fresh cases have occurred since Janu-
ary 19, when the first heavy ruins fell. A long spell of dry weather preceded the outbreak of the disease. The first
symptoms in most of the cases were those of sudden and intense cerebral congestion ; but iu souie the indications of
THE PAROXYSMAL -AND CONTINUED FEVERS. 557
fierions inflammatory disease of the brain came on gradually, and were occasionally preceded by symptoms of ordinary
catarrh. One case was ushered in by violent convulsions, which were followed by couui lasting nearly ten days;
another, which proved fatal in twelve hours, was cliaracterized by sudden collapse, the i)aticut becoming cold and
pulseless, though retaining his senses till death, which was preceded by a copious petechial eruption. Petechial
blotches were present in nearly all the cases, generally appearing during the first twenty-four or thirty-six hours.
The disease may bo divided into three stages or periods: The first, that of attack, is characterized by intense head-
ache, stupor, a small quick pulse, duskiness of countenance and a condition approaching colla])se — one man died in
this stage. This is followed by reaction with noisy, almost maniacal delirium, deafness, squinting, slight opistho-
tonos and sleeplessness, ending in coma; most of the deaths have occurred in this stage. The third seems to be a
typhoidul state, which gradually re]ilaces the moro acute symptoms of the second stage. Pont-morlem examination
has shown in most cases a deposit of lyuii)h and pus upon the membranes of the brain and spinal cord; in some
instances there was Intense pericarditis; one ease was complicated with iritis and another with effusion into the
synovial capsules of the knee and elbow.' There is no evidence that the disease as it appeared here was contagious.
Until within the past two weeks fresh vegetables have lieen issued three times a week. Potatoes are now pur-
chased out of the company fund. The average meat issue has been one day's ration of pork, four of salt beef and
live of fresh beef in each ten days.
Several facts eonnected with the history of camp-fever in this department lead me to the opinion that the dis-
ease is not due to malaria alone, nor is it purely typhus in its origin. It arises, perhaps, from the eombined action
of these two causes; but the cases occurring in any one regiment are too few to warrant a definite ojiinioii.
A few cases reached the hospitals in New Berne from some of the other regiments in
the vicinity, and as these were camped under canvas, the green himber used in the con-
struction of barracks was relieved from the imputation of having caused the disease. Indeed,
in view of this and of the fact that the 45th Mass. escaped attack in February by its detail
to duty in the city, while the 51st, and perhaps the 44th, continued to suffer, the locality
rather than the quarters should be indicted. Surgeon E. P. MoRONG, 2d Md., in charge of
the Foster hospital, New Berne, reported, April 1, 1863, as follows:
The disease made its appearance about January 1; it approached an epidemic form in the Mth and Slst Mass.,
but was sporadic in character in the department at large. I have seen no new cases within the past four weeks, but
I learn that two have been admitted into the Stanley hospital. The two regiments named above have had about
twenty-five cases each ; the 45th and 46th Mass. had several ; the 168th Pa. three or four, and the 43d Mass. one case.
The disease was confined to the new troops that came out in November and December, 1862, unacclimated both to
camp life and this locality. The 44th, 45th and ulst Mass. were quartered in barracks deficient in light and venti-
lation, with not more than 100 cubic feet of air to each man. The 3d, 5th, 43d and 46th Mass., the 168th and 174th
Pa. were quartered in tents, the Sibley, I believe, but there were less than fifteen cases all told in these six regiments.
The 17th and 24th Mass., the 85th N. Y. and 103d Pa. (old regiments) were also quartered in barracks of similar con-
strnctioD, but the disease did not make its appearance among them. While acting Medical Director I bad the 51st
ordered away, believing that the disease would thus be arrested. The regiment went out to Deep Gully, about ten
miles distant, and camped for five days in shelter-tents. It rained three days out of the five. There have been no
new cases since. The disease was arrested iu the 44tli in conse<iuence of a similar move and the fact that the barracks
of this regiment were whitewashed and inijjroved during its temporary absence.
Dr. Upham regarded the disease as pai'taking of the nature of typhus in a severe and
malignant form, and having in this instance a special direction to the membranes of the
brain and spinal cord, as in other typhus epidemics, the weight of the morbific influence
has at one time fallen on the brain and at another on the lungs or other important thoracic
or abdominal viscera. Kneeland, on the contrary, supposed the disease due to malarial
influences. He remarks in his Monthly Report for January as follows;
•FREDKRirK D. Lexte, wTiting June 25, 1804, to the American Medical rimes, gives the history of a case of spoiled fener In which the syiiorial mom-
branes were sjieciallT affected. The patient, Dr. C, 40th N. Y., age 43, was at tlie time of tlic attack, Februar.v, ISM, at a hotel in Xew Yorit await-
ing the i-nit>arkatiuu of his regimeot. One day soon after dinner he wjis taken \fith nausea and headache, soon folluwed by dizziness and feverishness.
Xexl day he w.ts somnolent and in the evening unconscious. Strong counler-irritation to the nape of tlie neck and along the spine restored consciousness
before morning; but the patient was very weak and suffered from headache and mental confusion. On the third day the right eye w.x^ highly injected
and the siglit lost, with little or no pain then or sulisequently. At this time his whole surface, with the exception of tlie face, was covered with purplish
unelevated spots from the size of a pin-head to that of a three^:ent piece; there was manifest effusion into the knee joints, and the extremities below the
joints were tumefietl ; pain in the Inmlmr and sacral regions extended along the crest of the ilium and down the thigh to the knee. He continued for
Kveral weeks much prostrated and occasionally slightly delirious. A febrile movement occuiTcd for some time every afternoon. The spots began to fade
Boon after they were first noticed, and disappeared in a few days ; but on the exposed parts, as the bauds, they dried into thick dark scales aud peeled olf.
Th« tumefaction of the exlreinilies subsideil, but the joints continued affected in June, when the account of the case was written. Tlie l>all of the right
eye had become atr,ii>liied and soft, the cornea h.izy, the pupil contriicteil and insensible to light and the lens cataractoue. The patient was gaining flesh ;
hia general appearance was good ; but ho still complained of pain, aggravated by the slightest exercise— in fact ho was pcrre<tly at ease only when lying
down. See also the case nentioncd by Bontecov in his report supra, page 5S3.
558 DISEASES ALLIED TO OR ASSOCIATED WITH
There have been five cases of what has been generally called " congestive fever," but as they differ very much
from the congestive fever prevalent here in summer they have in this report been put under "brain fever," the
symptoms and post-mortem appearances indicating the brain and its membranes as the seat of the disease. As the
same disease was seen last summer here, occurring with, but markedly different from, congestive intermittent fever,
the prognosis being different, it may be naturally inferred that they are distinct diseases, though originating prob-
ably from the same cause, malaria. Since this cause cannot ordinarily be supposed active at this season, I am inclined
to seek its origin in the green pine wood of which the barracks are built; most if not all the cases have been in
regiments quartered in barracks, and none, I think, in regiments living in tents or the city proper. The healthiest
and stoutest men have been taken, and every case has terminated fatally; neither general nor local bleedings, sina-
pisms or other stimulating applications to the skin, quinine stimulants, mercurials or narcotics have had any per-
ceptible effect in arresting the disease. After the occurrence of the first case, January 5, three grains of quinine were
administered at night to every man going on guard, and afterwards coffee and hard bread were issued to the guard
during the night. Of the five cases reported three died in camp and two in general hospital.
Twenty-seven cases from the records of the Stanley and Academy hospitals at New
Berne are given below in the order of their occurrence :
Case 1. — Private Daniel B. Richmond, Co. H, 8th Mass., was taken Dec. 5, 1862, with pain in the bowels and
back of the head and neck. He fainted while at the regimental sink, but recovered and returned to his tent, where
he had a decided chill. Three or four hours later he was sent to hospital in an almost unconscious state — delirious,
cold, breathing heavily and at times excited and incoherent; pulse 116, small, irregular and unequal; tongue dry
and red; spots of purpura covered his arms and legs. Hot applications were prescribed, with ten grains of quinine
in camphor-water and sweet spirit of nitre, to be repeated every four hours. On the 7th there were symptoms of
iritis. On the 9th the dark spots were sloughing. Kext day the mind became clear, but the cornea was opaque and
green. After this the indications of cerebro-spinal meningitis gradually disappeared, but the iritis became chronic.
Quinine was continued, with belladonna ointment and an occasional blister to the temple. The patient was dis-
charged from the service March 27, 1863.
Case 2. — Frank Doughty, a deck-hand on steamer Patuxent; age 23; was admitted Dec. 20, 1862, violently
excited and with contracted pupils and tenderness at the nape of the neck ; his pulse was not much quickened. He
improved for three weeks under calomel and ipecacuauha, with cups and blisters, but his mind continued confused.
Iodide of potassium was tried for a week, during which he was able to sit up and give rational answers in most
instiinces ; but after this he became suddenly worse, and died Jan. 24, 1863. Post-mortt-m examination : The pia mater
was much injected ; yellowish lymph was deposited in the sulci of the upper surface of the brain and thick purulent
matter in the pons Varolii and medulla oblongata; the lateral ventricles contained two ounces of serum. The spinal
column was not examined. The thoracic and abdominal viscera were healthy.
Case 3. — ^Private John Cramer, Co. G, 132d X. Y.; age 17; was admitted Jan. 10, 1863, his previous history
being unknown. He was delirious and had a hot and dry skin, frequent and feeble pulse, a dry tongue which was
protruded with difficulty, dyspncea, coldness of the extremities, lividity of the surface, a tympanitic abdomen and
black, involuntary stools. He died on the loth. The treatment consisted of the administration of one grain of blue
mass every hour, two of quinia every two hours, whiskey and beef-tea, with hot applications to the back, abdomen
and extremities; a grain of ipecacuanha was subsequently added to the mercurial, the quinia increased to three grains
and towards the end of the case to five, when, also, blisters were applied to the chest and back of the neck. Post-
mortem examination: Body livid. The membranes of the brain were somewhat congested, the arachnoid having a
slightly clouded appearance; the cerebral substance presented a larger number of piiucta than usual. The lungs
were greatly engorged ; the heart normal. The liver was slightly enlarged and' congested; the spleen nearly double
its usual size and greatly engorged ; the kidneys normal. Some of Peyer's patches were thickened and friable, with
apparent ulceration in one of them.
Case 4. — Private Elijah H. Wellington, Co. D, 45th Mass.; age 31 ; one of the healthiest and strongest men of
his company, ha\ ing been on duty all day Jan. 11, 1863, felt unwell in the evening and about midnight went to the
regimental hospital to get medicine for a headache. Hoffmaun's anodyne was given. Later in the night he had a
severe chill with headache and pain in the boues, for which, next morning, ten grains each of calomel and quinine
were administered, moving the bowels in a few hours but fiiiling to relieve the headache, \itrate of potash, Dover's
powder, capsicum and ciuiuiue were given, after which he persjiired freely and expressed himself as having less pain,
although the headache persisted. At midnight he became comatose, his pupils fixed, one dilated, the other natural,
and large ecchymoses appeared on the surface of the globes; the jaws were locked and respiration performed in a
hissing manner through the tiglitly shut teeth, but there was no rigidity other than the trismus; pulse 125, moder-
ately strong, compressible. At 2.30 A. M. of the 13th the respiration became slow and interrupted, the pulse fell,
and death took place quietly. Post-mortem examination : Body well formed and nourished ; conjunctiva' injected and
ecchymosed. The meningeal vessels were engorged with blood; the cerebral masses were less firm than usual, the
upper part of the left hemisphere being markedly softened. The heart was large and flabby, its right cavities filled
with dark fluid blood. Both lungs were engorged with dark blood, especially in their posterior parts. The liver
was nearly twice its usual size and weight, pale-yellow, fatty and friable, its veins much engorged; the spleen was
slightly congested; the kidneys enlarged ; the other abdominal viscera healthy.
Case 5, — Private James McComb, Co, F, 45th Mass,; age 21 ; was admitted Jan. 14, 1863, in an algid condition,
exhausted and delirious, He was seized on the I2th with a chill followed by high fever and delirium, He had been
THE PAROXYSMAL AND CONTl.NUED FEVERS. 559
treated by cups at the nape of tlie nerk, quinine and stimulants. Delirium contiuutd, with jactitation and subsultus ;
the pulse was 80 and very weak, the skin cool and moist, the respiratiou-ijuiet and the bowels open. He died at mid-
night of the 15th. Fost-morltm examination: Both ventricles of the brain were distended with a semi-opaque liquid
having a pus-like deposit at the bottom; a lymph-liko deposit was observed at the base of the cerebellum, and par-
ticularly about the origins of the nerves of sense, where it resembled a false membrane. The right lung was congested.
The jiericardium contained three ounces of serum. The liver, spleen and kidneys were normal. The stomach was
slightly congested: Peyer's patches were somewhat prominent.
C.\SE 6— Private George B. Young, Co. G, Uth Slass.; age ■>2: was admitted Jan. II, mvi, having had a con-
gestive attack on the previous morning, with intense headache and vomiting. Five ounces of blood v. ore removed
from the neck by cupping, and forty grains of quinine given in twenty-four hours. On admission his mind was clear
although the pupils were dilated; pulse 86, moderately full; skin moist and cool; tongue moist and slightly furred;
abdomeu natural and bowels regular. Ho improved under treatment by quinine until the 291)1, when, coincident
with the occurrence of severe headache, the pulse became quick and full, the respiiation embarrassed and the tongue
dry. In the evening delirium supervened, but subsided gradually, so that on February 1 the patient's mind was
again quite clear; nevertheless the headache continued witli convergent strabismus of the right eye; a slight diar-
rhiea also occurred. Next day ho appeared souu'what better, but on the 3d he died rather suddenly without any
symptoms of exhaustion. Post-tnortcm examination: Body but little emaciated. There was some cloudiness of the
arachnoid and a slight subjacent deposit of lymph in the sulci of the upper cerebral surface; the cerebellum and
medulla oblongata were covered on the inferior aspect by a layer of lymph about one-sixth of an inch in thickness,
firm and ligamentous in texture; both lateral ventricles contained about an ounce of Oaky licjuid with a small
quantity of pus in the intl-rior horns; the cerebral substance was of natural consistence. The lungs wore slightly
congested in their posterior parts. The heart and abdominal viscera were' healthy.
Case 7.— Private O. W. Washburn, Co. B, 10th Conn.; age 22; was admitted Jan. 1.5, 1863, having been suddenly
attacked on tbel3th with fever and violent headache. On admission the patient was delirious and frequently attempted
to get out of bed; the pulse was 79, full and moderately strong; the skin hot; the face dusky; the respiration easy.
An ounce of wine every two hours, six grains of quinine every three hours and fifteen grains of calomel as a cathartic
were prescribed; carbonate of ammonia was given subseiiueutly. The fever declined but llie delirium increased; a
few spots appeared on the left forearm. Death occurred on the 22d. Post-mortem examination found the dura mater
healthy, but the upper surface of the brain slightly engorged ; around the origin of the nerves of sense and upon the
medulla oblongata, sheathing it completely, was a deposit of consistent pus-like lymph, about two lines in thickness,
extending thence into the crevices of the brain: a simihir deposit was also found in the lateral ventricles together
with a copious dirty-looking, 8emi-opac|ue liquid. The heart was normal. The left lung was liepatized red and its
bronchial tubes tilled with a lymph-like substance, tenacious enough to be pulled out with a forceps. The stomach
and kidneys were normal ; the liver slightly congested ; the spleen small and light colored; Peyer's patches normal.
Case 8. — PrivateJ. Moody, Co. F, 44th Mass.; age 21; was admitted unconscious and with insensible pupils
Jan. 16, 1803, having been suddenly and violently taken sick during the previous night. He had frequent epileptic
spasms. He died on the 17th. Post-mortem examination : The membranes of the brain were much congested, the
substance slightly congested : a pus-colored liquid was found in the ventricles, on the base of the brain and on the lobes
of the cerebellum. The lungs were congested, especially in their posterior parts. The heart contained a fibrinous
deposit in both ventricles. The stomach, intestines, liver and kidneys were healthy. The spleen was of normal
size but highly congested.
Case 9. — Private S. Parsons, Co. F, olst Mass.; age 32; was admitted Jan. 16, 1863, in a moribund condition,
having been taken sick suddenly on the jirevious day. Quinine and whiskey with capsicum were freely given, and
an enema of brandy and oil of turpentine administered. Next morning his head was thrown back and ho groaned
heavily as if in great pain; he was roused with diOiculty; the pulse was 120 and weak, skin moist and moderately
warm, tongue dry and dark ; sordes appeared on tlu' teetli and petechia; on the limbs. He died on tlie morning of the
18th. I'ost-mortem examination: Body not emaciateil ; rigor strongly marked ; a few petechial sjiots on the arms and
hands. The membranes of the brain were engorged with venous blood, and underlying them a purulent lymph-like
sabstauce was spread over the surface of the hemisplieres, on the base and lobes of the cerebellum, and more abund-
antly on the surface of the medulla oblongata and about the origin of the cerebral nerves; a similar substance, but
thicker and more opaque, was found in the lateral ventricles. The lungs were congested posteriorly. The inner
surface of the pericardium was uniformly congested and covered with ditUuent lymph ; the ventricles were filled with
dark fluid blood which afterwards clotted in the basin. The spleen was of a deep maroon color, enlarged and slightly
softened; the liver and kidneys healthy. The intestines were normal with the exception of a .slight thickening of
one or two of Peyer's patches, and in one of them a loss of substance not amounting to ulceration.
Case 10.— Private J. W. Merrill, Co. F, 4.5th Mass.; age 21: admitted Jan. 17, 1863. Died 20th. Post-mortem
examination: The surface of the cerebrum beneath the arachnoid was covered with a questionable diffluent and
greenish-yellow lymph, most abundant along the longitudinal fissure and in the sulci between the hemispheres; a
larger deposit was found at the base of the cerebellum, lietween its lobes as well as over its surface; there was a free
deposit also at the crossing of the optic nerves, along the roots of the nerves generally and in the posterior horn of
the left lateral ventricle; the pia mater seemed normal. The cavities of the heart contained firm fibrinous clots. The
abdominal organs were healthy.
Case 11. — Private Frank L. Moore, Co. I, .51st Mass.; age 27; was admitted Jan. 18, 1863, having been taken
with a chill on the previous evening. He wa8 in a state of semi-stupor; pulse 85, feeble; extremities cool; tongue
560 DISEASES ALLIED TO OR ASSOCIATED WITH
clean. The case was treated with quinine, calomel and cupping, but no improvement was manifested until the 21th,
when medication was discontinued. A day or two after this he had jiain in the face and head, tenderness at the nape
of the neck and helietude of mind. At times his symptoms appeared neuralgic and at other times inflammatory. He
was treated witlKjuinine, calomel, cups, tonics, stimulants and counter-irritation, and on March 7 was gaining strength
and taking iron and fluid extract of cinchona as a convalescent. He was sent to Foster hospital on .\pril 8 [where
he died of cerebro-spinal meningitis on the 26th].
Case 12. — Private Walter Bradbury, Co. C, 44th Mass., was taken Jan. 19, 186.3, with chills, followed by hot
skin, full, quick and frequent pulse, the surface soon afterwards becoming cool and moist. During the day ciglity
grains of quinine were, administered with stimulants and beef-tea, and the patient "was cupped to the extent of five
ounces. His condition on admission to hospital at 7 P. M. was as follows: Intense headache but no active delirium;
recognized his friends readily; intelligence good when aroused; general powers good; some deafness; face dusky;
eyes natural; lies upon right side; tongue dry, tending to brown at base, with a pasty yellowish stripe along its
sides, natural at tip; respiration 28; some dulness on percussion; mucous rales at left base; pulse regular, rather
full, hard, 132; skin moderately warm, somewhat moist and covered, except on the face. With typhiis-like sjjots
from the size of a pin-head to a split pea, dark-colored, persistent, not prominent to the touch but seemingly imliedded
in the substance of the skin; there was slight fulness of the abdomen; an enema of turpentine had produced one
dejection. Active delirium soon after set in accompanied with spasms of the facial muscles and convergent strabis-
mus. There was tumultuous action of the heart with a well-defined triplicate sound. The patient gradually grew
worse till his deatli, which occurred without much apparent Exhaustion on the 22d.
Case 13. — Private Charles Burdock, Co. H, 10th Conn.; age 18; was admitted Jan. 19, 1863, in a moribund con-
dition, having been attacked the day before with chills, headache and delirium. To relieve these symptoms cups to
the back of the neck, cathartics and the free use of qninia had been resorted to. On admission the respiration was
44, irregular, difficult and accompanied with groaning; the skin had a mottled or petechial appearance. He died at
4 p. M. Post-mortem examination: Tlie brain was but slightly congested; at its base was a deposit or membrane-like
exudation with a pus-colored fluid, most aliundant around the origin of the nerves of sense and on the base of the
cerebellum; a simular exudation was found in the ventricles. The lungs were extensively congested and in their
superior portions tuberculous ; they presented some well-defined spots resembling those of pulmonary apoplexy. The
heart contained large fibrinous clots in both ventricles. The liver and spleen were enlarged and congested, the latter
being twice its normal size. The kidneys and intestines were normal.
Case 14. — Private George Boynton, Co. G, 44th Mass.; age 21 ; was suddenly seized with symptoms of a severe
cold and some disposition to paralysis of the tongue and muscles of the face. Incomplete reaction came on after
cupping the nape of the neck to the amount of five ounces and administering quinine in lialf-drachm doses, with
stimulants and beef-tea. Delirium supervened Jan. 19, 18G3, and a few hours afterward he was admitted from the
regimental hospital in a state approaching collapse ; he died shortly after admission. Post-mortem examination: Arms,
chest and legs studded with petechial spots from one to three lines in diameter. There was but little congestion of
the cereliral membranes, although the arachnoid was slightly opaque. The lungs were engorged, especially at the
posterior and dependent portions. The pericardium contained six or eight ounces of sero-purulent liquid with large
masses of flocculent lymph floating in it : its surface was covered with a layer of lymph, membranous in tenacity and
thickness: the ventricles contained fibrinous clots. The liver, sjileen, kidneys and intestines were normal.
T
Case 15. — See case of private Davis N. Hosmer, No. 303 of the jjost-mortcm records of the continued fevers.
Ca.se IG.^Private Edwin F. Whitney, Co. H, 5th Mass.; age 18; wasadmitted Jan. 30, 1863, with violent delirium
and opisthotonos, which came on after a slight chill on the previous afternoon. His pulse was full, 90; tongue clean
and moist; nape of neck tender. A powder containing two grains of calomel and half a grain of ipecacuanha was
•given every two hoiirs, with wet cups to the neck and mustard to the .si)ine. He died on the morning orFebruary 3.
Post-mortem examination: There was a deposit of lymph on the ujiper surface of the cerebrum and cerebellum and
some effusion in the ventricles; the bloodvessels of the brain were much engorged. The thoracic and abdominal
viscera were healthy.
Case 17. — Private Forrest L. Whittridge, Co. I, 44th Mass.; age 20; was admitted Jan. 31, 1863, having had a
chill at noon, followed by a slight febrile action. One cathartic pill was given at bedtime. Next day at noon he
was suddenly seized with violent delirium and great excitement, requiring force to restrain him in bed ; pulse 90;
pupils contracted; back of neck tender. Applied cups to the neck, mnstard to the spine and extremitiee and gave
eiglit grains of quinine and five of calomel, the dose to be repeated at 9 p. Ji. and at six o'clock next morning.
On February 2, the symptoms being unchanged, two grains of calomel and half a grain of ipecacuanha were ordered
and the cupping repeated. This treatment was continued until the 5th, when conjunctivitis was developed with an
eczematons eruption aronnd the lids. The patient became weaker but the delirium lessened. Half an ounce of
. whiskey with milk was given every three hours and two grains each of cajomel and quinine every four hours. Next
day the delirium subsided and the patient gradually recovered without further medication than that directed locally
to the eyes. On March 7 he was sitting up and appeared to be well but for the conjunctivitis. [He was transferred
to Foster hospital April 8, and discharged from service May 2, 1863.]
Case 18. — Private Henry G. Longley, Co. C, 51st Mass.; age 21; was admitted l-'eb. 2, 1863. While in perfect
health this man had been taken with chilliness followed by violent delirium, during which his pulse was full, 85.
skin moist and tongue clean and moist. Cups were applied to the nape of the neck, mustard to the spine and
extremities, and two compound cathartic pills were given with repeated doses of calomel and (|uiuine, ipecacuanlia
being afterwards substituted for the latter. On the 5th opisthotonos was developed and the pulse became wore rapid
TIIK VAROXY^MAL AND CONTINUKD FKVKKS. 561
and feeble. After this the case [iiofiii'ssed sh)\vly, the luiiiil frequently dwelling on exotic snUjects. At the end <if
the second week the spasm of the nmscles of the neck relaxeil, hut ten days later it returned, and he died on the 24th.
His nourishment consisted chielly of milk-])uncli. rosl-iiwrlini examination: The cerebral nieniliranes were very red
and the sinuses filled with black blood; the brain was .somewhat softened and its ventricles contained three ounces
of scrum: the medulla oblongata and spinal cord were covered with a thick yellowish cxudalinn, and the sheath of
the cord contained a yellowish eli'usion.
C.vSE 19. — Private Jno. T). Manter, Co. B, 3d Mass., wa.s admitted Feb. 4, 18()3, having been taken sick on the
previous day. He had violent delirium; pulse feeble, 80. The treatment consisted of cups to tlie neck, nnistard to
the spine, turpentine enemata and repeated doses of calomel and ipecacuanha. Ho died on the morning of the 6th.
rusl-mortnn examination: The pia mater of the brain was congested and lymph was deposited in the sulci and over
the medulla oblongata and pons Varolii; the pia mater of the cord was congested and the sheath, in the lower dorsal
region, contained some effusion.
Cask 20.— Private Henry .1. Kendall, Co. C, ."list Mass.: age I'J: was admitted Peb. 4, ISfiS, having been taken
sick on the night of the 2il with chilliness and headache, followed next day by delirium, for which large doses of
quinine liad been given. On admission he was (piite delirious, and the cervical spine was so tender that he cried out
violently when pressure was made over it ; the pujiils were contracted, tongue clean and moist, pulse 84 and full. He
was treated with wet cups, mustard, turpentine enemata and calomel and ipecacuanha. Next day the head was
thrown back by spasm of the muscles. On the (jth the pulse became quick and feeble, the other symptoms remaining
unchanged. Heef-tea, milk and whiskey, with small doses of (luinine and calomel were taken. Not until March 3
did the mind become clear, after which the patient continued to improve slowly. On .\pril 8tli lie was transferred
to the Foster hospital. [The records of this hospital show that Kendall died April 10, of cerebrospinal meningitis.]
C.vSE 21.— Corporal Austin A. Darling, Co. K, "ilst Mass.; age 19, taken with headache and chilliness on the
evening of Feb. 10, 181)3; admitted next day in :i state of violent delirium : pnlso 90 and feeble; countcnan<-e pale:
pupils contracted; skin moist ; tongue furred and moist. He was treated with cups, mustard, turpentine enemata,
qniniiie. calomel, ipecacuanha and milk-i>uiieh. His bowels were moved, but his condilion otherwise remained
unchanged until the Mtli, when the tongue became swollen and dry, the throat slightly reddened and the puiiils con-
tracted. Cups and blisters were applied to the back of the neck. After this he became weak, pulse 120, mind dull
and pupils dilated. He died on the 17th. Post- mortem examination: The sinuses of the brain were engorged with
blood: the pia mater uniformly injected ; a deposit of yellow lyuiph covered the cerebrum, cerebellum, pons, medulla
oblongata and spinal cord ; serum with some pus was contained in the ventricles, and a yellowish liquid in the sheath
of the cord. [The medulla oblongata and cerel)ellum of this case constitute Sjiecimcn 32, Army Medical Mnsenm.
The lymph masses which originally coated tlieir surface were to a great extent washed away during the tiaiisporta
tii.n of the specimen to the Muscuiii.J
Case 22. — Corporal Kdwin II. Bliss, Co. C, olst Ma.ss.: age 23 years; was taken with violent headache early in
the morning. Feb. 11, 18t)3, and a<lniittcd in the evening : Pulse 106, respiration hurried, pupils natural, tongue dryish
and skin moist. Cups were applied to the back of the neck and mustard over the s]>ine; a turpentine enema was
given, and (juinine, calomel and ipecacuanh.a by the mouth. His liowels were opened so freely that opiates had to
be used; Imt in other respects his condition remained unchanged until the 14th, when the pul.sc fell to 80, the pupils
became contracted, the eyes injected and the tongue dry and brown A blister was applied to the back of the neck.
Next day the pulse had risen to 130 ; he was very feeble and bathed in perspiration ; he died at 10 r. M. Post-mortem
examination: The sinuses of the brain were engorged with black blood ; the pia mater highly injected; one ounce ot
serum was found in the lateral ventricles and a deposit of lymph over the entire surface of the cerebrum, cerebellum,
medulla oblongata and spinal cord. The thoracic and abdominal viscera were healthy. [Spfcimen 33, Army Jledical
Museum, is from this case — a piece of the right lobe of the cerebrum on which, near the miildle of the longitudinal
fissure, is an opaque layer of lymph.]
Cask 23. — Private George W Moore, Co. C, oth Mass., was taken Feb. 11, 18G3, with nausea, vomiting, head-
ache and depressed circulation, and admitted at 6 P. .vi. almost pulseless, stupid and with contracted pupils. Cups,
mustard, turpentine enemata, and calomel at first as a purgative and afterwards in two-grain doses, with ipecacu-
anha, were employed, but without result until midnight of the 12tli, when the bowels were moved several times,
after which the calomel was discontinued. Next morning ho showed sigus of salivation, and in the evening was
rational, answering questions clearly and readily; his pupils al.so bad become sensitive to light. The case progressed
with copious salivation, but with no other untoward event, until March 10, when the patient was returned to duty.
Case 21. — Private Charles W. Haven, Co. C, olst Mass.; age 18; was taken sick on tho morning of Feb. 17,
1863, and admitted at 6 r. M. He was unconscious but very restless, his skin and pupils natural, pulse 90 and
full. The removal of twenty-four ounces of black blood caused the patient to remain quiet for twenty minutes, but
thereafter the jactitation became aggravated. A turpentine enema was given, and a powder consisting of live grains
of calomel and two each of opium and camjihor was vomited as soon as swallowed. At 8 I'. M. the powder was
repealed and retained. Muscular action being very violent and the pul.se 86 and strong, sixteen ounces of blood were
removed while the patient was held upright in bed, but no syncope resulted nor any diminution of the muscular
action. Two grains of calomel were ordered to be taken every two hours. Death occurred at 8 P. M. of the 18th.
PoBt-morlcm examination: The bloodvessels of the brain were much congested and the dura mater strongly adherent
to the skull along the longitudinal sinus; the entire surface of the cerebrum and medulla oblongata was clouded;
the ventricles contained one ounce of etl'used serum, and the choroid vessels were much congested; the spinal cord
presented evidences of inllammation along its whole length and the lower part of the canal contained turbid serum.
Med. Hist., Pt. 111—71
562 DISEASES ALLIED TO OR ASSOCIATED WITH
Case 25. — Private L. G. Parker, Co. G, -Jotli Jlass., was admitted Feb. 19. 1863, having had a slight chill on the
17th, followed quickly by fever and delirium. On admission he was wholly unconscious, pulse 124, small and corded,
surface hot, tongue dry and covered with a dark fur, respiration somewhat accelerated, abdomen natural and bowels
regular; there were petechial spots ou the arms and breast. Decided relief followed the removal of eighteen ounces
of blood; the patient became semiconscious, the jmlse fuller and less frequent and the respiration easier. As deglu-
tition was impossible quinine and turpentine were given by injection every three hours. His progress was gradual
but satisfactory. Ou the 21th he was perfectly rational, pulse 110, respiration 16, skin moist and cool. A slight diar-
rhoia occurred about this time. Next day he asked for more food, and on March 4, his strength being good, he insisted
upon getting up. After this his pulse fell to 70 and he was manifestly improving, when, on the 10th, his skin became
hot and dry and delirium recurred, with frontal headache and great pain in the limbs and back of the neck, whicU
persisted with more or less intensity until the 18th, when he became unconscious, muttering and sometimes singing
in a low delirium and catching at objects real or imaginary. Bedsores appeared about the 15th. On the 20th he
answered questions correctly and then relapsed into stupor: vision was lost or greatly impaired. Next day the head
was persistently thrown back. On the 22d an eruption appeared on the face and abdomen ; the tongue was dry, brown
and cracked.- On the 24th the patient possessed no intelligence; his limbs were cold; he died at midnight. Post-
mortem examination: Body but little emaciated; rigor mortis well marked. The cerebral membranes presented no
unusual appearance on their external aspect, but the veins beneath were somewhat engorged ; the surface of the cere-
brum showed spots of thin milky tluid with clots of pus-like lymph near the longitudinal fissure ; on its base, covering
the origins of the nerves of sense, pons Varolii, medulla oblongata, posterior fissures of the cerebellum, and appar-
ently extending down the spinal cord, was a mass of tenacious yellowish lymph three-eighths of an inch iu thickness
and by estimate from half to three-fourths of an ounce in ciuantity. A deep longitudinal incision through the jions
and medulla oblongata caused three ounces of slightly clouded serum to well up with some force; the lateral ventri-
cles were filled with serum holding in suspension a quantity of pus-like matter. The lungs were healthy: the peri-
cardium normal; the right ventricle of the heart contained two or three drachms of "partially organized lymph."
The liver was normal ; the gall-bladder distended with dark liquid bile ; the spleen natural. One of Peyer's patches
was a little thickened and others presented the shaven-beard appearance, but otherwise the intestines were healthy.
Case 26. — Private Perley Goddard, Co. E, 51st Mass.; age 28 years; was admitted Feb. 22, 1863, having been
taken suddenly sick with headache and pain in the back of neck ; pulse 90 and full ; tongue clean and moist. Cups
to the neck, mustard to the spine, with a purgative of calomel and jalap were ordered. The bowels were freely ojiened
during the night, and next day powders of calomel and ipecacuanha were directed to be given every four hours, and
continiied until the 28tb, when the imiiroved condition of the patient warranted their discontinuance. He was
returned to duty March 10.
Case 27. — Private A. Wolf. Co. D, 103d Pa.; age 20: was admitted March 17, 1SG3, having been taken sick on
the previous night while on picket after a fatiguing march of sixty miles in two days. The attack began with a chill
and vomiting, followed by headache, pain in the limbs, fever, jactitation and next morning delirium. On admission
be was collajised and pulseless, yet the restlessness continued; his skin was cold and livid and covered, ou the legs
and body, with purpuric spots. He was violently restless until death took place at 11 P. M. Post-mortem examina-
tion: Body well developed, rigid and almost covered with purpura. A thin layer of lymph coated the upper surface
of the cerebral hemispheres and to a less extent the base of the cerebellum, the medulla oblongata and the origins
of the nerves of sense ; lymph was also seen in the lateral ventricles and "a fungoid growth appeared attached to the
floor of each ventricle, being each about fifteen lines long and four lines thick;" the spinal cord, examined to the
extent of three inches, was apparently healthy. The cavities of the heart were filled with firm lymph of a bright lemon
color, — the right auricle containing a complete cast of the cavity, with an exteusiim into the superior cava. The
lungs were congested. The liver was one-half larger than usual and somewhat congested: the spleen enlarged, con-
gested and softened; the kidneys healthy but with a small (juantity of fluid lymph in the pelvis of each. The
stomach and intestines were healthy.
Eleven of the New Berne cases were reported briefly by Surgeon MoRONG of the Foster
liospital. Two of these cases made a perfect recovery:
Private ,Iohu Hook, Co. G, Marine Artillery, was admitted Dec. 30, 1862, with opisthotonos strongly marked.
On the third day the muscles of the neck and back became so rigidly contracted as to prevent the patient from lying
flat on his back. He was returned to quarters on the twelfth day jierfectly convalescent. Treatment was by wet
cups to the neck, beef-tea and stimulants.
Private Henry E. Fuller, Co. G, 43d Mass., was admitted .Jan. 3, 1863, and returned to quarters March 12.
Two others recovered, one with partial paralysis of the face, the other with comiilete deafness. Seven cases
died, but in one only was an examination made after death; — the usual iuflannnatory deposits were discovered.
During the continuance of the epidemic at New Berne some cases occurred in the 11th
Me. and 104th Pa. on the coast of South CaroHna. These regiments, aggregating 1,200
men, had been confined for twenty-two days on board the transport Cahawba. On the
twentieth day a member of the 10-ith died of congestive fever. Next day two men of the
lltli were attacked, one of whom died on that dav. The regiments hmded February 10,
and witliin a week after this seven men died. A board of medical officers, consisting of
THE PAEOXyf>MAI. AND CONTIKUED FKVEES. 563
Surgeons W. S. \\'ooDS, .52a Pa., M. S. Kutixger, lOOtli X. Y.. and W. T. Uobixson, 101th
Pa., convened to inquire into the causation and prevention of this deadly affection, reported
it due to malaria, ochlesis and deficiency of food.
The Medical Board appointed to euiiiiiie into the causes of luoitality in the lltli Maine re^inient met Eeb. 2.">.
ISSi, at St. Helena Island. S. C, and lespeetfuUy report that they have made a careful inve-xtigation into the cirenm-
stauees attendant upon the sickness and deaths lately reported; that they have inspected thoron;;hIy the location of
iLe camp and the condition of the men as to cleanliness and health, the manner of cooking, the policing of flic camp
and the situation of the sinks : that they have attended the Surgeon's call and carefully examined the cases that were
presented for treatment and the prescriptions for these cases: that' they liave examined Ilie records of the sanitary
coudition of the regiment for the past six months, and find that the fatality attendant upon cases occurring -in this
command is accounted for in their ntinds by tlie knowledge of the fact that five-sixths of the cases that have proved
fatal were in the persons of recruits enlisted in the State of Maine in August, 18C2, and transferred thence to York-
town, Va., in September: These men came from the northern counties of the state, where the miasmatic intluencesof
a sonthern climate, so productive of disease to those uniised to the exposure, arc entirely unknown, at a season,
.too.when this miasm Tv.is most alive in all its deadly violence, and on their arrival at Yorktown they occupied a camping
ground notoriously unhealthy and unfit by its peculiar location for the occupancy of any troops at that season of the
year. Tbese recruits, suddenly transferred from civil to military life, from the active duties of home life to the more
confined and passive duties of garrison life, and subject to this poison of miasm in all its malignity, soon succumbed
to its baneful influence, many dying during their first months of service and many otlicrs remaining prostrated by
disease. This was the condition of tilings from whidi the rogimeiit was slowly rallying when it left that place for
active service in December, the constitutions of the men so sadly impaired that climatic intiiicnces, producing no
serious consequences to troops perfectly healthy and strojig, proved more than their weakened systems could bear
and almost necessarily fatal. Certain iiUluences not climatic had great weight in connection with this matter, as for
instance the impaction of the command for twenty-two days on the transport Cahawha. Many of the men occupied
the upper deck and were subjected, with scarcely any protection from the weather, to great and sudden changes of
temperature: others were crowded iilmost to sulVocatibn in confined and badly policed quarters below. During this
time the regiment was obliged to subsist on half rations for want of proper facilities for cooking. The policing of
the camp was found by inspection to be thorough and the men creditably neat in their persons and clothing. The
reasons here given are in our minds sufficient to account for the peculiar susceptibility of the men of this regiment
to climatic diseases.
This regiment, the 11th Maine, had a few similar eases in April, after a confinement
uf eight days on board a transport. Medical Inspector W. II. Mussev, who was present at
the post-mortem examination of one of these cases, considered that clinically and anatomically
the fatal affection was identical with that which was prevailing at New Berne.
Exclusive of these outbreaks in North and South Carolina, only five cases suggestive
of the presence of cerebro-spinal meningitis were recorded during 1863. But in this con-
nection reference should be made to the cases reported as congestive fever. '•■
Case 28. — Private Oscar Kondcbush, Co. E, 111th Pa.: age 22 years: was admitted Feb. 1.5, 18G3, with aphonia.
On March 26th the conjunctiva became slightly congested, and next day he complained of severe pains in the liack
and tightness across the temples: his voice returned and his cries of pain were heard at a distance of sixty rods.
Cold water was applied to the small of the back and morphia administered every two hours, producing considerable
relief and some sleep during the night. On the 28th the pulse was 120, very weak and compressible; the ocular
conjunctiva chemosed and nearly black ; the skin purple with dark spots, not removed by pressure ; the tongue covered
with a thick dirty-white coat ; blood oozed into the mouth, giving a sweetish taste to everything, and the urine looked
like blood. At 8 r. .M. the pulse was 130 ; respiration 30 : temperature 110°. At 3 P. M. of the 29th violent delirium came
on, followed by coma and death next morning. Post-mortim examination: Rigor mortis marked; body muscular; trunk
and extremities, even to the fingers and toes, covered with dark-purple spots about one and a half lines in diameter,
which did not disappear on pressure ; face comparatively free from purple spots ; ocular conjunctiva ecchyinosed and
overlapping the cornea: pupils each two lines in diameter. The brain appeared healthy. The mucous membrane of
the larynx and trachea were softened and discolored with purple spots. There was some hypostatic congestion cf
the lungs; the pleura presented re<Idish and purplish patches of irregular shape. An ecchymosis two inches long
was found at the base of the pericardium, and there were black S]iots under its visceral portion; ecchymoses were
also found in the right auricle, on the outer aspect of the )iiilmouaiy artery and between the aorta and the u'soi)Iiagus.
The mucous membrane of the (esophagus was eroded in two places, each nine lines in length. The peritoneum was
ecchymosed in spots. The liver, ninety-four ounces, was pale in color ; the pancreas, four and a, i|uarter ounces, was
also pale : the spleen, fourteen ounces and a half, was reddish-purple and firm. The mucous membrane of the stomach
was much congested and covered with bright red spots, especially at its fundus. The duodenum was small and its
macous membrane of a dull ochre color. The villi of the small intestine Avere highly injected; Peyers patches were
congested and one was ecchymosed : the solitary glands were somewhat enlarged. The vermiform appendix was
* S:^a mpra, page 140 el acq.
564 DISEASES ALLIED TO OR ASSOCIATED WITH
ecchymosed; the large intestine was distended and its mncons membrane covered with bright red spots. The right
kidney, ten ounces, was covered with ecchymoses, its pyramids darli-colored, pelvis and ureter disintegrated, rough-
ened, mammillated and dark red ; the left kidney, eleven ounces, was ecchymosed ; the pelvis blackish and roughened
ivith minute papilhe, the cortical substance of a bright pink color; the mucous memV)raue of the liladder was ecchy-
mosed.— Lincoln Hospital, Washington, D. C.
Case 29. — Private Alexander Sniedes, Co. K, 25th N. Y., was admitted June 22, 1863, in a comatose condition.
I^othiug of hi.? previous history was ascertained except that he had been ill but a short time and had been delirious.
He died on the 24th. I'ost-morlem examination: Thcie was an abundance of lymph lieneath the arachnoid, at the
superior and lateral i)ortious of the cerebrum and at the inferior portion of the cerebellum. The liver and kidneys
were fatty and the urine albuminous. — Act. AssH Surg. Austin Flint, Ladies' Home Hospital, Sew Tori:
Case 30. — Private Charles V. Woolard, Co. F, 115th III., was admitted Sept. 12, 1863, with severe headache,
confusion of mind, giddiness, staggering gait and a small and wiry pulse, 120. His lower extremities were paralyzed
on the 17th. Next day the jjaralysis became general and he died. Post-mortem examination: Body well nourished.
The membranes of the brain were opaque and thickened; they contained a large quantity of serum and their vessels
were distended with dark blood; the brain-substance was healthy, but the lateral ventricles contained two ounces
of turbid serum. The spinal vessels were highly injected and the membranes inHamed in the cervical region, beyond
which the examination was not carried. — Hospital, Tullahoma, Tenn.
Ca.se 31. — Private S. C. Scott, Co. I, 25th Iowa, was admitted Nov. 14, 1863, with active cerebral symptoms.
Coma supervened on the 18th, on which day he died. Post-mortem, examination: Body well nourished. The vessels
of the dura mater were distended with dark blood; a few patches of lymph were found on the surface of the convo-
lutions and an ounce of clear serum in the ventricles, but the substance of the brain was healthy. The abdominal
cavity presented evidences of general peritonitis; it contained eight ounces of straw-colored serum. There were
patches of inflammation in the ileum; otherwise the intestine was healthy. — Hospital, Tullahoma, Tcnn.
Case 32. — Sergeant-Major Philip Beaufort, 33d N. J., was admitted Dec. 18, 1863. While on the march he was
taken with a chill followed by fever, constipation, headache and inability to sleep. On admission he had severe pain
and great tenderness in the lower part of the spine, shooting pains in the thighs, obstinate constipation, headache,
delirium and wakefulness. He afterwards suffered from constriction about the abdomen, dysuria, opisthotonos and
gradual loss of motion and sensation in the left arm and both lower extremities; there was hypenesthesia with a
wheal of large size on the anterior surface of the trunk; his pupils were dilated ; he had frequent rigors and was
usually delirious. After a continuance of two weeks these symptoms began to subside; the head symptoms disap-
peared and the spasms became less frequent. The paralysis of the lower extremities continued for some time after
the dysuria and constipation had ceased. Sensation returned by degrees, and afterwards motion. Treatment con-
sisted of counter-irritants to the spine, purgatives, calomel and conium, and lastly iodide of potassium and tonics,
with iodine as a local application. — Act. Ass't Surgeon J. W. IKghij, Hospital, Chattanooga, Tenn.*
The I'ullowing extract from the report for January, 1864, of Surgeon Ed. E. Phelps,
XJ. S. Vols., General hospital, Brattleboro', Vermont, refers to the occurrence of the disease
among the recruits stationed in the barracks at that place:
During this month recruits have been assembled at the U. S. Barracks, less than half a mile from this hospital,
and their sick form the greater part of those brought under my care. Among them, it will be seen, arc six cases of
cerebro-spinal meningitis. These were brought in presenting a variety of symptoms, having been attacked suddenly
with nausea and vomiting or with violent headache ; two were admitted in a sta,te approaching collapse. They have
all died but one. In these cases the ordinary symptoms of epidemic cerebro-spinal meningitis were observed, — nausea
and vomiting, cephalalgia, rachialgia, delirium, retraction of the head, obstinate costiveuess, loss of consciousness,
cutaneous eruptions, together with the accidental or less constant symptoms of temporary or fugitive febrile reaction
and moderate paralysis. Nausea and vomiting, which were not always the earliest symptoms, were neither severe
nor obstinate. Cephalalgia was the most prominent and constant of the symptoms; it occurred early, and although
leraitting, did not entirely disappear until consciousness was lost. The pain was usually in the frontal region at
iQrst, but as the disease progressed it became more general, extending to the occiput, neck and back. It was described
as hard and steady; the patient complained of it but did not cry out from its intensity. Opium, when used, had a
happy ett'ect in moderating it. Rachialgia Avas present in one-half of the cases but was by no means severe, and was
jnuch although not entirely relieved by dry cupping and opium. Delirium was noticed in all, in some low and mut-
tering, in others more active; the patient could easily be aroused by a direct question, which would be answered
correctly. It did not persist continuously during the progress of the disease but occasionally intermitted. Ketrae-
lionof the head was but slightly marked in two of the cases; in the others it was a prominent and characteristic
■syjnptom; in two it entirely prevented the dorsal decubitus and in one the head was twisted on the neck. In thos»
cases in which it was severe it continued throughout the attack. Obstinate constipation existed in all, occurring
somewhat earlier in some than in others. Loss of consciousness was of gradual origin except in two cases, in which
it was sudden and the earliest evidence of the disease ; usually it was not a prominent symptom until the later stages ;
most of the patients died comatose. Cutaneous eruptions were present in three of the cases ; they were herpetic and
-appeared on the face and neck; in one a petechial discoloration was noticed on the parts of the body subjected to
pressure. Febrile reaction was incomplete in every case; at times a hectic condition was developed in a few hours,
* I)r. Roberts Barthulow i»ulj!ist]rJ this case in the Cineimmti Lancet and Ohserfer, July, 1864.
TIIK I'AKOXVSMAL ASD CO^'TI]S"UKI) FKVKRS. 565
liut iu all the cases the skin was not inclined to be above the normal tenipeiatnre. lusoinnia, nervous agitation,
jjaralvsis and iliarrluva seemed to be aeeidental syniploms, oeenrring each in only a sinjclo case. J'osl-iiiorlnii exami-
nation in all except one revealed the followini; appearances: Opacity of the arachnoiil, both cerebral and spinal, and
injection of the cereliral pia mater: exmlation of yellowish and brownish sernm beneath the arachnoid and in the
cavities of the brain varying from two to eight ounces: copious infiltration of the choroiil ]>lexus with turbid serum
.'.nd purulent exudation beneath tlic arachnoiil in the meshes of the pia nutter. In some cases nearly two ounces of
pus covered the base of the brain in front of the pons Varolii and extended by the side of the medulla oblongata and
spinal cord ijuite into the lower dorsal region. The pus varied in character, in some lluid or semilluid and in
others thicker; it was nearly concrete In one case on the lateral aspect of the s))lnal cord and on the top of the cere-
binm. dipping down between the convolutions. Microscopic cxanu'nation showed it to consist of a sparingly fibrous
stroma, with pus corpuscles more or less changed and an innneii.se number of fat globules. The thoracic and abdom-
inal viscera were generally but little altered. The spleen was usually very small and hard; its section showed a-
surface much studded with white shreds as of newly-organized material. The liver in all cases was small, rather
hard and fatty. In fact most of the tissues, while they appeared to the eye natural, were highly charged with fat.
.•<uch was the case with the heart, the muscles of the thorax, the walls of the intestines and the kidneys. I'ns In
small quantity was found in the pelvis of one kidney.
Dr. B, W, BowLKs, cm lint)' as assistant at this hospital, trivcs I'nrlliiT int'uniiatioii con-
cern in g these cases : ''''
Of eight patients, two lived two days, one four days, one five days, one nine days, one twenty-eight days, one
thirty days and one recovered. The last case was subject to the whole catalogue of diagnostic symptoms for twenty-
four to thirty-six lionrs, after which the patient was quite himself in every way for several days. Kepeated relapses
were followed by Intermissions of increasing duration until convalescence was established.
The disease manifested itself in the northern part of the state Ijefore appearing al the barracks. It <;iused
deaths iu the town after its ajipearance at the barracks, luit no case originated in the hospital, although the cases
received were not isolated from patients afteeted with other diseases. Some of the recruits w ho left the barracks and
returned to their homes were seized with the disease after their arrival at home. The barracks were in a remarkably
healthy location : they were well ventilated and moderately clean. For a month before the outbreak they had been
crowded : each building contained a hundred men, t he strength of the camp being two thousand. The rations were
of the best finality and well cooked. The weather for a month before and at the time of the outbreak was good
winter weather.
Dr. Bowles s^tates that there had been no typhoid or typhus fever during the winter;
but in one of the protracted cases of cerebro-spinal meningitis examined by him the patches
of Peyer were slightly ulcerated, and the monthly reports of the hospital show that in
November, 1863, fifteen cases of typhoid were admitted, in December fifteen cases in Jan-
uary, 1864, six cases and in February four cases.
Acting Asst. Surgeon J, Thorxe refers, in a report dated .January 1, 1864, to the prev-
alence of this disease in the hospital at Kansas City, Mo.:
Cerebro-splnal meningitis has lately been luevailing in this district. In the report of this hosjiital for the
mouth of Xovember a death reported as typhus should have been credited to this disease. A strong typhous conditioii
is undoubtedly present. The jiatient is taken with a chill, the pulse rising to 100 or 120 ; inteu.se pain in some p;utic-
ular sjiot along the course of some of the larger nerves near their origin, but usually no headache ; complete jiaralysLs
of some of the limbs involving both motion and sensation, the paralytic influence beiug in certain cases metastatic.
The whole body becomes covered with large petechia' containing grumous blood. If punctured phlegmonous erysip-
elas at once suiiervenes. Obstinate constipation is usually present. The lungs are generally oppressed, and upon
peienssion more or less dulness is freriuently detected. A few hours after the disease has manifested itself delirium
sets in with opisthotonos, wild rolling of the eyes, stertorous breathing and heat in the occiput. These symptoms
terminate in death in from six to twenty-four hours.
Quinia seems to be powerless; opium and stimulants have succeeded better. Counter-irritants at the occiput
develope erysipelas ; along the course of the spiue they prove of great value. Iron, opium, stimulants and counter-
irritants constitute my present treatment. Of seven cases during the mouth of December, 1863, three have died.
Recovery is tedious, and during convalescence ulcers form in various jiarts of the body and erysipelas appears upon
the slightest irritation. The organs of special sense are deranged and there is a constant tendency to ulceration In
cicatrices. Every indication of an irritated condition of the blood is present.
I have examined 7«)«(-»ioi/em in five cases during the month. The following is an illustrative specimen: John
.Martin, a Wyandotte Indian, private, Co, E, 15th Kansas Cav.; age 22. Body covered with large petechia'. Nearly
three ounces of purulent serum were found between the membranes of the brain; the spinal cord contained a largo
quantily of similar liquid. The membranes adhered to each other by lymph, princijially along the longitudinal
fissure, .\dhesions covered the cerebellum over its whole surface, also the pons Aarolii, medulla oblongata an<l
nerves arising therefrom. The nerves involved were of a pinkish color throughout their substance. All the tissues
« i?ii;, -Yew J'ort Acad. Mai., Vol, II, p. 2C8.
566 DISEASES ALLIED TO OK ASSOCIATED WITH
implicated iu the diseiise were softened, and a remarkable feature was tlie want of coagulability of the blood. The
lungs were engorged, the liver nearly normal, the spleen enormously engorged. The intestines were not ulcerated.
In 1864 the recorded cases became more numerous, and in the following year the
disease was observed with comparative frecjuency in the field hospitals. Surgeon Charles
M. Clark, 39th 111., appears to have been the only medical officer who preserved a full
record of liis observations. During the first quarter of the year 1865 a number of cases
occurred in the 24th Army Corps, and of tliose treated in the field hospital he made notes
of fifteen which are summarized below. '"
The country occupied by the troops was high, rolling and heavily timbered, about three miles back from the
James River, near Vienna Landing. The season had been remarkably wet, and intermittent, remittent and typho-
malarial fevers prevailed extensively. The men had also been continuously exposed to fatigue and excitement.
C.\SE 33. — Private Samuel Farnsworth, Co. H, 10th N. H., was admitted Dec. 21, 1864, -with a coated tongue,
dry and burning skin, pulse 120, severe cough, difficult respiration, diarrhoea with involuntary discharges and con-
stant pain in the hack of the head and neck. Delirium occurred on the 23d, and he died on the 24th. Post-mortem
examination : The dura mater was intensely congested ; the hrain-tissue softened, the ventricles dry; the cerebellum
covered with lymph ; the membranes of the cord congested in the cervical region. The right lung was hepatized and
the lower lobe of the left infiltrated with pus, the pleura on both sides being slightly involved. The heart, liver,
spleen and kidneys were normal. The mucous membrane of the intestinal tract was congested throughout and ulcer-
ated in the ca'cum and lower part of the rectum, where the congestion was of a dark-mahog.any color.
Case 34.— Private John Hughes, Co. G, 158th N. Y.; age 24 ; was admitted Dec. 24, 1864, without history. His
face was flushed, pupils contracted, pulse 120 and full, skin hot and dry and respiration hurried; he talked inco-
herently and had a disposition to tonic spasm. He died on the day of admission. Fost-mortem examination: The
membranes of the brain were highly congested ; the cerebrum was covered in spots with a yellow exudation and on
the left hemisiihere, near the longitudinal sinus, the arachnoid was raised by a collection of turbid serum about a
half drachm in quantity; each of the lateral ventricles contained a drachm of milky §eriim; the base of the cerebel-
lum was coated with a pus-like exudation; its substance was jiultaceous; the spinal cord was congested throughout
but no exudation was apjiarent. Nothing unusual was discovered iu the chest or abdomen except a slight enlarge-
ment of the liver.
Ca.se 35. — Private Arthur Smith,.Co. G, 7th Conn.; age 23: was admitted Jan. 6, 1865, having been taken with
a chill followed by fever and general pain; he vomited a greenish matter occasionally. No change iu the symptoms
occurred until shortly before death, when delirium, dilatation of the pupils and tonic spasms were developed. He
died com.atose on the 22d. rost-mortem examination: Body slightly emaciated. The membranes of the brain were
distended with serum ; its surface was covered with pus and its substance softened, the cerebellum in particular was
so soft that a stream of water disorganized it; the ventricles contained no etfusion; the spinal cord was congested.
The right Inng was normal ; the left congested, its upper lobe coated with recent lymph. The pericardium contained
eight ounces of serum ; the heart was normal, the blood in its cavities liquid. The liver was hypertrophied : the gall-
bladder distended ; the spleen somewhat enlarged ; the kidneys normal ; the bladder nearly empty. The small intes-
tine was congested and the ileum ulcerated in patches throughout its extent. The colon was healthy.
Case 36.— Private F. M. Dwyre, Co. C, 9tb Me.; age 23; was admitted Jan. 15, 1865, with high fever, pulse 120,
dry and brown tongue, jaundiced, dry and harsh skin, injected eyes, contracted pupils, epistaxis and severe paiu iu
the back. Soon after admission he became delirious and so continued until death. For the first three days the cathe-
ter was required, and the urine withdrawn had a high color, strong odor and heavy reddish sediment; but after this
it became more copious, light-colored and passed naturally. The pupils remained contracted; trismus and dysphagia
became manifest. On the fifth day there was some jactitation, and the hearing and vision were very obtuse. He
continued with no other noticeable change of symptoms until death on the 24th. Fost-mortem examination: Body
greatly emaciated and jaundiced. The dura mater was intensely congested and the pia mater covered with lymph
and pus, especially over the Ijase of the cerebellum, medulla oblongata and optic tract; the cerebrum was softened
in places, the cerebellum very soft and almost disorganized ; the lateral ventricles were full of bloody serum with
pus in the cornua; the membranes of the cord were distended w ith serum and pus. The right lung was healthy but
the left was in process of hepatization, and recent lymph was ett'used on its pleura. The heart was healthy. The
liver was fully one-third larger than normal, its surface mottled and its substance soft and friable; the gall-bladder
was empty; the spleen and kidneys normal. The stomach and transverse colon were inflated, the latter measuring
fifteen inches in circumference; the vessels of the whole intestinal tract were injected and the mesenteric glands
enlarged ; three inches of the ileum were intussuscepted at one place and four inches at another ; the appendix vernii-
formis was enlarged and congested; the right colon considerably congested.
Case 37.— Private G. W. Bean, Co. C, 9th Me.; age 24 ; was admitted Jan. 16, 1865, with what was considered a
ivell-marked eruption of rubeola together with slight fever, pulse 98; a red and dry tongue, severe pain in the right
jide, dy.spnoea, cough and rusty expectoration. The eruption appeared three days before admission. In the progress
of the case complaint was made of severe paiu in the head and down the back. Delirium came on and the patient
continued insensible until death on the 31st. Fost-mortem examination: Bodv greatly emaciated. The membranes
* Surgeon Clark pubL-sbed bis cases in tlie CJtkago Medical Journal^ January and March, 1867.
TIIK TAKUXYSMAL AN].> (.-ONTIXVED FEVERS. 567
of t lit' 1)iaiu were ^loatly ron^estod iiiiil ilistoiulod with scrum, the arachnoid tliickcned; the corohnini and ci'vehelluni
were oovored witli patches of lymi>h, tlie ojitio tract witli ims: the hraiii-tissuc was softened, hul no eli'nsion was
found in tlie vent rick's; the membranes of the cord were in lilt rated with serum. The left lunjL; was sli;;htly con<;csteil
and its lironchial tuUes contained pus; the rijiht was hcpatized in its upper and in a portion of its lower lohe. The
heart was nornnil. Tlie liver was enlarj^ed one-third and mottled : the gall-bladder nearly empty: the spleen normal :
the kidneys slightly conge'Jited. The intestines were nonnal; the mesenteric glands enlarged.
Case 38.— Private Joshua .1. Drake, Co. H, I'jath Pa.; age 26; was admitted Jan. 18, 1865, with well-markeil
typhoid symptoms; tongue dry and brown, teeth encrusted with sordes, pulse full and rapid. 120, urine scanty, an
occasional cough, marked subsultns and furious delirium. These symptoms continued with an increase of the sul:-
snltns and .1 tendency to opisthotonos, epistaxis, suiVusion of the eyes and eomalike stupor, luit without change in
the pupils, lie dieil on the 22d. roal-morttin examination: llody emaciated, abdomen discolored, Iocs blnisli. The
dura mater was highly engorged : the ])ia mater contained serum with lymph especially over the cerebellum, and ]ins
especially over the optic tract ; the substance of the brain was softened, but there was no effusion in the ventricles;
the nrembr;ines of the cord were distended with serum. The upper lobe of the left lung was consolidated and the
lower highly congested; pus exuded from sections of the right lung. The pericardium contained eight ounces of
sernm, with manifestations of the iiresence of inflannnation; the blood in the ventricles was not coagulated, hut tlw
right auriclecontained an albuminous clot. The liver was enlarged one-third ; the gall-bladder enormously distended ;
the spleen weighed one pound and a half; the kidneys were normal. The intestines were generally healthy, but thcr(^
was some congestion of the jejunum, and the ileum was contracted fully two-thirds in calibre: the colon was filled
with fa'ces and the bladder distended with urine.
C.\SE :!!>. — Private David Small, Co. I, fltli Me.; age 16 ; was admitted Jan. 18, 186."), with a wcll-nuirked erui)tion
ofrnheola; rapid ]>nlse, 120: hot skin; red and dry tongue: hurried respiration; cough; natural pupils ; no delirium
but some duliu'ss of intellect. The i)atient afterwards became delirious and showed a tendency to keep the head
thrown back: the pnjiils were contracted. Ho died on the 23d. /'oi(Nm«i-(<m examination : Body extrenu-ly cnniciatcd.
There was arterial and venous congestion of the cerebral membranes, with deposits of lyni])h and patches of lloc( ii-
lent pus under the arachnoid and around the optic connni-ssure ; a quantity of sernm, about six drachms, was fouml
in the left lateral ventricle, none in the right; the cerebellum and pons were softened; the mend>ranes of the spinal
cord were loaded with scrum. The left lung was nonnal ; the lower lobe of the right lung was infiltrated with pus,
its posterior surface coated with recent lymph and lying in a small quantity of exuded serum. The pericardium con-
tained four ounces of serum; the heart was atrophied and its substance softened. The liver was one-third larger
than normal, its tissues congested; the gall-bladder atrophied, congested and empty; the spleen normal ; the kidneys
slightly enlarged. The intestines were engorged with blood and there was an intussusception of eight inches of the
ileum, the mucous nicuibrana of the containing part being much thickened and congested.
C.isE 10. — Private James Kirki)atrick, Co. C, ISIllth Pa., admitted Jan. 20, 186.5. Died February 2. rosl-morlii:i
examination: The dura nuiter was congested, the arachnoid blackened, and there was considerable effusion beneath
them, with a large deposit of lymph over the right cerebral hemisphere and pus over the optic tract ; the brain-tissue
was soft and ventricles partly tilled with turbid sernm ; the spinal cord was much congested. The upper lobe of the
left lung x^as engorged and adherent ; the right lung was bound down by old adhesions. The pericardium contained
three ounces of serum; the substance of the heart was dabby and its veins greatly enlarged. The liver was enlarged,
the gall-bladder empty, the spleen and the kidneys normal. Tlio peritoneal cavity contained some effusion; the
omental vessels were engorged and the intestines congested.
C.VSE 41. — Private H.Manshur, Co. E,2d X, 11., was admitted Feb. 6, 1865, having been sick for two weeks in regi-
mental hospital with chills followed by fever and di:irrhfea. On admission he had delirium with contracted jiupils,
dry and discolored tongue, hurried respirat ion and pulse 130. In the progress of the case there apjieared well-marked
trismus and oi)isthotonos, with rigidity of the abdominal muscles, dilatation of the pupils, involuntary dejections,
some petechia' on the body and a purplish color and coldness of the hands and feet. He died on the 10th, Poxt-morti:i;i
examination : The membranes of the brain were puffed out with liquid except the pia mater, which was closely adherent :
the convolutions were covered with lymph and in some places with patches of pus; the substance of the cerebrum
and cerebellum was softened and each of the lateral ventricles contained a drachm of flaky serum; the spinal mem-
branes were infiltrated with scrum. The heart, lungs and kidneys were healthy. The liver and spleen were slightly
enlarged: the gall-ldadder distended. There was a well-marked appearance of inliammation over the stomach and
peritoneum generally; the small intestine w;is impacted with f;cces, the ileuni ulcerated throughout its whole extent ,
the colon distended.
Case 42.— Private James Reynolds, Co. I, 89th N. Y.; age 24; was admitted Feb. 7, 1865. He had been taken
aick Januaiy 17 with a chill, severe pain in the head, back and extremities and persistent vomiting. About twelve
hours after this seizure collapse threatened, but by the free use of stimulants reaction was induced. He had no
delirium, convulsions or paralysis, but his head was disposed to be thrown back and there was some dysuria. His
hearing was very acute, the least noise disturbing him. The pains gradually left him. On admission he had slight
fever, and although very restless in body evinced no deraugcnu-nt of mind : he was not disposed to talk, but answered
questions correctly and fully. His eyes were greatly injected, pupils dilated, tongue thickly coated ; he did not desire
food, but took toast and tea or coffee at the usual hours. His kidneys acted freely and naturally, but his bowels
were on several occasions moved involuntarily. He died comatose on the 13th. Post-mortem examination : The dm a
mater was extensively congested: turbid serum was found in large quantity in tlie membranes and ventricles; the
]>raiu-tissuo was softened; a thick layer of pus covered the medulla oldongata; pus was found also on the cervical
568 DISEASES ALLIED TO OR ASSOCIATED WITH
jiortion of tbe spinal cord, the substance of which was softened. The left lung was tubercular, the right healthy,
i'he liver was engorged; the gall-bladder greatly distended; the spleen and kidneys normal. A lumbricoid worm
was discovered in thejejununi ; tlie ileum was thinned and congested but not ulcerated ; the trausver.se and desceudino'
portious of the colon were contracted.
C.4SE 43. — Private Dennis Brow, Co. M, 4th Mass. Cav.; age 26; was admitted Feb. 19, 1865, suffering from a
severe chill, delirium and much dyspncea. He had been taken sick on the previous day. His tongue was red with
a brown centre, eyes suffused, pupils natural, pulse scarcely perceptible, 120-150, respiration short and quick, respi-
ratory murmur clear; he had diarrhoia with involuntary discharges and some abdominal tenderness; he was very
restless and indisposed to talk or to answer (piestions ; purpuric spots appeared over the whole surface of the body.
Xext morning there was an increase of the purpura, and the skin was cold and moist but hypenesthetic; there was
a puffy condition of the face and neck. The patient could retain nothing on his stomach and occasionally vomited
:i greenish matter ; his pupils were dilated. He sank gradually , and died at 2.30 r. M. rost-mortem examination : The
dura mater presented petechial discolorations over the whole of its upper surface and considerable effusion beneath
it; the arachnoid was thickened; the pia mater injected and streaked with purple; bloody serum was found in the
lateral ventricles and pus iu patches in the cerebral pia mater generally, and over the optic tract, the cerebellum and
in the fourth ventricle and spinal canal. The light lung was adherent but healthy. The pericardium presented
numerous purple streaks of congestion and contained two ounces of purulent serum ; the lieart was covered with
patches of pus, especially around the aortic sinuses, and its muscular tissue was condensed, catting like cartilage;
the left ventricle contained an ounce of thin bloody serum. The liver was softened and congested m patches both
externally and Internally, the left lobe presenting a small ulceration ; the spleen was one-third larger than usual ; the
kidneys normal. The intestinal tract was covered with hemorrhagic spots but was otherwise healthy.
Case 44. — Private Benjamin llyman, Co. F, 11th West Va.; age 20; was admitted Feb. 20, 18G5. He was fiercely
delirious, constantly changing his position, often breaking into loud exclanuitions and moans, starting up with a
wild expression of countenance and requiring restraint to keep him in bed ; his pulse SOj tongue moist and natural,
skin dry and cold, hands and feet purplish, pupils slightly contracted, urine scanty and bowels constipated. Soon
after admission he vomited a large quantity of greenish matter. Next day petechiie appeared, mostly on the fore-
arms and legs, but other than this no marked change in the symptoms took place until the 26th, when the pupils
became dilated and the delirium subsided in a comatose tendency. He had involuntary passages, trembling of the
limbs, opisthotonos, a recurrence of bilious vomiting, dysphagia, deafness and a gradually failing pulse. Just
prior to death pustules of acne appeared on the face and neck and a few on the arms and legs. He died March 5th.
rost-vwrtem examination : The dura mater was generally injected with both arterial and venous blood; the arachnoid
had a shiny opalesceut look and was thickened at the vertex on either side of the longitudinal fissure; lymph and
pus were found iu the pia mater ; a thick layer of pus covered the pons Varolii, optic tract and base of the cerebelhnii ;
when the brain was placed on the table slight pressure caused the escape of about six ounces of serum from the mem-
branes and ventricles; jius was found iu the third and fourth ventricles and in the anterior and posterior horns of
the lateral ventricles; the cortical ]iortion of the brain was soft and pultaceous, but the white substance ajipeared
unaltered except by an increase iu the nnmber of vascular poiuts ; a large quantity of serum and pus flowed from tbe
membranes of the spinal cord. The viscera of the chest and abdomen presented nothing abuorraal except that the
under surface of the liver had a dark shining look.
Case 45.— Private W'illiam Statlen, Co. C, 15th West Va.; age 21 ; was admitted Feb. 26, 1865, with high fever,
restlessness, delirium, contracted pupils, vomiting of small quantities of greenish li(iuid and petechial spots over the
whole surface, most nuirked on the chest and abdomen. He could not be aroused or made to understand anything;
jir.lse 120. He died comatose at noon of the 28th without presenting any notable change of symptoms in the interval.
I' .f~t-mortem examination : Body not emaciated. The whole cerebral surface, particularly the pons Varolii, was covered
with lymph and pus; the brain-ti.ssne was congested and softened and one drachm of bloody serum was found iu
e;;c!i lateral ventricle ; the membranes of the cord were infiltrated with pus, two ounces of which were collected on
section through the cervical region. The lungs were normal. The heart looked ana-mic and felt hard and horny;
the ventricles contained large, firm and hard albuminous clots which extended iuto the auricles. The liver was
normal: gall-bladder distended; spleen hypertrophied; kidneys normal. The calibre of the ileum was contracted;
the mesenteric glands enlarged. The bladder was greatly distended with decomposing urine and its walls inflamed
and discolored.
Case 46.— Private F. R. Spillen, Co. H, 199th Pa.; age 26; was admitted Feb. 26, 1865, without history, but with
high fever, furred tongue, hot skin, rapid jjulse, 120, suffused and watery eyes, hurried resi)iration and considerable
co'.:gh. Next day an eruption was noticed over the whole surface of the body, and the i)atient complained of great
pLiin in the head and soreness in the lungs; afterwards delirium and jactitation supervened, and he died March 1.
roit-mortcm examination: Body emaciated; rigor marked. Great effusion was found beneiith the arachnoid, which
vra:j thickened; the pia mater was congested and the cerebrum and cerebellum covered with lymph ; the brain was
nmch softened but the ventricles contained no serum ; the spinal cord was not examined. The lungs were normal. The
pericardium contained some effusion, the right cavities of the heart coagulated blood and the left ventricle a large
fibrinous clot. The liver was normal: gall-bladder distended; spleen fully two-thirds smaller than usual; kidneys
healthy. The peri*onenm contained four ounces of liquid; the mesenteric glands were enlarged; the intestiues
cangested and spotted.
Case 47.— Privr.te Emory .Wells, Co. D, 39th 111.; age 25; was admitted at 10 a. m., June 14, 1865, in a comatose
condition : Eyes suffused, pupils largely dilated, respiration rapid, pulse 140-150, tongue moist but not furred ; he had
THE PAROXYSMAL AND CONTINL'ED FEVERS. 569
a great disposition to tonic spasm, keeping the head thrown back. This man had been apparently in liis nsnal health
on the day before admission. He died at 11.30 r. M. Post-moitim examination: Hody euiaeiated. The dnra mater was
greatly injected : there was a large deposition of thick yellowish pns nniler the visceral arachnoid ; the ventricles were
tilled with turbid bloody seriim, and the lirain-tissue was congested and softened, a slight stream of water snfflcing to
wash it away: the medulla oblongata and cervical portion of the cord were inliltrated with pus. The kidneys were
fatty. All the other organs ajipearcd healthy.
Tlie records of the field hospitals have preserved only the five cases which follow:
C.vsK IS.— Private Albert R. Turner, Co. A, 1st Me.; recruit ; age 17; was admitted .Jan. 1, 1865. He had severe
headache and was so stupid as to be unable to tell his name: his jjupils were dilated, ])nl.se 100 and full. A blister
was applied to the back of the neck and a liniment of chloroform, ammonia and oil to the spine; castor oil with
turpentine was given as a cathartic. About midnight the bowels and l)ladder were moved involuntarily and the
patient vomited freely; the stools were very fetid; coma came on, and next morning petechial spots were found
thickly and evenly distributed over the entire surface: the pupils were contracted and there was opisthotonos with
hypera-sthesia, the least touch inducing spasm. At noon he began moaning, lying unconscious and motionless, the
puise llXI and feeble and the extremities cold. The liniment was continued to the back and extremities: ([uinine in
live-grain doses, with tincture of iron and brandy, was given every four hours. At midnight very fetid matters
were vomited. An emetic of sulphate of zinc was given which operated freely, and two hours later twenty grains of
ralonud produced free evacuations. On the following morning he spoke for the tirst time since admission, asking for
water. The hypera'sthesia and opisthotonos continued, with complete deafness; the tongue was brown and dry but
protruded at command: pulse about 90: pupils natural. His condition remained unchanged nntil the iUh, when ho
moaned constantly and was very restless, the opisthotonos, general rigidity and hypera'sthesia continuing, the i)upils
dilated and the petechial spots fading. The quinine was omitted twice, on the 9th and again on the 12tli,and on both
occasions this was followed by an aggravation of the symptoms; but on renewing and continuing the medicine his
improvement was steady. Beef-tea and egguog were freely given. The rigidity disappeared, the spots fjided and tho
patient regained the use of his arms sullicieutly to assist in turning himself in bed. On his transfer to ho.spital at
City Point, Va., February 1, he was much improved and had full use of his arms, but could not stand alone or turn
himself in bed without assistance; his pupils were greatly dilated and on attempting to read he found he could not
see the letters: he had headache and was entirely deaf; but his appetite was good, bowels regular, pulse 85, mind
clear and occupied with what was going on in the ward. [He was moved to Baltimore and thence to Philadelphia,
where, on May 10, the McClellan hospital records show him as undergoing sulphur treatment for scabies and taking
milk-punch and citrate of iron and nuinine for emaciation, impairment of the general health and a small chronic
abscess of the right cheek. He was discharged from the service June 23 on account of deafness.] — Second Division,
Sixth Corps Hospital, Army of Potomac.
C.vSE 49.— Private Henry C. Tibb, Co. B, 1st Me., muscular and of sound constitution, was admitted Jan. 7,
1SC5, at 3 r. M., having been taken during the previous night with a severe chill which had not entirely left him at
the time of admission. He had intense pain in the head and back, his legs dragged in the effort to walk and he was
so giddy that he could scarcely see: pulse 108, quick and full; tongue dry and brown: countenance livid; eyes suf-
fused; pupils normal; petechia; were scattered over the trunk, and on the lower extremities uuiuerons dark-brown
ecchymosed spots varying from the size of a small pea to that of a ten-cent piece and co.ilescing in many places. A
cathartic of castor oil and turpentine was given, bottles of hot water were applied to the feet and stimulating
liniments to the surface. At 5 f. M. he was unconscious, restless and moaning constantly. He died at 3 a. m., thirty
hours after the attack, in convulsions, ^yithout purging or vomittug. The surface of the back, lower part of the
abdomen and the lower extremities, except a small part of the anterior aspect of the thighs, were almost black. —
Urcoml IHrision, Sixth Corps Hospital, J rmy of Potomac.
Case 50.— Private Henry McDowell, Co. C, 21st Pa., complained of headache at 4 v. M. Feb. 16, 1865, and at 11
p. M. had a severe chill, after which dark blotches appeared on the face and extremities. He was admitted at 11 a. m.
next day almost pulseless, tongue slightly furred, face somewhat jaundiced, skin of natural temperature but cov-
ered with irregular purple blotches; his mind was dull but he was able to answer questions correctly; he was very
restless although unable to sit up or even turn himself in bed. Ten grains of quinine were given every four hours
and an ounce of whi.-^key every half hour; warmth was a))plied to the feet and sinapisms to the spine: carbonate of
anuuonia was also employed. Coma came on with increasing yellowness of the skin and ])rofusc persiiiration ; be
died at 7 r. M. of the 18th. — Second Division, Sixth Corps Hospital, Army of Potomac.
C.\SE 51. — Martin (Jray. nnassigned; age 26: was admitted March 16, 1865, with delirium, dilated pupils, invol-
nntary passages, dysphagia, stertonms breathing, opisthotonos, partial paralysis of the lower extremities, acute pain
along the spine, a small wiry pulse, 110, and moi.st skin. Fifteen grains of blue mass were given at once and a half
drachm of hyphosulphite of soda every three hours. As his condition was unchanged next day, a tly-blistcr was
applied over the spine and a purgative of croton oil administered. On the 18th the delirium abated and the dyspha-
gia was relieved: the pupils were dilated but not insensible, and although the stools were passed involuntarily tho
bladder acted naturally. Xext day his appetite returned; pulse 90: skin moist; there was no paralysis or involun-
tary evacuation. The record is defective after this date, giving only notes of treatment, thus: 21st, Gave two ounces
of castor oil as an enema, 23d. Gave ten grains of blue mass. 26th. Gave compound cathartic pills. 28th. Gave
one grain of calomel and one-tifth of a grain of opium every two hours. 29th. Gave two drops of fluid extract of
aconite every two hours. 31st. Died.— Hospital. Port Stronj/, I'a.
Med. Hist. Pt. 111—72
570 DISEASES ALLIED TO OR ASSOCIATED WITH
Case 52. — Teamster Daviil Carter, colored; Co. F, Art'y Eeserve ; admitted Jan. IG. IHkl Diagnosifi — typhoid
fever. Died 22d. rosi-nwrtcm examination: The pia mater -nas injected, the arachnoid thickened and there were
yellow patches overlying several parts of the brain, the largest patch at tlie hase: tlie ventricles contained four or
five ounces of serum. Tlie lungs and heart were healtliy: the left ventricle contained a large fibrinous clot. The
liver, spleen, kidneys, duodenum and jejunum were healthy. The solitary glands in the greater part of the ileum
were injected, as also were two of Peyer's patches. — Field Hospital, Fifth Corps. Army of rotomiic.
Ill tlio o-encral hospitals clinical and ]>ost-mortcm notes were made, some of which are
herewith submitted:
Cases at the Xatioital Hospital. Baltimore, Maryland.
In some of his cases at this hospital Ass't Surgeon George M. IIcGill, XJ. S. Army, seemed to doubt whether
he had typhus fever or the so-called spotted fever under consideration. Thus, cases 56 and 57 were indexed in his
note-book Spotted fever! Typhus fererf, and 63 Typhusf, while some were recorded in accordance with post-mortem
observations as Coiifiestion of the l)rain, lungs, etc. Moreover, the suggestion of a contagions quality is made. Among
his notes the following occurs: It is my painful duty to say a word in memory of Mr. Caulk, a young gentleman of
high promise, a student of medicine at the University of Maryland, who, after assisting us iu our examination of the
bodies of so-called " spotted fever" cases at the National hospital, himself contracted the disease and died of it.
Case .53. — Spotted fever. — Private Isaac York, Co. A, 13th Ind., was admitted Jan. 14, 1865. The patient had
walked to the liospital from the provost marshal's office, and, altliough his expression was dull, he gave his name and
regiment and told how the former was spelled. About noon he became restless and crazy, rolling and tossing in bed.
attempting to get up and requiring two men to restrain him. His eyes were somewUat injected: his jiupils rather
dilated but responsive to light: pulse frequent and full but soft. He did not speak, but appeared to sutler pain in
the abdomen and shrank from pressure, especially over the right iliac fossa. The lungs could not be satisfactorily
examined on account of his extreme restlessness, but no marked abnormal sounds were heard. Counter-irritation was
applied to the back of the neck and a turpentine enema administered. His condition remained unchanged during
the night : occasionally he was quiet for a few minutes, but most of the time he rolled from side to side and made vio-
lent etforts to get up, to restrain which a sheet was tied across his body to the sides of the bed. Next morning he
was more quiet and appeared partially to understand, answering questions with a nod; his tongue was covered with
sordes, pulse softer and weaker, pupils natural or a little contracted. Some ecchymoses on his arms, chest and abdo-
men were ascribed to friction against the restraining sheet ; three' pints of urine, natural in appearance, were drawn
oft': deglutition was difficult, but he occasionally took small quantities of liquid. Towards evening he became heavy
and comatose, the evacuations involuntary. On the morning of the 16th the breathing was stertorous; a number of
dark blotches of ditferent sizes and some small iiink spots were found on the chest and abdomen. During the day
some contraction of the llexors of the right side was followed by paralysis of that sit^e; he frequently moved the left
arm and leg but never the right. He died at 3 a. m. of tlie 18th. Post-mortem examination : The dura mater adhered to the
summit of the cerebrum and was somewhat injected: the pia mater was finely injected and its larger veins full of
blood ; the arachnoid was opaque ; the substance of the brain was congested and of a pink color ; the lateral ventricles
contained liquid and their serous lining was clouded : the veins of the choroid plexus were distended : a liquid looking
like pus was found about the right hippocampus major; the lining membrane of the posterior horn of the right side
was congested and had its veins enlarged ; the third ventricle contained serum ; the fourth ventricle was covered with
ivhat was considered to be plastic exudation and showed small quantities of puruloid liquid : the pineal body appeared
gelatinous and was three times larger than usual. The lower lobe of the left lung was intensely congested, — a por-
tion, one and a half inches square, sank readily in water; the lower lobe of the right lung showed lobular solidifica-
tion. The heart contained white clots iu both ventricles. The liver, spleen and kidneys were congested.
Case 54. — Congestion of the brain ; Sjiotted fever. — Private Orlando Jones, Co. C, 81st Pa.: admitted Feb. 16, 1865.
Died next day. He was partially comatose and could give no account of his previous history; but after counter-irrita-
tion to the back of the neck he became able to speak and stated that he had lieen sick only a few days. The pupils
were dilated; there was great pallor of countenance, with dulness and rhonchus over the lower part of both lungs,
retention of urine and tenderness on pressure in the right iliac fossa. The urine was removed by catheter. Post-mortem
examination : Body well developed and in good condition ; blood liquid throughout the vessels. The veins of the pia
mater were quite full ; the Pacchionian bodies were numerous on the summit of the hemispheres and resembled recently
thrown out fibrin ; the brain was firm and somewhat full of blood ; the ventricles contained small quantities of serum
and the lloor of the fourth ventricle was reddened. The lungs were black from melanie deposit; the posterior part
of the lower lobe of the left lung was congested by hypostasis, and when cut into showed spots ofinten.se congestion
along the tracts of the bronchial tuljes of one-eighth inch calibre. The liver was dark in color, firmer than usual, and
marked with fibrinous lines along the course of its vessels; the gall-bladder contained black bile: the spleen and
pancreas were apparently normal. The jejunum and ileum were somewhat reddened. The kidneys were full of blood;
the urine healthy; the suprarenal capsules enlarged and firm.
Case 55. — Spotted /m-cr.^Private William Doty, Co. D, 91st N. Y.; age 27; temperate, but subject to epilepsy:
was admitted March 2, 1865, having had a convulsive attack on the previous day. On admission no sign of disease
was discovered, but on the 4th he had pyrexia, severe pain in the left side and a faint friction-sound over the lower
part of the teft lung. A blister was applied and a large dose of Dover's powder given. He complained but little
next day and seemed to be doing well, but at night became delirious. On the 6th he was restless, tossing about iu
bed, and in the absence of restraint getting up and wanderiug about the ward ; pulse rapid and feeble ; pupils natural
THK PAKOXYSMAI. A.ND CONTINUED FEVEKS. • ojl
lint iusensiWo: hcail thrown liack liy spasm of the miiscles. lli> dieil early on the 8lh. rosl-morlan exaiiiinatioii
seven hours after death: lieneatli tlic visceral layer of the arachiioiil, which was clear and smooth, was a white lilirin-
likc sul>stance. most almndant alonj; the course of the larger vessels: a small quantity of serum escaped on opening
the lateral ventricles, the linins; memhranes of which were arborescent from eonnestion and spotted with small
pcchvmoses posteriorly and iuferiorly. especially on the left side: the cornna contained also aliout three drachms of
pus-like liquid : in the upper part of the left lobe of the cereVielluni, one inch withiu its posterior semicircular lioriler,
was a small clot from which bloodvessels radiated irregularly; in synnnetrical positioi\ on the other side was a similar
clot : a third clot, thin and small, was found on the right side of the valley of the cerebellum : the lloor of the fouitli
veutiicle was covered with a bluish, tenacious, pus-like substance overlying ffue irregular arborescent cougestions; a
red spot was found lu the centre of the cross section of the medulla oblongata. The lower part of the pons, the per-
forated spaces and their vicinity, especially along the tracts of the vessels, were coated with a bluish fibrinoid sub-
stance. The cerebral and cerebellar tissues were congested. The posterior surface of the right hiug was uneven and
ecchymosed and portions of its upper lobe sank iu water: there were interlobar and saccular adhesions of the left
lung with snbpieural ecchymoses, and at one point intense congestion. The heart contained black and white clots.
The liver was large, dark-colored and full of Vilood; the gall-bladder contained black bile. The spleen, weighing
twelve ounces, was light-colored and easily broken up: the kidneys and pancreas were congested. There were regions
of intense congestion iu the stomach, duodenum and jejunum ; the large intestine was slightly reddeiu'd. The blood
in the vessels was lluid. The urine was highly alliumiuous. The spinal cord was examined thirty-three hours after
death : About a drachm of serous liijuid mixed with lymph-liakes escaped on opening the theca : bluish Hakes of lilirin
were found enveloping the spinal marrow, especially posteriorly: a cross section in the dorsal region revealeil much
softening, but no other similarly aflected spot was discovered.
C.VSE 5t). — Spoiled ferer? Tijphusf — Culbert Wliitcomb, (iovernment employ<?, was admitted March 8, 18G.5, with
well-marked symptoms of typhoid pneumonia. Cups followed by blisters were freely applied over the surface of the
chest. On the 11th the breathing was easy, cough slight, expectoration natural, and a clear sound was heard over
all parts of the chest : but on the 16th the patient was seized with delirium and diarrhira and his tongue became <lry
and cracked. He died on the 18th. Posi-morlvm examination: Body not much emaciated. The veins of the pia
mater were so engorged, especially on the posterior aspect of the cereljral hemispheres, as to present t he appearance of
a superficial clot: the cerebrum was congested: the lateral ventricles contained a considerable quantity of serum
which, in the posterior horn of the left side, was tinged with blood: the lloor of the fourth ventricle was discolored
at its extremities and crossed above the origin of the auditory nerve by a white zone presenting four lines of marked
congestion: the substance of the cerebellum was apparently softer than that of the cerebrum. The right lung was
congested posteriorly and seemed ecchvinosed in its substance and superficially under the pleura: the left was car-
nified posteriorly. The right cavities of the heart contained white inelastic clots: the cardiac walls were llaccid
and of a dark red color, looking as if tliey had been bruised: the lining membrane of the aorta was of a dark -scarlet
color. The liver was dark-colored and friable; the bile very black: the spleen small, tough and dark-colored; the
kidneys tlaccid. tinted red and not distinctly marked on section into tubular and cortical portions: the sac of the
right suprarenal capsule was distended with a granular bloody liquid; the pancreas was reddened. The stomach
presented a large submucous ecchymosis at the fundus; the small intestine was intensely congested, with Peyer's
patches well developed and the solitary glands enlarged ; the large intestine was similarly congested and presenicd a
few round and irregularly oval ulcers. No albumen was found iu the urine. The blood generally was li(jnid.
C.\SE o'.—SpolhUfercrf Tiipliusf—Cor]}'l Frederick Bossardo.Co. I, 21th Mich.: age 20; was admitted March 11.
1865, in a state of partial coma with tremor. He could be aroused to take nourishment and stimuLants, but quickly
relapsed into stupor. He had involuntary evacuations and at times violent spasms of the extensor muscles. Deep
pressnre in tlie right iliac fossa appeared to cause pain. The stupor and spasms continued until death on the 17th. Posl-
inoiUm examination ; Body greatly emaciated. The Pacchionian bodies were well develojied : the arachnoid contained
limpid serum: the substance of the brain was firm; the lateral ventricles contained a small quantity of .serum and their
lining membrane was opacjue : the floor of the fourth ventricle was white but marked by arborescent cougestions above
the origin of the auditory nerves: the substance of the cerebellum was softer than thatof the cerebrum. The right lung,
twenty-eight ounces, was full of blood, and under the pleura on the posterior portion of its lower lobe were two ecchy-
nu)sed spots; the left lung, twenty-six ounces, was partially solidified posteriorly and had :in ecchymosed appear-
ance. Both ventricles contained clots, white in the left but mixed in the right. The liver was light-colored, friable
and odorous; the spleen enUnged to twelve ounces, dark-colored and easily broken down; the pancreas reddened;
the kidneys congested; the suprarenal capsules healthy. The stomach was enlarged and mottled internally: the
jejunum yellow and ecchymosed; the small intestine thinned generally and Beyer's jiatches conspicuous: the largo
intestine discolored and the colic glands enlarged and blackened.
C.vsE 58.— S;>o//((f/<r(T.— Private Aaron James Brown, Co. I, .52d Ohio : age 32: admilted March 11, 186."'. The
body of the patient exhaled an ammoniacal odor: its surface was of the ordinary temperature but very dry and covered
with dark mulberry-colored spots irregularly circular in form, about the size of a split-pea, but not elevated and not
disappearing entirely on jire-ssure : the tongue was stift'and, like the teeth, coated with dark incrustations ; the pni.iis
were at first responsive .o light but afterwards became insensible. He had delirium, which increased and was accom-
liauied with muscular spawns, drawing the head strongly backward. He died on the 21st. Voat-morlem examiuation :
Body not much emaciated; skin measled with dark-colored and apparently fading spots. There was no serum in the
sac of the arachnoid, but the veins of the pia mater were full, and this membrane was detached with dilliculty from
the convolutions ; there were numerous puucta on the cut surfiice of the brain, which also wa.s somewhat reddened ;
OlZ DISEASES ALLIED TO OR ASSOCIATED WITH
liloody serum was found in the posterior Iiorn of the left lateral ventricle — but very little in the anterior horn : the '
floor of the fourth ventricle was opaciue and the roots of the auditory nerves indistinct; the medulla oblongata was
somewhat congested. The right lung Avas adherent on its posterior aspect : its lower lobe presented several sub])leural
apoplectic spots posteriorly; some mottling was observed over the exterior face of the whole lung; though full of
blood the organ was not thought to be congested. The left lung was also full of blood but not congested except in the
posterior part of the lower lobe, where the outlines of the lobules were well defined and their substance on section
presented light-red polyhedral spots in a matrix of effused blood; a portion of this tissue sank in water, and when
broken up by the finger yielded a bloody pulp. The heart was free from clots. The liver presented oval discolora-
tions on its upper surface ; its substance was finely congested, especially in the regions indicated by the congested
superficial jiatches ; the upper surface also showed irregular light-colored mottlings, which were shown by section
to extend into the subjacent tissue; the gall-bladder contained black bile. The sijleen was normal; the kidneys
slightly congested ; the suprarenal capsules reddened ; the pancreas enlarged, light colored and friable. Dark ecchy-
niosed spots were found under the mucous membrane of the stomach. The upper part of the jejunum was reddened;
congestion in the small intestine seemed to have a tendency to determine itself in spots of irregular form, with a diam-
eter not generally larger than one-fourth of an inch ; Peyer's patches appeared healthly. The lower part of the large
intestine was congested. Albumen was found in large quantity in the urine. The blood was generally fluid.
Case 59. — Congeslion of the hrain and lungs. — Corp'l Jacob Crow, Co. 1, 20th Ohio; age 32: was admitted March
11, 1865, with symptoms of incipient typhoid fever. While apparently improving, on April 1, he was seized with
erysipelas of the face. On the subsidence of the inflammation he became delirious and was restrained with difficulty;
opisthotonos came on, and he died on the 10th. rost-mortem examination: Lateral ventricles each containing an ounce
of serum ; pia mater, fourth ventricle, pons and medulla congested. Lungs congested, with some solidification and
emphysema of the lobules; bronchial tubes congested and containing purulent fluid. Heart filled with mixed clots.
Spleen large and jnilpy; kidneys congested. Ileum hyperiemic and jireseuting the shaven-beard appearance.
Case 60. — Congestion of Uingi and brain. — CorpT Jacob Brubaker, Co. B, 12th U. S. Inf.; age 21 ; admitted March
17, 1865, after three or four weeks sickness. On admission there was fever with a coated, dry and tremulous tongue,
twitching of the mouth and sonio hesitation in articulation; slight cough was also present, with resonance and
sibilant and sonorous rales over the posterior aspect of the chest. The nervous symptoms became more marked, the
patient rolling restlessly from side to side, and a slight purpuric rash was observed over the abdomen and chest, not
elevated and not disappearing under pressure. He died comatose April 7. Post-mortem examination: Pia mater
injected: arachnoid opaque; ventricles containing serum. Lungs generally congested, with lobular consolidation
and emphysema in the posterior portions; bronchial tubes reddened and containing much tenacious bloody mucus.
Spleen large. Intestine hypera?mic ; Peyer's patches conspicuous and marked with black points.
Case 61. — Cerelro-spinal meningitis. — Private Eobert Minchion, Co. D, 2d Mass.; age 18; was admitted March
18, 1865, with symptoms of nervous disturbance, and on the lower extremities from the hips downward a peculiar
eruption, consisting of a red areola varying from the size of a five-cent piece to that of a half-dollar, enclosing a dark
centre in a state of incipient sloughing. The tongue was dry and coated with a dark -yellow crust ; the abdomen but
slightly tender: the evacuations regular. The patient complained much of the fatigue of travel and of hardships
endured on Galloupe's Island, Boston Harbor, stating that inferior food and scarcity of water were the causes of his
present condition of prostration and filth. He was rational but slightly deaf. About a week after admission an
eruption resembling that produced by croton oil appeared on the left cheek and neck, and as this in the course of
two days became somewhat umbilicated the patient was isolated. The central portions of the spots on the legs had
in the meantime gradually sloughed, and incoherence, delirium, dimness of vision, contraction of the pupils, sutt'usion
of the conjunctivse, with increasing opisthotonos and ultimately partial coma had supervened. The comatose con-
dition lasted until twenty-four hours before death, when he became wild and almost uncontrollable; this was fol-
lowed by great muscular prostration from which he did not rally. Death took place April 12. Post-mortem examina-
tion: Body emaciated, rigid and marked by ulcerations, especially on the lower extremities and left side of the face
and neck. The sac of the arachnoid contained a small quantity of liquid in which, especially on the right side, flakes
of lymph were floating; lymph-flakes were also loosely or closely attached to the perforated spaces, optic commis-
sure, left fissure of Sylvius, anterior portion of the jions and to the arachnoid stretching over the valley of the cere-
bellum; the pia mater was finely congested: puucta were numerous on the cut surface of the cerebrum: the right
lateral ventricle, the lining membrane of which was highly congested, contained half an ounce of amber-colored
llocculent liquid, with flakes of lymph iu the cornua and on the choroid plexus; the left ventricle presented less
liquid, more flocculi and more intense congestion of its lining; the third ventricle was filled with a similar liquid, the
flocculi of which had lodged chiefly iu the infundibulum; the pineal body was large; the fornix and lower part of
the corpus callosum were greatly softened, the former being of the consistence of thick cream ; the floor of the fourth
ventricle was discolored generally and presented small blood-spots, seven on the left side and two on the right in the
situation of the line* transversiP. The sac of the spinal arachnoid contained serum, and a mass of lymph was attac'.ied
to its visceral surface; the pia mater was congested; the cord was softened and broken in the middle of tho dorsal
region, — the break may have been made by accident iu opening the canal, but the softening was observed opposite
the first lumbar vertebra. The bronchial tubes in both luugs were congested; the left lung was collapsed in some
parts but was otherwise normal; the right was hepatized, red in its posterior and upper part and gray in its poste-
rior and lower part. The heart contained fibrinous clots in all its cavities. The liver was normal: the spleen large
and firm; the pancreas, kidneys and suprarenal capsules normal. The stomach was congested; the ileum thinned;
Peyer's patches well marked but nut hyperiemic; the large intestine congested iu parts.
THK TAKOXYSMAL AND CONTINUED FEVEKS. 57;^
Case 62. — Spottrd J'cvrrf — Lt. Col. (instavus irelmrich, 40tli Mo.: a paiok-d prisoner: a^e .18; stout and mus-
cular: was admittod March 24, IMi."). with nervous symptoms, chielly manifesti'd liy twitcliinj; of the corners of the
mouth, jerking of the limlis, csiiecially when touched, tremor of the tongue and imperfect speech. He seemed to
understand ipiestions partially, es)iecially when put in tiernuin, hut his answers were incohercut. He tried to write
his name hut his hand was too trciuulous: w hen half throiijjh an attempt to spell it he lost the connection and turned
impatiently away. His pulse was soft and feelile : conjunctiva' injected and pupils contracted. There was a diffused
purpuric rash on the chest, abdomen and arms. Ho shrank from pressure over the epigastrium and over the ahdo-
men ■;enerally. He stated that he had vomited and that his liowels had not lieen moved for three days. The respir-
atory murmur was slightly diminished over the posterior parts of the chest and the hreathing was somewhat bronchial
under the left scapula. Coma supervened during the night following admission, and he died at 6 a. >i. next day.
J'usl-morlitH examination : Body well developed. The pia mater adhered to the cerebral convolutions and at the base
of the brain was linely and generally congested: a large quantify of serum was found under the visceral arachnoid,
aud two ounces tinged with blood were taken from under the tentorium after the removal of the brain. The cere-
bral substance was firm and showed many puncta on section: the lateral ventricles contained a small i|uaiitity of
serum: the large veins of the corpora striata near the foramen of Monro and those of the velum interpositum were
covered with an oi)aiiue translucent membrane; the fornix had many puncta at its union witli the corpus callosum
posteriorly: the third ventricle contained serum: the ])ia mater covering the valve of Vieussens was intensely but
delicately congested: the floor of the fourth ventricle was generally reddened, with arboresccnces in the ujiper part,
a scarlet point of extravasation ou each side above the linea' transversa- and more discoloration than usual near the
poiut of the calamus: the pons Varolii was congested. The right lung was engorgeil : the lower lobe of the left lung,
on section, exuded a bloody liquid and had adhesions on its outer face aud some subpleural dark spots on its posterior
asjiect. The right ventricle of the heart contained a small white clot: the right auricle and left ventricle had each
a soft mixed clot. The liver was tirm, heavy, smooth on section, reddish-brown, with indistinct acini; a small calca-
reous mass, surrounded by a star-shaped contraction of the cajisule, was found in the middle of the upper part of the
right lobe; the bile was thick, black aud granulated. The spleen, eighteen ounces, was much engorged and decidedly
softened, its capsule thickened. The kidneys were somewhat large aud congested in their tubular portions: the pan-
creas, enlarged and congested, contained a large calcareous mass. The mucous membrane of the stomach was not
apparently softened, but was of a dark ashred color generally and cherry-red at the fundus: the small intestine
presented in certain regions a somewhat ironed apjiearance: the upper part of the jejunum was darkly discolored;
I'eyer's patches were distinct, hard to the feel aud black pointed: the mucous folds of the ileum were blackened.
The Ciecuiu and colon were hypera'inic and their mucous coats blackened.
Cask 6;^. — Tiiphmt? — Private John Uramon, Co. D, 16th Iowa: age 12: was admitted Nov. 28, 1864, as debilitated
by recnrreuces of intermittent fever. About a week after admission the fever manifested itself, returning at regular
intervals until snVidued by quinia aud alteratives. The patient so far recovered as to be able to do light duty and
enjoyed apparently good health until April 1, 1865, when he was seized with fever and cough with Hght rust-colored
expectoration. Under treatment the pneumonia disappeared, the patient became able to sit up aud his appetite
returned: but on the 10th he was seized with great lassitude, anorexia and sleeplessness; the excretions became
scanty, the tongue dry and dark aud the abdomen somewhat tender. Next day a ditlused reddish papular eruption
appeared over the entire body. The patient contiuued rational, complaining only of excessive weakness nntil the
14th, w hen it was found diftieult to obtain replies from him : a peculiar odor emanated from the body; the urine C(ui-
tained no albnmeu: the bowels had been oi)ened by cathartics and enemata. On the loth the surface was mottled
and cold: the face dusky: eyes suffused: pupils coutracted and feebly responsive to light; tougue covered with soft
dark sordes and protruded with difficulty: impulse of the heart weak. There was no opisthotonos throughout the
case. He died ou the 16th. Pont-innittiii examination: Body rigid: its surface marked by a contineuce of discolored
sjiots of different sizes. The sac of the arachnoid contained about an ounce of scrum ; the pia mater was finely injected.
On the vertex of each hemisphere was an ecchymosed spot about the size of a cent; the cereliral substance was gen-
erally but slightly congested: the lateral ventricles contained a small quantity of serum; a single central line of
congestion was found on the floor of the fourth ventricle above the region of the auditory nerves. Both lungs were
adherent, collapsed, flaccid, but so injected posteriorly as to seem ecchymosed. The heart contained clots. The liver
was congested and of high specific gravity; the bile dark-brown; the spleen eleven ounces, softened; the pancreas
and kidneys normal. The mucous membrane of the stomach was congested at the fundus and along the lower curva-
ture. The duodenum was congested and had the iroued-out appearance; the adjoining parts of the jejunum and
ileum were stained with bile: the ileum was congested ia parts; Peyer's patches were conspicuously marked with
black spots. The ascending colon was hypcra-mic.
Case 64. — Spoiled fcrer. — Private Samuel I. Hargrave, Co. K, 152d lud.: age 19; was admitted delirious Aug. 11,
1865. His previous history was unknown, but it was understood that he had been sick about ten days. His pulse
was rajiid and thready, tongue dry and brown, pupils slightly contracted, bowels constipated, bladder distended,
right iliac region tender. The head was extremely extended and there were marks of recent vesication on the back
of the neck. No eruption was observed on auy part of the liody. The bladder was relieved by catheter aud the bowels
by enemata; a half-grain of morphia procured several honrs of quiet sleep; five grains each of quinine and chlorate
of potash were given every four or six hours, with beef-es.sence, eggs and milk-punch; cold was applie<I to the head
and blisters lietweeii the shoulders. The patient, when not under the influence of anodynes, was extremely restless,
tossing about in bed and getting up when not closely watched: occasionally he seemed rational, but re|)lied inco-
herently when addressed. Theoi)isthotouos continued uutil death. The urine, drawn off twice daily, was freiiuently
tested and fouud to be normal. Ou the 19th his tongue became swollen aud deglutition difficult. He died on the 2l8t.
574
DISEASES ALLIED TO OR ASSOCIATED WITH
rost-morlrm esauiiuation: Body much emaciated aud slightly rigid. Under the arachnoid, covering the valley of the
cerebellum, the crura cerebelli, perforated spaces, fissnres of Sylvius aud upper surface of the cerebrum were thicK
deposits of lymph: the pia mater was intensely and universally congested; a sac about the size of a pea, contaiuiun-
lymph and pus, was found in the right plexus of the third ventricle, flakes of lymph in the middle horn of the left
lateral ventricle and fine red arborescences on the floor of the fourth ventricle: the substance of the brain presented
numerous puncta but was not apparently altered in consistence. A grayish liquid flowed from the sac of the spinal
arachnoid when it was accidentally cut in the lumbar region; a large quantity of lymph, one to three lines in thick-
ness, was found under the visceral layer, especially at the lower part of the cord; the pia mater was intensely con-
gested; the substance of the cord was not softened. The lungs were congested and ecchymosed posteriorly. The
heart was firm aud of a deep-red color,— a large yellowish clot on each side. The liver was dark-colored, mottled
superiorly with yellowish- white, firm, full of blood and strongly odorous; the gall-bladder contained black fluid bile;
the spleen was normal; the kidneys small aud somewhat yellow, congested in their dependent portions. The stomach,
near the jiylorus, was congested. The small intestine was hypenemic, dark-red at the lower end : the solitary glands
were enlarged aud Peyer's patches well developed. The colon was somewhat injected.
Cases at the Hospiials of Jhxaiidria, Va.
Ca.s;e 6.5. — Private George Eice, Co. B, 10th Yt.; age 30; admitted Jan. 12, ISiJl. Diagnosis — acute rheuma-
tism. Uu the 14th he was seized with opisthotonos. Conuter-irritauts along the spine gave but little relief. He
<lied on the 17tb. roit-mortem examination: The pia mater was congested aud there was exudation of lymph alon<'
the spinal cord. The luugs were congested.
Case 66. — Private William Hitchen, Co. B, Ist N. J. Cav.; age 25; was admitted Jan. 26, 1864, as a case of
quotidian intermittent. The fever was arrested by quiuiue, but on the 29th the patient was seized with paiu in the
limbs, headache, some delirium aud paralysis of the right arm and leg, while his tongue became dry aud his pulse
frequent. Cups and blisters were applied to the back of the neck, after which he became quieter and ultimately coma-
tose, in which condition he remaiued until death, February 1. Posi-morfeHi examination: The brain was congested; pus
was found on the cerebro-spiual membranes. The luugs were congested and part of the left lung hepatized.
Case 67. — Private John K. Jones, 1st Me. Cav.; age 18: was admitted March 8, 1864, with what was supposed
to be congestive intermittent fever, but in a few days symptoms of cerebro-spiual meningitis were manifested. The
patient died comatose on the 13th. He was treated with calomel, saline cathartics, quinine freely administered and
enemata of colocynth. rosl-mortem e.xamiuation: Extensive inflammatiou of the membranes of the brain and spinal
cord, extending as far as the middle of the dorsal region: large lymph-deposits on the arachnoid: the ventricles of
the brain were unusually diy.
Case 68.— Private C. R. Spencer, Co. B, 107th N. Y.; age 23; admitted Xov. 2, 1864. Died 5th. rost-morlem
examination : No emaciation ; marked rigor mortis ; extensive suggillatiou posteriorly aud on abdomen. The aracli-
uoidal surfaces along the longitudinal fissure were adherent : the pia mater was congested : there were purulent deposits
bj' the sides of the large veins in the subarachnoid space and at the base of the brain, covering and in some plqces
fluctuating on the under surface of the pons, cerebellum and medulla oblongata, the roots of the cerebral nerves
and the spinal cord. The lungs were healthy. The heart was disteuded with dark uuclotted blood. The spleen
was enlarged and the intestines somewhat meteorized, but otherwise the abdominal viscera were healthy.
Case 69.— Private Marshall Stowell, Co. E, 189th N. Y.; age 16; was admitted Nov. 30, 1864, with typhoid fever.
He was restless and noisy, his face flushed, eyes suffused, tongue dry, swolleu aud with the papilla; uuich enlarged
in the middle and at the base, mouth and throat dry and sore, teeth and lips covered with sordes, pulse frequent and
irregular, skin hot aud dry; but there w,as no diarrhcea. He was treated with cold to the head, sinapisms to the feet
and abdomen, hyosciamus, brandy-punch, beef-tea and a few doses of turpentine and chlorate of potash. On December
10, having been alternately restless aud quiet in the meantime, he was seized with pain in tlie head, much abdominal
tenderness and vomiting, morning aud evening, of a thick brownish li(iuid. The tenderness increased and the patient
became very irritable — pulse 130 — until the 13th, when there was less pain, some appetite aud a better pulse, 100.
But on the 16th he became somewhat comatose. As there had been no stool for a week oil of turpentine was given
with the effect of producing a full natural evacuation; but the coma gradually increased Avith quickened aud labored
breathing, aud he died December 20. Post-mortem examination: Body emaciated; face pale; surface-showing a little
stasis but no petechiie or spots. The surface of the brain was congested and covered with patches of opaque green
lymph ; the lateral, middle and fourth ventricles were filled with serum aud sticky pus; the substance of the brain
was not softened. The posterior and lower portion of the right lung was mostly crepitant but of a dark-red color,
and its smaller tubes contained muco-pus; the posterior and upper part of the left lung was dark-red and softened
but crepitant. The right side of the heart was disteuded with a firm white clot aud with thick but fluid black blood.
The liver was pale and had yellowish spots extending from its surface into its substance; the spleen, about the size
of tlie fist, was firm and of a light red-brown color. The kidneys were fatty and granular: the bladder disteiuled,
reaching to within three inches of the umbilicus. The mesenteric glands were enlarged. The ileum was congested
on its mesenteric side but not ulcerated. The colon contained a moderate quantity of fteces of normal appearance
and presented oval dark spots of a bluish tinge on the mucous membrane from the transverse colon to the rectum.
[Sj)ecinien 520, Med. Sect., Army Medical Museum, shows part of the left lateral ventricle, the choroid plexus, rough-
ened by pseudo-membrane, with shreds of lymph hanging from various parts of the ventricular lining.]
Case 70.— Private Sylvester Slow, Co. K, 20th Mass.; age 24; was admitted Dec. 28, 1864, having walked from
the Washington street prison. He complained of pain in the joints and insisted that there was nothing else the
matter with him; his tongue was somewhat brown in the centre, but the edges were clean and moist; skiu dry and
THK PAROXYSMAL AND CONTINUED FKVEKS. O < 0
rool; eyes natural: liowels iiioveil during tli<" i>icviiius iii^lit ; breathing soniewliat liurried: sli;;lit duliiess over Iintli
Inn us; no headache. During the night he had a lit lasting but a short time, after which he became delirious, muttering
incoherently, and aftecled at the sanu' time with a short harassing cough accomi>anied with frothy, bloody exjieeto-
rafion. He died at 11 A. M. of the 21Hh. I'ont-mnrlrin examination: Yellow exudation at the base of the brain and
between the cerebrum and cerebellum: some slightly turbid serum in the lateral ventricles: a i>igment de])osit llio
size of a pea in the lower part of the right optic thalamus, i)resumcd to be the result of a former extravasation of
blood; slight hardening of the brain-substance. Some lobular pneumonia: cirrhosis of i'h- !i\er; enlargement of
the spleen: inflammatiou of the solitary follicles of the ileum and ca>cum.
Case 71. — Private John Fitzpatrick, Co. G, 28th Mich.; age 37 ; admitted Jan. L'O, liSij."). Uiagno.si.s — acute bnm-
chitis. Died February 2. /'o.v(-mor/<Hi examination: No emaciation: ftiarUed rigor mortis; much suggillation pos-
teriorly. The longitudinal sinus was filled with dark clotted blood : the dura mater was normal but the jiia mater
was covered with unorganized lymph; the brain was healthy, with two drachms of serum in its ventricles; the
spinal cord was not examined. The mucous membrane of the trachea and bronchi were inllaiued, thickened and
roughened ; the bronchial glands enlarged and very dark. The lungs w ere somewhat emphysematous in their upper
and congested ij their lower lobes. The heart was enlarged and showed large numbers of fat-globules under the
microscope; the pericardium was normal. The omentum was congested; the livcrenlarged and very pale; the intes-
tines normal except for a softening of the mucous membrane of the ileum ; the mesenteric glands enlarged and dark ;
the remaining abdominal viscera normal.
Case 72.— Private William E. Tappan, Co. II, 28th Mich.; age 17: admitted Jan. .SI, ISm. Skin hot and dry;
Hmgue dry and somewhat fissured, red at the edges and coated dark yellow in the middle; pulse f|ulck and feeble;
bowels rather loose; urine scanty and high-colored; respiration somewhat liurried; ho was rational and complained
of pain in the back of the head and neck. He did not rest well during the following night, and next day, although
his tongue was less dry, his pulse was fuller and the pain more intense, extending from the head down the spine and
over the body generally; he was peevjsh, fretful and slightly delirious at times, though he answered ([uestious cor-
rectly. A blister was applied to the back of the neck and alteratives administered. On February 2 delirium was
constant: the patient muttered, tried to get up, and had occasional at tacks of opisthotonos which increased in violence,
but there was no paralysis: he refused all food. Wet cups were api)lied along the spine. Next day opisthotonos
was less marked, but delirium continued with dilated pupils; the catheter was required to relieve the bladder. On
the 4th the pulse became weak and intermitting; the respiration labored and accompanied with a rattling in the
throat: he was semi-comatose but easily aroused: the tetanic convulsions returned with violence, and he died at 11 r. M.
I'ost-moriem examination: Body not emaciated. The veinsof the cerebral membranes were distended with black blood;
the brain was firm and slightly injected; its lateral ventricles contained thick pus and their veins were black and
engorged: the velum in terposi turn, valve of Vieusseiis and the membranes from the optic connnissure down the medulla
as far as could be seen were covered with lymph and pus: the gray matter of the cerebellum was so pale as to bo
scarcely distinguishable from the white matter ; the cer*belliim and spinal cord were softened. The upper and lower
lobes of the right lung were somewhat congested and showed dark-purple or blackish patches of softened tissue : the
middle lobe was oedematous, of a gray color tinged with pink, and presented at its margin a patch of shrunken liver-
red tissue full of enlarged bronchial tubes containing pus ; the left lung was similarly affected but in a less degree.
The heart was normal. The liver was somewhat enlarged, yellow and granular; the spleen small, its trabecule
andMalpighian bodies enlarged, dry and bloodless: the intestines and kidneys normal; the bladder largely distended
and the overlying recti muscles of a bright-red color.
Case 73. — Private Nicholas V. Sharp, Co. A, 25th Wis.: age 3(5; admitted Feb. 9, 1X().5, from Washington street
prison. Diagnosis — typhoid fever. The only symptoms on the record are: Dark-purple sjiots covering the body;
tongue slightly coated; pulse 130, weak; some frontal headache; bowels loose. He died during the day. Post-mortem
examination : Lymph was effused at the base of the brain and between the cerebrum and cerebellum : there was also
engorgement of the cerebral veins and serous effusion in the ventricles. The pericardial sac contained effused serum.
Part of the upper lobe of the left lung was iullamed and softened. The liver was large, fatty, soft and gr.anular; the
spleen large, soft and discolored: the small intestine normal; the colon slightly inflamed.
Case 74. — Private Jacob Evans, Co. E, 1st Del., was admitted Feb. 14, 1S65, unconscious and in a condition of
low delirium. In a few days opisthotonos came on, and he died on the 24th. Stimulating liniments and sinapisms
were applied to the spine and extremities, while the head was kept cool. Post-mortem examination : The membranes
of the brain were injected; lymph and pus were deposited from the medulla upwards to near the optic commissure;
the brain-substance was cream-colored and softened; the lateral ventricles were filled with pus and serum, the choroid
plexus of each opaciue and pale and the wall of the posterior cornu softened; the third ventricle was distended with
scrum, the fourth with serum and pus. The spinal membranes were unaffected. The lower lobe of the right lung
was dark-brown, soft, non-crepitant and heavier than water; the left lung was softened, its bronchial tubes injected.
There was a slight effusion in the pericardial sac. The walls of the stomach were soft and white; the liver light-
colored and cirrhosed: the spleen auasmic; the portal veins full; the colon distended with llatus.
Case 75.— Private James O'Leary , X'. S. Inf., unattached ; admitted Feb. 23, 1865, from Washington street prison
so nearly moribund that no history could be obtained from him. His eyes were fixed and vacant, skin cold, dry and
livid. He died soon after admission. I'ost-mortim examination : The meningeal vessels were pale and watery, as were
those of the vascular processes in the lateral ventricles: serum was effused beneath the arachnoid and lymidi at the
vertex and over the base of the brain ;. the cerebral substance was pale, soft and ana-mie, and the ventricles contained
576 DISEASES ALLIED TO OR ASSOCIATED WITH
serum with some lymph. The spmal cord was soft. The glands at the root of each lung contained calcareous deposits.
The liver was large; the spleen soft and pulpy; the bladder largely distended.
Case 76. — Serg't William R. Brock, Co. F, 6th Tenn.; age 34 ; was admitted Feb. 17, 1865, with pneumonia. He
imjiroved steadily until March 6, when he was attacked with cerebro-spinal meningitis, for which he was blistered
on the neck and spine and treated with veratruni viride and saline cathartics. He died on the 8th. Post-morhm
examination: The pia mater was congested; there was a large quantity of purulent liquid beneath the arachnoid,
one ounce of yellowish serum in the ventricles and two ounces at the base of the brain ; the cerebral substance was
normal but the cerebellum was softened. The membranes of the spinal cord were thickened and the subarachnoid
space filled with purulent licjuid. The middle part of each lung was hepatized.
Case 77. — Private John llcClnre, 2d U. S. Cav , was admitted April 8, 1865, in an imconscious state. He writhed
incessantly; his pnl.se was slow and labored; his eyes fixed and staring and his pupils dilated. He had no convul-
sions, but died comatose on the 11th. rost-mortem examination: Serum and yellow lymph were found beneath the
arachnoid, especially on the right side, and also between the optic tracts and crura cerebri; the substance of the
brain was normal, but the choroid plexus on each side was darkly congested and somewhat thickened or opaque on
its anterior margin. The right lung was jiale, bloodless and solidified in the posterior parts of its upper and middle
lobes and deeply congested in its lower lobe; the left lung was congested. The heart was large and slightly fatty;
some old opacities were found ou the anterior surface of the right ventricle. The liver was pale, the spleen small and
hard; the lower ileum natural.
Cases at various General Hospitals.
C.\SE 78. — Lieut. R. X>. Edwards (rebel) was admitted Feb. 1, 1864, in a condition of low delirium from which
he could be aroused to answer questions rationally: Thirst; constipation; pulse strong, 115; deafness; eyelids purple
and swollen and pupils sluggish; severe jiain in the forehead and left side of the face; pain and stiffness of the
muscles of the back of the neck and back, with tenderness over the last cervical and first dorsal vertebr;e; sensation
somewhat lessened and motion greatly impaired in the left arm and 'eg. The delirium increased and with it the
paralysis, which extended to the other side. For four days before death he was in an almost helpless condition, drowsy
and stupid, complaining only when moved. He died on the 7th. rost-mortem examination: Rigor not well marked;
considerable suggillation posteriorly; some reddish spots on the limbs. An ounce of reddish serum was found
at the base of the brain and a quantity of exudation, diffluent and pus-like, around the left lobe of the cerebellum
and adhering to the tentorium; the veins of the pia mater were filled with blood; the membranes were easily
detached from the convolutions, and a thin semitransparent exudation covered the surface of both hemispheres; the
puncta vasculosa were numerous and the lateral ventricles filled with liquid, but the vessels of the choroid plexus
were not injected ; the pineal gland was broken down into a thin yellowish liquid adhering to the velum interposituni,
and there was some exudation about the optic commissure. Bloody serum, amounting to five and a half ounces, was
found in the spinal canal, with some blood-clot and an exudation of a membranous form extending from the last cervical
to the tenth dorsal vertebra; the cord, which was bathed in a yellowish creamy fluid, was soft and semifluid at the
points where the false membrane terminated; the gray substance was scarcely distinguishable from the white. Both
ventricles of the heart contained fibrinous clots; blood, partly coagulated, flowed from the great vessels. The lower
lobe of the right lung sank in water and the ui)per lobe was saturated with reddish serum; the lower lobe of the left
lung was dark-blue posteriorly and condensed in patches. The liver was soft, greasy and of the nutmeg appearance;
the gall-bladder contained half an ounce of reddish-brown bile; the spleen, five ounces and a half, was bluish-green
anteriorly, reddish posteriorly, its substance diffluent and the Malpighian bodies enlarged and distinct; the kidneys
were healthy. The mucous membrane of the stomach was softened in several places, especially about the cardiac
orifice. The Intestinal walls were thin ; the ileum in part colored blue, its epithelial layer softened in oblong patches
and its solitary follicles visible. The large intestine was healthy but the open mouths of the solitary glands appeared
quite distinct. — Ass' t Surg. Eoherts Bartkolow, U. S. A., EospitaJ, Chattanooga, Tenn.*
Case 79, — Andrew Galespy, Government employe, admitted Feb. 1, 1864, Diagnosis — pneumonia. Died 4th,
Post-mortem examination: The vessels of the brain were much engorged; serum was eft'used under the arachnoid and
lymph around the choroid vessels and at the base of the brain over the optic commissure; the lateral ventricles con-
tained each two drachms of serum. The lungs were much congested. The heart contained large butt-colored clots.
The liver and kidneys were fatty; the stomach, spleen and intestines healthy. — Eospital Xo. 1, Nashville, Tenn.
Case 80, — Private James Draper, 9th Ohio Batt'y , was admitted Feb. 10, 1864, with laryngitis. He had regained
his strength and was about to rejoin his command when he was suddenly attacked with active delirium, during which
his pulse was 160, tongue dry and red and eyes suffused. These symptoms lasted forty-eight hours, after which he
became comatose, and died March 21. Post-mortem examination: The Pacchionian bodies were enlarged and appeared
to be ulcerated; the cerebro-spinal membranes, as far as the fifth cervical vertebra, were congested and contained
four ounces of clear serum; the cerebral vessels were injected, the convolutions covered with lymph and the floor
of the ventricles with fibrinous deposits. No other organs were examined. — Uosirital, Tullahoma, Tenn.
Case 81. — Private Robert Carr, Co. Ci, 1st Mo, Eng'rs; age 15: was admitted March 2, 1864, with meningitis.
He died on the 6th. Post-mortem examination : There were heavy deposits of lymph on the surface of the brain but
its substance was healthy. The lower lobe of the left lung was heiiatized. The right cavities of the heart contained
large yellowish clots and there were smaller clots in the leftside; the endocardium in the left auricle was roughened.
The abdominal viscera were healthy. — Hospital No. 1, Nashville, Tenn.
*Dr. Baiitiiolou- pub'.isbeil tliis case in tlio diifiintati Lmicel initi Obnerrer, Julj, 18G4.
TIIK PAROXYSMAL AND CONTINUED FKVKRS. 577
Cask 82. — Private (ieoi'se W. Hassiugcr, Co. F, IL'tli Mo. Cav., wa.s admitted March 19. 186-1. having had a chill
on the previous day. He complained of pain between tlie shoulder.s, which increased in severity until the 21st,
when lie was taken with a congestive chill or collapse and l)ecame insonsilile. The muscles of the hack and neck
contracted spasmodically; the surface was cold, the pulse small, freciucnt and thread-like, digestion dillicuU ami tho
discharges involuntary. After three days tlie pulse heeame fuller and slower, tlie surface warm and consciousness
returnid. the ]ialient complaining of pain in tlie head and hack and of extreme sensitiveness of the surface. From
this time he had fever of a typho-nnihirial type, which lasted three weeks without any material change except a
grailual improveuu-nt. On the date of the report, April 20, he was considered convalescent. He had weakness of
the back and symptoms of paralysis of the lower extremities, but not" such as to i)revent him from walking about
the wards. — Surgeon Ira Ilitssell, U. S. I'ols., Benton liarraeks, Mo."
C'.vSE 8.S. — Private Alfred Lockwood, -list Ohio, was admitted from the military prison March 2.i, 18B1, in a semi-
comatose condition, with the head drawn back, rigidity of the muscles of the neck and tenderness on pressure over
the cervical vertebra". The eyes were injected, pupils dilated and fixed, ]uUse 90, soft and full, tongue furred yel-
lowisli-white and abdomen slightly tympanitic. When roused and (|uestioned he always gave the same answer, an<l
when placed upon his feet he staggered like a drnnkon man. Six cups wore used on the temples and nape of the neck
for tlie extraction of eight ounces of blood and cold cloths thereafter ajiplied to the head : at the same time croton oil
was administered, which operated feebly. After this the patient seemed improved: he had better eommand of his
faculties when his attention was tixcd, but when left to himself he fell into a wandering slate of mind, talking and
making freiiuent coniplaiiits of pain in his head while tossing himself continually from side to side in bed. On
the third day dark iivid spots appeared, scattered sparsely over the whole surface but in greater numbers on tho
lower extremities and particularly around the joints: restlessness and delirium became aggravated and were accom-
panied with decided opisthotonos: the face w.as dark-hued, especially on the lips and aUe nasi; the pupils con-
tracted : the pulse 9(5 and rather weak. As the case progressed the pulse rose to 10(i-130, while tho dark moist coating
of tlie tongue changed into a dry black crust, and sordcs appeared on the teeth and lips. On the fifth day the patient
lay on his back with the thighs and legs partially flexed, the toes contracted on the soles and the thumbs drawn
into the palms. Suhsei|uently tho countenance became haggard, tlie eyelids half closed, the eyeballs fixed and the
cornea' glazed, the extremities cold and the surface covered with a clammy sweat, tho pulse hardly perceptible, the
abdomen excessively tympanitic and the respiratory movements short and rapid. Death occurred April 1. On the
second and third days small doses of tartar emetic and nitrate of potash were given every two hours with croton oil
to the spine: on the fourth day these were replaced by eight grains of iodide of potassium every four hours; lastly
carbonate of ammonia and wine were given. Post-mortem examination: Several recent adhesions were found between
the dura mater and the visceral arachnoid, with thickening of the latter and a purulent mass between it and tlio pia
mater, the vessels of whicli were enormously distended with lilack flui<l blood. Tlie spinal aracliiioi<l was inliamed
througliout; in the region of the third or fourth dorsal vertebra lialf an ounce of pus was found with softening of
the substance of the cord. — let. A><s't Surg. F. C. Leber, CUiij Hoxpital, Loiilsrille, Jiy.i
Case 84. — Private .John L. Smith, Co. E, 74th Ohio, was admitted March 2.5, 1864, with iii(iil:il derangement
which soon passed into delirium. He pointed to his foreliead and temples as the seat of violent pain, while at the
same time his face was flushed and dusky, eyes injected and pupils fixed. A white fur on the tongue quickly changed
to a dry brown crust: the pulse was 130, full but not hard, and the respiration iiuickened. He was very restless,
made freiiuent attempts to get out of bed and when on his feet reeled like a drunken man. His delirium was of a
humorous character. The treatment consisted of cold applications to the shaved scalp, alistraclion of blood by cujis
on the temples and nape of the neck and the administration of a jiurgativc do.se of Epsom salt with one grain of tartar
emetic, followed by smaller doses of the latter. During the night he was restless and did not sleep, but next day the
pulse fell to 120 and the pain in the head abated somewliat, although there remained great heat of skin and dryness
of tongue. He talked continually and still attempted to get out of bed. He did not seem to sufter from thirst, yet
he drank whatever was oftered him. such as milk, lemonade or water, without apparently noticing what he was
taking. On the 27th the pulse was reduced in volume but not in frequency; the face pale; eyes dull and heavy;
leeth and lips covered with sordes: etibrts to talk were made but the patient could n6t articulate; his head was firmly
retracted and there appeared on the surface, particularly on the neck and ii|)|ier part of the chest, dark-colored ji.'itches
hming the appearance of blood extravasated under the cuticle. Dry cujis were applied to the back of tho neck,
crotou oil along the spine and a blister to the scalp. .Stujior developed on the 28th, speedily deepening into coma
and death, roit-mortem examination: The arachnoid was thickened; lym]ih was acciiiiiiilated in the cerebral sulc'i
and covered the entire base of tho brain ; the lateral ventricles were not distended with liiiuid, but tlie right poste-
rior cornu contained a small quantity of pus and lymph. Numerous black spots were ob.servc<i in the substance of
llie cerebrum, which appeared otherwise healtliy. The spinal arachnoid was thickened and presented undi'rlying
exudation. The blood in all the vessels remained fluid. The thoracic and abdoiiiinal viscera were not examined. —
■Act. J»»7 Surg. 11. JVirth, Clay Hospital, Louiacitle, Jiy.f
C.\SE 85. — Private Henry C'lymer, Co. K, 128th Ind.; age 40; was admitted comatose April '), 18CI , and died next
day. /'osf-nior/ein examination: Body nniscular; rigor mortis fairly marked; face, head and shoulders bronzed. The
veins of the cerebral membr.-vnes were distended ; a layer of soft lymph covered the surface of the brain and a similar
layer was found between the membranes; thebrain was softened, particularly in its mi<ldle lobes; the medulla oblongata
and pons were also somewhat softened; the gray substance was pale in color and few puncta wore visible, but
•Sorgoou RrssELL's cases were published iu the Boston Medical and Suryical Journal, May 19, 1864.
ti?nrKPon .\lex. T. Watson, U. S. Vol?., in charge of the hoi^pital, pu1>li!-lirii t)iit« caw in the Amvrican Medical Timee, May 7, 1864.
Med. Hist., pt. Ill— 73.
578 DISEASES ALLIED TO OE ASSOCIATED WITH
the vascular processes in the interior of the. brain were congested. The lungs, which weighed fifty-six ounces, -were
congested iiosteriorly and presented collapsed and a-dematous patches of a dark-lilue color. The heart was well sup-
plied with fat ; the walls of the right ventricle were thinned, those of the left ventricle were three-quarters of an inch
thick, but their substance was easily torn; the right cavities contained a small fibrinous clot. The liver, seventy-nine
ounces, presented the nutmeg appearance, and bile flowed from it on section; the gall-bladder was distended; the
spleen measured nine by six inches and was unusually firm, bluish-gray externally, purplish-brown internally, the
JIalpighian bodies very distinct; the kidneys were externally of a bluish-purple color, the centre reddish-brown and
the pyramids jiurple, streaked and patched with yellow. The omentum and mesentery were loaded with fat. The
mucous membrane of the stomach, yellowish-gray in color, presented many small but highly congested points. The
solitary glands of the small intestine were prominent, especially those near the ileo-ciecal valve, where also were many
small ulcers each about two lines in diameter. The mucous membrane of the circum was bluish-gray, its follicles dis-
tended and pigmented; in the upper part of the rectum were several large dark-blue and brown patches, where the
mucous membrane was softened and easily detached. — Hospital Xo. 1, Sashville, Tenn.
Case 8G. — William S. Kay, a civilian, but formerly a confederate soldier, was admitted April 6, 18G4, com-
plaining of pain in his head, neck and back and in his bones generally; his eyes were injected and face tlushed, but
he was jierfectly rational and able to walk uii a flight of stairs — half an hour afterwards, however, he was delirious.
He seemed to be in great distress, moving about in bed, raising himself up and falling back again; pulse rapid but
not strong ; no increase of temperature was perceptible about the head. Five cathartic pills were given; cups were
applied along the spine and croton oil and sinapisms to the lower extremities ; cold applications to the head distressed
him. During the afternoon the jiatient was inclined to sleep: for some minutes he would lie quiet aud then startup
as if frightened. He took no nourishment and was indift'erent to drink. The .skin bad become so insensitive that
mustard applied for hours made no impression. During the night he was very restless. Next morning dark-red spots,
varying in size aud form, were found on his neck, breast and legs; he continued delirious, talking aud moving con-
stantly; his head became firmly drawn back and coma speedily supervened. He died thirty hours after admission.
No jiost-mortiin examination was made. — Act. Ass't Surg. E. Wirth, Clay Hospital, Louisville, Ky.*
Ca.se 87. — John B. Muzzey, a recruit; age 3.5; was admitted comatose April 7, 18G4, having been taken two days
before with severe chills and pain in the head and back. His body was covered with purplish-red spots of various
sizes, one of which appeared on the right sclerotic; his eyes were closed, head somewhat thrown back, muscles mod-
erately rigid, respiration 24 and labored, pulse 6(5, full and slow; he was unable to protrude his tongue. A hot bath
restored his consciousness and he inquired — ''Where all this water came from ?" On removal to bed he was rubbed
briskly with tincture of capsicum, after which he broke into a profuse perspiratiou. Four grains of quinine were
given every two hours, with whiskey at the rate of ten ounces daily aud beef-tea and milk ad libitum. In the evening
he was stupid aud unable to articulate: pulse 84. Six ounces of blood were taken from the neck and a cathartic of
calomel administered. Next morning the skin was moist and the patient, with some support, sat up in bed, talked
rationally and said he felt better; pulse 84, respiration 32 and tongue coated with a creamy fur. The quantity of
stimulant aud quinine was diminished. On the 9th there was an inclination to sleep; pulse 96, full and hard ; skin hot
and dry; tongue dry and brown. In the course of this day subsultus tendinum, abdominal respiration and involun-
tary evacuations were noted. Cupping the najie of the neck was again resorted to, followed by blisters to the neck
and extremities. Next day, however, he was completelj' comatose ; pulse 117, full and hard ; respiration 44, sighing;
pupils insensible ; toes of the left foot strongly flexed ; the spots had nearly disappeared. He died April 11 at 3 A. M.
rosl-mortem examination : A few spots were seen on the extremities. The vessels of the dnra mater were turgid with
blood and a layer of coagulable lymph one-sixteenth of an inch thick covered the whole of the arachnoid and pia
mater; the lateral ventricles were filled with bloody serum and two ounces of a similar li(iuid were fouudat the base
of the brain ; the choroid vessels were injected. The medullary portion of the Spinal cord was noruuil, but the mem-
branes were deeply injected aud the pia mater exhibited along the posterior aspect of the cord a layer of lymph-like
exudation which was found to consist wholly of pyoid cells. — Filbert Street Hospital, Philadelphia, I'a.i
Case 88. — Wm. H. Alien, Co. B, 12th Mo. Cav.; age 18; of small stature and delicate constitution, was admit-
ted April 11, 18r>4, having been sick for two days in quarters, during most of which time he had been delirious. On
the day before he was taken sick he had eaten heartily of trash bought from a sutler and had drunk six bottles of
ginger pop. On admission he complaiued of pain in his head, back, neck and throat; his expression was wild, and
although at first rational, iu a few hours he became delirious, talkative and restless, rising from bed and walking
across the ward with a wild vacant stare. Constant attention was required to keep him in bed. Restlessness and
delirium continued with little intermission until within a few hours of his death on the 20th. When roused he gavo
rational answers but immediately relapsed into delirium; his discharges were passed involuntarily; he complained
of pain in his legs ; the muscles of his back and neck were contracted; on the day before death his pulse was IGOaud
respiration 60; he took but little nourishment and ground his teeth constantly. Post-mortem examination : The mem-
branes of the brain and spinal cord were highly injected; the cavity of the arachnoid contained an ounce and a half
of serum; pus aud lymph were deposited on the medulla oblongata, pons Varolii and spinal cord except in the cervical
region, in which, however, the membranes were much injected ; the lateral ventricles each contained half an ounce of
sero-purulent fluid ; the substance of the brain was congested and softened. The lungs were considerably congested.
The mucous membrane of the stomach was quite dark in color and softened. No other morbid appearance was
recorded. — Surgeon Ira llussell, U. S. T"., Benton Barracks, JAo.t
* See note to case 84.
■j- Act. Ass't Surgeon A. DorGLAS Hall commuuicated this case to tlio rouimitteo on "Sltuttotl Fever, so-called," of the American Jledical .Associa-
tion. See .\pi)endix to the Report of that Committee, l). 354, Vol. XVII of the Transjictions. J See note to case S'2.
THE PAROXYSMAL AXD CONTINUED FEVERS. 579
Case S9. — Private Jas. F. Joliiisoii, Co. H. 13tli 111. Cav.: age about 15: small and lielicate. was admitted April
13, 1864. On the 10th he had eaten a large ([Uaulity of canned strawberries, apples and sardines. Next eveuini; ho
had spasms and vomited freely, bringing up with the ingesta five large himbricoid worms. He became delirious and
had contraction of the muscles of the back and neck. Death occurred on the 17th. rost-moileiii examination: The
dura mater was injected; lymph and pus followed the course of the large cerebral veins and sulci and covered the
medulla oblongata, pons and cerebellum: the brain was congested and softened and its ventricles contained sero-
puruleut tluid. A large quantity of pus was found on the lower part of the cord and cauda equina. Both lungs were
somewhat congested. Nineteen lumbricoid worms were found in the stomach and intestines. — Surgeon Ira liiismll,
I'. S. v., Benton Barracks, Mo. *
C.\SE 90. — Private William Hurd. Co. C. 81st X. Y.: age 17 : robust : was admitted April 27. 18tU. having suffered
for several days from severe pain in the head with nausea and vomiting. Shortly after admission he became delirious
and had well-marked oi>isthotonos: pulse 81, full but not hard; tongue dry; teeth covered with sordes. Next
morning a few indistinct dark spots were discovered on the loins. Two days later a circumscribed red spot, an inch
in diameter and of inllamniatory character, ajijieared upon the palmar aspect of the right forearm near the wrist,
and from that time the arm was parli.illy paralyzed. Delirium continued till within a few hours of death: it was
active but not violent, the patient being easily restrained and capable of giving a rational answer when aroused.
The tetanic spasm involved only the muscles of the neck. There was no sutiusion of the face or of the eyes. The
bowels were inclined to be loose and the stools dark. The urine was passed freely and contained no albumen. A few
hours before death the )mlse became more frequent and feeble, the muscular spasm relaxed, the pnpils dilated and
the patient unconscious. He died May 1. Posl-morlem examination: Some hypostatic congestion; no spots visible
except that on the arm, under which was some serous aud tibrinous efl'usion. The brain was of full size, its veins
distended. There was a moderate serous. effusion under the arachnoid, and also a greenish membranous exudation,
one to two lines in thickness, deposited in large patches over the cereliruiu and along the course of the vessels
extending into the tissures of Sylvius; this deposit was more abundant on the verte.v than on the sides, on the left
side than on the right and on the base than on the upper surface; an extensive patch, two or more lines in thick-
ness, lined the fissures of the cerebellum and covered the crura cerebri, pons Varolii aud medulla oblongata;
the brain was very vascular but not softened, aud there was but little serous eftusion in the ventricles. The
spinal cord was not softened, but was invested under the arachnoid in its whole length by a uniform plastic
layer about two lines thick; a section of the cord, in its lower part, gave exit to a distinctly greenish liciuid. The
lungs aud pleura- were healthy. The heart, firmly contracted, contained a small tibrinous deposit near its apex. The
liver showed generally a moderate amount of fatty degeneration with occasional patches of completely degenerated
tissue: the spleen w.is healthy; the pancreas vascular; none of the solid viscera were softened. There were a few
ecchymoses on the mucous membrane of the stomach. The intestines were tympanitic; the jejunum was normal;
the ileum contained a small quantity of greenish fjeces; Peyer's patches were distinct but not diseased; the vessels
of the colon were much congested, especially at its commencement, and this condition lessened in proportion to the dis-
tance from that point: in the lower ileum aud ca'cum the mucous membrane was moderately softened, uniformly
reddened aud ecchymosed in many spots; the solitary glands were prominent aud distinct as in cholera, each about
the size of a millet-seed, but there was no ulceration. The mesenteric glands were uualfected. The semilunar
ganglion aud solar plexus .showed no vascularity, softening or other indication of disease. The blood in the vessels
was generally fluid. — CentraJ Park Hoxpital, .Veir Tork City.
Case 91. — Private John Minisberger, Co. I, 90th Pa.; age 40; convalescing satisfactorily from a resection of
the left elbow joint, rose on the morning of July 28, 1864, in his usual good health, dressed himself and went out
to the pump for a drink as was his daily habit. About 6 .4. M. he was suddenly seized with a severe pain between
the shoulder-blades, the feeling being as if some one was pressing a bar of hot iron into his back bone. A mustard
plaster gave speedy relief, and after the attack was over he got up and walked about the ward. An hour later the
pain returned, but was relieved in ten or fifteen minutes by a reapplication of the mnstard. He a])peared to be sick
at stomach aud tried to vomit ; he declined food but had no thirst. His strength appeared good, but after the attack
he fell into a profuse perspiration and slept an hour or two. At 10 A. M. the pain returued with such increased severity
that he cried out in anguish; it also lasted longer. At 11 a. M.,on raising him up in bed for the application of cups,
he was seized with a fourth paroxysm, and exclaiming "Oh I such painl" fell over on the shoulder of an attendant and
immediately became unconscious as if in syncope, his face deathly pale, eyes fixed, muscular system relaxed, radial
pulse fluttering and breathing interrupted by long intervals. In a few minutes the pallor of the face and lips gave
place to the lividity of asphyxia ; the eyes were open, fixed and glassy, the left pupil contracted, the right dilated;
the muscles completely relaxed and the pulse imperceptible at the wrist. He took afterwards only three or four long
sighing inspirations, with long intervals between them, although annr.onia was applied to the nostrils and Marshall
Hall's method of artificial respiration was faithfully tried. He died at 11.30 a. m. There was no thirst or any unnatural
warmth of skin during the five and a half hours his sickness lasted; nor were petechial or any other kind of spots
visible on the surface. PosZ-inor/cm examination : On removing the skull-cap four ounces of blood and serum escaped;
the veins and sinuses of the brain were congested with fluid blood ; there was a moderate quantity of subarachnoid
effusion over the hemispheres and the ventricles contained about an ounce of serum. The spinal cord and its mem-
branes appeared healthy. The lungs were intensely congested witu venous blood; the pleural cavities contained
eight ounces of serum and the pericardial sac two ounces; the valves of the heart w?re sutticieut. All the abdominal
viscera were healthy except the kidneys, which were congested of a bright maroon color; the urine obtained at the
* See note to case 8^
580 DISEASES ALLIED TO OR ASSOCIATED WITH
autopsy was albuminous. The blood remaiued fluid everywhere; it was dark iu color and flowed freely wherever
an incision was made in the body. — Ass't Sury. Geo. A. Mursick, V. S. V., Stanton Hos^jitul, Washinyto}!, D. C*
Case 92. Private John Davis, Co. E, 8th Vt.; age 28; was admitted July 26, 1864, with quotidian intermittent
of moderate severity. This was immediately checked by quinine, and the patient seemed in a fair way to recovery
when, on the morning of the 31st, he remained in bed feeling weak and without appetite. The tongue was clean ;
there was no heat of skin or heart disturbance, but the countenance expressed a good deal of anxiety. He said that
about midnight he had been seized with great restlessness which lasted twenty minutes, but he had not slept until
towards morning. He did well during the day until 5.30 p. M., when he was again attacked with restlessness and
convulsive movements resembling those presented by certain cases of hysteria. He became delirious, tossing him-
self about in bed and uttering shrill screams; his pupils were dilated ; resi)iration 14; pulse 100 and full. Ice was
applied to the head and spine and mustard to the epigastrium ; a turpentine enema was given. No medicine was
prescribed by the mouth as the ability to swallow appeared to be lost. Coma gradually supervened, and the patient
died at midnight, twenty-four hours after the onset of the attack and six and a half hours after the full development of
its character. Toward the last he was bathed in perspiration. Post-mortem examination : Body well developed ; surface
of back of neck and shoulders showing twenty-five or thirty dark-purple spots from the size of a mustard-seed to that
of a pea, circular, somewhat elevated, with well-defined margins, and consisting of an infiltration of dark-colored
blood in all the layers of the skin and to some extent in the subcutaneous connective. During the removal of the
skull-cap about six ounces of serum colored with blood flowed away; the Pacchionian bodies were unusually numer-
ous, large and adherent for a subject of 28 years; the arachnoid was opaque, especially over the vertex, and some
limpid serum lay beneath it ; the ventricles contained a moderate quantity of serum ; the choroid i)lexus in the fourth
ventricle was thickened and looked like a lamina of pale flabby granulations, but the vessels in the other ventricles
presented no abnormity; the substance of the cerebrum, cerebellum, pons and medulla oblongata was moderately
congested throughout. The theca vertebralis was well filled with serum, notwithstanding the large quantity which
had escaped during the examination of the brain, and the cerebro-spinal fluid contained flocculi in the lumbar region ;
the arachnoid was opaque and the vessels beneath it intensely congested ; the substance of the cord seemed healthy.
The lungs were engorged and the middle lobe of the right lung contained an apoplectic extravasation as large as a
walnut. The heart-clots were small. The blood was much more fluid than natural. The liver and intestines were
health.v; the kidneys congested; the urine highly albuminous. — Stanton Hospital, Washington, D. C*
Case 93. — Private Simeon Bond, 37th Co. 2d Batt. V. R. Corps; age 25; a member of the hospital guard, was
admitted from quarters on the evening of August 14, 1864. He had complained of debility and loss of appetite for
several days, and the orderly sergeant thought him slightly out of his head. On admission he was weak, feverish,
thirsty and sick at stomach, but did not vomit; pulse 90; he had headache but no other pain. Neutral mixture
and aconite were prescribed. He was restless and slept but little during the night, and next morning he did not seem
to realize where he was. He wanted to get up and steal away, but was quiet withal. His head was hot, eyes some-
what injected, tongue furred, pulse 95 and stronger. The ice-bag, a brisk purgative and acetate of ammonia with
antimouial wine and nitric ether were prescribed. Morphia was administered in the evening and he passed a better
night. On the 16th he was mildly delirious, sinking into stupor when left undisturbed; pupils somewhat dilated,
symmetrical ; eyes more injected; i)nlse 80 and full ; respiration deep and regular but slower than natural. He had
no spasm of any kind. A blister was applied to the nape of the neck and sinapisms to the epigastrium and inside
of the thighs; quinine was given in full doses. His bowels had been freely moved. No improvement followed, —
the stupor grew more profound, and he died comatose about 11 P. M., a little over forty-eight hours after his admis-
sion.— Stanton Hosjntal, Waskiniiton, D.C.*
Case 94. — Sergeant Frederic H. Reed, Co. B, 175th Ohio, was admitted Oct. 16, 1864, complaining of severe
frontal pain and slight fever; the latter came on daily in the evening and ended in a few hours without sweating.
Castor oil with laudanum was administered, and next day he felt better. On the 18th there was slight delirium,
with increased pain in the head. A six-grain dose of calomel was given; but as he raved incessantly, during the
following night ice was applied to the shaven scalp and a blister to the nape of the neck, while two grains of tartar
emetic with twenty-five drops of laudanum were given every two hours. On the 20th the delirium continued but
with a tendency to stupor, which ultimately ended in coma and death on the morning of the 21th. roKt-mortem exam-
ination : Pus was layered over the surface of the arachnoid and the meningeal vessels were injected; the ventricles
of the brain were dry. The thoracic and abdominal viscera were normal. — Hospital Xo. 8, KashviUe, Tenn.
Case 95. — Private Jesse Briner, Co. B, 50th Ind.; age 24; was admitted Oct. 20, 1864, iu a comatose condition
attended with opisthotonos ; pulse 60, tongue moist and white, skin moist, pupils dilated and turned upward ; he had
been apparently in good health until the day before his admission. Blisters were applied to the back of the neck,
the bowels were moved by repeated enemata and a quart of high-colored urine was drawn off by catheter. He died
on the 21st. Post-mortem examination: Body large, well-formed, fleshy and without external marks of injury. The
dura mater was congested and the surface of the arachnoid covered with a fibrinous deposit ; the brain was congested
and there were deposits of fibrin iu the ventricles, at the base and over the cerebellum. The lungs were somewhat
congested posteriorly and contained tubercles, chiefly aggregated in the lower lobes. The heart and the abdominal
viscera were normal. — Hospital A'o. 8, Xashville, Tenn.
Case 96. — William B. Poer, a citizen of Missouri, died Dec. 3, 1864. Post-mortem examination : Body not emaci-
-ated. The posterior part of the cerebrum, the pons and tire lower portion of the cerebellum were covered with a thin
« Jolix A. LiDElL, U. S. v., published this case in an article on Evidemic Cerebrospinal MeniiigUis in the American Jour. lied. Sciences, June, ISGS.
TITK I'AKOXY.-MAI. ANli COXTINUKn FKVKRS. ilSl
layer of ]ialo iiuiuleiit matter overlaid liy the intlanuMl inemlpraiies: the ineiUiUiiry portion of the oerehrnm was
■iofteued ami iireseiited many imneta: the ventricles contained only half a draehni of sernin: the eereliellinn was
almost i>nlj)y: the thoracic and ahdominal viscera were normal. — Jcl. Ass'l Sunj. J. E. lUookt. Itock Island llospilal, III.
Case !I7. — Kandolph Moxley, a citizen of Missouri, admitted Dec. 16, 18tit: died 27tli. roxl-moiUm examina-
tion : About one drachm of pus escaped on reraoviug t ho dnra mater ; the cerelirnm and cerebellum were covered with
pus; the lateral ventricles contained two ounces of turbid serum. The left lung was congested and adhered to the
diaphragm, where it communicated with a cavity in the sjilcen containing four or five ounces of thick pus and a white
calcareous deposit. The spleen was grjeatly enlarged, softened and disorganized as stated; the liver and mesenteric
glands were enhirged; the colon and rectum were highly congested; the kidneys were normal in size but appeared
somewhat softened. — Jd. Jss'l Siitij. J. £. Brooke, Itock Island Hospital, III.
C.vSE PS. — Private II. P. Sersing, 62d N. C. Meningitis. Admit ted and died .Ian. 19, 186.5. Post-moi tcm ex.iniina-
tion : The surface of the brain was covered with pus. its substance softened and its membranes inllamed. The bladder
was distended with urine. — Act. Ass'l Sury. II. C. Xitckirk, Hock Island llospilal. III.
Case 09.— Private Robert Ecdick, Co. F. 1st X. Y. Light Arfy : ago 32; was admitted Jan. 31, 186.5, at 8 r. >i.
This man was taken suddenly ill on the previous day with high fever and delirium; pulse 130, eyes injected, skin
dry, tongue dry and coated, teeth covered with sordes, respiration slow, stools involuntary and the lower extremities
aud back covered with dark-purple spots in size varying from a i>inhcad to a largo pea. On admission he was sufl'er-
iug from nervous prostration; the radial pulse was almost imperceptible: there was intense dyspncea, a dull heavy
feeling about the head and a dull pain between the shoulder-biaaes; the face was livid, the lips purple and the
extremities cold. He died two hours after admission. Post-mortem examination: liody of full habit and fleshy, exhib-
it ing spots of eccliymoses from one-fourth to three-fourths of an inch in diameterover the whole surfa(!eand hypostatic
congestion in the depending portions. The bloodvessels of the brain were very much engorged; an ounce of serum
was found in the cavity of the arachnoid, a similar quantity in each ventricle and about two ounces at the base of
the brain: the Pacchionian bodies were largely developed; the substance of the brain normal. The spinal cord and
its membranes were healthy. The heart was normal; a fibrinous clot was found in its right ventricle, liolli lungs
were highly congested, considerably collapsed and contained a few small apoplectic blood-clots; the bronchial tubes
were filled with serum and frotlij* mucus. The liver was normal ; the gall-bladder distended with dark viscid bile;
the spleen congested. The stomach and bowels were distended with flatus. The kidneys were uormal; the urine
slightly albuiuinons. The blood generally was remarkably fluid. — Stantoti Hospital, Washington, D. C*
C.\SF. 100.— Private .lolin V. Kisley, Co. B, 50th Ohio; age 21; was admitted Feb. 3, 1t65. having been sick for
five days. The di.sease commenced with a chill which lasted an hour and was followed by severe lumbar pain. On
.idmissiou ho hail no headache, but pain iu the loins was very distressing: lie w;is restless and had a wild expres-
sion, a moist and coated tongue, full and rapid pulse, coryza, covigli and some opjiression of the chest; a dark rash,
which disappeared on pressure, was noticed on the surface. Rochelle salt and morphia were administered and dry
cups applied, but in the evening he was no better, lie was restless during the night. Next day the dark rash covered
the whole of the body; the patient was drowsy, his pupils contracted; abdomen tympanitic; respiration dillicult,.
He died comatose before midday. Post-mortem examination; Chest, abdomen and posterior aspect of extremities;
covered with a dark-purple rash and petechial spots; face presenting purpuric patches but no petechia?. The blood
throughout the body was thin. The veins of the cerebral and spinal membranes were engorged and there was serum
beneath the arachnoid; but the substance of the brain and cord was healthy, Eccliymosed spots were found on
the parietal pleura and serum tinged with blood in each pleural sac, but the lungs were healthy. The peritoneum,
mesentery, stomach aud intestines were covered with scarlet aud dark-red petechial spots. The liver weighed one
hundred and sixteen ounces; the gall-bladder was large and full. The right kidney weighed eleven ounces, the left
teu ounces; their capsules and the sunounding connective tissue were eccliymosed, — Domjlas Hospital , (I'ashinrjton, D. C.
Case 101. — Private Elisha Cotton, Co. I, ,S6th Ohio; age 23; was admitted Fob, 18. 1865, with severe pain
in the head, lie was rational: his appetite good; bowels constipated; pulse 48, Castor oil with oil of turpentine
was given and repeated. Next day four cups were applied to the nape of the neck, from which slight relief was
derived; pulse 16, The pain continued and on the 21st delirium set in, which, on the 23d, became violent and accora-
•Ttiis case was commuuicatcd by Dr. D. W. PaEXTiss to the Committee on "Spotted Fever, so-called," of the Aincriculi Medical At«soci]ition, and
pnbliithtMl, p. ;i.V., Vol. XVII of the 3Va»iVir/ioii*. At the same lime Dr. Pbkxtiss submitted as a case of spotted fever the following, which appe.irs on the
reconl:! of the ht«»pital as one of cerebral apoplexy: Private James K. Ilaye.s, Co. C, 10th V, It. Corp?, was admitted Jan. 7, ISO'), with headache, assumed
to be the result of a delmnch. Ne.\t day persistent coma came on, and he died on the 10th. J'oft-moyteiii cxaminatiou : Rigor mortis well marked. Thero
was a quantity, about oi^jht ouuces, of effused blood between the membranes of the brain and a large clot on the side of the right hemisphere : the sub-
stance of the brain was ht*althy. There were oltl adiiesiuns of the lungs, and. in the heart, slight iniluRition of the aortic valves. The other organs were
not examined. — ^ittitint /f(Mj»i7(i/, }\'ii.*hiiigtoitf h. C. Tlie coagulation of the bloo<l is inconsistent with the theory of cerebro-sjiinal fever in this case, as
in the following, which was apparently the result of violence : Priv.^te John Hutchinson, unassigned recruit ; age 18 ; while wrestling Feb. -1, 18G4, was
tripiR'J and fell heavily, striking his bjick.but hedi<i not complain of injury and was present at roll-call in the evening. Next tlay, however, he remained
in his tent, where, in the evening, he was found groaning. On admission to hospital at this time he was very restless and delirious, unable to reply
intelligibly aud Liiuing into drowsiness occasionally for a few minutes at a time ; his extremities were cold hut the surface elsewhere was natural ; the
odor of alcohol w.is de ti-cted abotit his person. During the night he had two loose stools ; his tongue became red and dry and sordes appeared on his teeth.
On the t;ih the delirinm was more active ; he trie<l to pet out of bed — moved in every direction, rose on his knees and was r<.'strained only by force ; his
pulse was rapid and weak, 130; alidomcn not tender. He refused to swallow medicine ; two small doses of quinine and opium were given per rectum.
Towards midnight be lK*came comatose and died. P^nJ-iiutrtt-tn examination : IJotly well develojjed and showing no marks of violence. The mrmbranes of
the brain were much congeste^l ; the substance of the bniiu lieatthy. The membranes of the spinal coni were congested, and external to the dura mater
there w-is some clotted blot,d which decreiised in quantity from above downwards. The lungs, liver, spleen and kidneys were congested ; in one of the
kidneys was a clot of blood the size of a jtesi between the ca]>sule and parenchyma. Tlie bladder was distended with slightly albuminous urine. Peycr's
patches and the snnill intestine generally were slightly congested. — Turner's Latie Hi^xpital, Philatti^lptiiii^ Pa.
582 diseases; allieu to or associated with
panieil witli accelerated pulse, 100. On March 1 there was marked prostration, with muttering delirium; pulse 120.
He died on the 3d. Posl-moi-lem examination: The pia mater was injected; lymph was deposited at the fissure of
Sylvius, around the sella turcica, on the surface of th.-> cerebellum and pous Varolii and ou the roots of the optic and
pueumogastric nerves; the pous and cerebellum were injected and softened; the substance of the brain was con-
gested and its ventricles contained serum and fibrinous deposits. — Cumberland Hosj>ital, Md.
C.\SE 102. — Private W. G. Hicks, Co. L, 1st N. H. Heavy Art'y; a temperate man of full habit ; complained from
March 1, 18G5, of pain between the shoulders, but was otherwise apparently well. On the 22d he was seized with a
severe chill and headache, for which a mercurial purge was taken; at 10 P. M. the pain extended along the spine and
was attended with vomiting and some febrile action; pulse 100. Three cathartic pills were given, with cohl appli-
cations to the bead and mustard to the back of the neck. He vomited the medicine, passed a restless night, and in
the early morning went out and walked half a mile, when he was found nearly insensible. On admission to hospital
on the 23d he was partly conscious but unable to speak; his face was flushed, skin hot and dry, pulse 100 and feeble;
his eyes opened when he was addressed, his right hand moving incessantly toward his head, which was thrown back
by tetanic spasm; his lower extremities were also in constant' motion ; he moaned at short intervals and resisted
efforts to open his mouth for the administration of food and medicine. Six wet cups were applied to the back of the
neck and were followed by a cantharidal blister; mustard was used along the spine and on the feet and calves of
the legs; two drops of croton oil were given and ten grains of the sulphate of quinine. At noon the bowels were
moved freely, but the patient was unconscious and the opisthotonos aggravated. At 9 r. M. there was no change,
although the blister had drawn well. Ice was applied to the head and beef-essence given freely. He passed a restless
night, his lower extremities in constant motion and his breathing labored. He died at 7 P. M. in an attack of severe
tetanic spasm, rost-morttm examination: Body robust. The pia mater covering the cerebrum, cerebellum and cord
was much congested. The brain was not examined. Beneath the spinal arachnoid was a large collection of pus,
which seemed mixed with a small quantity of oil; the substance of the cord appeared healthy. The right ventricle
of the heart was nearly filled with a firm coagulum. The lungs were healthy. — Husjiitul, Fort Bino, D. C.
C'.\SE 103. — Private Benjamin Lond, Co. E, 2d Mass. Cav.; age 19; was admitted April 4, 1865, complaining of
aching in all the joints. His knees were slightly swollen ; pulse 100, weak ; tongue large and red, with prominent
papilhe and a dirty-white fur. He remained in this condition, his appetite good, until the 10th, when he was seized
with pain in the back of the head and neck and opisthotonos. He gradually grew worse, his countenance becoming
anxious, pulse 130, mind confused, tetanic spasms more violent, pupils dilated and deglutition difficult. He died on
the 27tli. rost-mortem examination: The membranes of the brain were congested and its sinuses turgid with blood;
lymph was deposited around the optic nerves, the pituitary gland and along the anterior surface of the medulla; the
substance of the brain was softened, its ventricles filled with serum and the choroid plexus of each congested and
thickened. The membranes of the spinal cord were inflamed. The lungs and jilenra were healthy. The pericardium
was congested and contained an ounce and a half of sero-pus; the mitral valves were thickened. The abdominal
viscera were normal. — Cumhcrland Hosintul, Md.
Case 104.— Private George \V. Ferguson, Co. G, 8th Tcun. Cav.; age 18; was admitted Pec. 2, 1864, with chronic
diarrho'a, from which he recovered and was placed ou light duty. On April 10, 186.5, he had vertigo and his eyes
were inflamed. On the 19th a slight chill was followed by high fever, the jiatienfs face being flushed and swollen,
eyes suffused, respiration hurried, skin hot and dry, tongue heavily coated with whitish fur, bowels loose, pulse 120
and full, limbs weak and sore. At 4 P. M. he had a copious perspiration, lasting an hour, and followed by a recur-
rence and aggravation of his former symptoms, which continued during the night. On the 20th he was delirious; at
11 A. M. comatose, pupils dilafeil, evacuations frecjuent and involuntary, thin, very oft'ensive and of an ochre color;
at 3 r. M. opisthotonos and trismus supervened, pulse 120, full and strong, respiration 30, loud, abdomen tympanitic;
at 8 P. M. he had 'several severe convulsions followed by increased opisthotonos and trismus, which continued until
death at 11 a. m. of the 21st. He was treated with veratrum viride and ipecacuanha, with nitrate of potash, turpen-
tine enemata, mustard to the abdomen and extremities and ice to the head. Post-mortem examination; The mem-
branes of the brain were congested and the sinuses filled with dark blood ; the brain weighed sixty ounces; its sub-
stance was softened, especially in the corpus callosum, optic thalami and pons; the lateral ventricles contained two
drachms of bloody serum and the choroid plexus in each was highly congested; the medulla oblongata was softened.
The lungs were engorged. The heart, stomach and large intestine were healthy, but the lower part of the ileum was
congested and the mesenteric glands much enlarged. The liver and kidneys were congested; the gall-bladder nmch
distended; the spleen larger than normal. — Hospital, Madison, Ind.
Case 105. — Private James Wesley Turner, Co. D, 126th Ohio; age 30; was admitted at 2 r. M. June 27, 1865,
from his regiment, which was en route home. He was insensible; his eyes much injected and watery; pupils con-
tracted and fixed; lips covered with sordes; head hot; general surface of natural temperature but covered thickly,
especially on the legs, arms, back and face, with dark-purple spots, some of which were elevated, having a diameter
of from one-eighth to three-eighths of an inch. He lay on his back with his knees drawn up and head thrown back,
but he was withal very restless; there was tenderness on pressure over the occiput and spine. As the bladder wai
much distended the catheter was used and fifty ounces of high-colored and strongly animoniacal urine were removed
with decided relief to the restlessness. At 3 p. m.-, on the manifestation of some tetanic spasm, bromide of potassium
was ordered in fifteen-.grain doses hourly until 9 P. M. and thereafter every two hours. At 6 P. u. the patient was
quiet. After the withdrawal of forty ounces of urine by cath.eter at 10 P. M. the tetanic condition disappciired, the
eyes became less suftused, the pupils dilated somewhat and responded to light and the macuhe seemed of a bri,ghter
color; respiration was natural. He slept well for three hours during the night, but towards morning became a little
THE PAROXYSMAl, AND COKTIXI.-KD FEVKRS. 583
restless; lie drank water ami was able to lioM tlRM-np in lus liaiuls. At 8 a. m. tliirty-six ounces of urine were removed,
the patient evincing -jreat dislike for the operation. A teaspoonful of a solution of one grain of sulphate of strychnia
in four ounces of camphor- water was directed to l)o fjiven every two hours, alternating with the bromide, the spine to
1)C rubbed with a liniment of ammonia, olive oil, chloroform and turpentine. In tlio evening ho was quite conscious:
he gave his naute, said he was married and that his home was in Lawrence, Ohio. At this time the strychnia was
omitted and the bromide reduced to ten grains every four hours, lie was comfortable during the night, urinated
voluntarily and had two stools towards nu)rning. On the 29th a tea.«poonful of a solution of sixteen grains of sul-
pliale of quinia and one grain of sulphate of morphia in three ounces of water was ordered to be taken every four
hours: a tablespoon fnl of brandy with milk was also given. At H A. M., after the second dose of ([uiuia and morphia
had been taken, hi' became unconscious but without tetanic .symptoms*, eyes injected: pupils con I racled; head hot and
perspiring profusely: general temperature elevated: pulse 180; imjiulse of heart strong aud respiration hurried. The
fjuinia-morpliine solution was omitted and the bromide renewed every two hours; tincture of veratrum viride in
three-drop doses was also ordered to be taken every two hours, l)ut as it made no impression it was discontinued.
He grew steadily worse, passing urine and fseces involuntarily. At 1 a. .m. of the .30th ho had a severe chill which
lasted an hour aud was followed by high fever, after which his pupils gr.adually dilated and coma supervened, ending
in death at 5 r. >i. rost-mortem examination: The skin was of a decided yellow color. The membranes of the brain
were much injected; the anterior, superior and posterior surfaces of the cerebral hemispheres, the cerebellum aud
medulla oblongata were covered with patches of yellowish matter which were thickest along the median lino aud in
the sulci; there were about two ounces of bloody serum at the base of the brain; the brain-substance was normal'
the pineal gland congested. The membranes of the spinal cord were deeply congested and filled with bloody serum.
The pericardium contained three ounces of blood-tinged serum; the coronary Aessels were turgid; the walls of the
heart softened; the aorta reddened. The right lung was slightly cougested; the left much congested posteriorly,
partially hepatized and softened. The omentum was congested in patches; a portion of the lower ileum, about two
feet in length, was congested. The blood was dark and uncoagulated except a slight clotting in the right ventricle
of the heart. — Cumhcrlaiid Hospital, J/rf.
Dr. Calvin G. Page has published* the clinical records of nineteen cases of cerebro-
spinal meningitis that occurred among recruits at Galloupe's Island, Boston Harbor, Mass.,
from September, 1 864, to May, 1865. Medical Inspector G. H. Lyman, U. S. Army, referred,
March 20, 1865, the causation of these cases to overcrowding and defective ventilation.
Measles prevailed among the recruits at the same time.
The post was organized for the reception of recruits and drafted men from this state, and as a depot for those
in transit from the rendezvous in Maine and New Hampshire. There are twenty barracks in all; four are occupied
by the permanent garrison, the remaining sixteen, 100 x 20 x 10 feet and furnished with two tiers of bunks, were each
intended for one hundred recruits, giving two hundred and eighty feet of air-space per man. These ijuarters have
been sufficient for the post until this winter, when they became overcrowded, owing to the ditticulty of obtaining
transportation. Each barrack has been occupied by an average of from one hundred and fifty to two hundred men.
The consequence has been an increased amount of sickness and the development of a few cases of cerebrospinal men-
ingitis. To add to the difficulty an epidemic of measles occurred, but this is now declining.
The following excellent report of fulminant cases among recruits at Concord, N. H.,
was filed March 1, 1865, by Act. Ass't Surgeon Albert H. Crosby. Overcrowding had
apparently little to do with these developments, as none of those affected had been at the
rendezvous for more than a few days. The evidence points rather to an infection in the locality
whence the young men were derived.
I have the honor to report the details of eight cases of epidemic cerebro-spinal meningitis, five of which occurred
in camp under my personal observation. Of the latter four died, and as the disease seems now to be attracting
attention, owing to its appearance in other places, I have thought that a record of these might be of value.
Case 1. — Oilman McAlpin, recruit, 18th N. H.; age 20 years; in camp six days; well developed, with light hair
and eyes and lymphatic temperament, came into hospital January 30, saying ho had had a fit. As he came from the
barracks and had no bunk mate I could not obtain a reliable account of this tit or of his condition during the previous
night. At this time, 8 a. >i., he was somewhat feverish and intensely thirsty; he was inclined to vomit and had
frequent dark-colored and fetid watery discharges from the bowels; his pulse was small, thread-like aud rapid and
his extremities cold ; tongue covered with a brownish coat ; skin dry and harsh, but subsequently bathed in a clammy
perspiration. He was immediately placed in bed; hot stimulating drinks were administered, with powders of quinine
and capsicum. Four hours afterwards he became very restless, throwing himself about in bed, groaning and pressing
his head with his hands, his eyes somewhat injected and watery and the pupils dilated. At 2 p. sr. hecea.sed to answer
questions, but the jactitation increased and the groans changed to screams, the patient being apparently in great
pain, which seemed general and not confined to the liead. At 3 P. M. many pctechiic were discovered below the knees
and on the forearm aud hands, — small and of a bright-red color, not changing or disappearing under pressure. About
• Id the BoXoii 3fnf. omi Siirg. Joiir. LXXIII., ISS5, jiagc 109 c! trq.
584 DISEASES ALLIED TO OR ASSOCIATED WITH
tbo same time the liead was drawn backward ujion the neck, and this iiosition was not altered even in his most restless
moments. The treatment was stimulating, with heat to the extremities and general friction. The watery discharges
from the bowels continued, becoming involuntary during the night ; there was also occasional vomiting. At 9 p. M.,
I called Surgeon J. Smith Ross. U. S. N., in charge of the Depot hospital, to see the case. He suggested cerebro-spinal
meningitis and advised a continuance of the treatment, with immediate vesication of the spine from the occiput to
the dorsal vcrtebne and the free use of turpentine internally by enema and externally by friction. This was accord-
ingly done. The symptoms remained as described for five days, when the patient began to grow more quiet and to
notice what was said to him. It was then discovered that he was totally deaf and that the sight of the right eye
was wanting. He was able to read questions written upon a slate and to make intelligent replies. On the eighth
day after his seizure he began to comjilain of excruciating pain in the knees, both of which were found to be swollen
and tender. A wash containing acetate of lead and opium soon gave relief, and from this time convalescence was
rapid. To-day, March 1, he is able to be out of doors, slightly deaf and with some dimness of vision.
Case 2. — February 2, at H a. m., I was called to see a recruit for the 18th regiment, Henry H. Hook, aged 19
years, who had been four days in camp. He was an uncommonl_y stout, well-built young man, and obviously of
great muscular strength. I found him lying in the bunk next to that which had been occupied by McAlpin, and my
attention was at once attracted to certain very dark-purplish sjiots upon his cheeks and neck. In fact, his whole
body and limbs were covered with them, from the size of a half-dime to that of a Spanish dollar. He complained
of nothing but a slight pain in his head and intense thirst ; said he had vomited once and had one thin discharge
from the bowels. At this time it was impossible to detect any radial pulse, and the action of the heart was well
described by the hospital steward as a jerk and ajhittcr; respiration thirteen per minute and quite loud; extremities
cold. He was at once removed to hospital and an actively stimulating treatment commenced. Whiskey and quinine
were freely administered; sponges saturated in alcohol placed in the axillie; alcohol, hot water and turpentine used
freely iipon the body and limbs, and constant friction maintained by two "reliefs" of four men each. Professor D.
CiiOSBY, of Dartmouth, happening to he in town, was called in, but declined to give an opinion as to the disease.
Dr. Ross, U. S. N., also saw him. Both concurred in a fatal prognosis. After two hours of incessant labor the radial
pulse could just be felt but could not be counted. At this time the patient said he felt better and was confident he
would recover. The spots on the surface became darker and more numerous and th&eyes injected and watery, but
the pupils continued nearly normal. Toward evening respiration became more hurried and the patient vomited
several times, the ejected matters consisting merely of the lluids he had taken during the afternoon. His mental
faculties were entirely unobscured until two hours before his death, when he became comatose. He expired at 9 p. Ji.,
just ten hours after he entered the hospital. He was probably sick about thirteen hours, for it was found that he
was up and dressed early that morning and that he jjartook of breakfast at 7.30 a. jr. It was also learned that
during the previous day he had been eating canned lobster, and that during the evening he had been in unusually
good spirits, having kept bis comrades from sleeping by his jokes and fun until 11 o'clock. As the body was removed
at once it was impossible to make a post-mortem examination.
From February 2 until the 15th we had no other case of the kind and were hopeful that we had seen the last
of the disease, but upon the morning of this day occurred Case 3. — Albert B. Goldsmith, recruit 18th N. H., age 18,
who had been six days in camp, and was a stout, hearty, fine-looking fellow. He was admitted to hospital at 10
A. M. suffering with headache, rigors, intense thirst and vomiting; pulse 126 to 130, small and thread-like; tongue
covered with light-brown fur; extremities cold and skin moist and clammy. He was at once put under treatment
similar to that applied to the last case, — this by the advice of all the physicians who saw him. For some hours his
system responded aud we seemed in a fair way to get reaction established, when, at 9 p. M., the fatal plague-spots
made their appearance on the leg, thence spreading over the whole body, but much less numerous than in Hook's
case; the color, however, was the same, dark purple-like ecchymosis. Respiration-now became hurried, rising from
12 to 20 per minute, and a rattling sound was heard in the trachea. He complained of no pain and talked freely
about an expected furlough. Three hours later he became utterly unconscious and expired at 2 o'clock, fourteen
hours after entering the hospital and iive hours after the appearance of the spots.
The disease liadnow become so serious that I requested the commanding officer of the rendezvous to convene
a board of medical aud military officers to investigate it and make a thorough sanitary inspection of the camp. Such
a board was in fact ordered, but owing to pressing official duties Surgeon Ross of the Depot hospital was not able
to attend, and only a partial autojisy was made in the case with the assistance of Dr. A. H. Robinsox of this city:
Rigor mortis slight; body more mottled than before death; on reflecting the scalp we found a large quantity of fluid
blood opposite the occipital protuberance; this flowed freely and ran in a stream to the floor. Upon removing the
calvaria there was a slight escape of serum with some blood intermixed ; the membranes of the brain seemed to have
lost their clear silver-like transparency and were dark-colored; the superficial veins were distended with dark blood
and were considerably increased in size, numy of them being as large as a common quill ; the sinuses were also enlarged
and distended with uncoagulated blood. The substance of the brain was apparently healthy; the ventricles con-
tained a moderate quantity of serum, and the choroid plexus was natural save in color, which was lighter than
usual. The tentorium was darker and more opaque than the dura mater and arachnoid and seemed distended with
fluid; on puncturing it slightly there was an immediate and rapid flow of greenish-yellow syrupy liquid, — in
quantity about five ounces; the veins of the cerebellum were distended and the surface dark in color. Nothing
unusual was observed in the medulla or the upper portion of the cord. The spots on the skin were found to consist
of dark blood eftused into all the tissues down tf> the subcutaneous cellular; on disseeting oft" a portion the color
was perfectly retained by covering the cut edges with gum-paper. As it was necessary to send the body home for
THE PAKOXYSMAL AND CONTINUED FEVERS. 585
iuterment by an early train I was obliged to stop the cxamiuatiou at this point ; Init it «as continued by some med-
ical gentlemen after the body reached home, and I am indebted to Dr. T. F. Buowx, of Chester, for the report of the
autopsy of the trunk and contained ors;ans, nuide about forty-two hours after death by Drs. Buow.N, Eastman and
Clauk : The integument ou the neck and breast was of a scarlet hue, with spots of extravasated blood throughout
the greater part of the reuuiinder of the body. The internal organs were engorged with bluish-black blood, the
veins of the chest in particular being filled with blood almost blue in color. The liver was generally darker than
natural and the thinner portions of its lobes presented a marbled Idue appearance. The mucous coat of the stomach
was intact, but the others were congeste<l, the inllammatory conditiiui of the middle and sulimucous showing in
irregular light-red spots through the mucous lining; some of these were mere points, others extensive patches. The
intestines were normal. The lungs appeared natural. The other lilgans were not examined.
Four days more elapsed when we had Case 1. — .John C. T. Webster, recruit, 18tli N. 11.: age 19 years: five days
in camp: c.-.mo into the dispensary and asked me to look at his arms to decide if certain spots he had discovered
were liike those upon tJoldsmitli. To be sure they were, — the same dark-purple sjiots, only few in number and small
in size. lie complained of iiothiug but thirst, and the only other obvious symptom was the injected and watery
appearance of the eyes: pulse 112, soft and siiiall. Tho treatment was the same as in Hook's ease, — stimulation by
every known method within reach and every effort to restore the skin to its natural condition. He complained of
no pain at auy time, and was only troubled by excessive nausea and freiiuent voiuiting. Three hours after taking
to bed he became entirely comatose and remained in this condition eight hours. During this period our elVorts to
induce reaction were unremitting, and at 9 P. M. nature rewarded our labor, for tho patient opened his eyes, the
pui)ils of which were slightly dilated, and recognized me, calling me by name and expressing a desire to pass water,
which lie accomplished with ease. He drank a glass of whiskey-punch, holding the tumbler himself, and said he
felt perfectly well. Tho stimulating treatment was continued during the night and he apparently grew no worse;
answered when spoken to and changed his position iu'bed frequently. His extremities were warm and the skin
natural, with no new spots. In fact I could not but believe that he was in a fair way to recovery. This continued
until I) A. M., when he called for water; the attendant stepped to the table to prepare him a punch. Immediately a
gurgling sound was heard, and when the nurse turned he found the patient's head thrown back on the pillow, the
spots ou his face darker in color and the breathing slow and labored. Everything that was possible was done to
arouse him, but he sank rapidly, and expired at 6.15 a. m., twenty hours after the attack. The post mortem examina-
tion in this case also was hurried; but the following was developed: Brain healthy save in the distention of its veins
with tluid blood ; membranes dark and with a considerable eft'usion of light-red lymph about the cerebellum. Lungs
and liver engorged but healthy. Stomach covered in places with light veruiilion spots which showed through tho
intact mucous coat and also through tho peritoneal covering; the muscular coat was engorged with blood, — in fact,
by holding a freshly-cut jiiece edgewise the division between the three layers was perfectly distinct, the muscular
portion seeming more than one-sixth of an inch in thickness.
Case 5. — George D. Moore, recruit, 18th X. H.: a fine looking, healthy young man; age 21; twelve days in
camp: came into the dispensary February 23, and after leaning against the counter invited my attention by the
imiuiry if I thought he had Ihv (lisroxc. He complained of thirst and great pain in the head; his eyes were injected
and overflowing; pulse small and rajiid; respiration hurried. He was at once placed in the ward and an active
course of internal and external stimulation commenced. Turpentine was given rather more freely than in the other
cases, and Avas used generally about the body. At this juncture Capt. Silvey, Assistant Provost Marshal General for
the .State and ix ojlicio at the head of the recruiting service, requested me to telegraph to Hanover for Professor Dixi
CiiOSBY. This was done ; he and some other medical gentlemen were summoned, but unfortunately did not arrive in
time. This patient said he had felt unwell in the night and been very thirsty for hours, but pain in the head had not
come on until after daylight. He was put under treatment at 8 o'clock. Under the influence of a drink composed of
whiskey, ginger and capsicum ho rallied somewhat and his pulse gained in strength but did not increase in fre-
quency. About 10 a. m. one spot made its appearance ou his leg, followed in two hours by a few others sparsely
distriluited over the body. The purple spots were less marked in this case than in any of the others. About noon
he became comatose and his respiration slow and very peculiar; he would draw in the air with a jirolongcd cft'ort,
and after a second or two suddenly expel it with great force, — repeating this eleven times per minute. Before
becoming completely unconscious he would snap with his teeth at the glass containing his drink or medicine and
was apparently in some pain, although he could not be induced to answer qtiestions. At 2.4.5 i: .M. ho threw his uead
back violently upon the pillow; his breathing became shorter and was accomjianied by a rattling in the trachea.
He died at 3 i-. M.. seven hours after his admission. I'OHt-mortem examination seventeen hours after death, in presence
of Drs. I), and H. B. CitosHV, Dartmouth College, and Dr. I". H. Stii-wkll, IT. S. A.. Rigor mortis well established;
considerable discoloration about the neck and helix of the ear, — in fact this has been observed in all the fatal cases.
On cutting through the scalp blood of a dark color flowed readily; the membranes of the brain were nearly or quite
natural and the veins and sinuses but little enlarged. All present, however, were struck with the very great differ-
ence existing in the size of the hemispheres, the right being less than two-thirds the size of the left, and the dividing
line, instead of running exactly in the centre, ran directly under tho right parietal protuberance. There was a very
slight eft'usion into the ventricles, and the substance of the brain was apparently healthy. Upon removing the cere-
bellum entire, small points of calcareous matter were discovered at the base, on the surface and under the investing
membrane. There was no effusion into the ventricles and the cerebrospinal fluid was normal in c|uantity. The lung.s
were somewhat engorged, blood flowing freely after the scalpel; and the same was true of the liver, although tho
color of the latter was nearly natural. The stomach was filled with an amber-colored liquid, probably consisting of
Med. Hist., Pt. 111—71
586 DISEASES ALLIED TO OR ASSOCIATED WITH.
the medicines au<l drink administered, and in the interior, near the large curvature, were scattered bright vermilion-
colored spots arranged in points and patches.'
It should be stated that all these young men came from Chester and its vicinity. In fact these and three
other cases which occurred at home during the last week of February, came from or resided within a radius of ten
miles from that village. 1 am indebted to Dr. Bhowx, of Chester, for a report of the case of a young man who died
within a few rods of Goldsmith's residence:
Case 6.— II. M., a young farmer, 19 years of age, of strictly temperate habits, who had not been from home for
several months, complained of a feeling of uneasiness during the forenoon of February 17, but continued about his
business until 4 p. si., when he gave up his work on account of hendache, and thinking he had caught cold took some
domestic stimulanis to overcome the feeling of chilliness which oppressed him. He had a burning thirst, which was
allayed by copious draughts. Severe rigors were experienced during the night, and be had several dark-colored dis-
charges from the bowels; the urine was free and apparently natural. This was gathered from the attendant, as I was
not called until 8 o'clock next day, at which time the resjiiration was hurried and the pulse at the wrist almost imper-
ceptible, though the heart could be heard, its first sound being a kind of snap, the second only a quiver or tremor.
The left side of the face was swollen, the eyes congested, the skin beginning to show the peculiar spotted appearance
of extra vasated blood, dark-red and generally distributed over the surface ; one spot was large, three or four lines in
its longest diameter. His ears were bluish, especially at the helix. The respiration continued rapid and the heart
beat with less force until midnight, when he died. During the whole time the intellect remained clear; the patient
said he sutfered no pain, yet his countenance wore an indescribable look of anguish and despair, although he had
not been informed of the terrible nature of the disease. No post-morlem examination was obtained.
Case 7. — A fnrloughed soldier from the 18th N. H. died at his home February 27, in Londonderry, after an
illness of eleven hours, with symjitoms like those of Hook. No report of his case could be obtained.
C.\SE 8. — A young woman employed in one of the factories at Manchester died February 28. She was appa-
rently well the evening before, but woke up in the night complaining of violent pain in the head and intense thirst,
soon followed by chills. She was treated by a Thompsoniau with the nsual red pepper and hot bath. These at first
relieved her, and the spots did not make their appearance until 9 a. m. They were of a dark color and very numer-
ous. Other physicians were called, who persisted in a stimulating course of treatment, but she became comatose
and at 2 p. M. died, thirteen hours after she first complained.
It will be seen that in all the fatal eases the spots were of a dark -red or purple hue, while in the first case,
which recovered, they were bright-red and small in size; all had rigors, the chill being usuallj- the first symptom; all
complained of thirst and all but one of pain in the head: in all there was an injected and watery condition of the
«yes; in all the intellect was clear until the supervention of coma : all were under twenty years of age and of remark-
ably good habits, sons of farmers in the same neighborhood; all had been in camp only a few days; none of the
liermauent garrison or recruits from other places were attacked. It is worthy of notice that the history of six of
these cases shows that on the day jireceding their seizure the patients were in uncommonly good spirits. This was
so marked in the cases of Hook, Goldsmith and Webster that it was observed at the time by their comrades, and I am
informed that the same was true of the young woman who died at Manchester. Only two points of uniform resem-
blance are observed in the j)os«-mo)-<em appearances: Ist, The unusual fluidity of the blood, and 2d, the peculiar spots
upon the inner coat of the stomach. The appearance of the brain and its surroundings dift'ered in every case, and in
no case was there true inflammation. Great uniformity will be observed in the manner of death, i. e., rapid asthenia,
f.ll seeming to have been prostrated at once by the shock of the invasion acting upon the nervous centres. In con-
clusion I would state that I adopted every means in my power to prevent the spread of the disease. The cases were
put in a separate ward; the recruits themselves were isolated. The whole hospital and barracks were thoroughly
purified and ventilated; free use was made of the disinfectant agents furnished by Government. Permission to
furlough the men from the particular locality whence all these cases were derived was refused by the Secretary of
AVar on the ground that this measure might tend more to the 2>ro2>a gat ion than the suppression of the epidemic.
Among the Colored Troops, according to Surgeon Ira Russell, U. S. Vols., the dis-
ease presented essentially the same features as in the cases of white men. This officer when
on duty at Benton Barracks, St. Louis, Mo., observed an epidemic in January, 1864, among
the colored troops at that rendezvous. The men, who were mostly escaped or emancipated
slaves, had endured many hardships before their arrival. They were crowded together in
imperfectly heated quarters and had an insufficient supply of clothing for the very cold
weather of that season.
Forty-two cases were reported, many of them genuine cases of cerebro-spinal meningitis, — post-mortem exand-
uation showing exudation of lymph or pus on the arachnoid of the brain and spinal cord, with the superficial
cerebral vessels highly congested and the arachnoidal and ventricular cavities filled with serum. The early .symp-
toms were much like those of pneumonia: The patient had a slight chill, white tongue, small rapid pulse, dull
headache and pain in the back and limbs. These symptoms continued several days, when a severe chill ensued,
.attended at first with violent delirium and afterwards with coma, the surface all the while cold, the pulse small or
* A water-color drawing of these light-red spots of submucous exti'avasation was filed with Dr. Crosby's report.
THE PAROXYSMAL AND COXTIN'VED FEVERS. 5^7
imperceptible, the muscles of the buck ictractin<; the heail spasmodically aud tliose of the legs and arms uiim- m ii->>
riyid, deglutition imperfect or impossible, and death as the nsnal result. Occasionally, however, after from one to
four days, reaction took place, warmth returned to the surface, the spasms relaxed, coma was dissipated, and fever of
a typhoid type set in Avhich ran a longer or shorter period with variable results. Quinia was given freely in the
early stages to exercise a controlling influence over the disease. During I he cold and comatose stages sinapisms to the
surface and cups to the spine were employed, with (luinia, capsicum aud alcoholic stimulants internally.
Perhaps the epidemic among the negro laborers at the cavalry depot at Giesboro' Point,
Md., was an outbreak of this disease, but the records do not identify it. The request of the
superintendent for assistance, dated Xov. 25, 1863, states that "colored men perfettl}' liealthv
at night are found dead in the morning and many of the employes are becoming jianic-
^tricken." A board of medical officers appointed on the following day to enquire into the
causes of the epidemic did not extend its researches beyond the official requirement. The
opinion was submitted that the prejDonderating causes of the epidemic existed prior to the
admission of the negroes into the camp, there having been exposures and lack of suitable
food and clothing, and that the development of the disease had been consummated by the
continued operation of these causes, together with sleeping on damp hay in Sibley tents
without Hoors or ventilation. The report states that the epidemic affected chiefly those who
had come from the eastern shore of Maryland and Virginia, and that among live hundred
men from these localities there had been twenty-eight fatal cases. But nothing is said of
the disease in its clinical or j)athological aspects.
Among the Confederate Troops. — A single case-from the records of the Pettigrew
hospital, Raleigh, N. C, signed by E. Burke Haywood, C. S. A., appears among the papers
on file in this office. The case was regarded as one of typhoid fever, but opisthotonic rigidity
and paralysis sufficiently indicated the implication of the-cerebro-spinal system.
Private John Snyder, a conscript from Xorth Carolina: age 39; muscular and strong; was admitted March 9, 1801.
He coiuplained of being diilly and had some fever. Four grains of Dover's powder were administered every three
hours. In the evening the skin was moist though there was still some fever. Epistaxis occurred during the night,
and next morning the pulse was 8.5 to 90 and moderately full and the tongue coated with a white fur. Sweet spirit
of nitre in teaspoonful doses was ordered every two hours. Soon afterwards he conijilaiued of nau.sea and vomiteu
some blood with bile anil curdled milk. A sinapism was applied over the epigastrium, after Avliich the vomiting
ceased. In the evening he liad some pain in the back aud aching in the legs; as his bowels had not been opened for
several days a. pill of blue mass, rhubarb and aloes was administered. At 7 a. m. of the 11th his pulse was about
90, less full aud more compressible ; the tongue when projected was somewhat pointed and still furred ; he complained
of aching in the neck, shoulders and legs, and of pain in the small of the back; he was rather dull in answering
(jnestious. His bowels being still coutined, he was given a tablespoonful of castor oil, which quickly produced two
good stools. A sinapism was applied over the lumbar region. The disease appearing to be typhoid fever, oil of tur-
pentine, five drops, with sulphate of quinine, one grain, and sweet spirit of nitre, a drachm, were given every
three hours. In the afternoon he was reported worse aud was found scratching continuously against the wall of
the room with his right hand, his brow corrugated, pupils dilated and expression wild; he was ahso speechless:
pulse about 90: temperature raised ; muscles of the extremities and back rigidly contracted. Sixteen ounces of blood
were drawn. An hour afterwards there was no change iu the symptoms. Various measures were tried, — hot foot-
baths, sinapisms to the back of the neck and down tlie spine, bandages dipped iu hot turpentine wrapped around
the legs aud allowed to remain until in some places blisters appeared, — but the patient grew worse; the pupils con-
tracted almost to the size of a pin's point; the eyes became much congested : the breathing stertorous and suspended
at intervals for fifteen to twenty seconds ; he strangled when liquids were placed in his mouth. He died at 4.30 next
morning. From the beginning of the attack to the end his right arm was active but the left leg was motionless.
The Confederate States Medical-and 8urgical Journal, published under the auspices
of the Surgeon General'.s Office, C. S. A., contains two articles on cerebro-spinal meningitis.
In the first, Surgeon G. A. SIosES, of Mobile, Ala., called attention to the disease as he observed it among the
negroes. He was particularly struck by the suddenness of its declaration, its rapid development and termination.
The subjects, generally young and robust, were to all appearances iu good health, when a chill or pain in the head
attracted attention. This pain was concentrated about the base; the neck became stifl'and pains were felt in the
extremities or in the abdomen; opisthotonic convulsions occurred, every movement attended with intense pain.
Meiinwhile the patient became stujiid and ultimately comatose, the pupils dilated or inactive. The tongue, at first
moist and nonnal or covered with a whitish fur, became dry, hard and swollen; the bowels constipated; the pulse
588 DISEASES ALLIED TO OR ASSOCIATED WITH
small and slow and the respiration labored, with profuse diaphoresis before death. Sometimes the severe symptoms
intermitted for twelve or twenty-four hours, suggesting the hope of a favorable issue, but suddenly a relapse occurred
which ended in death. The first symptom which attracted attention appeared to indicate not the commencement of
the disease but its maturity. In cases that ended fatally in from ten to lifteeu hours lymph was effused largely in the
pia mater. Dr. S. C. You.vG, P. A. C.S., was cited as having known of no recovery in thirty-five cases that came
under his observation when the disease prevailed in Grenada, Miss., in the winter of 1863-154. None of Dr. MosES'.s
cases lived through the fifth day. He does not state their number, but gives notes of four as typical of the others.
These are abstracted as follows:
1. Alec, a slave; age 25; was admitted March 24, 1864, at 10 a. m., having felt somewhat unwell on the previous
day. There was some congestion of the left lung and rigidity of the jjosterior cervical muscles. A purgative of
calomel and jalap was prescribed, but he refused to take it; wet cups were applied to the chest and the cold douche
to the head, the latter used continuously for half an hour at a time every alternate half hour ; one drachm of whiskey
was given every half hour. At 1 P. M. he became noisily delirious and was restrained in bed with difficulty. At 5
r. >i. the pupils were largely dilated and inactive; the patient passed his urine involuntarily and cried as if suffer-
ing; pulse 80, irregular, soft and quick; respiration 28. Next day he was comatose; pupils contracted ; skin perspiring;
pulse 110, fuller and softer ; respiration somewhat cjuicker. He died at 6.30 A. M. of the 2Gth. Post-moriem examina-
tion: The vessels of the cerebral meninges were much congested, very tortuous and surrounded with exuded lymph;
the base of the brain was coated with lymph and pus and the ventricles contained turbid serum: the spinal cord
posteriorly was covered with exudation.
2. Henry, a slave; age 25; was admitted at 9 p. M., March 9, 1864, having had a chill before entering. Until
4 p. M. of the 12th pain in the head was so intense that the i)atient had to be removed to a detached room on account
of his groans and outcries. As coma supervened the pupils became dilated and almost inactive. Death occurred
at 4 A.M. of the 14th. He was treated with five grains of iodide of potassium every hour, and towards the end the
scalp was blistered and stimulants administered. Post-mortem examination: Pacchionian bodies enlarged; deposits
of lymph between the arachnoid and pia mater; lymph and pus at the base of the brain; substance of the cerebel-
lum reddened and slightly softened superficially.
3. John, a slave; age 28; was sick for two days with a profuse and frequent diarrhcea before admission at 5
p. M., March 19, 1864, when his bowels were quiet, tongue dry and covered in the centre with a white fur; skin
natural; pulse 148, small and soft; pupils contracted and motionless; he complained of pain in the head, neck and
extremities, particularly in the arms. Half an ounce of whiskey every hour constituted the only treatment. He died
twenty-four hours after admission. Post-mortem examination : The dura mater in several places near the Pacchionian
bodies adhered to the visceral arachnoid; lymph was found in the course of the meningeal vessels and posterior to
the optic commissure; the spinal cord was healthy.
4. The patient was admitted Feb. 24, 1864, with symptomsof pneumonia, but in twenty-four hours indications
of meningitis w-ere developed and death occurred on the fifth day. The peculiarity of this case consisted of the
enlargement of the contracted pupils on exposure to light. The usual post-mortem appearances were discovered.
The article written by Dr. Moses led Surgeon P. Gervais Robixsox, P. A. C. S., to publish an account of 'four
cases which occurred in the 22d N. C. in the winter of 1802-63, while encamped on the Rappahannock near Fredericks-
burg, Va. The soldiers attacked were members of the same company; three were conscripts and had been in camp
but little more than a month; the fourth was a veteran. Of the conscripts two were brothers and the tliird their
brother-in-law. The veteran only recovered:
1. The patient complained at first of a persistent dull headache, the only other symptom being a constipateil
condition of the bowels. On the fifth day he became profoundly comatose and died. Croton oil overcame the con-
stipation; blisters over the spine and cold applications to the head had no evident influence on the course of the
disease. Post-mortem examination : The surface of the brain was much and generally injected, and there was an exten-
sive effusion beneath the arachnoid with occasionally coagulated patches of a yellow color, particularly along the
longitudinal sinus, at the base of the brain and the commencement of the cord. No effusion was found in the ven-
tricles, nor did the substance of the brain present any sign of having participated in the inflammation.
2. On the day the first soldier died his brother complained of dull headache and in the evening became
violently and suddenly delirious, requiring the aid of several men to restrain him. The more violent paroxysms were
controlled by the cold douche to the head, and by the continued application of cold cloths delirium subsided and
reason was restored. The bowels were moved by croton oil and blisters were applied to the spine. During this
period of intermission the patient was tranquil, jiartakiug of such light novirishmeut as could be procured in camp;
the pulse, tongue and skin were normal, and perhaps the only appreciable signs of a brain lesion were exhibited in
paralysis of the sensory roots of the fifth jiair and an unnatural acuteness of hearing. Towards the end of the fifth
day the pupils became dilated and the patient comatose until death occurred, about the seventh day. Post-mortem
examination: The lymphy exudations were more extensive than in the first case and the injection of the meningeal
vessels greater; the lateral ventricles were distended with liquid.
3. The case of the brother-in-law followed closely on the second. In this headache was succeeded by maniacal
delirium, after which there wa.s a period of deceptive intermission. Deafness was observed on the third day; collapse
and coma supervened about the sixth ; death occurred on tlie ninth. Small doses of calomel were given until a gentle
ptyalism was developed; stimulants were administered during the intermission and stimulating euemata in the last
stage, but without apparent benefit. The j^os^-mor/cm appearances were similar to those in the second case.
4. Before the termination of the third case the veteran was taken with headache succeeded by delirium less
violent than in the two cases immediately preceding. This subsided in the course of thirty-six hours, and although
THE PAROXYSMAL AND CONTINUED FKVKRS. 589
the pain in the head continued for some days tlie patient gradnally iniiiroved until about tlir >i\lli or siv.iuli ilav.
when convalescence was fairly established.
Dr. Joseph Jones lias published two reports from the files of the Burgeon Geaenvl's Office,
C. S. A., which, with two cases recorded by himself and the papers already presented, consti-
tute the main portion of the fragmentary records of cerebro-spinal fe\cr preserved In- tin'
medical officers of the Confederacy.
W. V>. MncnEi.i., Senior Siiifieoii. Hhoilcs' Jjiiijailv, I\b. 1, 1SG3. — The following case is one of six fatal cases which
have occurred in my regiment, all similar in the symptoms, with a few trilling and unimportant variations. It is
well to remark that in every instance the sulijects have been robust, healthy men and in the prime of life:
.Sergeant A. Gcmeany, 3d Ala.; age 28 years, tall and robust : was taken on the morning of the 5th of January
with a severe chill attended with vomiting and pains in the abdomen ; the bowels were constipated ; be sulleied dur-
ing the day with severe headache and pains in the back and neck ; t he feeling of chilliness continued ; he was perfectly
sensible during the day, talked to his friends in a natural manner and partook of food in the shape of soup at the
dinner house: he continued in this condition until about 10 I". M., when a convulsion caused his messmates to call
mo to see him: they had up to this time considered his case as one of chill and fever and paid but little attention to the
matter: tuis convulsion, which they described as exceedingly violent and of nearly a half-hour's duration, was the
first symptom to excite their fears. On arriving at his tent I found him in a condition resembling the collap.se of
cholera Asiatica (could be aroused when spoken to in a loud voice or when shaken, but his answers were not very
intelligible), surface of body cold and covered with bluish-red patches such as are seen in hemorrhagica purpura.
There was not at this time any symptom of either paralysis or tetanus; the pulse was full but very slow, the pupils
contracted but responding readily to the action of light; respiration was labored, and there was a constant flow from
the nostrils of a yellowish slightly fetid fluid. This condition continued without the appearance of other symptoms
until about 1 .\. M., when a species of reaction ensued, severe and entirely uncontrollable. (Expecting this from the
condition of the pulse upon my first examination, I had nuide the attempt, notwithstanding the appearance of col-
lapse, thinking that the condition of the pulse warranted me in this, to lessen the quantity of blood by opening the
temporal artery, but the blood refu.sed to flow, as it did also from the arm.) Convulsion, or, more properly, spasm
after spasm in rapid succession ensued. The efforts at respiration became painful to the beholder; nuittering delirium
followed after about two hours' duration of this condition : the intestines had remained cold during the whole of this
time: respiration became less labored: the pulse was now fast and thready. At 8 o'clock next morning I found the
patient fitst sinking: the mutterings had ceased, respiration was slow but not labored, the pulse very fast but scarcely
l>erceptible. the pu]iils preternaturally dilated and not responding to the action of light, the sphincters relaxed, the
entire surface of the body cold and the spots before spoken of very much increased. With these symptoms gradually
increasing, the patient died at 11 .\. M.
Dr. Mitchell was inclined to consider his cases related to tvphus. The other report
is by Surgeon J. T. Banks, 13th Ga., Fredericksburg, Va., March" 28, 1863.
Dr. Baxks does not state the number of his cases, but gives the particulars of his fifth case as illustrative of the
whole. All, he says, were stout, healthy soldiers; three or four of them careless of protection, confident in their
physical endurance and all inured to camp life ; ages from 19 to 27 years.
Thompson, of Co. F : age 24 ; felt well and ate a full supper on March 13, 1863, but complained of feeling badly
at bedtime. During the night he had a chill and vomited his supper. At 4 a. m. the chill passed off; pulse 100, large,
soft, compressible; skin warm; face flushed, with a slight purple tinge; eyes injected and watery; jiupils normal;
expression dull and dejected; tongue coated white and moist; head easy; mind clear; respiration of a moaning char-
acter, but without cough, and full and easy when engaged in conversation. He complained of intense and tmbearable
pain in his legs and begged for something to relieve it. Three grains each of calomel and ipecacuanha, with half a
grain of opium, were given, and at G A. M., his condition being unchanged, two ounces of blood were drawn by cups
from the nape of the neck. An emetic of ipecacuanha and warm water given at this time brought up nothing but a
little glairy mucus. An hour later the purple tinge in his face was deepened and the circulation depressed. Mustard
was applied along the spine and quinine, four grains, camphor and capsicum, of each six grains, and calomel, three
grains, were prescribed for administration hourly. At noon there was no pulsation at the wrist; nevertheless the
patient was able to rise from his bed and walk about, aided by two comrades. Morphia was added to the treatment,
but the pain continued unrelieved. Towards evening the extremities became cold and the flush on the face changed
to a mottled purple hue. He died at 11 r. M., his mind clear to the last, rost-niortim examination: Body in good
condition; skin discolored by extravasation of blood. The arachnoid was somewhat cloudy and had three small,
well-defined, opaque spots over the upper part of the left cerebral hemisphere. The veins were engorged, but there
was no effusion in the ventricles and the brain-matter was of natural color and consistence. The condition of the
spinal cord is not stated. The only notable ai)pear.ance3 in the abdomen consisted of slight injection of the small
intestine, enlargement of the spleen to double its usual size and great distention of the gall-bladder by yellow healthy-
looking bile. The lower half of the right lung was engorged and its lower border coated with plastic lymph; its
upper half and the left Ituig were healthy. The pericardium was normal; the heart contained firm fibrinous clots
in all its cavities closely interwoven with the valves; the veins emptying into the heart were full of fluid blood.
Although at the time the ground was covered with snow Dr. ILvNics was inclined to
590 DI^;^:A?I:s allied to or associated with
coiiiiiler liis cases congestive malarial fevers, as remittents and intermittents lia«l been com-
mon in his regiment all the winter. He did not regard the meningeal lesion sufficient to
account for death, while the course of the disease negatived the idea of tyjahus.
Dr. JoNFJs's cases were two of six which occurred at Augusta, Ga., early in 1865, in
the 3d Ga. This regiment was encamped in a valley; regiments occupying the neighboring
Iiills were unaffected. All the cases ended fatally. The symptoms were nausea, vomiting,
diarrhoea and convulsions followed by severe pain in the head, extending along the spine,
alternate contraction and dilatation of the pupils, low muttering, spasms, delirium and coma.
Case 1. — Private Goosbywas takeu,Feljruary 12, Tvith soreness in the chest and cougb.paiu in the head and bacls,
nausea and sliglit diarrlicea. As the liver was enlarged and tender, a blister was ajiplied to relieve the engorgement.
On the llth delirium set in with uncontrollable restlessness and loud cries. In lucid intervals the patient coniplamed
of violent pain in the head. A blister was applied to the back of the head and neck, ten ounces of blood were
abstracted and (juinine freely administered at intervals, but the disease progressed steadily, the prominent symptoms
being muttering delirium, contraction of the pupils, deafness, rigidity of the muscles of the neck and spine, slow
pulse, impeded respiration and torpid bowels. Death occurred on the 25th. Post-mortem examination eight hours
after death: Dura nuiter normal ; arachnoid opalescent over the sulci; pia mater congested and the larger veins and
many of the arteries distended with dark-colored blood. The parts at the base of the brain and the spinal cord
were coated with a firm, light, greenish-yellow, wax-like fibrinous exudation of considerable thickness. Large tracts
of the cerebrum, cerebellum, the cauda equina and most of the roots of the spinal nerves were also coated, but the
dejiosit on these parts was thinner and less consistent than at the base of the brain or on the cord, and in many places
it required close inspection of the pia mater for its discovery. The third and lateral ventricles were distended with a
light greenish-j'ellow, semi-fluid, pus-like matter, and their walls were coated with a layer of semi-organized plastic
lymph. Under the microscope the layers of exudation resembled the lymph thrown out iu mechanical injuries and
acute inflammations ; the liquid exudation of the ventricles consisted of a serous fluid containing numerous exudation
cells similar to those of ordinary inflammatory processes, together with free nuclei and granules in considerable num-
bers. No exudation was observed on the free surface of the arachnoid. The right lobe of the liver was congested and
dark-colored, its under surface slate-colored; the spleen was somewhat larger and softer than usual. The mucous
membrane of the stomach was congested and ecchymosed iu spots; that of the intestinal canal, particularly of the
lower part of the ileum, was also somewhat congested, but the glands were apparently normal.
CiSE 2, — Private H.Powell; age 20; was brought to hospital at noon March 12, having been taken sick during
the previous night. His head was thrown back and he cried out in agony when disturbed from this position ; pulse
90, small and quick ; eyes slightly crossed; pupils dilated but mobile; hearing impaired ; mind stupefied, but he put
out his tongue when desired to do so. On the IGth he became very deaf and was unable to articulate. Death on the
17th was preceded by labored breathing and profuse perspiration. Post-mortem examination : The cerebro-spinal
membranes were congested, their veins distended with black blood, the cavity of the arachnoid filled with serum.
The base of the brain was covered with lymph and the ventricles contained liquid eft'usion. The cord was coated
with lymph nearly one-fourth of an inch thick on the posterior aspect but thinner in front.
Amo^-'o the prisonees. — The records present nothing definite with regard to the occur-
rence of cerebro-spmal fever among the prisoners on either side, Probably the disease was
relatively more frequent among them than among the troops on service. The patients in
several of the cases given above were received from the guard-house or prison. . Unfortunately
the prison reports do not intimate the existence of cerebro-spinal fever or meningitis; they
show, however, a larger death-rate from liypertemic conditions of the cerebro-spinal svstem
than those of the wliite troops generally: In the nine prison dejaots already described theiv
were 160 deaths reported as from inflammation of the brain, of its membranes and of the
spinal cord. This is equal to an annual death-rate of 1.96 per 1,000 men; but the corres-
ponding rate among our white troops was only .93 per 1,000.
II.— SYMPTOMATOLOGY AND PATHOLOGICAL ANATOMY.
The clinical histories of the one hundred and five cases jjreserved by our medical officers
necessarily present some variety, as their course extended from five and a half hours to more
than that number of weeks. A better understanding of the character of these cases may
be obtained by disregarding for the momont the extreme cases while studying those of mean
TITK I'AKOXYSMAI. AND CONTIXrKli FKVKRS. ."li]
or average duration. The pheiioniena of the simple I'oruis of these consisted of a chili fol-
lowed bv more or less reaction, during which intense lieadache and restlessness eventuated
in delirium, coma and death, the process occup3'ing from three to ten days. To these svmp-
toms in the more complicated cases were added pain in some part of the spine, extending
thence occasionally to the extremities, tetanic spasms and paralysis; and these phenomena
were associated or not with tlie appearance of petechite or purpuric spots or lilotches on the
L'cnerai surface.
Till' first-mentioned series includes eases 43. 15, 16 and 100, with tluii luiiionliagir Uliitc-lies;
-Vnd cases 5, 21, 29, 31, 33 and 51, in which no spots were recorded.
The second series comprises cases 9, 12, 53, S3, 81, 87, StO and lO."!, which were v;iriousl.v spotted.
And cases Hi, 30, 34, 38, 55, 57, 65, 66, 67, 72. 7!, 77. 89 and 103, which were free from spots so far as appears
from the record.
The initiaiurv chill in these ihirly-lwo cases was usually distinctly marked, although
in 1() it is said to have been slight, while in a few cases the record does not mention its
occurrence, the attack having commenced apparently with lieadache, nausea and vomiting.
In 67 the severity of the chill led the case to be regarded as one of congestive intermittent
fever. The reaction in this instance was imperfect, for it is stated that a low form of cerebro-
spinal meningitis was developed; usual!}', however, the reaction was of some intensity,
the face becoming flushed, the eyes injected and water}^ the skin hot and dry and the
secretions diminished. Nausea and vomiting, generally of green biliary matter, as in 43,
45 and 90, were sometimes noted; in the first of these cases the vomiting was persistent.
Exceptionally, as in 89, the ejecta contained lumbricoid worms, many others of wliich were
afterwards found in the storaacli and intestines. Intense pain was developed, usually iu the
occiput and back of the neck, but sometimes, as in 84, iu the forehead and temples; in 10->
the pain extended down the spine and in 72 over the body generally. On tbe other Land,
in 100 there was no headache, the distressing pain being confined to the lumbar region.
The pulse was frequently quick and full; in a few instances it was characterized as hard;
in a-few also it was rapid and almost imperceptible.
As reaction was established the tongue from being moist and clean, or more or less
furred, was observed in 9, 83, 84, 105 and others to become dry, red and afterwards dark-
colored, while sordes appeared on the teeth and gums. The increasing pain was generally
associated with delirious restlessness, moaning, outcries or incoherent talk, the patient tossing
himself from side to side of the bed or so persistently endeavoring to get up that men had
to be constantly on guard to restrain him. In one case, 84, the delirium is said to liave
been of a humorous character. The pupils were natural or contracted. Sometimes also
retention of urine added to the distress of the patient at this stage; in 105 delirium and
restlessness were certainly in part due to the suffering from this cause. Jactitation was in
many cases modified by tonic spasms, generally of the extensors of the bead, the patient lying
on his back with his knees drawn up, his head thrown back and the cervical muscles rigid;
in case 12 the facial muscles were involved and tlie patient squinted; in 53 contraction of
the flexors of the right side was followed by their paralysis; in 66, also, the right side was
paralyzed; in 83 and 84 the patients reeled and staggered when roused from their delirium
and placed upon their feet; and in 30 this staggering gait was followcil by paraplegia.
Sometimes, as in 43, there was hypertesthesia of the general surface.
Delirium continued for an uncertain period, but ultimately the patient became less vio-
lent, noisy or restless, and was aroused to consciousness with increased difficulty. ]n some,
592 DISEASES ALLIED TO OR ASSOCIATED WITH
as 72, tlie tetanic spasms persisted notwithstanding the deepening coma, but generally these
subsided as the jjupils became dilated, the pulse softer, fuller and weaker, the skin cool and
covered with moisture, the breathing labored and the stupor profound; involuntary passages
were common during this period.
The presence or absence of purpuric spots appeared to exercise no influence on the
progress of the disease. These generally appeared during the stage of delirium. They con-
sisted of purplish-red spots of various sizes, usually from one-eighth to three-eighths of an
inch in diameter, although sometimes larger originally or by coalescence. They persisted
under pressure and were in some instances slightly elevated. Certain regions of the surface
were specially aflfected in individual cases but not in the aggregate. A few indistinct spots
were observed on the loins in case 90. Usually, however, they were scattered over the sur-
face, sparsely as in 83, but generally closely set and more numerous on some parts than others,
as on the limbs in 9; on the lower extremities and especially in the vicinity of the joints in
83; on the chest and abdomen in 45. In 100, besides the petechial spots, a dark rash, dis-
apj^earing under pressure, is said to have been present, and in 53 some pink spots were noted
in addition to the dark-colored blotches.
The post-mortem appearances .of the cerebro-spinal axis were very similar in all these cases.
A hypersemic condition of the pia mater constituted the anatomical or local essential, and
on this depended ct>rtain secondary changes in the subarachnoid sjaaces and ventricles. The
vessels underlying the visceral arachnoid were engorged with black fiuid blood. Serum was
sometimes noted, as in 105, at the base of the brain and in the membranes of the cord, but
the characteristic lesion appeared to be the exudation of a yellowish or greenish lymph or
pus beneath the arachnoid, apparently thickening that membrane and destroying its trans-
parency throughout more or less of its extent. The parts most frequently and extensively
affected by the deposit were the base of the brain, the pons Varolii, cerebellum, medulla
oblongata, the spinal cord and the sulci between the convolutions of the cerebral hemispheres.
Tlie deposit was tough, fibrinous and oftentimes two or three lines in thickness, or it was soft
and semi-purulent. Witli tlie exception of cases 57 and 100, which will be referred to par-
ticularly hereafter, and 12, which was not examined after death, it was present in all the
above-mentioned cases, always at the base of the brain, frequently in the sulci and some-
times over the surface of the convolutions. In some instances the condition of the pia mater
of the cord is not stated, probably because it was not examined. In others the cord is said
to have been coated with this plastic or semi-purulent deposit, sometimes uniformly, as in
90, at other times chiefly on its posterior aspect, as in 55 and 87; while in some cases, as
45, the membranes are said to have been infiltrated with pus. But in certain cases, as 34,
it is definitely stated that although the membranes of the cord were congested there was no
exudation on its surface, and in 74 there appears to have been not even congestion. The
serous surface of the arachnoid was unaffected except in two cases — 43, in which the cavity
contained effusion, and 83, which presented some recent adhesions between the visceral and
parietal layers. The ventricles usually contained a turbid effusion or serum with a semi-
purulent deposit, while their walls were coated with yellowish lymph. In some of the spotted
cases, as in 43, 45, 87 and 105, the effused serum was tinged with blood, but in others it
was turbid or purulent, as in the unspotted cases, and while in 46, a spotted case, there was
no serum in the ventricles, in 67, an unspotted case, these cavities were unusually dry.
The exceptional cases, 57 and 100, presented no positive sign of inflammation of the mem-
THK PAfiOXYtiMAI, AND CONTINUED FEVERS. 593
branes, although more or less congestion was present. The former was characterized by stupor
and spiisms, and typhus or fulminant typhoid, as in 58, 59 and 63, to be instanced hereafter,
was not wholly excluded in the diagnosis. The symptoms in the latter pointed to a spinal
meningitis; but although the pia inater was engorged and serum efl'used into the subarach-
noid space no mention is made of the characteristic deposits of lymph and pus; the blood,
which was liquid and dark-colored, formed ccchymosed spots on the viscera of the thorax
and abdomen, as in case 28, to be mentioned hereafter.
The substance of the brain was not uniformly affected. In some its condition was not
stated, in others it was recorded healthy. In 84 it presented dark-colored puucta; in 54 and
55 it was congested; in 45, 46, 89 and 103 congested and softened. In 34 the cerebellum
was considered pultaceous; in 72 it was soft and its gray matter almost as pale as its white
substance; in the former case the cord was congested, in the latter softened. The cord was
also soft in 83 and 90, a section of its lower part in the last-mentioned case having given
issue to a greenish liquid.
The anatomical appearances of the thoracic and abdominal viscera were inconstant, and
hence more or less accidental. They are omitted at this time to permit of the uninterrupted
study of the symptoms and meningeal lesions of the remainder of the one hundred and five
cases presented as cerebro-spinal fever.
Twenty of these cases ran a more rapid course, ending fatally in a few hours or in a day
■ •r two after the development of the disease.
Teu of them were maculated, l.S, 14, 27, 28, 49, 50, 62, 86, 92 and 99;
The remaiuder, 4, 8, 24, 47, 80, 91, 93, 95, 102 and 104, so far as appears from the records, were free from spots.
Neither the symptoms nor the post-mortem appearances of these cases presented the
uniformity observed in the cases already discussed. Some, however, were characterized by
a sequence of symptoms similar to that noted in the cases of longer duration. In cases 8,
13, 24, 27, 47, 80, 92, 95 and 102 the short history of the fatal attack embraced chills,
fever, headache, delirium and coma, with or without spasms or paralysis, or the defective record
shows only the sudden development of fatal coma with or without convulsive seizures; and
in all these cases the characteristic deposits of lymph or pus were observed under the arach-
noid. In 102 the purulent deposits were confined to the spinal cord, the cerebral pia mater
having been congested merely.
But in the two cases, 24 and 92, the exudation appears only to have clouded the mem-
brane, and instead of a purulent infiltration of the pia mater and subarachnoid tissue the
<erebro-spinal fluid was generally clear, being turbid only in the lower part of the cord. These
cases, anatomically considered, form the only links of connection between the few cases that
presented simple engorgement of the vessels with perhaps serous effusion and the many that
were characterized by well-defined inflammatory products. In 4, 91, 99 and 104 the men-
ingeal vessels and sinuses were filled with dark-colored fluid blood, but no deposits of lymph
or pus were present. These may be regarded either as cases of malarial congestion or of
cerebro-spinal fever in which death anticipated the developraentof the local lesion, as in typlioid
fever it may anticipate the ulceration of the glands or even in fulminant cases their enlarge-
ment. In 91 a healthy man was seized with an agonizing pain between the shoulder blades
and, after paroxysmal recurrences of the pain, died suddenly five and a half hours after the
first attack. In 4 a sequence of headache, chill and perspiration was followed by coma, trismus
and death within thirty hours of the seizure. In 99 death took place from collajise after
>Ieu. Hist., Pt. 111—75
594 DISEASES ALLIED TO OR ASSOCIATED WITH
-twenty-four hours of fever, delirium, headache, maculae and nervous prostration. In 104
chill, fever and perspiration were followed by a recurrence of the chill and fever with dehrium,
opisthotonos, trismus and coma.
It is perhaps as impossible to discriminate between these cases and cases of pernicious
malarial fever as it is to determine the etiology from the symptoms alone in cases 49, 50, 86
and 93, which were not examined after death. A diagnosis of cerebro- spinal fever or malarial
congestion, in cases where only meningeal congestion is present, involves a determination of
the cause, if there be, indeed, two separate and distinct diseases manifesting themselves by
this condition of the cerebro-spinal membranes. In 50 and 86 analogy would anticipate the
presence of inflammatory products in the pia mater; the symptom^ in the former were head-
ache, chill, irregular blotches, dulness of mind, coma, profuse perspiration and death in about
fifty-one hours; in the latter, pain in the head and neck, restless delirium, petechise, an
anaesthetized condition of the skin, contraction of the posterior cervical muscles and coma,
with death at the end of two days. Case 49 was probably congestive; it was characterized
by a severe and long-continued chill, petechise and coalescing purpuric spots with coma follow-
ing, and death within thirty hours. The record of 93 is, on the other hand, suggestive of
typhoid fever in its virulent form : Debility and slight mental aberration, fever and headache
lasting for several days, ultimately mild delirium, stupor and death forty-eight hours after
admission to hoepital but an uncertain number of days after seizure.
Three cases still remain for remark — 14, 28 and 62. The nervous symptoms in the last
are notably unlike those associated with undoubted cerebro-spinal inflammation ; and typhoid
fever is by no means contraindicated by the post-mortem observations, — the membranes of
the brain finely congested and the patches of Peyer distinct, hard to the feel and black-
pointed. Case 14is of interest, inasmuch as it occurred in an epidemic of spotted fever attended
with the exudation of products of inflammation within the cranium and spinal canal, and was
regarded by the attending medical ofiicers as a case of the prevailing disease. Nevertheless it
presented but little congestion of the cerebro-spinal membranes, although the arachnoid was
slightly opaque ; it ended in collapse, not in coma, and the fatal lesion was developed in the
serous lining of the pericardium instead of in the membranes of the nervous centres. The
pericardium contained six or eight ounces of sero-purulent liquid with large masses of floccu-
lent lymph, and its surface was covered with a layer of lymph membranous in tenacity and
thickness. The connection of pericarditis with a diseased condition of the blood, as in rheu-
matic fever, albuminuria, etc., and its infrequency as a spontaneous idiopathic aff'ection, argue
that in the present instance it was due to a blood-poison, and in view of the nature of the
cases then prevailing at New Berne, where it occurred, to the same blood-poison that in other
instances educed inflammatory results in the cerebro-spinal membranes.
The following case illustrates the association of pericarditic lesions with a clinical his-
tory KUggestive of cerebro-spinal meningitis :
Private John Buchanan, Go. L, 15th N. Y. Cav., was admitted Feb. 12, 1864, w-ith headache, severe pain in the
back, nausea and slight inflammation of the fauces. He was sent to a tent where eruptive diseases were treated.
The tongue became heavily coated and the fever and headache increased ; low delirium followed in a day or two, with
an intense rigidity of the muscles of the neck, tympanitic abdomen and strangury. He died at midnight of the
15th. He was treated with blue-pill, Dover's powder, sweet spirit of nitre, ice to the head, catheterism, wine-whey
and milk-punch. Post-mortem examination: The anterior and lower part of the right lung was congested. The peri-
cardium contained an ounce of sero-purulent liquid and a small deposit of fibrin on the surface of the heart. The
peritoneum was slightly congested; the intestines distended with gas; the gall-bladder large; the urinary bladder
distended and its mucous surface congested. — Jet. Ass't Surg. John GoMsborough, Hosjyital, Frederkl; Md.
THK PAROXYSMAL AND CONTINUED FEVERS. 595
Case 2S is of equal interest, but from another point of view. Agonizing pain in the back
was associated with purple spots on the skin, an oozing of blood into the mouth, giving a
sweetish taste to everytiiing, and a blood-color in the urine. These symptoms were followed
hv high fever, violt- lit delirium, coma and death. At the jpost-morlem examination the brain
was found to be healthy. The spinal cord imfurtunately does uot appear to have been exam-
iiird. All the other organs of the body were covered wjth ecchymosed spots. On account
of the uncertainty as to the condition of the spinal cord the presence of a spinal fever or
meningitis, as anatomically distinct from the hypencmia of a congestive case of malarial
dlsea.se, cannot be determined. The coma and death in this case must be ascribed to the high
febrile condition brought about by a deterioration of the blood analogous to that present in
malarial hematuria or hemorrhagic malarial fever.* Case 100, already described, was of a
similar character.
In the following case, submitted in this couuectiou, the dissolution of the blood and
its appearance in all the organs and secretions led to the diagnosis of purpura hemorrhagica.
The mercurials which the patient had taken, although the cause of some of the symptoms
enumerated, cannot be held responsible for the purpuric colorations, delirium and death.f
Corporal Joseph B. Grow, Co E, 3(1 Vt. Art'y; age 25: muscular; wa« admitted Jan. Ifi, 18fi5, having been
attacked four days liefore with aseverochill, general pains, much thirst, nausea, vomiting and diarrhoea. On admis-
sion the vomiting and diarrhrea were reported as having abated: the patient had headarhe hut no delirium; his eyes
were darkly surtused and their lids oedematous; tongue moist, slightly coaled, protruded with difficulty ; gums soro
and exsanguine; fauces swollen and inflamed; tiow of saliva excessive; submaxillary and cervical glands enlarged
and painful ; he had also a profuse coryza, pain in the chest and cough with bloody sputa; his face, neck and breast
were of a bright-red color, a.s if covered with a scarlatinal rash, which also appeared in patches on the lower part of
the trunk and limbs: this coloration disappeared under pressure. Another eruption, scattered over the entire surface,
and consisting of bright-red spots varying from the size of a pinliead to that of a three-cent piece, persisted under
pressure. The patient had been suffering for five months from syphilis, for which he had taken mercury. A saline
cathartic was given and Dover's powder at night. He vomited the cathartic, passed a restless night, and next
morning was found with all his symptoms aggravated, — thirst, glandular swelling and conjunctival congestion
increa.sed, scarlet etllorescence spreading and persisting, spots more numerous and larger: he had also severe pain in
the head and loins; his stomach was irritable and his bowels unmoved. Ou the 18th the skin was of a dark-purple
color, unaffected by pressure save in a few places; blood oozed from the gums and fauces and was mingled with
the expectoration, saliva and tears : the urine was dark-colored from venous blood; the patient was delirious ; pulse
100 and soft. Tincture of iron and whiskey were given at intervals during the day; in the evening a natural-looking
stool was obtained by an enema of castor oil and turpentine ; chlorate and permanganate of potash were also added
to the treatment. The delirium increased, the pulse became rapid and weak and the secretions continued, mixed
with blood, until death took place on the evening of the 19th. rost-moriem examination : Rigor mortis well marked;
surface covered with a coalescence of purpuric spots which, on the thighs, had become greenish-black in color and
were roughly elevated , the lachrymal sacs were filled with dark fluid blood : the conjunctival membranes were con-
gested and projected between the half-open lids. The mucous covering of the mouth, tongue, gums, fauces and
•esophagus was pale except where spotted with purpuric extravasations. The pericardium showed on its anterior
surface a sen'.itrahsparent, gelatinous nuiss the size of a lemon; the heart was covered with purpuric spots; both
ventricles contained well-washed clots. The lungs were congested and spotted, as were the costal pleurje; the bron-
chial tubes were filled with bloody froth. The stomach contained eight ounces of dark coffee-colored liquid; its
submucous tissue was colored with coalescing ecchymoses. The intestines were in the same condition as the ccsoph.agus
and the peritoneum was similarly spotted. The omentum was contracted and of a deep straw-color and the mesen-
teric glaniis distended with dark venous blood, which flowed freely on incision. The liver, weighing six pounds and
a half, was covered with large purpuric spots, and presented on its under surface several ash-colored patches about
an inch square, which extended a (juarter of an inch into the substance of the organ ; the gall-bladder was distended
and contiguous organs were tinged with a dark-green color: the spleen was spotted externally and congested. The
connective tissue around the kidneys was tilled with blood; the pelves and tubuli were distended with coagulated
• See ntpra^ page 12G.
t W. S. .AnsisTRoso, Mobile, Ala., in describing an epidemic of cerebro-pjiinal nieningitis which occurred in that city, — Atlanta Medical aud Sitrtjiatt
Jrtmnial, .June, ISO;, — gives the case of a soldier euffcriiig from mercurial ptyaliHui, which is in strong contrast with that submitted in the text. On Feb.
3, I8W, when Ihe |<itient was admitted, his skin was yellow and he had vomited bile several times ; his tongue was swollen and ulcerated and he suffered
from |Ain iu the forehead and temples. On the 7th he had severe pain in the head and his mind wandered. Next day the pain was more intens(3 and
exlende<l along the spine, which was t'-nder on pressure ; he coniplaiuerl of jmin in the neck when his head was moved. Delirium continued, the pnpil>
l>e.-*nn- stu^gi>li, the pulse we;\ker; the jwitient refu!-<-d nourisliiiieut and picked at the bwlrlothes. He died on tlie lUh. Ho pnH-mortem examination
WM held. Keithei petccbiee nor purpuric extravasations are mentioned as having beeu olwerved duriug this epidemic.
596 DISEASES ALLIED TO OR ASSOCIATED WITH
blood; tlie ureters showed purpnric spots on their mucous surfaces; the bladder, which was filled with bloody urine,
had its mucous coat covered with small scarlet spots, those around the neck of the organ being arranged in a stellate
form. — Hospital, Second Division, Sixth Army Corps.
lu tlie series of one liunclred and five recorded cases twenty-eight of those which liad a
fatal issue were protracted in their duration from ten days to three months.
Only seven of these were maculated, 7, 15, 25, 41, 58, 60 and 63, and iu none were the spots so profuse as in tlie
more rapidly fatal cases.
The others, 2, 3, 6, 11, 18, 20, 35, 36, 37, 39, 42, 44, 51, 52, 59, 61, 64, 78, 88, 94 and 101, were unspotted so far as
is shown by the records.
The characteristic symptoms of an implication of the cerebro-spinal membranes were
present in many of these. In eleven, viz: 7, 35, 36, 41, 42, 44, 64, 78, 88, 94 and 101,
the delayed issue was due to a 2>rolongation of the febrile or delirious period, but in 2, 18
and 25 the increased duration of the attack was the result of a temporary amelioration of
the symptoms. In 2 the improvement continued for three weeks, the excitement abating
and the patient becoming able to sit up and give generally rational answers ; but at the end
of this time he grew worse suddenly and died. In 18 the delirium and rigidity of the pos-
terior cervical muscles following the initiatory chilliness subsided at the end of two weeks,
but ten days later the spasms returned gradually and continued until death. In 25 chill,
fever and delirium were followed by unconsciousness, which by the eighth day had passed
off, leaving the patient j^erfectly rational; the improvement lasted for two weeks, when
continued fever of an adynamic type was developed; low delirium, floccitatio, bedsores,
unconsciousness and stupor were successively manifested; pain in the back of the neck
characterized the early jjeriod of this relapse, and a persistent backward tilting of tlie head
its later period; an eruption appeared on the face and abdomen on the thirteenth day of the
second seizure, and death occurred two days later. In all these cases post-mortem observa-
tion revealed the presence of meningeal congestion and of deposits of lymph and pus such as
were found in the majority of the more speedily fatal cases.
No examination was made after death in cases 11, 20 and 51, but the clinical records
favor the supposition that cerebro-spinal meningitis was present.
Identical inflammatory lesions were found also in cases 6, 15, 37, 39, 52 and 61, which,
in their clinical aspects, differed considerably from the average.or typical case of the disease.
These cases in fact suggest that the cerebro-spinal inflammation originated in the deteriorated
condition of the blood consequent on congestive malarial, typhoid or the eruptive fevers
instead of on that due to a special and peculiar febrile poison. Seventeen days elapsed in
case 6 between the occurrence of a congestive chill and the supervention of severe headache,
febrile delirium and convergent strabismus, which ended in death five days afterwards. The
only clinical statement in 52 is the diagnosis of typhoid fever, which, however, cannot be
considered substantiated by the intestinal lesion, — the injection of two of the patches of
Peyer. But in 15 chill, headache, pain in the back, and limbs, recurring epistaxis with
febrile movement, cough, sibilant rales, sordes, diarrhoea, gurgling in the right iliac fossa,
violent and afterwards muttering delirium, and the appearance of several undescribed spots
on the eleventh day, with coma on the twelfth and death on the fourteenth, constitute a
sequence of symptoms indicating a possibility of typhoid fever, which is by no means neg-
atived by the enlargement of the solitary glands and the thickening and ulceration of the
patches of Peyer, noted in the post-mortem record; occipital pain and the extended position
of the head were the only symptoms pointing to the implication of the cerebral membranes.
THE PAEOXYSMAL AND CONTINUED FEVERS, 597
The following report brings prominently into view tlie occurrence of cerebral cases in
an epidemic of typhoid fever:
Act. AssU Surgeon J. P. De Bruler, August 30, 1862. — Typlioiii fever has been very prevalent in llio hospitals ^^(
Evansville,In<l.,an<l in many cases entirely unmanajjeable. Inllaiimiiitions of the brain and its membranes prevailed,
it seemed to nie, to an nnnsnal extent. Tenderness and jiiu'slin^ in the right iliae region and diarrlnea oeenrred in a
large majority of the eases. The rose-colored ernption wa.s distinctly marked in over two-thirds of thoso alfectcd.
Petechiie were observed in a number of cases; the tendency to jiuriinra was so marked that the slightest friction,
as of scratching, would be followed tiy ecchymoses. I may hero add that scorbutic symptoms were common in all
diseases associated with debility. In mild eases the treatment consisted of gentle diajdioretics and cooling refriger-
ants, with aperients, oiiiales or astringents, as seemed to be indicated, and a diet of barley-watcr, animal broths and
boiled or thickened milk. When tlie bowels were prominently ati'ected turpentine emulsion was very generally relied
on, with turpentine ajjplicatious to the abdominal surface: many other remedies were tried, but on the whole this
seemed the most satisfactory. lu another class of cases evidences of imperfect oxygenation of the blood were
prominent: The skin was dark -red or livid all over the body, especially about the lips, gums and ears; pressure
readily produced a white spot, but when the finger was removed the color was restored very slowly, — in a word, the
capillary circulation was sluggish ami the vessels engorged. The surface was often cool and the pulse frequent and
feelde. In these cases stimulants were earlv resorted to and the results were often very satisfactory; porter, ale,
wiue and brandy were freely given. Indeed, I think that brandy given in largo and freciuently repeated doses was
the means of saving a number of lives. Another rcme<ly much valued in this variety of the disease was chlorate of
potash — given iiweight or ten-grain doses every four or live hours. We understand but little of its modus operandi,
but it seems unipiestionable that it does in some way .assist in oxygenating the blood. In cases accom()anied with
iullannuation of the br:iin there was often forced respiration. This was promptly and pernuinently relieved in so
many cases by blistering the najie of the neck that something more than a coincidence is suggested.
Fourteen poM-mortnn examinations were made in fever cases. In nine there was well-nuirked ulceration of
Foyer's glands, often extensive and in one perforating, — there was probably perforation in another case not exam-
ined:—in two the glands were enlarged and unusually distinct; and in three the ileum was uuatfeeted, but in two
of these the disease seemed to have spent its force upon the brain, having proved fatal in a comparatively short
time, and in the third the immediate cause of death was an acute iullannuation of the lungs.
Siinilixr cerebral complications were developed in the pi-ogress of measles in cases 37
and 39; while Ass't Surgeon McGiLL, U. 8. Army, regarded 61 as originally a case of mod-
ified variola, in the course of which, "under the cerebral type of disease ]>rovailing, general
cerebro-spinal meningitis supervened." Nevertheless, as this patient contracted his disease
at Galloupe's Island, Boston Harbor, where measles and the so-called spotted fever were pre-
vailing, the sloughing spots on the lower extremities are probably to be attributed to the
same deteriorated condition of the blood that produced them in some of the cases recorded
by Pr. Calvin G. Page at the station mentioned.*
In the remaining five of the protracted cases a fever was present which cannot be identi-
fied as cei-ebro-spinal by the lesions found after death. In 3 and 60 fever, delirium and a
typhoid condition were associated with some injection of the membranes and cloudiness of
tlie arachnoid, apparently not inconsistent with the presence of a continued malarial fever,
as the spleen in both was large and the patches of Peyer conspicuous, marked with black
points in one and slightly ulcerated in the other. The difficulty of discriminating between
malarial and cerebro-spinal fever was, as may be seen by these instances, not confined to the
congestive cases of the former. The following case of remittent fever would probably have
been considered an example of cerebro-spinal fever had it occurred during the epidemic prev-
alence of that disease;
Private Joseph Barne,"!, I2th 111.; age 25; was admitted Nov. 22, 1864, crying aloud from intense pain in the head
and back. The pain continued unabated for several days, notwithstanding treatment by oi)iates, sinapisms to the
back and feet, cups to the back and free movement of the bowels by castor oil. On the 2!)th it became less severe,
but the tongue was dry and lissured, the eyes suffused and the mind wandering. A blister a]>plied on the 30th to
the back of the neck jiartially restored consciousness, but the delirium returned, the patient at times attempting to
leave his bed and at other times being inclined to muttering delirium .and stupor. He died comatose on December 8.
Posl-morlrm examination: The skull-cap was ren\arkably thin. The membranes of the brain were somewhat congested
and nioister than usual. There was no evidence of inllammation about the base of the brain and the brain-substance
•Seo mpra, iwge 583.
598 DISEASES ALLIED TO OR ASSOCIATED WITH
appeared healthy; but the lateral veutricles were distended with bloody serum and the floor of each was coated with
white coagulated libriu which extended iuto the cornua ; a similar exudation was found in the other ventricles. The
other organs were not examined. — Act. Ass't Smy. H. C. May, Hosjrilal Xo. 8, XashviUe, Term.
The three cases, 58, 59 and 63, occurred at the National hospital, Baltimore, Md., where,
as already stated, the occasional presence of true typhus was suspected. In 58 a typhous
condition, with muscular spasms drawing the head strongly backward, presented some con-
gestion of tlie brain and its membranes, some opacity of the floor of the fourth ventricle and
bloody serum in the cornua of the lateral ventricles. In 63 the patient, wlio was subject to
intermittent fever, and had just recovered from pneumonia contracted while in hospital, sud-
denly developed typhous symptoms which proved fatal in six days without the occurrence
of convulsions; slight injection of the brain and its membranes with two small extravasa-
tions of blood on the convexity of the hemispheres were observed in this case, with some
congestion and ecchymosis of the mucous membrane of the alimentary canal and pigmenta-
tion of the patches of Peyer. The clinical history of 59 shows delirium and opisthotonos,
while the post-Tnortem record reveals only congestion of the pia mater and lungs^ enlarge-
nif^nt of the spleen and pigmentation of the agminated glands.
In eighteen of the one hundred and five cases there is no clinical record, or the symptoms mentioned are insuf-
ficieut to identify the disease. These are cases 10, 19, 22, 40, 50, t)8-71, 73, 75, 76, 79, 81, 85 and 96-98; in only one of
these cases, 73, is the existence of spots indicated.
A few of these were recorded as typhoid fever; but this view of their nature was not
sustained \>j post-mortem observation except perhaps in 56, in wliich engorgement of tlie pia
mater, congestion and ecchymosis of the mucous membranes, enlargement of the solitary and
agminated glands and ulceration of the large intestine might be supposed to indicate a typho-
malarial fever fatal in its early stage. In all the other cases the characteristic lesions of
cerebro-spinal meningitis were discovered after death.
Four of the recoveries, 1, 17, 23 and 26, were reported during the New Berne epi-
demic, one, 32, from Chattanooga, Tenn., one, 48, from the Army of tlie Potomac, and
one, 82, froni Benton Barracks, Mo.; and in all the accuracy of the diagnosis appears to have
been fairly established. The patient in 26 was returned to duty on the seventeenth day,
and the only recorded svmptoms were headache and pain in the back of the neck; in 23
the patient was returned to duty at the end of a month, having rallied from his stupor
on the third day of the attack on tlie establishment of profttse salivation. In neither of
these were tlie characteristic symptoms present, Ijut the type of disease then and there pre-
vailing warrants their acceptance as cases of cerebro-spinal fever in the absence of post-
'inortem testimony to the contrary. Petechial spots were observed in 48 and a wheal of
large size on the anterior aspect of the trunk in 32 ; but case 1 is the only instance of recovery
which was characterized by the early development of purpuric blotches, — they appeared on
the arms and legs during the reaction from the chill ; the patient was unconscious, but neither
coma nor convulsions were developed; improvement was manifested by the return of con-
sciousness on the fifth day; the spots sloughed instead of fading, and the cornea appears to
have become opaque and greenish.* Case 17, although unspotted, was somewhat similar in its
course; in both instances the men were discharged between three and four months after the
attack. In 32 the onset was by chill, fever and headache, but the pain was most severe in
the spinal cord and along the thighs; delirium and piaralysis continued for two weeks, after
* Case n of the series reported from Galloiipe's Island, Bostou Harbor, — see page 583, — was of a similar character. There was Deitber opisthotonos
uor cerebral disturbaucf, but the spots on the arms sloughed uud a discharge exuded from beneath the crusts that formed on the legs ; improvement
dated from the sloughing, but vision was greatly impaired.
THp; PAROXYSMAT, AND CONTINUED FEVERS. 599
which recovery was graJually effected. In 48 heiKUiche, stupor, vomiting, involuntary pus-
sages, opisthotonos, hypera?sthesia of the surface, petechise, delirious moaning and completa
deafness continued for about three weeks, and terminated in a gradual improvement; but
deafness persisted and necessitated the discharge of the patient at the end of six months. In
82 a chill was followed by pain between the shoulders; two days later a congestive chill was
experienced; reaction was not fully established until three days had elapsed; after which
pain in the head and back, extreme sensitiveness of tbe surface, indications of paralysis of
the lower extremities and fever of a typho-raalarial type continued for three weeks before
the occurrence of convalescence. A malarial element appears to have been recognized in
this instance, as in 17, in which a chill at noon of one day was followed by violent delirium
at the same hour of the following day.
Of the one hundred and five cases submitted, seven recovered and in eight no post-
mortem examination was held. Of the ninety cases remaining seventy-five were identified
as cerebro-spinal meningitis by the post-mortem appearances, while fifteen were characterized
by more or less congestion of the cerebro-spinal mend)ranes. Most of the seventy-tive cases
presented a certain sequence of symptoms of sudden development and comparatively rapid
progress; but in a few cases, as 6, 15, 37, 39, 52 and 61, the disease supervened on a con-
tinued fever of malarial, typhoid or tvphous origin or on an eruptive fever. Two cases, 24
and 92, appear as connecting links between the inflammatory and congestive cases. An
uncertainty attaches to the fifteen cases in which positive evidence of inflammation was not
observed: In some congestive or continued malarial fever, in some typhoid and in some
typhus is suggested as a probability, instead of a specific febrile poison manifesting its pres-
ence in the system by cerebro-spinal congestion. One of these, 62, was probably a case
of typhoid fever; one, 14, was a distinct pericarditis anatomically; four, 57, 58, 59 and 63,
may have been typhus or fulminant typhoid; one, 56, typho-malarial ; two, 3 and 60, con-
tinued malarial fever; two, 28 and 100, hemorrhagic malarial fever, and four, 4, 49, 99 and
104. congestive malarial fever.
SUMMARY OP THE POST-MORTE^t APPEARANCES IN THE RECORDED CASES.
The LUNGS were more frequently the seat of morbid chauges than any other organ or tissue excepting the
cerebral niembraues. Kefereuce is made to their condition in seventy-four of the ninety fatal cases the records of
which have been preserved. In twenty of these they were healthy; in fifty-four altered. Generally, as in 5, 7, 35,
36, 39, 40, 54, 73, 81 and !I7, one lung only was affected, but more frequently both were implicated in the congestions,
extravasations and intiauimatory changes that constituted the morbid condition. Congestion characterized the ra]i-
idly fatal cases ; pneumouitic processes were more frequent in those that ran a protracted course.
The condition of the pleural membrane is indicated in twenty-eight cases, in ten of which it was normal; it
was probably normal also in nine other cases in which the lungs are said to liave been healthy, the serous membrane
remaining unmentioued. Of the eighteen case.s presenting morbid changes there were adhesions in 40, 43, G3, 08 and
97; in some of these the adhesions were old and unconnected with the fatal illness, but in the last-mentioned case
comnmnication was established with an abscess in the spleen. In 39 and 91 there was effusiou of serum; in 33, 35 and
36 exudation of lymph, and in 28, 55-58, 62, 61 and 100 ecchymoses.
The HEART was normal in twenty-three cases, and in twenty others in which its contents are stated its con-
dition did not appear to call for remark. Morbid changes are mentioned in thirteen cases : In 4, 39, 85 and 1U5 the
heart was softened, in 40 flabby, in 56 flaccid, in 71 and 77 fatty, in 64 firm and dark-red, in 28 ccchymosed, in 45
aua>mic and horny, in 43 dense and cartilaginous and in 103 thickened in its mitral valve. In thirty-four cases the
cardiac contents are mentioned : In 58 the heart is said to have been free from clots, in 4, 9, 35, 68 and 105 to have con-
tained dark fluid blood, in 63 and 92 clots, in 55 and 59 mixed clots and in 79 and 90 fibrinous coagula. I'ibrinons
deposits Were observed in both sides in 8, 10, 13, 14, 27, 45, 53, 61, 61, 78 and 81 ; in the right side in 25, 38, 56, 62, 69,
85, 9;t and 102, and in two of thes<% 'M and 62, the contents of the left side are respectively specified as uucoagulated
blood and mixed clots; in the left side in 46. 52 and 57, the right side in the first containing coagulated blood and in
the last mixed coagula.
The PERICAKWU.M is said to have been normal in two of seventeen cases in which its condition was noted. The
aac contained an unstated quantity of serum in 46, 73 and 74, two ounces in 91, three in 5 and 40, four in 39 and
600 DISEASES ALT.IED TO OR ASSOCIATED WITH
eight in 35; in 105 the effused liquid was tinged with blood, and in 9, 14, 38, 43 and 103 there were definite indications
of pericarditis; in 28 the serous membrane was ecchymosed.
The STOMACH was the subject of report in forty-two cases, in twenty-three of which it was normal. Congestion
was noted in 5, 55, 61-64 and 85; ecchymoses in 28, 56, 58, 90 and 100; mottling in 57; softening in 74, 78 and 88;
lumbricoid worms in 89, and intlation or distention in 36 and 99.
The condition of the small intestine, in whole or in part, is noted in sixty-eight cases, in twenty- seven of
which it was normal and in one, 99, distended merely. In five cases, 3, 5, 9, 15 and 25, the condition of the intes-
tinal glands only is stated. The bowel as a whole is reported more or less congested in 28, 33, 35, 36, 39, 40, 56, 58,
60 and 64; in 58 the congestion tended to form small irregular spots ; in 35 there was also ulceration of the ileum and
m 36 and 39 intussusception. Ecchymoses were present in 43, 46 and 100 and lumbricoid worms m 89. The duodenum
was congested and of an ironed-out appearance in 63, and the duodenum and jejunum in 55 were similarly affected.
Abnormal conditions in 38, 42, 54 and 62 were confined to the jejunum and ileum — in the first-mentioned case the
jejunum was congested and the ileum contracted : in the second a lumbricoid worm in the jejunum was noted, with a
thinned and congested state of the ileum ; in 54 both divisions were reddened, and in 62 the upper was colored dark-
red and the mucous folds of the lower thinned and blackened: in a fifth case, 57, the jejunum is said to have been
yellowish and the ileum thinned, its aggregated glands tumid. The ileum alone is mentioned in fourteen cjises: In
45 contracted; in 31, 59, 69, 104 and 105 congested, 59 presenting the shaven-beard appearance; in 78 softened, pig-
mented and the solitary glands enlarged; in 4 and 85 ulcerated, the solitary glands prominent in the latter; in .52 the
agminated and solitary glands were injected and in 70 the ciypts were inflamed; in 61 the mucous folds were thin and
ironed-out, in 71 softened, and in 90 reddened, ecchymosed and softened.
The LARGE INTESTINE is referred to in fifty-seven cases; in thirty-two no notable change was reported; in
fifteen of the remaining twenty-five cases the intestine as a whole is described : It was injected or congested in 36, 39,
40, 55, 60 and 61, discolored in 57, ecchymosed in 28, 43, 46 and 100, ulcerated in 33 and 56; its solitary follicles were
inflamed in 70 and in 89 it contained lumbricoid worms. In ten cases morbid appearances are noted only in connec-
tion with one or two of the anatomical divisions of the bowel : The solitary follicles of the ca'cum were prominent in
78; the colon was congested in 63, 64 and 73 and pigmented in 69 ; the caecum and colon congested in 62 and 90, pig-
mented in the former, ecchymosed and with prominent follicles in the latter; the colon and rectum congested in 97;
the lower part of the intestine congested in 58; the solitary follicles of the caecum prominent and the mucous mem-
brane of the tectum softened and pigmented in 85.
Besides the abnormity of the patches of peyer and solitary follicles in specified portions of the intestinal
tract already noted in cases 52, 57, 70, 78, 85 and 90, the agminated glands were conspicuous or thickened in twelve
cases, iu four of which, 5, 56, 61 and 64, there was no other alteration, in one, 28, ecchymosis, in three, 3, 9 and 15,
slight ulceration, and in four, 25, 60, 62 and 63, pigmentation ; the solitary follicles were enlarged in 15, 28, 56 and 64.
The condition of the liver was reported in sixty-nine of the examinations. It was normal in twenty-seven
and altered in forty-two cases : It was large in eight, 34, 35, 38, 40, 41. 75. 97 and 100 ; pale in two, 69 and 77; large
and pale iu three, 28, 71 and 72 ; fatty in five, 29, 78, 79, 85 and 90 ; large and fatty iu two, 4 and 73; engorged in two,
42 and 55: congested in six, 7, 43, 53, 58, 63 and 104 ; large and congested in four, 3. 13. 27 and 39; large and mottled
in two, 36 and 37; light, friable and odorous iu 57 ; dark superficially in 44; dark, firiu and odorous iu 64; cirrhosed
in the two cases 70 and 74, and dark and firm in the three cases 54, 56 and 62.
The gall-bladder was distended iu eleven cases, 25, 35, 38, 41, 42, 45, 46, 85, 99, 100 and 104; empty in 36, 37,
39 and 40. The bile, when specified, was generally dark-colored and frequently viscid, as iu 25, 54, 55, 56, .58, 62, 63,
64, 78 and 99.
The state of the spleen is reported in sixty-eight cases, in thirty-three of which it was healthy. Morbid changes
are recorded in thirty-five cases : Tlie organ was congested in four, 4, 8, 53 and 99 ; large and congested in three, 3, 13
and 27: large and soft in six, 9, 59, 62, 63, 73 and 97, with an abscess in the last-mentioned case. Enlargement is the
only change recorded in the nine cases .35, 38, 41, 43, 45, 60, 68, 70 and 104; softening in two, 75 and 78. The spleen
was large and firm in three, 28, 61 and 85 ; large, light-colored and friable iu 55 and large, dark-colored and friable in
57. It was anieiiiic in 74 and small iu the five cases 7, 46, 56, 72 and 77, light-colored iu the first mentioned, hard in
the last and dark and tough in 56.
The kidneys were normal in thirty-nine cases, abnormal in twenty-three. They were enlarged iu 4 and 39;
ecchymosed in 28 and 100, each kidney weighing ten or eleven ounces ; fiitty in 29, 47, 69, 79 and 85 ; soft or flaccid
in .56 and 97, and congested in 37, 53-55, 57-59, 62, 64, 91, 92 and 104.
The SUPRARENAL CAPSULES were reported normal in 57 and 61, enlarged and firm in 54, reddened in 58; the
riglit capsule in .56 was distended with a bloody granular liquid.
The urinary bladder was reported abnormal iu two cases only, 45 and 28, — in the former inflamed, discolored
and distended with decomposing urine, and in the latter ecchymosed; it was empty in 35 and distended in 38, 69, 72,
75 and 98. The urine was reported albuminous in 29, 55, 58, 91, 92 and 99, healthy in 54 and not albuminous in 56.
The pancreas is said to have been normal in 15, 54, 61 and 63, pale in 28, reddened in 56, 57 and 90, congested
in 55, friable and light-colored iu 58, and large, congested and containing a calcareous deposit in 62.
The PERITONEUM was ecchymosed in 28 and 100 and inflamed iu 31 and 41; the omeutum was congested in 71
and 105 and the serous sac contained some effusion in 40 and 46.
The mesenteric glands were enlarged iu 36, 37, 45, 46, 57, 69, 71, 97 and 104, and in two of these, 57 and 71,
they were dark-colored.
THK PAROXYSMAL AND CONTINUED FEVERS. 601
Thf lii.oop, besides baving lieen diirk and fluid iu the heart-cavities in 4, 9, 35, 38, 68 and (iO, was said to liave
been fluid {jenerally in 54, 55, 56, 58, 90, HI. 92, 99, 100 and 105. It was dark, thin or fluid in lour of the twenty rapid
cases, 4, 19, 92 and fii>: in seven of the thirty-two cases of medium duration. 9, 38, 54, .")5. 90, 100 and 105: iu two, 35 and
."i8,of the twenty-eight protracted cases, and in three of lliose in which the clinical record was insutlicient to identify
the disease, 56, 68 and 69. A similar condition was noted in seven of the twenty-nine spotted cases, 9, 58, 90, 92, 99,
100 and 105, and iu cases 4, 35, 38, 54, 55 and 91 of the fifty-one unspotted cases.
Pathology. — The disease under consideration was sometimes spoken of as spotted fever
and sometimes as epidemic cerebrospinal meningitis; but neither title was applicable to all
the cases that were aggregated under it. Some were free from maculse and others, whether
maculated or not, presented no evidence of inflammation of the membranes of the brain and
spinal cord. Of course, if the inflammatory products that were found in the subarachnoid
spaces of a majority of the cases be assumed to have been characteristic of the disease, all
cases f;\iling to present tliese appearances must be referred to congestive malarial fever, ful-
minant typhus, typhoid or other pernicious febrile cause, no matter how closely in their clin-
ical aspects and etiological associations they may have resembled the accepted cases of
so-called cerebro-spinal meningitis.* But there was no warrant for setting up an anatomical
standard of this kind. Cases must be considered as thev occurred, whether agreeing or
failing to agree with preconceptions and arbitrary assumptions. Case 1-4 was as truly one
of the disease then prevalent at New Berne, N. C, as any of the twenty-six other recorded
cases; and yet there were no inflammatory products under the arachnoid^ although such
products were found in conueotion with the serous envelope of the heart. This case alone
demonstrates that the disease was certainly not in its essence a cerebro-spinal meningitis nor
even in all cases a cerebro-spinal fever. So also cases 28 and 100, in which the dark-colored
and fluid blood escaped from the vessels, forming ecchymosed patches on the cutaneous,
mucous and serous surfaces, must be regarded as true cases of spotted fever, although there
was no evidence of the presence of cerebro-spinal meningitis. Some of the cases at Galloupe's
Island were of a similar character, as Ko. 11 of Dr. Page's record,f in which the cutaneous
blotches sloughed; and although in this case there was no opisthotonos or cerebral dis-
turbance, its connection with a true cerebro-spinal meningitis is proved by case 61, from tliat
station, which terminated fatall}^ at the National hospital, Baltimore, Md. Dr. Crosby's
cases at Concord, N. H., were also specimens of the disease now under consideration, although
his fifth case presented no post-mortem evidence of an inflammation of the cerebro-spinal
membranes.
Two of the writers who have discussed the spotted-fever cases of the war concluded
that their essential was an inflammation of the membranes of the brain and spinal cord.|
(}i course, in the army as in civil life, there no doubt occurred cases of idiopatliic cerebro-
spinal meningitis; cases unconnected with any primary blood-disorder, — in fact, Bartholow
regarded 32 and 78, already submitted, as of this character; but Jones and Hunt have
thrown the whole of the spotted-fever cases into the idiopathic phlegmasise. They con-
sidered that the post-mortem examination of a typical case, that of Private Goosby, 3d
Georgia militia, § did not develop a single fact to justify the classification of this disease with
the pyrexiae. Both regarded the disorganization of the blood as a secondary result of derange-
* Tlius, SaXFORd B. Hes'T, page 39$ of the Medical itfirmoirs, U. S. Sanitart/ Ccmimtsnon, says of tbe case given mpra as case 4, that posl-mi>rtem exam-
ination n-vt-aled no evidence of cerebro-spinal meningitis ; and since he regarded the disease Itnown as spotted fever, typhus synco|tali8, etc., as a common
phlegnituta of llie cerebro-spinal membranes, thi.t case was therefore to him not a case of tlie disease wliich prevailed at the time of its occurrence at
New Berne.
t See mpra, page 583.
JSee Jones's SletUcal etid Siirgu-al .Vemoin*. pp. 411 ft v*f., also Cnvhro-npinal MetiiinjHi:', by SA\roRn It. HtNT, r. S. Son. Com. Memoir*.
I See mpra, page 5VtO.
Med. Hist., Pt. Ill— 76
602 DISEASE? AT.LIKD TO OR ASSOCIATED WITH
ment of the circulation and respiration induced by tlie disturbance and j^erversion of the
cerebro-spinal functions, — and the discoloration of the skin was referred to irregular capillary
action and congestion dependent on deranged nervous action and circulation.
It is unnecessary, perhaps, to point out to those who have examined the submitted
cases, that the disorganization of the blood was not proportioned to the continuance of the
inflammation or the amoimt of the inflammatory products, but rather to the rapidity of the
progress of the cases; and that in several instances in which the presence of inflammation
was not satisfactorily established the blood was as fluid and as dark as in those that, having
persisted for a longer time, exhibited well-defined evidences of inflammation. It is equally
manifest that the purpuric spots were not dependent on deranged nervous action, for they
sometimes appeared during the initial chill and before symptoms of an inflammation of
the membranes were recognized. They were more profuse, as a rule, in the rapid cases
than in those of slower progress, although the latter presented a greater accumulation of
the products of inflammation on the cerebro-spinal surfaces to derange the nervous system.
Indeed, an investigation of the cases that have been submitted demonstrates that the danger
was proportioned to the deterioration of the blood as shown by the presence of purpuric
spots, for of twenty rapidly fatal cases one-half were maculated ; of thirty-two cases fatal in
from three to ten days three-eighths were maculated; of twenty-eight protracted fatal cases
one-fourth were maculated, and of seven cases that did not terminate fatally two only were
spotted. Moreover, while the spots in the rapid cases presented frequently the characters of
ecchymotic blotches coalescing and covering the whole of the surface of the body, in the pro-
tracted cases they were more often minute and sparsely scattered over some particular region.
But if these spots were due to disordered capillary action resulting from meningeal inflam-
mation they should be found in inflammationsof traumatic origin. The symptomsof traumatic
spinal meningitis are pain and tenderness in the affected part, often extending into the extremi-
ties, pyrexia, restlessness, cutaneous hypersesthesia and paralytic tendencies; the posterior,
cervical and dorsal muscles become rigid and the patient's head is curved backward; when
the cerebral membranes are involved intense headache, restlessness and delirium are followed
by coma and death, although occasionally death may be the result of the sevei'ity of the tetanic
spasms. The anatomical conditions associated with tliese symptoms are identical with those
found in the inajority of the spotted-fever cases, — plastic lymph on -the surface of the brain and
spinal cord, with accumulations of pyoid serum in tlie subarachnoid spaces. The identity of
the symptoms in idiopatliic and traumatic meningitis indicates that their inflammatory pro-
ducts exert a similar influence on the economy; but as the products of traumatic origin are
not associated with ecchymotic blotches, tjie maculge in the idiopathic cases must be due to
some other cause than the inflammatory derangement of the nervous system.
On the other hand, where the blood is in a degenerated condition, whether slowly pro-
duced by defective alimentation, as in scurvy, more rapidly by the primary influence of a
blood-poison, abetted by the retention of the products of febrile waste, as in typhoid, typho-
malarial and continued malarial fevers, or immediately by the pernicious influence of a
virulent miasm, as in congestive malarial fevers and some cases of typhus, these ecchymoses
appear not only on the cutaneous surface but on the mucous and serous surfaces.
The cases submitted in this chapter must therefore be regarded as due to a powerful
fever-cause acting primarily on the blood* like those of typhoid, typhus, the malarial and
* A committee of the .\mericau Medical A.ssociation reported ou this point as follows: **In every case the blood was fluid, even when death took place
iu four hours was this the case. A specimen of blood taken from a spotted-fever patient aud examined by the committee presented the following appear
THK PAROXYSMAL AND CONTINUED FEVKRS. 603
eruptive fevers, producing pur|>uric or eochymosecl spots as these do, and like them having
a tendency to the development of internal congestions and inflammations. The ecchymoses
which suggested its popular title of spotted fever are certainly not peculiar to it; and the
determination to the membranes of the brain and spinal cord, which obtained for it the name
of epidemic cerebro-spinal meningitis, is often associated with congestive and inflammatory
actions in other organs, and is sometimes absent, as in case 14 and others already instanced.*
In fact this fever-cause acts on the economy like other specific febrile causes; and as it
is apparently always associated with one or other of them in the community, and sometimes
even in the individual, their relations are intimate.
Occurring as a complication in the progress of well-developed measles, as in cases 87
and 39, the disease would present no difficulty clinically in its recognition; but if the impli-
cation cf the cerebro-spinal system took place prior to the manifestation of the characteristic
symptoms of the specific eruptive fever it would be extremely difficult, indeed impossible,
to discriminate between the fever and the complication. Tn other words, the deterioration of
the blood produced by the virus of the eruptive fever would originate a ease of cerebro-spinal
fever with inflammatory lesions, ecchymoses and death before the real nature of the morbific
cause was declared. In individual cases of the eruptive fevers the symptoms and poat-
mortem lesions of cerebro-spinal meningitis apparently originate in the deteriorated condition
of the blood produced by the cause of the primary fever. There is at least no necessity for
calling in the aid of a special cause to account for phenomena which are sufficiently explained
by causes known to be already present. It becomes a question, tiierefore, whether in epi-
demics of the eruptive fevers the prevailing miasm may not develop cases not only indis-
tinguishable from but identical with those assumed to be caused by the specific miasm of an
epidemic cerebro-spinal meningitis.
The poison of typhus fever affects the blood in tlie first instance, and in consequence of
its deterioration a perversion of nutrition and general disorder of the functions are developed,
too;ether with a further degeneration of tin- blood bv the accumulation of tissue-waste. The
alimentary mucous membrane, the puhnunary tissue and bronchial lining are the sites of
extravasation and other hypernemic processes; the spleen and kidneys are engorged, the
liver altered, the skin maculated. All these organs are usually more or less affected, but
sometimes the diseased action is greater in one organ than in another, and some epidemics are
characterized by the special implication of a particular organ. The brain and its mem-
branes are seldom affected, notwithstanding the severity of the cerebral symptoms which are
attributed to the circulation of a degenerated blood; nevertheless cases do occur in which
there is a true meningitis, and these are more common in some ej)idemics than in others.
Xor must it be forgotten that prior to the separation of this cerebro-spinal fever from typhus
at Geneva in 1805, epidemics of typhus with cerebro-spinal complications were not infre-
quent. The history of many of these has been investigated, and they are now cited by most
writers as epidemics of cerebro-spinal meningitis. But some medical observers do not concur
anc*^: Tbe rtM corpUfsi'le!* wtre slirivelled, creiiated, not in roulpaiix, mid iniiiieroiirt white coi-puscles were iioticeJ in the lield. * * It will be remerii-
lieretl that the ouly fviix/mtf |KithiilugicuIcoiiditiuii \» uri uttered state ut' the blood, — one in which it fails tu coagulate after death uiid in which thecorpumlei*
have uudergune certain marked physical cliaiigi>ri indiaitive of a dimiiiislied vitality." — Tranmct'ums, 18Gt;, p. 329.
* III the report of the discilSi^ion on Spotted Fever at the New York Academy of Medicine, April 20, 1864, in the American Medical Tom^x, Vol. VIII,
p. 237, Dr. Clakk is repre^-nled as stating that iu some cases the hniin and spinal ctird were involved in the inllanimation, and no far the term cerebro-
spinal meningitis yax* correct enough ; but in other caj<e8 Mie inllaniination was limited to the bruin, while in still other caries the brain and curdes<'aped
altogether and the inflammation spent xU force upon the p«Ticardinui, the pleura* and even upon the lungs. That being the Ciuie the disease, iu hia
opinion, wa--< due to a cundiliou of the sy.si.-m in which there is a tendiii. y to inflammation, which iuflammatiOD might show itself iu one or auotber
part of the body de|>«-ndeiii ii|«)n cin uni i.iiu .-^ whii b we cauuot as yel appreciate.
604 DISEASES ALLIED TO OR ASSOCIATED "WITH
in the propriety of separating this disease from typhus. Boudin endeavored to prove their
identity.* Muechison, after reviewing tlieir points of similarity and difference, concluded
tliat before attempting to establish a new specific disease it was necessary to keep in view
the many modifications which those already known to us may undergo, and more particu-
larly to study their etiological relations and the circumstances under which they arise and
are propagated. f Buchanan considered that in some at least of the epidemics of cerebro-
spinal fever the primary fever was akin to typhus, if not actually identical with it.J In this
country several observers and writers have held similar views: Upham considered the dis-
ease to partake of the nature of typhus in a severe and malignant form; Webber§ and
Baltzell|| concluded that epidemic cerebro-spinal meningitis is only epidemic typhus wherein
from some cause the cerebro-spinal system is the principal seat of attack. D. W. Draper
argued in like manner: The causes from which cerebro-spinal meningitis originates are sim-
ilar to those of typhus; the symptoms are many of them identical and all of them referable
to the same essential dyscrasia, and the lesions, though presenting some striking peculiari-
ties, have all of them been described as belonging to typhus.^
The symptoms of typhus are usually slow in their developiment as compared with those
of cerebro-spinal fever. Delirium in typhus does not occur until the end of the first or the
beginning of the second week. It is due to the influence of the deteriorated and progres-
sively deteriorating blood, and appears to be indejDendent of the passive congestions of the
meningeal vessels and the subarachnoidal serum which are often present. On the other
hand, in cerebro-spinal fever the delirium is frequently developed in a few hours, and is due
in niost cases to the inflammatory processes in the pia mater. The eruption of typhus
appears on the third or fourth day of the disease; the spots of cerebro-spinal fever oftentimes
in as many hours. But if the influence exercised by the typhous miasm is more than
usually virulent, constituting that variety of the disease called typhus.sicfcra?is, the symptoms
may be intensified and the fever reach its fatal ending in a few days or even hours from the
beginning of the attack. Case 388 of the post-mortem records of the continued fevers pre-
sents the appearances observed in a colored soldier said to have died of typhus, — the brain
and its membranes were coated with purulent matter as in cerebro-spinal meningitis. In
such cases, especially when accompanied with opisthotonos, it may be impossible to discrimi-
nate clinically between the two diseases, and it may be equally impossible to decide after
post-mortem observation ; for if meningeal inflammation be present it may be regarded either
as a result of the cerebro-spinal febrile cause or as a meningeal complication of typhus, while,
if the inflammation be not present, the disease will probably be regarded as typhus; but a
doubt will remain on account of the possibility of death in cerebro-spinal fever before the
development of the local lesion.
Thus in typhus, as in the eruptive fevers, the individual case may be complicated by
cerebro-spinal symptoms and lesions which may consistently be referred to the primary dis-
order of the blood, while in its epidemic prevalence occasional cases of cerebro-spinal men-
ingitis may appear to raise the question whether a cerebro-spinal fever, originating under
conditions which in other instances give origin to typhus, should be regarded as a manifesta-
tion of the typhus miasm, wdiich is arapl}' sufficient to explain its peculiarities, or as a disease
due to a miasm distinct from that of typhus and all other febrile diseases.
* HiMoire dti Tifphis C^r^o-spinal otc de la maladie impropretiieitt appeUe Mtningite CHr^ro-sphuile I^idemique, par J.-Ch.-M. BouuiN, Paris, 1854.
f On the Cerebrospinal Sijmplorm ami Lesions of Typhus.— Lancet, 1865, p. 418. J Tijphm Ferer, in Bei/notd's System of Medicine, Vol. I, p. 56U.
g rerebro-iqniial Meimiiiil!s.—'Roy\sUm Prize Essay, 1860, Boston, Ma.*i., 18C5. || Amer. Jour. Medical Sciences, Oct61)er, 1SC4.
f See bis paper in the Bidletiu of the New York Academy of Medicine, Vol. II, page 245 et set/.
THE PAROXYSMAL AND CONTINUED FEVERS. 605
Similarly the supervention of cerebro-spinal symptoms, duo tu iuHammatory chaiigts in
the pia mater, is regarded as an uncommon result of the typhoid fever-poison. The history
of medical progress in tlie study of fever is responsible for this belief. At the beginnimr of
the ]>resent century typhus, tyjthoid and cerebro-spinal fevers were confounded. The cerebro-
spinal cases were first separated from the others; afterwards typhoid was distinguished from
typhus fever. Since typhoid fever has attained recognition as a distinct disease, cerebro-
spinal cases occurring during its epidemics liave been considered only in other connections.
Nevertheless a few cases of true meningitis supervening on typhoid fever suffice to show
the intimate relationship of the two diseases. Ordinarily delirium is slowly developed in
typlioid, and is due to the gradual deterioration of the blood by the accumulation of the
])rodacts of metabolic change; but in fulminant cases, where death occurs in a few days,
delirium and coma are early s^'mptoms due to the primarv influence of the miasm in the
blood. Ecchymotic blotches or petechise are infrequent, but they do appear in certain
virulent cases, which, if speedily fatal, may present the patches of Peyer conspicuous, con-
gested, black-pointed or tumefied but not ulcerated. Of the few cases of apparently pure
typhoid fever, submitted in a previous chapter, in which the brain and its membranes were
tound to have been affected, there was congestion with rdore or less eflusion of serum into
the ventricles and subarachnoid space;* but these cases were selected as presenting no anoma-
lies suggestive of a modification by any complicating influence. In the classical cases of
Ch. a. Louis, congestion of the cerebral membranes, with effusion of serum, was a frequent
observation, but rarely was the serum turbid from flocculi ; some opacity of the arachnoid,
which a])parently antedated the tj'phoid attack, was found in four cases, and in two cases
albuminous particles adhered to the visceral or parietal layer of this membrane.f These
cases also were selected to illustrate the ordinary course, progress and lesions of the newly
discovered typhoid affection. Among i\\c ■post-mortevi records of the continued fevers already
submitted are to be found two cases, 80 and 257, in which lymph was deposited on the
surface of the brain. In the former, which was regarded as a case of typho-malarial
fever, no cerebral symptoms were noted, liut the hemispheres were coated with coagulable
lymph, the ventricles contained turbid serum and the intestinal mucous membrane was exten-
sively diseased. In the latter, regarded as a case of typhoid fever characterized by delirium
and coma, the base of the brain was coated with a thin layer of lymph, the ventricular liquid
was turbid and, although the whole of the intestinal mucous membrane was congested, the
Jigminated and solitary glands were unaffected. Both of these cases, from the post-mortem
stand-point, might have been regarded as cerebro-spinal fever. Again, if the cases reported
as cerebro-spinal or spotted fever be examined it will be found that in some the disease
apparently supervened on or was coincident with a typhoid attack and while typhoid fever
was prevalent in the locality. When the fever ran a regular typhoid course, as in case 15
of the series presented in this chapter, the cerebro-spinal inflammation must be regarded,
like pneumonia under similar circumstances, as a complication or secondary result produced
by the perversion of nutrition consequent on the circulation of a vitiated blood. But in ful-
minant cases speedily fatal by coma after aggravated cerebral symptoms and convulsive
seizures, the diagnosis becomes obscure and the uncertainty may not be dissipated even by
a view of the post-mortem lesions, for the absence of typlioid ulceration of the patches of
Peyer is, in such violent cases, no evidence of the absence of the typhoid miasm, and the
*S*e analysis, sijpro, page 431. fSee his Recberchf*, etc., t. I, Parii?, 1829, page 373, — also anpra, ipuge -131.
606 DISEASES ALLIED TO OK. ASSOCIATED WITH
absence of lymph or pu.s in the nervous centres might be considered as no evidence of the
absence of the virulent cerebro-sjiinal miasm, while the presence of these inflammatory pro-
ducts might be regarded either as a secondary result of the typhoid influence or the immediate
consequence of a speciiil cerebro-spinal febrile cause. Again the question arises, as in similar
cases occurring in epidemics of typhus and the eruptive fevers; and again the reply is sug-
gested, that it is as unnecessary to assume the existence of a special miasm acting on the
cerebro-sj)inal system as to assume the existence of one acting under similar circuinstances
on the pulmonary tissue; since, in the individual, cerebro-spinal symptoms and lesions may
be referred for causation to the typhoid poison, cerebro-spinal cases occurring in tvphoid
epidemics may likewise be so referred.
But the cases tliat have been submitted from the medical records of the war appear to
connect cerebro-spinal fever more extensively, if not more closely, with malarial diseases than
with typhus, typhoid or the eruptive fevers. Congestive intermittents leave the blood fluid,
the shin maculated and the interior organs congested and ecchymosed after death b}' coma,
sometimes associated with convulsions. Jackson's cases of so-called spotted fever* were dis-
tinctly congestive. Their recovery under specific treatment demonstrated their malarial
character. In the fatal cases the membranes of the brain showed no trace of inflammation,
only passing engorgement. So long as the vessels of the pia mater remained in this congested
condition a complete and sjjeedy recovery was possible by appropriate treatment. Even if
the congested vessels became relieved by ef?"usion of serum into the subarachnoid space and
ventricles, a speedy return to health was equally possible. Sometimes the lungs, the kidneys
or the intestinal lining were the site of the congestion and, as in the case of the cerebral
membranes, recovery was readily effected if the congestion was j^assive and did not terminate
in inHammatory exudation. The hypersemic processes are continuous one with the other;
the boundary line between them can be discovered only with the microscope ; yet the passage
of this line was generally of vital importance to the patient, as its consequences were the
establishment of a pneumonia, a nephritis, a dysentery or a cei'ebro-spinal meningitis, accord-
ing to the locality of the hypercemic tissues. Dr. Jackson did not observe any case pass
beyond the stage of congestion; but some of Merritt's cases of pernicious fever"]" at Beau-
fort, S. C, in May, 1863, presented symptoms of spinal meningitis. Kneeland recognized
at New Berne, N. C, the occurrence at the same time and place of congestive malarial cases
and cerebro-spinal febrile cases, and considered them due to different causes of the same generic
nature. But it seems wholly unnecessary to call in another cause when influences already
recognized as in operation suffice to explain the phenomena.
Undoubtedly the clinical differences between congestion of the brain from malarial poison
and cerebro-spinal meningitis are very great. Recovery is effected under proper treatment
as if by magic in the one instance, while in the other the result, notwithstanding all treatment,
is death or a ^jrotracted illness, differing wholly from the usual course of malarial congestion
and too often disabling the patient by a permanent impairment of sight, hearing and muscular
power. Quinine is an efficient remedy in the one instance and is valueless in the other.
These important dissimilarities, seeming to indicate a radical difference in the cause, have
obscured the fact that anatomically the difference between the two conditions is small and
pathologically even smaller. The prevalence in a malarious locality of the congestive and
inflammatory forms of a spotted fever, in which the cerebro-spinal membranes are imjjlicated,
* See sujirii, pages 128 aud HI. f See supra, page 142.
THE PAROXYSMAL AND CONTINUED FEVERS. 607
forms a strong argument in favor of a similar origin for botli, and as the malarial poison has
been identified with the causation of the one it may well be regarded as the essential of the
other. The impotence of quinine as a remedial agent in cases of cerebro-spinal fever does
not antagonize the theory of its malarial origin. When malarial congestion of the intestinal
mucous membrane has been followed by the ulcerations of dysentery, or when pulmonary
congestion of similar origin has developed into pneumonia, the secondary inflammatory result
is uninfluenced by the specific for the primary disease; so when congestion of the cerebro-
fcpinal membranes is followed by the extrusion of the products of the secondary inflamma-
tion relief may not be expected from quinine. But if the disease had in these instances been
due to malaria, quinine ought to have proved in some measure prophylac'tic. Unfortunately
there is no evidence on this point. The attention of our medical officers does not appear to
have been directed to it. Dr. Kneeland was apparently the only officer who tried (o protect
his men in this manner. His experience, so far as it goes, is interesting. Only four cases
occurred in his regiment after the death of the first case led him to use quinine as a pre-
ventive. Not all of the men were so protected, but only those ordered on dutv necessitating
exposure during the night; meanwhile the two neighboring regiments continued to furnish
cases for the New Berne hospitals.
It has already been shown that in continufd malarial fever congestion of the membranes
of the brain with efi"usion was a common fost-mortevi observation; in case 287 of the post-
mortem records of the continued fevers there weie in addition ecchymoses of the surface of
the cerebrum and on the floor of the fourth ventricle; but in 80 and 257 distinct evidences
of inflammation were presented. In the first of these cases the patches of Peyer were promi-
nent and speckled with blood; in the second the ileum was gangrenous; in the last the
agminated glands were reported as normal.
Similar conditions of congestion of the brain and its membranes were found in the typho-
malarial and mixed or uncertain cases; but in 111 the examination revealed thickening and
opacity of the arachnoid over the interpeduncular space; in 379 exudation on the arachnoid,
engorgement of the brain-substance and distention of the ventricles with blood-stained serum,
and in 303 injection of the membranes, turbid effusion in the ventricles and extruded lymph
at the base of the brain. In the first of these the jmtches of Peyer were enlarged ; in the
second their condition was not stated; in the last ulcerated.
Some of these cases indicate the existence of cerebro-spinal lesions complicating con-
tinued malarial and typho-malarial fevers, and since these lesions may occur in the individual
case as a result of the malarial poison, there is every reason for referring to the same poison
those cerebro-spinal cases or spotted cases without cerebro-spinal symptoms that occurred in
localities wliere malarial fevers were prevailing. It may be objected, however, that the
season of prevalence of epidemic cerebro-spinal meningitis was not that of the malarial fevers.
The former was distinctly a winter phenomenon. None of the 105 cases submitted occurred
in the month of May, 3 in June, 2 each in July and August, 1 in September and 2 in Octo-
berC Cases were rare in the months when the malarial tide was higli, but on its subsidence
they became more numerous, — in November 3, in December 8, in January 31, in February
25, in March 18 and in April 10. No reliance can be placed on these figures as indicating
monthly prevalence, but they may be accepted as sustaining the statement of many of our
officers that spotted fever was seen cliiefly during the colder months of the year. But thi-
argument would exclude hemorrhagic malarial fever from the list of malarial diseases, an .
608 DISEASES ALLIED TO OR ASSOCIATED WITH
also the many cases of undoubted congestive chills that occurred, as in Jackson's command,
during the winter months. It may be, as already suggested in treating of malarial hsema-
turia, that in these virulent cases the malarial miasm effected an entrance into the system
in a concentrated state by means of the water-supply.
Lastlv, the occurrence of cerebro-spinal or spotted fever may be referred to the fulmi-
nant operation of that miasm which produced pneumonia under ordinary conditions. Viewing
pneumonia as a specific constitutional disease, with a local lesion in the lungs,* it becomes
connected causatively with cerebro-spinal meningitis by the arguments that have served to
effect a similar connection between typhoid fever and the cerebral manifestations. This
connection will be found to be no mere theoretical idea, for in the instances in which the
medical records of the war show an epidemic prevalence of pneumonia with a corresponding
intensity of the febrile poison, the so-called cerebro-spinal meningitis was present at the
same time. Surgeon Ira Russell, who reported fifty cases of cerebro-spinal fever among
the colored troops at Benton Barracks, Mo., in January and February, ISG-i.f reported also
the great prevalence and fatality of pneumonia, 784 cases, of which 156 proved fatal, having
been received into hospital during the four months, January 1 to April 30. J In another
instance tlie report of Surgeon D. Porte Smythe, 19th Texas Inf.,§ shows that the epidemic
pneumonia which affected his regiment and others of the same division gave him in one
month, in a strength of 900 men, 200 cases of pneumonia, ten per cent, of which were of cere-
bral or erysipelatous types. The cerebral cases, which were at first regarded as meningitis,
were characterized by rigors and headache; there was little pulmonary disturbance, but death
ensued in from twelve to twenty-four hours with convulsions and delirium. ||
From the constant change in the blood, the frequent ecchymotic blotches and the occur-
rence of cases unattended by cerebro-spinal inflammation, it is evident that in the disease
under consideration there was more than a cerebro-spinal meningitis due to those general
atmospheric conditions, such as cold, exposure and bad ventilation, that provoke the com-
mon phlegmasise of fibrous and serous membranes. A febrile poison must be assumed in its
causation. The natural history of this febrile cause is extremely obscure, or as Chauffaed
expresses it, the etiology of the disease is envelopie d ombres impen^trables.^ This is chiefly
owing to the apparently contradictory observations that have been made and recorded. But
if the causation be referred to the occasional operation of any of the miasmatic influences
which destroy the integrity of the blood and develop hypersemic conditions of the various
organs these contradictory observations become reconciled.
The cause, for instance, judging from the intensity of the disease in the individual case,
is one of great virulence; but in its operation on the community this virulence is not corre-
spondingly evidenced. The cases of an epidemic are comparatively few and scattered, and
there is no explanation of the protection of the many analagous to that which holds good in
other febrile diseases, as scarlet fever or measles; but if they be regarded as the cerebro-
spinal or spotted manifestations of a prevailing febrile cause, the virulent scattered cases
become bound together by others of less malignancy.**
* See infra, page 804. f See nipra. page 586. t See infra, page 758. ? lo/ra, page 758.
I JuEKGENSEN refers to the frequency of the association of an epidemic meningitis with pneumonia, and cites Immermann and Hellee as baTJng
recently called the attention of physicians to this point. Out of thirty autopsies in cases of pneumonia they found nine in which meningitis was also
present. It was ascertained beyond question that an epidemic of cerebro-spinal meningitis was prevailing at the same time. — Zientssen' t Cydopfdpi,
American Ed., Vol. V, p. 115. ^ Quoted by Ziehssen.
•* The Committee "On Spotted Fever, 80.caned," in its report to the American Medical Association, drew attention to this, — see page 337 of the
Transactions, 1866: "When the attention of the profession in Philadelphia was called to the existence of spotted fever there was prevailing in that city
ft severe and wide-spread epidemic of influenza or epidemic catarrhal fever. » * « Several medical men in active practice were at once struck with the
THK PAROXYSMAL ANI> COXTIKUED FKVERS. 609
On this view the different statements with regard to the climatic and other conditions
associated with its epidemics may also be understood. Dr. Upham continued his study of
the disease after tlie war and furnished an able report to the Massachusetts Board of Health
on the epidemic of 1873, based upon communications from two hundred physicians trans-
mitting the facts in five liundred and seventeen cases.* From these he found that all ao;es,
occupations and nationalities were susceptible of the disease. The cases were distributed
among all classes and grades of society, — "the high and the low, the rich and the poor, loca-
tions unexceptionable for situation, open to abundant light and air, and the pont-up hovels
of the lowly and wretched have all contributed to the material of the epidemic." STiLLi^f
savs that localities of every sort, high and low, dry and moist, those saturated with marsh
miasmata and those favored by the pure breezes of mountain districts have been alike
invaded; the disease has passed by large cities reeking with the corruptions of a soil satu-
rated with ordure and a population grimed with filth to devastate clean and airy villages and
the families of substantial farmers inhabiting isolated spots. Its greater prevalence in the
winter months appears to be one of the few features which remain unaltered in the investi-
gation of many epidemics; but even this is unconnected with low temperature, for while
Yagee represents the beginning of the Chillicothe epidemic as having coincided with a snow-
storm following dense fogs and chilly east winds, Wape reports the outbreak at Kew Berne
as having been preceded by a period of drv warm weather. In the former instance measles
prevailed;, in the latter typhoid fever and malarial diseases.
In many cases the disease occurred suddenly and unexpectedly in the strongest and
apparently the soundest men of the command; but in this it did not differ from congestive
malarial fever. In the greater number, however, the sufferers were broken down by con-
tinued hardshij5s, fatigues and exposures. This was specially noted by Russell in his
account of the epidemic among the escaped and emancipated slaves. The disease frequently
selected its victims from the guard-house or prisons, and the inmates of these before their
commitment had usually undergone inanv liardships, among which may be particularly noted
exposures at night in malarious localities, with insufficient food, shelter and clothing. Even
after their commitment they were often insufficiently provided with clothing and blankets.
A large number of victims was also drawn from detachments of recruits who had frequently
to endure unnecessary suffering on account of their ignorance and that of their officers, while
they were at the same time peculiarly liable to those scourges of new regiments, typhoid
fever and measles. Overcrowding is frequently referred to as a probable cause ; but it seems
that this oj^erated as a predisposing cause of cerebro-spinal fever only when the diseases just
mentioned were present and aggravated by deficient air-space and defective ventilation. In
the presence of other and essential elements of causation, overcrowding no doubt exercised
a pernicious influence, but of itself it was as incompetent to explain the jsresence of cerebro-
spinal fever as to account for the large death-rate among Confederate prisoners, when their
Union guard, who were similarly crowded, had a comjjaratively small rate.J
rosomblanc'^ of many of the symptoms of the two discnscs, and wore led to inqniro if influcn/.a might not I»p but a mild manifestation of that epidemic
inrtuenoe which in its intensity prfwinced spotted fever. Xor, it will he seen, were their symptoms very dissimilar siive in degree. • • » The Com-
mittee do not propose to reoi»en this subject more than to call the attention of the .\ssociation to the interesting fact of the almost uniform coincident
prevalence of spotted and of catarrhal fevers."
• .\lthough the year 1873 was considered an epidemic year it does not follow that the di^ase was alwcnt in other year^. During the ten yeare,
1873-82, 2,053 deaths occurT«<l in Massachusetts from cerebro.spinal meningitis. Of these 747 occurred in 1873 and an average of 130 in each of the nine
other years.
\Epiilemk .Vniiiiyi/i..— .\LrBr.n StillS, Philadelphia, Pa., 18C7, p. 95.
I See «*j>r.i, page l».
Mei.. Hi.st.. Ft. Ill— 77
610 DISEASES ALLIED TO OK ASSOCIATED WITH
Dr. Gaillaed, in an article on the disease in the civil population, noted what he con-
sidered a remarkable feature of its prevalence in the Southern States. Contrary to its
recorded history elsewhere, as many adults as cliildren were the subjects of its attack.* The
greater prevalence of malarial disease, affecting young and old alike in the South, would
account for this want of consistency with returns from localities wdiere susceptibility to typhoid
and the eruptive fevers constituted an important factor in the prevalence of cerebro-spinal
fe^■er.
By some observers, especially in Europe, the disease has been regarded as contagious.
A suggestion of contagion appears in the records of the jSFational hospital, Baltimore, Md.,
wliere typhus fever was probably present,f and perhaps in Page's recorded case 13, from
(^alloupe's Island, where measles prevailed extensively in a virulent form, J but in other
instances no mention is made of contagion unless to deny its existence. Waee, in his account
of the disease in the malarious region around I^Tew Berne, states that there was no evidence
of contagiousness, § and it is well known to the writer that the disease did not spread in the
division field hospitals of the Army of the Potomac, although no attempt was made to isolate
the occasional cases that were received from the regimental camps.
In conclusion it is submitted that as the so-called typhoid condition may occur in the
progress of any fever by tlie gradual deterioration of the blood, so the so-called spotted fever
may be the result of any febrile miasm which destroys the integrity of the blood. When
death is not a quickly following consec^uence of this alteration perversions of nutrition are
in order, more actively manifested in some organs than in others, and depending generally,
perhaps always, on local or accidental conditions involving among others climate, exposure,
overwork and the physiological status of the organs as determined by hereditary tendencies,
growth, age and previous disease. The lungs, the pleural, pericardial or synovial membranes,
the liver, spleen or kidneys, the alimentary mucous membrane or the vascular membrane of
the cerebro-spinal system may become the parts chiefly involved, and death is imminent in
proportion to the deterioration of the blood, the activity of the localized hypersemia and the
vital importance of the part aflected. When the brain, lungs or j^ericardium become involved
death may result before those special signs are manifested which permit of a discrimination
between one febrile miasm and another; hence spotted fever ending fatally prior to local
developments or with congestive or inflammatory conditions of these important organs, rnav
be attributed to malarial, typhous, typhoid, eruptive or other tniasm, according as the locality
and other circumstances bearing on the etiology appear to determine. When death is not
so inmiinent the peculiar phenomena attending the cerebro-spinal lesion are so profound as
to veil the true nature, etiologically speaking, of the disease, giving it characters apparently
sui generis, but in no way inconsistent with its original development from the identical cause
that produced a tyj^hoid, typhus or remittent fever in another sufferer.
III.— PREVENTION AND TREATMENT.
Pkeventio^". — If the views that have been submitted on the etiology of the diseased
condition under consideration be admitted, preventive measures may be undertaken with some
hope of diminishing the number of attacks. These measures will embrace those necessary
to the suppression of existing epidemics of febrile disease: Isolation and disinfection in some
instances, and the application of certain hygienic rules to the individual, the command and
* Hkhmond MeiUcal Jounml^ Vul. T, ISGr,, p. 20.5.
t S!-e svjira, riage 570. j Si'jirn, (.age .583. | Siijjra, page 557.
THE PAROXYSMAL AXD CONTINUED FEVEKS. 611
their surroundings in all instances. But these tlo not require special mention in this eonnfi^-
tion, as they properly belong to the specific diseases.
It is 2>robable that in many cases during the war the use of prophylactic doses of (juinine,
as employed by Surgeon Kneelaxd, would have been ot" value, for although cases occurred
when the patients had been taking quinine just before the attack, other miasms than the
malarial were evidently present with the command afiected in these particular instances.
The avoidance of unnecessary causes of exhaustion is an elementarv or essential prin-
ciple in militarv hvgiene sometimes contravened bv commandino; officers ignorant of the
effects of the parades, drills and disciplinary exercises imposed by their orders. In times of
epidemic febrile disease all exhausting work not imperatively required by the military con-
ditions should be particularly avoided, for overfatigue, want of sleep, exposure to the elements,
hunger and overstrain of mind which the private soldier mav underuu at his post on picket
or in the rifle-pit, appear to have been factors of some importance in the determination of
cerebro-spinal complications. Certain hardships, exposures and anxieties are unavoidable.
Picket and guard duties have to be performed in all weathers, during the night as during
the day, and when the men are exhausted after a long march as when they are fresh after
some days of rest in camp. In such cases much may be done to control the evil consequences
of overfatigue and exposure by official inspection to insure that the men be well provided
against possible contingencies and that the exhaustion of hunger be not associated with that
of overfatigue.
Treatment. — The great disorganization of the blood in nuieklv fatal cases, and the
o
rapidity with which inflammatory products were extruded on the surface of the nervous
masses in the majority of cases, alike intimate tlie probable inefficiencv of all plans of treat-
ment; for in both sets of cases a lesion was inflicted which proved fatal without affording the
time needful to effect its reparation.
In most of the recorded cases purgatives by the mouth or rectum were administered.
In the earl)' period of the attack cold was generally applied to the head, cups to the neck
and counter-irritation by mustard to the extremities; later, blistering plaster or mustard was
applied to the scalp, neck and along the spine. But although these remedial measures are
frequently found on the records as part of the treatment it is seldom stated that any benefit
was derived from them. In 83 cold cloths, cupping to eight ounces and purgation bv castor
oil were followed by temporary improvement, and in 87 and 101 some relief was attributed
to cupping, but in 86 and many others no apparent effect was produced.
These measures were usually reinforced by attempts at specific medication. Quinine
was a favorite remedy. In case 1, a recovery from cerebral symptoms and sloughing spots,
ten grains were given every four hours; in 48, also a recovery, the symptoms became
aggravated when quinine was intermitted and were relieved on the resumption of the med-
icine, and in 6 its administration was followed by temporary improvement. But eighty
gi'ains, administered on the first day of the attack in 12, did not prevent a rapidly fatal
course ; ten-grain doses every four hours in 50 and half-drachm doses in 14 were not effica-
cious, nor was the remedy more successful in 4, 13 and 67. Indeed, in case 92 the patient
was taking quinine with apparent success for an intermittent at the time of the cerebro-
spinal onset. In some instances, as 5, 7 and 9, stimulants were used in conjunction with
the quinine. Evidently certain cases were benefited by quinine, although in others its
administration was apparently valueless. Surgeon Ira Russell, U. S. Vols., considered
612 DISEASES ALLIED TO OR ASSOCIATED WITH
tliat the remedy, if given early and liefore the state of collapse came on, in many instances
averted its onset, but whether by exercising a specific influence on the disease or merely
removinif one of its predisposing causes he was unable to determine, as his experience was
confined to cases occurring in a malarious locality.
Calomel was sometimes given as a purgative; generally, however, it was used in small
doses with quinine, as in the favorable case 17 and the slowly fatal case 11, which was at
one time regarded as a recovery. Calomel was given alone in case 32, which I'ecovered.
Ipecacuanha was conjoined with calomel or calomel and cpinine in a number of cases, as in
26, which recovered; in case 2, in which an improvement lasting three weeks terminated
unfavorably and in 18 and 20, in which also an amelioration of the symptoms preceded a
fatal relapse. In 23 salivation took place, but it is doubtful if the favorable issue in this
case should be attributed to the constitutional action of the remedy, for two cases have already
been submitted in which the patient at the time of the attack was under the influence of
mercurials.* Moreover, in 16, 19, 20, 21 and 22 the progress of the disease does not appear
to have been influenced by this treatment. Similarly, in case 3, in which blue-pill was used
instead of calomel, no manifest effect was produced.
In 93 acetate of ammonia, antimonial wine and sweet spirit of nitre were used without
beneficial eff'ect. In 84 small doses of tartar emetic and in 94 two-grain doses of this sub-
stance every two hours for some time were similarly valueless. Veratrum viride, ipecacuanha
and nitrate of potassa were without success in 101. Iodide of potassium was given in case
2 during a temporary remission. Bromide of potassium in fifteen-grain doses every hour
was followed in 105 by subsidence of the tetanic convulsions; small doses of strychnia were
then added to the bromide in this case, which ended fatally. Dr. F. Le Baron Monroe
claimed decided advantages over other remedies for the bisulphite of soda, and stated that
two of his recoveries at Galloupe's Island, cases 12 and 13 of Page's series, were treated
exclusively with this substance ;f but a fatal case of the same series was also treated in this
manner. A warm bath returned the patient temporarily to consciousness in 87. Morphia
is said to have given relief in 28 and 93. Dr. Lidell enunciates the proposition that treat-
ment to be successful must prevent effusion or cause its absorption prior to fatal compression
of the nervous centres, and conceives that in opium freely administered we have a remedy
which will eff'ect this, in view of its power to arrest exudation from serous membranes, as seen
in the treatment of pleurisies and puerperal and traumatic peritonitis. J In protracted cases
stimulants were invariablv eiven.
General bloodletting appears to have been tried in two cases: In 25 the abstraction
of eighteen ounces was followed by decided improvement, which continued for some time
under quinine, but death took place in a relapse; in 24 the renroval of twenty-four and
afterwards of sixteen ounces of black blood had no influence in postponing the fatal issue
and but little in relieving the restless delirium. Regarding tlie disease as primarily a men-
ingitis, Jones recommends bleeding to faintness, cups, purgatives and mercury, with quinine
and opium during the active period; but as his pathological views are manifestly incorrect,
the treatment by general bleeding cannot be accepted unless supported by better results
than have hitherto been brought forward.
*See the case of Corporal Joseph B. Grow and that reported by ^V. S. Armstrong, of Mobile, .\la., siipya, p. 5'J.j.
f Boston Medkal and SimjicnlJoiiriml, Vol. LXXIII, 1S66, p. 253.
. XAinerican Jour. 3Ied. Sciences, Vol. XLIX, 1SG5, p, 17, — Opium, however, was in cormnou use in tlie tre.ttnient oftliis disease as early as the begin-
ning of this century. See SriLtt, On Epiilemic Meiiiiojitis, riiilndeliihia, ISr.T, p. 154.
THE PAROXYSMAL AND CONTINUED FEVERS. 613
Catheterization was frequently required, and in some instances was followed by decided
temporary relief to the restlessness, as if the distended condition of the bladder had been
responsible for a part at least of the distress which was its cause.
Viewing the disease as a manifestation of a disoi'dered condition of the blood produced
by a miasm which may not be the same in all cases, a rational plan of treatment requires in
the first instance the determination of the causative miasm. By this means cases that will
be benefited by the early and free use of quinine may be separated from those in which no
satisfactory results are to be anticipated from its administration. But obviously, even in
malarial cases, no good can be effected by the specific after exudation has taken place. In
the stage of collapse hot applications and other stimulants to the surface, with alcohol and
ammonia internally, appear to be suggested irrespective of the nature of the cause. During
reaction cold to the head, mercurial purges in malarial cases characterized by constipation,
cups to the neck, antimonials or ipecacuanha may be used, with opiates when there is much
pain and restlessness. When the manifestations of cerebro-spinal exudation indicate that the
gravity of the case depends more on the local lesions in progress in the nervous centres than
on the primary condition of the blood, blisters to the back of the head and spine and small
doses of calomel, as generally used by our medical officers, or iodide of potassium in large
doses, may be employed. But meanwhile, if typhoid symptoms supervene, stimulants should
be administered and continued with appropriate nourishment thi'oughout the progress of
protracted cases.*
II.— PNEUMONIC FEVER.
In referring to certain of the pneumonias of our camps and hospitals under this title the
writer departs advisedly from the official nosology which regarded, and still regards, pneu-
monia as a local disease associated with catarrhs and bronchitic affections that are usually
ascribed to atmospheric vicissitudes and exposures. He has less hesitancy in taking this
liberty with the official methods as his investigation into the nature of the continued fevers
has shown that the diseases of which our soldiers died were by no means in all instances
those under which they were reported in the Monthly Report of Sick and Wounded. Indeed,
the connection between cases of pneumonic disease and the fevers, malai'ial or typhoid, of our
camps was so striking that the medical officers in attendance set the example of a departure
from the official nomenclature. The term pneumonia on the blank forms in use did not
seem to give full expression to the diseased conditions present in their cases, and in many
instances they qualified it with the word typhoid. But the clinical resemblance of the dis-
ease in question to typhoid fever forms, as will be shown hereafter,f no part of the argument
wliich led to the adoption of the term pneumonic fever in the present connection.
By this term is, of course, understood a specific constitutional affection with a charac-
teristic and constant lesion in the lungs. In the continued fevers — typhoid, modified typhoid
* Thf Committee on " Spotted Fever, so-c.alled," of the American Medical Association, Vol. XTIII, 2Vaiw, 18CG, p. 341, after reviewing the various
plans of treatment that have In'en usi_'d, recommended, in view of the typhous character of the essential fever, that the same general principles adopted in
the treatment of tv'i'hus fever be applied to this disease. In the first stage the patient should be placetl in a hot bath, It'i-lOC^ Fiih. .\fter this he should
b€ rubbed with coarse towels, or oil of turpentine if thorw is a tendency to coldness of the surface. AMien the bowels are torpid an enema of turpentine
is recommended ; prostration should be treated by alcohol or ammonia, and pain, liyiwripsthesia or jactitation by opium. If opium is not required in
the beginning large doses of quinine may be advantageously given ; but this remedy is valueless and may prove hurtful if given after exudation Ilis taken
pUc«. Cold to the head and spine is advised when cerebro-spinal symptoms are prominent from the, first. Local depletion by cupping is cautiously
recommended in some instances, but the use of the laccet is condemned. Tincture of iron, mineral acids and turpentine may be used if tho stomach
will bear them, but care should be taken not to disturb that viscus. The iodides of potassium and iron are recommended when tho case has beconoe
chronic and presents unequivocal evidences of exudation. The Committee failed to get satisfactory results from blisters al?ng the spine.
t />i/V<i, page Sot.
014 DISEASES ALLIED TO OR ASSOCIATED WITH
and coutinued malarial — conditions usually regarded as results of pneumonic inflaniuiation
were frequently developed toward the close of the scene in fatal cases. The post-mortem
records illustrate this frecjuency by showing that in no less than sixty-eight per cent, of
the whole number of recorded cases there was congestion of the pulmonary tissues, with
more or less solidification from transudation, constituting the conditions indicated by the
terms oedema, splenization, hepatization and, when histolytic changes were in progress, pur-
ulent infiltration, or, as sometimes phrased by cautious observers, puru/o;V7 infiltration. Gen-
erallv, in these cases, the symptoms attending the progress of the complication were obscure.
There was no aggravation of the febrile conditions, and the vital activities were so depressed
that the occlusion of a large portion of the cellular structure of the lungs failed to exercise
a marked effect upon the ebbing life. jSTevertheless local changes, subsec^uently verified at
the post-morte7)i investigation, were susceptible of definition by physical examination. The
blending of different fevers maybe considered at the present time as a well-established path-
ological doctrine;* but it isdiflScultto recognize in these almost passive congestive changes
the supervention of pneumonic fever on pre-existing typlioid or malarial fever, although in
many cases the local lesions were precisely those of a pneumonic fever. Their explanation
must be found rather in the enfeebled condition of the heart and disordered state of the
blood, which together developed the pulmonary stasis, — the starting point of pulmonary
transudation, hepatization and subsequent degenerative changes. In these cases tlie post-
mortem condition of the air-cells as to crepitus, solidification or diflluence depended on the
duration and activitv of the vital processes subsequent to the occurrence of the congestive
stasis. This view, which associates these pulmonary lesions with prostration and a deteri-
orated condition of the blood, is sustained by the frec|uency with which similar pneumonic
changes were found to originate in the closing hours of other febrile and exhausting diseases,
as measles, small-pox, acute diarrhcea and dysentery.
But similar changes took place in the lungs at earlier stages of the continued fevers, con-
stituting what was recognized as intercurrent pneumonia, illustrations of which may be found
in the clinical records of those fevers. In these cases the constitutional disturbance markino;
the invasion of the pulmonary tissue was at times so prominent as to lead to a diagnosis
of pneumonia or typhoid-pneumonia when, as in cases 331-339, 353-360 and 370-372 of
the post-mortem records, the primary disease was a typhoid or continued malarial fever. It
is difficult to say whether in these cases the lung disease was a local congestion with conse-
quent transudation and a symptomatic aggravation of the constitutional disturbance which
was its cause, or the local expression of a pneumonic fever which had seized on tlie typhoid
or malarious patient and blending with the pre-existing fever tended to the more rapid extinc-
tion of life.
The frequency of the occurrence of similar lesions in the advanced stages of the con-
tinued fevers, and the intercurrence of similar attacks in other diseases characterized by a
depraved condition of the blood, suggest that in many of these instances the changes in the
lungs resulted from the action of the typhoid or other febrile poison. Congestions and tume-
factions of the spleen are common in all these fevers in accordance wnth the testimony of
clinical exploration and post-mortem observation; but the anatomical characteristics and
physiological uses of this organ are such that the distention of its vessels is not followed by
dangerous consequences. Similar hyperfemias of the lungs interfere with their physiological
« See ru.vT's Practice of MoUcitte, Phihi., 1SS4, p. ISl.
THE PAROXYSMAL AND CONTIXL'ED FEVEKS. 615
action, and the anatomical cliaracters of the puhnonary tissue permit of transudations wliich
give a greater permanence to the interference. Local hypertemias occurring in the progress
of fevers derive their importance from their locality: In the distensible spleen they are com-
paratively harmless, periiaps of value as protective against similar manifestations in more
important sites; in the non-elastic parotid they lead to necrotic changes; in the intestinal
mucous membrane they are productive of diarrhoeal and dysenteric lesions which, in many
cases, assume diphtheritic charactei's; in the lungs pneumonia is caused; in the nervous sys-
tem their deadly results are those of cerebro-spinal meningitis. It seems probable, therefore,
that in many of the cases under consideration tliere was mereh' a manifestation of the typhoid
or the malarial poison and not the supervention of a new disease.
Nevertheless the occurrence of a pneumonic fever in the person of one suffering from
typhoid or other continued fever must be accepted if the existence of a specific pneumonic
fever be allowed ; for there is nothing in the history of pneumonia or of the continued fevers
to show that the subjects of the latter were less susceptible to the attacks of the former than
healthy men who had been similarly exposed to its causes. Pneumonia was of frequent
occurrence as the only disease aflecting the system at the time. It was characterized by
febrile accession and local changes in the lungs, such as occurred in the progress of typhoid
or other continued fevers. But the special lesions of those fevers were not present; the pul-
monary changes were wholly independent of the typhoid or malarial poisons. In many cases
the spleen was enlarged and various changes were occasionally noted in the other viscera, but
only the pneumonic changes were constant.
Although unaccompanied with typhoid lesions this disease, as will be seen hereafter,* was
frequently associated with typhoid symptoms. Hence the term typhoid-pneumonia which,
unfortunately, became so familiar during the war. The typhoid symptoms, as when occur-
ring in the progress of a continued malarial fever, were apparently tlie result of the febrile
condition in asthenic states of the system, especially in that brought about by the hardships
of field service and overcrowding in quarters. In typhoid-pneumonia there was no typhoid
fever, although in cases of concurrent diarrhoea there was frequently a difficulty during life
in determining the absence of the specific typhoid poison.
The relations of pneumonic fever to the other continued fevers are thus seen to have
been by no means intimate, notwithstanding the apparent testimony of tlie clinical audpost-
moricm phenomena to the contrary. The seemingl}' intimate clinical relations of jDueumonia
to typhoid and the seemingl}- intimate jjost-mortern relations of typhoid and typho-malarial
fevers to the pneumonic disease were the result of similar, not identical, conditions of the
system. Pneumonic fever occurred in those fevers only as an intercurrent and accidental
disease, and with much less frequency Aan would appear from the separate consideration of
either the clinical or pathological phenomena.
III.— DIARRHCEA AND DYSENTERY.
As has been shown in the chapter on the Continued Fevers, diarrhoea or dysentery was
a frequent manifestation of the presence of a febrile miasm. It was due in malarial cases
to hyperaemic conditions of the intestines in which the large intestine and its solitary glands
were generally implicated ; in typhoid cases it was symptomatic of the condition of the patches
of Peyer. although in many instances the mucous membrane of the large intestine and
" /n/ni, \ta^v 767.
616 DISEASES ALLIED TO OR ASSOCIATED WITH
especially of the cteoum was also involved; and in the typho-raalarial or mixed cases it was
due in part to the typhoid ulceration of the ileum and in part to the malarial congestion
and follicular ulceration frequently observed in fatal cases in some part of the intestinal
canal. It is not surprising, therefore, that the symptom should occasionally have been
regarded as the disease, the diagnosis of diarrhoea or dysentery having been recorded when
the morbid lesions in the case were really those of a continued fever. Moreover, as will be
seen directlv, diarrhoea and dysentery were sometimes accompanied by constitutional sj-mp-
toms of an adynamic character, thus tending to the opposite error of regarding these diseases
in some of their instances as cases of continued fever or of paroxysmal fever in which the
remissions were slightly indicated.
But although diarrhoea and dysentery were so often an accompaniment of malarial fever
that they must be regarded in certain cases as indications of the presence of the febrile poison,
they were by no means so frequently accompanied by paroxysmal manifestations; hence
intermittent or remittent fevers may not be considered as symptomatic of diarrhoea or dys-
entery, or, in other words, these diseases must be ascribed to other causes than the causes of
the malarial fevers. Nevertheless, of seven hundred and eight3^-six fatal cases of diarrhoea
and dysentery recorded in the Second Part of this work, the patients in thirty-four were
reported as having been affected with intermittent fever and in twenty-seven with remittent
fever. The presence of the intermittent symptoms in the cases in which the records men-
tion them will scarcely be doubted. Similar credit should attach to the diagnosis of remit-
tent fever in the cases so recorded. Were the cases in which this association was observed
coincidences, i. e., results of an exposure to the causes of both the fever and the flux, or was
the latter a symptom of the febrile poison and due to the direct influence of that poison?
Dr. Woodward has discussed this question at length.* He was fully aware of the coexist-
ence of dvsentery and malaria in individuals and districts, and of the increased frequency of
the former in malarious regions, f as well as of the very general opinion of our armv surgeons
that malaria was a cause of dysentery. Indeed, at one time he held this ojainion himself;
but because Dutroulau and Hirsch gave instances of the prevalence of dysentery in non-
malarious sections and of malarial fevers where dysentery was unknown, he was led to abandon
the doctrine and to ascribe to malaria merely a predisposing influence in the causation of diar-
rhcea and dysentery; and so thorough a convert did he become to this new doctrine that he
referred to our American observers as having fallen into the error of regarding dysentery and
malarial fevers as due to a common cause.
But it has not been shown that our medical officers were in error. On the contrary,
the argument derived from clinical and pathological considerations appears to sustain their
views. The intestinal lesions of acute diarrhoea consisted of a hypersemia of the mucous
membrane of the small intestine, the villi and closed glands being somewhat enlar^-ed and
not unfrequently pigmented, especially in protracted cases, with usually similar inflanmiatory
appearances generally more advanced in their progress in the csecum and descending colon.
In what was regarded clinically as acute dysentery there was, in addition to these ajjpear-
".nces, a follicular ulceration of the colon with coincident thickening of its submucous coat,
or diphtheritic exudations, sloughs and ulcers in this part of the canal. In chronic cases
* See rages 2S7 and 308, Part II of this work.
t An examination of tbe relatious of diarrhceal diseases to the malarial fevers, as shown by the mortality tables of the Tenth U.-S. Census. 18S0,
may be of interest. Tbe following tabulation has been prepared from data derived from Table XI of tlie Mortality .Statistics, showing deaths in certain
grand groups with specification of cause. Proof-sheets of this table were courteously furnished to the writer by Gcforge W. Richards of the Census Bureau,
April 19, 1884. The grand groups embodied in the tabulation comprehend respectively the following portions of the country:
THK PAROXYSMAL A.ND CONTINUED FEV^ERS.
617
of diarrhcea and dysentery there was a chronic inflammation, with or witliout ulceration, of
tlie mucous and submucous coats of the intestinal canal, especially of the large intestine;
and this was frequently complicated in fatal cases by the development of more acute lesions
shortly before the occurrence of death. P)Ut these, especially in their acute forms, were pre-
cisely the conditions, so far as can be learni-d from the records, that characterized the inci-
dence of the malarial poison on the alimentary tract. It is imjjossible, therefore, to discrim-
inate by the intestiiuil lesions between a diarrhoea or dysentery due to a malarial hvpenemia
and that originating from other causes. Under these circumstances the clinical record o-ives
testimony of value. Unfortunately this seldom consisted of more than the recorded diag-
nosis. Nevertheless, as already suggested, it is entitled to credit as the opinion of qualitied
men based upon a consideration of the clinical phenomena. When the attending medical
Grotfp 2.
cities of Brook],
(71-oiiji 3.
Group 4.
Group 8.
Allcglicu.v Cit.v,
GrM,p :>.
aui] .\Iab.liim.
Cmiij) 10.
i;,\>iip n.
(.-.■.ii.ji 12.
lirovp 14.
Group l.'>.
aud Indiauapoli
Tlie Miihne AllaiiUc Cons/.— Dclawarc, the Bislriit of Columbia niiil parts of Now Yorl;, New Jorsoy, Maijlaml ami VirKinia, iiioliiding tbo
l.vri, Xew Yorl;, Camden, .ler-sey City, Xewark, Baltimore. M'iliiiiti^'ton and Washington.
Tht Soulh Alhiutit- (A'ciji/.— Part!* of North Carolina, Sontli Carolina and (h-orgia, including the City of Charleston.
The Gulf CoaM. — Parts of Florida, Alabama, Lotiisiana, Mississippi and Texas, inclniling the City of New Orleans.
Tlie lutcrutr rtn^aii.— Parts of New York, Pennsylvania, Virginia anil North Carolina, including the cities of Albany, Syracuse, Troy,
, Philadelpliia, Pittsburg, Keadiug and liichmond.
The Stutlierii Ceulral AppahicliUm Itegion.— Parts of Virginia, West Virginia, North Carolina, South Carolina, Kentucky, Tennessee, Georgia
The Ohio Rher /;.;(.— Paris of Ohio, Indiana, West Virginia and Kentucky, iucluding the cities of Cincinnati, Dayton ami Louisville.
Tbe Suutheru lulerior I'tiiUau. — Parts of South Carolina, Georgia, Alabama, Mississippi and Teunos.see.
The St*uth Mimsaippi Rit-er I:eU. — Parts of Kentucky. Tennessee, Slississippi, Louisiana and .\rkans.as.
27i(j SouUiiceft Central Itegiou. — Parts of Missouri, Arkansas, Louisiana and Te.vas.
The Central ii'ejioii o/ Pluius ami Prairies.— Parts of Ohio, Kentucky, Tennessee and Indiana, including the cities of Columbus, Nashvillo
Groit.
POPIUTIOX.
MORT.VLITV
R.^TES PER 100,000 LIVING.
Ratio of
malakial
DEATHS TO
i DIAIIUIKEAL
DlASKH<£A.
DVSENTERV.
EXTERITIS.
Total
diarrhieal
Total
malarial
DISEASES.
DISEASES.
S
5,714,(»3
20
21
21
02
20
1:3.1
10
2,440,330
23
24
20
73
25
1:2,9
9
2, C97, 958
21
35
19
75
23
1:2.7
2
4,370,135
42
34
22
98
35
1:2.8
15
4, 403, 002
15
25
24
04
39
1:1.0
11
3,025,545
21
31
27
70
88
1:0.0
3
875, OSC
37
24
19
SO
90
1:0.8
4
1,050,034
30
30
42
102
97
1:1.1
14
2,932,076
24
79
42
143
104 j
1 :1.4
12
710,250
23
31
33
87
129
1 :0.7
TOT.VL-.
28, 832,308
24
33
20
83
51 1
1:1,0
From this table it appears that in a population of nearly twenty-nine millions, occupying certain districts of the Vnited Stales, the deaths from
malarial fevers during the census year averaged 51 per 10n,(X)0, and those from diarrhroal rtisea.ses reported as diarrhtca, dysentery and enteritis S3 per
lUO.OOli. the former being to the latter as 1 : 1.0. It nniy be noted tlnit in Group 1,5 a malarial death-rate of only 39 ikt 100,000 was associated with a
diarrbtt-al death-rate which bore to it the avemge ratio of 1.0; and that those groups having a lower malarial d<-ath-rate than this had the ratio of
diarrhwal to malarial deaths higher than the average, while those with a higher nuilarial death-rate had the ratio of diarrhu':il to malarial deaths
cousidenibly loner than the average. Wliere the malarial death-rate was small the diarrhteal death-rate exceeded it very largely; and on the other ham!,
where the former was large the latter did not even eipial it. Thus, Group 8 had but 20 malarial deaths, which were to those from cnteritic disease as
1 : 3,1, while Group 12 had 129 malarial deaths, which were to the deaths from intestinal fluxes a-sl :0.7. Fronitb's it would seem that the relations, if any
exist, between malarial fevers and dinrrbrea and dysentery are not of so intimate a character .is to counterbalance other influences affecting tbe death-
rate of the latter diseases. Nevertheless it may not be concluded that there is no relation between them, for the diarrhceal death-rate rises with tlie
malarial rale, although neither in the s.ame proportion nor regularly in any proportion. Thus, while the low-est malarial rate, 20 per 100,000 in Group
8, is ilssociatol w ith the lowest diarrhoeal rate, 02 per 100,000, and the highest diarrbieal rate, 145 in Group 14, is as!-ociated with a high malarial rab-,
104, the bigtu^t malarial rate, 120, occurring In Group 12, corresponds with a diarrhceal r;ite, 87, which is hut slightly above the average of all the groups.
.\;i iucreasi-d fatalityof ni:ilarial dise;i,ses, therefore, implies an increased fjitality of diarrbieal disciises; but, as the increase of the one does not corresi)ond
with that of the other, it fjllows that they are due neither to the same cause norlo tbe same conditions of causative development in alloc even in a majority
of cases. It nnty be remarked that the figures here given are consistent with the position taken in the text, to-wit : that altbougb diarrha:*a and dysentery
are, in certain cases, symptomatic of the incidence of the malarial poison on the intestines, and although this poison may exercisea strongly predisposing
intlnence to diarrlueal and dysenteric attacV.s, there are other causes, some no doubt of a specific character, whicli exercise a far more powerful influence .
on the prevalence ami fat:ility of the intestinal .fluxes.
Mki>. Hist., Pt. Ill— 78
618 DISEASES ALLIED TO OE ASSOCIATED "WITH
officers recorded a case as one of remittent fever, and the post-mortem examination discovered
only the lesions of acute or chronic diarrhoea or dysentery, it is fair to assume that the flux
was the direct result of a malarial cause.
Manifestlv it would be absurd to argue from this that malaria was the direct cause of
diarrhcea and dysentery" in all cases. It has been proved that dysentery may prevail in
non-malarious reo'ions, but our medical officers did not hold that malaria was the onlv causo
of dysentery. It lias been shown that malaria may exist without dysenterv, but they did
not hold that malarial fevers were always characterize.d by dysenteric symptoms. Thev
believed that in many of tlie cases of dysentery that came under their observation an expo-
sure to malaria was the direct and efficient cause; and in view of the frequent incidence of
the malarial jjoison on the intestinal canal, causing diarrhceal and dysenteric symptoms, and
leaving in fatal cases only the hypersemic lesions common to these morbid conditions, it is
difficult to show that they were in error in assigning a malarial origin to certain of these
diarrhceal or dysenteric cases.
Some of the confusion that has crept into the discussion of this subject has arisen from
the mistake of regarding diarrhoea and dysentery as diseases jycr sc, when in realitv thev are
merely symptoms of active hypersemic conditions of the intestines which, though often due
to other causes, some of which are jirobably specific, may certainly arise from the nralarial
influence. Certainly, also, this influence may be viewed as a powerful predisposing cause of
the Ojuasi diseases in question, as in the presence of that tendency to intestinal congestion
wliich is its frequent characteristic, minor causative conditions, of themselves incapable of
overcoming the vis coiiservatrix naturce, may readily determine the onset.
The argument suggesting that the diarrhceal cases registered as remittents were really
febrile cases due to malaria, with diarrhceal or dysenteric lesions caused directly by the mala-
rial incidence, or indirectly due to a predisjsosing influence exercised by the malarial poison,
applies to the cases recorded as typho-malarial or ty})hoid-remittent. These are enumerated
in notes '•' and f to page 420, supra. Their anatomical appearances were such as are con-
sistent with the theory of an independent diarrhoea or dysentery; but since they are equally
consistent in some instances with a continued malarial fever and in others with a true typho-
malarial fever, there is no evidence to show that the views of the attending officers as to the
presence of a febrile element of a malarious origin were erroneous.
Looking now at the relations of diarrhoea and dysentery to typhoid fever, these will be
found so close in some instances that it is difficult to discriminate between the diseases not
only from the clinical records but even in full view of the recorded 'post-mortem appearances.*
Typhoid fever, when the intestinal symptoms attained a notable prominence, was frequently
called acute or chronic diarrhoea. In the post-mortem records of the continued fevers some
cases of this kind have been observed, to wit: Cases 304-324, in which the patches of
Peyer were ulcerated, and 343-348, in which, although the condition of the patches is not
stated, the character of the ulceration in the ileum is sucjsjestive of a tvphoid element.
If the cases of the diarrlioeal series be examined other instances of typhoid fever erro-
neously registered as diarrhoea or dysentery will readily be discovered. Thus, Woodwakb
* Dr. J. J. Booker, of Castloton, Ind., announced, in tho Tranmcliom of the Slnle 3Ie'Ucal S'xiel)/ of Iitdiam, Indianapolis, 18S3, p. 3.% tlie opinio i
that typlioid fever and camp diarrlioea aro produced by tlie same cause, because "when we find campdiarrhcea prevailing extensively we will find tyiiboid
f.'Ver increased in the same ratio, and vice versa," and because he found ;posl-niort€m in his diarrhceal cases "an intlamniatory ulcerated condition of the
nienibmne and epithelial structures of the lower intestine and also ulceration of Peyer's glands as in typhoid fever." Manifestly this opinion was based
npo:i limited and superficial observation and inaccurate diagnosis, for the difficulties mentioned in the text occurred only in exceptional cases.
THE PAROXYSMAL AND COXTINUKD FEVERS. 619
states* that certain cases of this series were really examples of some form of continued fever
in which the typhoid affection of the patches of Peyer was the prominent lesion. The cases
enumerated are 163, 164, 174, 210, 531, 854 and probably 836, 837 and 838. But to
these must bo added 141, 192, 240, 365, 461, 709 and 777, in which the ulceration of the
patches of Peyer appears to leave no doubt of the presence of typhoid fever; perhaps 278
and 308 should also be added to the list. In most of .tliese the typhoiil ulceration of the
patches was associated with prominent dysenteric lesions. In the two cases, 436 and 825,
having a typho-nialarial diagnosis, a t3-phoid element seems indicated by the character of
the ulceration Qf the small intestine, and in 870, diagnosticated typhoid fever, the ulcerated
agminated glands fully support the views of the attending physicians. Instances of tuber-
cular ulceration of the patches have been excluded from the cases above mentioned. More-
over, case 609 affords an interesting example of death from pneumonic complications in a case
of typhoid fever which was otherwise running a favorable course. The fever supervened
while the patient was improving in hospital under treatment for a debilitated condition of
system due to diarrhaa and a scrofulous constitution; rose-colored spots appeared on the
thirteenth day and convalescence was apparently established on the twentieth, but some pain
in the chest and muttering deliri-.nn set in and death occurred on the twentv-seventh. As
the glands of Peyer in this instance were thickened but not ulcerated, the supposition that
absorption was in progress is allowable, in view of the light character of the febrile symptoms.
In addition to these twenty-two cases of typhoid the diarrhoeal series presents thirtv-
seven cases in which at some period of the patient's hospital treatment his case was regarded
as typhoid fever, seven in which typhoid pneumonia was reported and twenty in which the
records show with certainty tliat the svmptoms were of a tvphoid character.
The lesions presented by the snuiU intestine in these sixty-four cases are worthy of consideration. In four, 267,
496, D33 and 620, its comlitiou was not stated. In twenty, or one-third of the remaining sixty cases, the intes-
tine was ulcerated, luit the .state of the patclies of IVyer was not recorded. These cases were 106, IMt, iy3, 200, 208,
2-12. 317, 310, 143,476, 501,505, 510,513, ()61, 750, 775, 812, 832 and 831. In one case, 6.52, the intestines were gangrenous.
It is [lossible that the ulceration iu these was sinijily a diarrlueal lesion, or, as in 8.32, probably the result in part
of malarial action: but iu view of the typhoid cases Instanced above it is not unlikely that some of these were
really cases of typhoid fever. Granting them to have been all cases of diarrhceal disease, their intimate relation clin-
ically to typhoid fever has already been shown by the cases of true typhoid found in the diarrheal series. Grant-
ing them on the other hand to have been all cases of typhoid, the presence of typhoid symptoms without typlioid
ulceration of the patches is satisfactorily shown by the remaining thirty-uiue cases. In four of those, cases 111, 263,
321 and 330, the intestine was healthy; in two, 4SI3 and 494, intussusception only is mentioned; in two, 116 and .540,
there was no ulceration: in one,. 334, the ileum was thinned; in one, 344, softened; iu one, 338, slate-colored; in eleven,
194, 246, 331, 352, 391, 397, 547, 624, 631. 639 and 672, congested; in four, 223, 328, 452 and 536, iutlamed ; in one, 332,
the jejunum only was ulcerated; in one, 201, the solitary glands of a highlj- congested ileum were ulcerated; while
in eleven, statements were made concerning the condition of the patches of Peyer, — normal iu three cases, 197, 266
and 467: not swollen but pigmented in one, 366; thickened iu three, 132, 264 and 398; dark iu one, 388; conspicuous
iu one. 326, and congested in two, 425 and 427.
From this list it is manifest that a febrile action having a similarity to typhoid was
present iu at least thirty-two of the cases, although no implication of the patches of Peyer
was observed after death. Tliese were undoubtedly cases of acute diarrhoea or dysentery in
which the deterioration of the blood, caused perhaps by the primary action of a specific poison,
but certainly by the accumulation of the products of metabolism during the continuance of
a syraptoraatic or coincident fever, was followed by such clinical phenomena as have been
shown to characterize typhoid fever and the protraction of acute malarial cases.
The few instances in which the patches of Peyer had undergone alteration do not indi-
cate that a typhoid element was present in them; for in many cases in which the mucous
* Page 521 of the Second Part of tbU work.
620 DISEASES ALLIED TO OR ASSOCIATED WITH
membrane of the ileum was tlie site of tlie morbid lesion the patches of Veyev participated
in the general congestion or tumefaction, thus becoming more conspicuous than usual, although
the associated symptoms were simply those of an acute diarrhoea if the lesions were confined
to the ileum, or of dysentery if they implicated as well the lower portion of the large intes-
tine. The patches of Peyer in twenty-six such cases are said to have been affected;* but
in no instance does the language of the reporter suggest that condition of the glands which
was characteristic of fatal cases of typhoid fever. They were slightly thickened, enlarged,
prominent or elevated, and with or without mention of this thickening, they were somewhat
injected, congested or inflamed. Gertaiidy specimen 98, Army Medical Museum, as shown
on the plate facing page 300 of the Second Part of this work, illustrates a condition of the
glands that may be more consistently referred to a general involvement of tlie mucous and
submucous tissues of the ileum than to a specific irritant operating mainly on the closed
glands. Xo suggestion of a typhoid element was offered in this case, 880 of the diarrhoeal
series, either by its history or its post-mortem appearances. "The intestines," according to-
Dr. Leidy, wlio was the reporter, "were inflamed throughout; in the small intestine the
inflammation increased in intensity towards the iieo-cascal valve ; the agminated glands were
slio'htly thickened and dark-red with inflammation."
Moreover, in most of the many diarrhceal cases presenting that pigmentation of the
patches which must be viewed as characteristic of our camp diarrhoeas,"}" there was a con-
gestion or slight tumefaction of the glands, or, if this was absent, the pigmentation itself
indicated the antecedent existence of the congested and slightly tumefied condition.
But this tumefaction, being in its nature essentially similar to that caused by the specific
irritant of typhoid fever, was prone in some aggravated cases to assume a greater resem-
blance to the characteristic lesion of typhoid by the establishment of the ulcerative process.
Thus, in 426 the thickened patches presented a spongy apjDearance in their centre; in 342
and 378 they were slightly ulcerated; in 463 they showed several small ulcerations; in 226,
311, 374, 743, 748, 800 and 855 a few of the patches, generally near the valve, were ulcerated.
It is possible that in some of these a typhoid element was present; but in view of the series
of cases that lead up to the ulcerated condition, and in the absence of any clinical indica-
tions of typhoid, this suggestion may not be entertained. Specimens 600 and 601, Army
Medical Museum, from case 881 of the diarrhoeal series, show that these slight ulcerations
of the patches in the diarrhceal cases were wholly different in their appearance from the
ulcerations in fatal cases of typhoid. A photographic representation of the former specimen,
facing page 302 of the Second Part of this work, gives clear evidence that the patch was
tumefied merely as a ^^art of the general affection, and that the minute ulcerations on its
lower part were due to local conditions of necrobiosis consec|uent upon this tumefaction. In
this case typhoid symptoms set in before the- end, and the cause of death was reported on
the hospital register as typhoid fever; but as Dr. "Woodward observed, in speaking of its
morbid lesions, — "here we have to do with a much less extensive disease of Peyer's patches
than that which is characteristic of typhoid fever."
In the discussion of the post-mortem a^spearances of the patches in the continued fevers,
similar congestions and tumefactions were referred to the participation of the glands in the
general affection of the mucous membrane of the ileum . ' The facts j ust submitted with regard
« These cases are 133, 146, 148, 149, 154, 163, 169, 1V2, 183, 225, 309, 329, 346, 34S, 351, 353, 354, 370, 37", 428, 488, 563, 578, 752, 791 and 671.
t .imong these nLiy be numbered the fullowiiig: 120, 128, 130, 134, 133, 1 :!7, 138, 140, 142, 143, 144, 147, 150, 151, 153, 154, 155, 153, lUO, 102, ICO,
170, 173, 174, 175, 203, 300, 315, 335, 355, 300 and perhaps also several others, as 330, 388 and 450, in which the glands were reported as dark-colored.
THE PAROXYSMAL AXD CONTINUED FEVERS. 621
to their iunjlication in the congestions clue to the irritant cause or causes of acute diarrhoea
sustain tlie views that have been advanced as to tlie absence of a typhoid element in certain
niaUirial fevers, which, nevertheless, owing to the incidence of the poison on the small intes-
tine, presented a notable involvement of the agminated glands.
From this presentation of the facts bearing upon the connection between these diseases
certain conclusions maybe reached:
1. Typhoid fever was one of the direct causes of diarrluva, ov.iiig to the ulcerative processes in the ai;iiiiMaiiil
gUuids and in the solit.irv gh\nds of the ileum and ciecuni, which are its anatomical characteristics.
2. Diarrhcea, as a symptom of typhoid fever due to the processes aforesaid, was sometimes regarded as an acute
diarrluea when the specific i)heuomen.a were not well developed.
3. Diarrhiea, due to other irritant causes operating on the mucous menihrane of the ileum and ciecum, was
sometimes regarded as typhoid fever, especially in acute cases of some persistence in which the continuance of a symp-
tomatic or coincident fever induced the suiierventidu of those adynamic symptoms I hut have liecn denominated
typhoid.
These errors in diagnosis, due to intimate relationship on the one hand and pathological
similarities on the other, were susceptible of recognition at the post-mortem examination, for —
4. Diarrhira, symptomatic of typhoid, was always indicated l>y the condition of the patches.
?. Diarrhiea from other causes had the patches nnatfeeted or i>igmented, often congested, tumefied and even
ulcerated; hut these conditions were usually readily distinguishable from theeongestiou, tumefaction and ulceration
of typhoid fever.
In many instances there were large and deep ulcerations of the intestine, but these were
either chronic cases in which the history excluded all doubt as to the character of the disease,
or diphtheritic cases in which an examination of the muct:)us membrane sufficed to determine
the character of the ulceration. Post-mortem examination, if sufficiently exhaustive, would
]irobably have developed a series of anatomical cases connecting the faintest reddening and
thickening of the patches in diarrhcea with the well-marked tumefaction and defined ulcera-
tion of typhoid; but the clinical history of these cases would have failed to show a parallel
or corresponding series connecting a simple diarrhoea at one extremity with a typhoid fever
at the other. In other words:
6. Piarrh(Pa did not liecome typhoid fever by the implication of the patches: nordid typhoid symptoms depend
upon their congested or ulcerated condition.
But, besides being the direct cause of a symptomatic diarrhoea, typhoid fever was other-
wise associated with the intestinal flux. The frequent occurrence of antecedent typhoid in
tlie history of diarrhoeal cases, and the known ulcerated or deteriorated condition of tlie
ni'.icous lining in such cases, warrants the conclusion that —
7. Antecedent typhoid was an influential predisposing factor in the determination of diarrhieal attacks.
The connection of dysentery with pure or unmodified typhoid fever cannot be shown by
•A consideration of the cases of typhoid with dysenteric symptoms that have been recorded,
because in these it is impossible to exclude the probability of a coincident malarial febrile
element; but from the absence of tormina and tenesmus in the clinical history of the pure
typhoid cases treated in the Seminary hospital, and from the rarity of inflammation or ulcera-
tion of the lower portion of the large intestine in the fifty typhoid cases given in ih& post-
mortem records of the continued fevers,* it may be inferred that —
8. The coincidence of dysentery and pure or unmodified typhoid was an unusual occurrence.
On tlie other hand, the connection of dysentery with remittent and continued malarial
fevers was so intimate as to lead them to be ascribed to a common cause; and in many
instances this opinion was undoubtedlv Correct, for, as has been shown above. —
9. Malarial fever was one of the direct causes of diarrhoea, and especially of dysentery, owing to the active
* See al5o the analytical summary, iwpra, page 423.
622 DISEASES ALLIED TO OR ASSOCIATED WITH
Lyper;piiiic conditions which it frequently established in any or all parts of the intestinal tract and particnlarly in
the large intestine.
10. Diarrbcea or dysentery, as a symptom of malarial fever due to the conditions aforesaid, was sometimes
regarded as au acute diarrhoea or dysentery when the paroxysmal features were not well developed.
Tliis error of diagnosis was not susceptible of recognition by post-mortera examination
of the intestinal lesions, for these were the same in diarrhoea and dysentery due to malarial
incidence as in the diarrhoeas and dysenteries due to other causes.
1 1. Diarrhoea or dysentery, due to malarial or other irritant or specitic causes, was sometimes regarded as typhoid
fever, especially in acute cases of some persistence in which the continuance of a primary symptomatic or coincident
fever called forth the well-known typhoid symptoms.
Tliis error, on the other hand, was easily recognized, for the presence of typhoid was
always indicated by the condition of the agminated glands.
From what has been said it is needless to enlarge on the connection between diarrhoea
and dysentery and the modified t3"phoid or true typho-malarial fevers that formed so large
a part of the continued fever series.
12. Typho-malarial fever was a direct cause of diarrhoea, owing to the constant but often localized oiieratiou
of its typhoid element and the occasional but usually more extensive action of its malarial element on the ileum and
ciecum.
13. It was also, in some instances, a direct cause of dysentery, owing to the occasional incidence of its malarial
.clement on the descending portion of the large intestine.
14. The fre<£uent attacks of diarrha-a to which soldiers who had suffered from this fever were liable manifests
the predisposing influence of both the febrile elements, but especially of the typhoid, while the frequency of dysentery
as a sequel of the fever must be referred to the predisposition induced by the local action of the malarial factor.
IV._SCURVY.
The scorbutic complications of the continued fevers recjuire notice mainly because of their
undue prominence in the medical literature of the war hitherto published. Scurvy, as will
be seen hereafter, threatened on several occasions to become epidemic in certain commands,
and, indeed, in 1865 the colored troops in Texas had a monthly rate of scorbutic cases which
for one month exceeded the maximum of the French army in the Crimean campaign. But
the references to scorbutic complications have not been restricted to camp fevers as affecting
the colored troops. Their application has been general, although at no time was there any
general scorbutic taint among the white troops. Woodward held that in the great majority
of cases of camp fever the enteric symptoms were comj^licated by malarial and scorbutic
phenomena. Acting on this belief he divided the enteric fevers of the army into three
classes according as the ty2;)hoid, malarial or scorbutic elements appeared to predominate.*
HuxT reported scurvy to the U. S. Sanitary Commission as one of the most common and
easily recognized diseases of the army.f Hammond al-o reported on scurvy to the Com-
mission, but his materials were drawn wholly from foreign sources, mainly from the experience
of the allied armies in the Crimea, the intention beino; to direct the attention of our officers
.to the importance of preventive measures.J Scurvy, according to the experiences cited by
him, was a formidable ally of the continued fevers.
Typhus was at that time (the winter of 1851-55) raging fiercely, and I am convinced that, if not its main cause,
certainly the cause of its great mortality was the scurvy. Of twenty patients admittetl during that period eighteen
were usually more or less scorbutic; eight, perhaps, would be so deeply affected (as indicated by sloughing ulcers,
gangrene of the mouth, geuejal dropsy and chronic diarrhoea) as to render recovery impossible. 9
Fortunately in our armies nothing of this kind was encountered. According to tlie
statistics the most marked outbreak among the white troops was that observed in July, 1862,
«Camp BUeases of Ihe Vniled Slates Armies, Vhiln., 1S63, p. 77. Tijpho-malarial fever : It it a tpecial lijpe of fever ?—Phila.., 1S76, p. -37.
t r. S. Sanitarif Coiumimioii, New Yoi-k, 1807, page 276. \ :\Iililary Medical and Savjieal ^^wi;/?, Phila., Pa,, pjige l7o.
g Ecperiencea of a Vifilian in Eastern MUilary Hospitals, by Petee Pixcoffs, London, 1857, p. 25.
THK PAROXYSMAL AND COXTIXUED FEVERS 623
ill the Army of tlie Potomac, when the liurdships ami privations ot" the Peninsahir carapaiori
cuhninatecl in the despoiulency which attended the seven days' fight during the retreat to
Harrison's Landing. Many causes, of which a deticient dietary was but one, contributed
to the deteriorated condition of that arm v on its arrival at the James River. An advnamia
pervaded its ranks, and all febrile complaints speedily assumed a typhoid character irrespec-
tive of the presence or absence of a specific typhoid element. This tendency to a typhoid
state was independent of a scorbutic cachexia, for it was seen at many periods of the war and
in other armies when there was no suggestion of a scorbutic element. The deterioration of
the blood in typhoid fever was evidenced in many cases by the presence of petechite, which
sometimes in fulminant instances appeared at an early stage of the disease; in malarial fevers
similar petechias were observed, and in the pernicious cases congestions, internal extravasa-
tions and cutaneous blotches were the rule; but tliese were the direct results of the typhoid
and malarial poisons on the blood. It was frequently noted that deadly congestive fevers,
fatal in a few hours and attended with hemorrhagic blotches, chose for their subjects the
healthiest and most robust men in the command, in whom there was no thoufht of a scorbutic
taint. As the febrile poisons are competent to Account for the hemorrhagic manifestations,
particularly when the adynamic tendency was strongly developed in constitutions impaired
by overwork, want of sleep, exposures of all kinds and moral influences of a depressing
character, it is needless to bring in a scorbutic element for their explanation. Undoubt-
edly, at the period mentioned, scurvy was present in the Army of the Potomac, and to a
notable degree in certain regiments; but it does not appear that it operated as a complicating
agency other than by increasing the tendency to adynamia. Of the fever cases that have
been submitted in this work, and these cover all the reported cases that possess any value
for other than purely statistical purposes, very few are noted as having been complicated
with scurvy. Of three hundred and eighty-nine cases presented under the title of Post-
Jlortem Records, two cases only, 316 and 374, recorded a scorbutic appearance of the patient.
Probably also starvation and scurvy were predisposing causes of death in 311 and 347,
and in perhaps a few other cases which, like these, occurred in the persons of men who had
been not only deprived of an anti-scorbutic diet but absolutely famished ; but to argue from
these that scurvy entered into the febrile cases of the war as a generally complicating element
would be inadmissible.
It is allowed that a scorbutic taint existed at times in many regiments and that its
influence in increasing the danger of tvphoid and malarial fevers was felt in individual cases;
but the facts do not apjDcar to authorize the establishment of a class of fevers in which the
scorbutic element was predominant. Such a classification is misleading, as it suggests the
X O' CO
sloughing ulcers, gangrene of the mouth and general dropsy just cited from Pincoffs'
experiences in the hospitals at Scutari and oth^r parts of the East. A reference to the dia-
gram facing page 694, in which is delineated month by month the prevalence of scurvy
among our white troops, will show how rare must have been a recognizable scorbutic com-
plication. There was recorded annually one case of scurvy in every 72.5 men. It is true
that when one man presents well-developed scorbutic symptoms other men, subject to the
same causative influences, will also be aS'ected to some extenft; but it is questionable if our
medical officers in their reports did not overestimate the frequency of well-developed scurvy
by reporting under that title cases which, but for their anxiety to anticipate its outbreak,
would have been regarded simply as rheumatic or diarrhoeal.
624
THE ERUPTIVE FEVERS.
The point insisted upon — the absence of a scorbutic complication in the camp fevers
of the war except iu rare instances of local epidemics in the field and among paroled or
exchanged prisoners in the general hospitals, — is sustained by the absence from the surgical
records of any general references to the indisposition of wounds to heal. This indisposition
was frequently noticed in the Confederate hospitals and particularly in the Confederate pris-
ons; but as no special mention is made of the scorbutic complication by Surgeons Otis and
Huntington in their review of the surgical work of the war, it would seem strange, indeed,
if the medical part of its history were permeated with a scorbutic taint which was capable
of assuming a predominance even in the presence of the typhoid and malarial poisons.
CHAPTER VI.— ON THE ERUPTIVE FEVERS.
In presenting the general statistics of the war period, as in Tables II, III and IV, and
in the diagrams facing pages 14, 20 and 24, the frequency and fatality of the eruptive fevers
have been specified. The following table gives a more intimate view of the statistics of
tliese diseases-
Table LII,
Showing the prei'alence and mortality of the Eruptive Fevers among the United States forces daring the
years of the icar and tite year following the zvar.
WHITE TROOPS.
Mav 1, 1801, to
June aUjlSUO.
1861-62.
1862-63.
1863-04.
lSM-65.
1865-66.
Average annual.
Mean strength :
In fie'-d ami garriton.
431,237
miWi
279, 371
288. 02U
614, 3-25
elo'.osi'
619, 703
675. 413
574, 022
645. .506
99, OSO
ioijigr
431, 237
1 '
1 '
'
' ■"!
Total number —
Katies of cases ami deaths per thousand of strength.
Cases.
Deaths.
Cases.
Deaths.
Cases.
Deaths.
Cases.
Deaths.
Cases.
Deaths.
Cases.
Deaths.
Cases.
Deaths.
Small-pox
12, 230
07, 763
578
23, 270
4,717
4,240
70
1,860
4. 68 1. 36
77. 57 1. 97
4.71
28.58
1 M
1.45
1.99
.02
1.23
8.08
28.07
.25
10.50
3.21
1.88
.04
.61
4.61
17.07
.13
11.25
1.75
1.68
.02
.77
3.37
1.98
.08
8.76
.69
.11
.01
.19
6.49
30.41
.20
10.46
1.95
1.75
.03
.77
Scarlet fever .
.48
9.49
.03
.42 10.95
103, 853
10,893
92.22
3.78 ! 44.58 4.69
46.90
5.74
33.06
4.22
14.20 1 1.00
46.61
4.50
COLORED TROOPS.
July 1, 1863, to
June 30, 1866.
1SG3-C4.
1804-65.
18C5-66.
i
.\verage annual.
Hoan strength :
'.- Iu field aud garrison.
In hospital also
01, 132
"03;'923"
44,785
"46,007"
83,571
"S9"T«"
55, 039
"56;'6i7
61,132
63,923
1
Total number —
Batio of cases and deaths
per thousand of strength.
Cases.
Deaths.
Cases.
:Deaths.
Cases.
Deaths.
Cases.
Deaths.
Cases.
Deaths.
6,716
8,555
118
1,530
2,341
931
2
247
61.63
121.54
IB. 52
12.35
23.30 8.69
33.88 3.75
1.41 .03
7.97 1.81
36.48
5.11
14.24
.51
36.62
46.65
.64
8.38
12,21
4.80 i
.01
1.29
Scarlet fever
Erysipelas
12. 10
1.32
5.96
.44
10, 925
3, 531
195.27
30.19
66.56 14.27
47.55
15.19
92.29
18.36
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SMALL-POX. b2o
These figures show, among otlier pointe which might be indicated, that small-i)ox and
ervsipelas were present to a limited extent throughout the wliole of the period, tlio former
attaining its maximum in the third year, the hatter manifesting but httle fiuctuation in its
annual rates. Measles was a disease of the early period of the war and scarlet fever an
accidental occurrence. Small-jwx caused 43 per cent, of the deaths from the eruptive fevers
among the white troops, measles 39 per cent., erysipelas 17 and scarlet fever less than one
per cent.; among the colored troops the percentages were small-pox 66.5, measles 26.5,
erysipelas 7 and scarlet fever almost nil.
I.— SMALL-POX.
Statistics. — Small-pox was present to a considerable extent in the United States during
the years of the war, but at no time could it be considered a prevalent disease among the
white troops serving in any of the armies or departments. During the five and one-sixth
years covered by the statistics 12,236 cases occurred among them, equalling an average
annual rate of 5.5 per thousand men ; the deaths numbered 4,717, or 1.95 annually per thou-
sand of strength. In accordance with the figures jifst given the fatal cases constituted 38.5
per cent, of the whole number; but this calculation exaggerates the rate of fatality as it does
not take into consideration the many cases that were taken sick at the general hospitals.
A more accurate estimate of the death-rate in small-pox may be obtained by following the
history of a series of cases treated in the small-pox hospitals. Of 1,166 cases examined in
this connection 679 reported as unmodified sinall-pox furnished 274 deaths or 40.3 per cent,
of the cases, and 487 cases occurring subsequent to vaccination gave 3 deaths, — a total of
277 deaths in 1,166 cases of variolous disease, or a death-rate of 23.8 per cent.
The average number of cases taken on sick report monthly was .46 per thousand men.
During the warm months of the year the rate was considerably below this average, and
during the cold months proportionately above it. In July, August and September the rate
was never more than a few hundredths of one per thousand men. The largest wave of
prevalence extended, as may be seen by the accomjianying diagram, from January to April,
1864, when the maxinuuu rate of 1.46 was attained.
This maximum was the result of no local epidemic seriously crijjpling a particular com-
mand, but of the occurrence of sporadic cases in all the commands. Small-pox may be said
to have been present in every department during every year of the war. The number of
men in the exceptional commands was too small to afford ground for objection to this gen-
eral statement. There was no small-pox in the Department of the Xorthwest during the
year 1861-62, the strength present having been 1,240 men, nor in the Department of New
Mexico in 1863-64, with a strength of 4,224 men, nor in the Division of the Pacific during
1865-66, with a strength of 11,332 men.
In view of this general diffusion of the poison of the disease it is creditable to the efibrts
of our medical officers that there was no serious outbreak. Isolation and vaccination were
recognized as efficient means of jDrotection. Vaccination and revacciuation will i^reserve
the individual from small-pox save in exceptional cases, such as case 9, submitted below;
but instances of this kind are so rare that the efficiency of the vaccine virus to protect an
army from small-pox may not be called in question. Many officers could give evidence from
their experience to corroborate the statements in tlie following reporte:
Med. Hist.. Pt. Ill— 79
G26 THE ERUPTIVE FEVERS.
Surgeon David Lk Eov, 9(7i 111., Brotnisville, Texas, Feb. 21, 18G4. — The men of this regiment, -when prisoners of
war at Benton Barracks, were all vaccinated, and although surrounded by small-pox, but one mild case of varioloid
has occurred among them during the year that has elapsed since their vaccination.
Medical Iiisjpcctoy G. W. Stipp, U. S. A., Nciv Orleans, La., March 20, 1864. — For some weeks previous to the date
of this insiiection there had been a considerable prevalence of variolous disease among the forces and the popu-
lation of the country occupied by them. This was for the most part of mild type, and its further spread seemed
almost wholly checked by sedulous vaccination.
That our troops were not satisfactorily protected by vaccination is eviilent from the
statistics submitted. Instead of so many thousands of cases there should not have been so
many hundreds. Kegiments were raised by the various States and rushed to the front, under
the successive calls of the President for men, without a thought of small-po.x; or vaccination.
The army regulations required that every man should be vaccinated, but few of the State
military authorities succeeded in fulfilling this requirement. For many years before the
war there had been no systematic vaccination in the civil communities. Many of the volun-
teer troops had never been vaccinated; few of them had been revaccinated, for at that
time the necessity of revaccination was not thoroughly appreciated by our medical men,
although European experience had demonstrated its value. There was, therefore, much
susceptible material in the ranks of our armies, but to give quantitative expression to this is
difHcult : as a rule men from rural districts had a greater susceptibility than those from
cities. The appearance of small-pox in the winter of 1861-62 caused Medical Director
Tripler to call for a report of the condition of the regiments in the Army of the Potomac as
regarded their immunity from the disease. The result of the inspection showed that while
some regiments were thoroughly protected, others adjoining them on the same camp ground
were composed of susceptible material. Thus, of four regiments of -the Third Brigade
of Sumner's Division, Surgeon Stiebelijig represented the 712 men of the 52d X. Y. as
sufficiently protected, and Surgeon Leach the 744 men of the 57th N. Y. as protected with
the exception of 20; while Surgeon McDermott, 66th X. Y., regarded 325 of his 738 men,
and Surgeon Iro^'berger, 53d Pa., 593 of his 818 men, as susceptible and requiring imme-
diate vaccination or revaccination. Brigade Surgeon D. AV. Haxd, in reporting that only
23 of the 2d X. Y. required revaccination, while 315 of the 1st Minn, appeared to be insuffi-
ciently protected, explained this by the statement that the former was a New York City
regiment, composed mostly of foreigners, who were protected by a jDrevious attack of the
disease or by well-defined vaccination marks, and the latter, a native regiment of Western
frontiersmen, wdiose antecedents showed neither inclination nor facilities for vaccination.
If the number of unsuccessful revaccinations in a command be regarded as an index of
its extinguished susceptibility to small-pox, some idea may be obtained of the constitutional
condition of our men when exposure to the disease necessitated a hurried use of the virus.
Every fourth or fifth man was perhaps liable to be attacked.'^' In view of this suscepti-
« Surgeon C. H. Wilcox and Ass't Surgeon J. A. Petess, 21st If . T., state — Buffalo Medical andSurgkalJoumal, Vol. 1, 18C1, p. 80— that of 70C men there
was evidence of previous vaccination in f44, but that more than seven years had elapsed since the previous vaccination in no less than 477 of the numle/.
Of those who exhibited evidence of funner vaccination 13 were revaccinated successfully, to wit : 11 of 107 who had been vaccinated within seven years,
and 32 of 477 whose previous vaceinatiou antedated that period. One man in fifteen was susceptible to the action of the virus without considering those
in whom the faihire of the attempted revaccination w.as due to other causes than insusceptibility. Xo case was reported by these medical officers as
successfully revaccinated unless the vaccinia ran its characteristic course. There is a great diversity in the recoi"ded results of revaccination, som>givin.L,'
so large a percentage of successes that, in the absence of a detailed account of what constituted a success, we are at liberty to suppose that by many any
inflammatory appearance at the points of insertion of the virus in a man showing evidence of a previous vaccination was regiirded as a true vaccini.i
modified by the partial protection of a primary operation. The animal matter of the crust frequently gave rise to inflammation, pustulation and scabbing
of a non-si»ecific character, which were iierhaps often reported as the evidences of a protective revaccination. — See Borhte vs. Humanized Virus as afectiu'j
the prei-ahnce and death-rate of Varioloid, by Charles Smart, Surgeon V. S. A., Medieal SetrK XL, Philadelphia, 1S82, p. 280. Others recorded so small a
percentage of successes that the use of inert crusts may be suspected. LymphM:oated points and vaccine crusts, particularly the latter, furnished to
medical officers during the war were occasionally inert. It became, therefore, a common practice in v.tccinating a regiment to rub together for insertion
parts of two or more crusts in the hope that one at leiist of the combination might prove eflcctive. Eviden'tly the susceptibility, as detern-.iaed by the
use of the dried crust and long-kept lympli, and the immunity conferred by them, might frefjuently be called in question. But the same objections do
SMALL-POX. 627
bility ami of the wide diffusion of the disease-poison it is evident that tlie prompt isolation
of suspected cases and the destruction by fire of all infected clothing, bedding and shelters
were measures of the first consequence in restraining the spread of the disease until immunity
was conferred by successful vaccination or revaccination.
The disease prevailed to a greater extent among troops in the vicinity of cities than
among those in the field. Thus, during the j^ear of greatest prevalence there were as many
cases among the 30,000 men in the Department of Washington as a,mong the 104,000 in
the Army of the Potomac, and a larger number of cases than was reported by either of
these commands occurred among less than 15,000 men, mostly quartered in barracks, on
recruiting duty in the ^Northern Department. The cases reported from tlie Army of the
Potomac were mostly due to exposure in tlie cities of Washington and Alexandria. The
sufferers were usually men recently returned from furlough or general hospital. As soon
as the disease was recognized the patient was removed to an isolati-d tent-ward of the
division hospital, or, in the absence of a temporary pest-house for the division, the regi-
mental .<urgeon establisiied one in a suitable locality near the camp. Usually men who
presented evidences of a previous attack of the disease were detailed to act as nurses.'"" In
other commands similar precautions were taken.
Surgeon Theo. B. Lashells, 171s( Pa., Xew Berne, y. C, Feb. 20, 18(53. — By inoper care in v.icciuatins, and iso-
lating the cases, the sjireail of sinall-po.x was speedily checked.
Siinjeon J. M. CuYLEn, U. S. J., Medical Director, Fortress ilonroc, la., Jan. 2S, INli'J. — A few cases of variolous
disease have appeared, chiefly among recruits ; bnt in every instance they have been at once separated from the rest
and carefully watched through the course of the di.sease in a building, affording them every comfort, at a distance of
more than a mile from the fort.
Small-pox prevailed to a greater extent among the colored troops than among the white
commands. During the three years of their service 6,716 cases, with 2,3-41 deaths, were
reported. The cases equalled an average annual rate of 36.6 per thousand of strength, the
deaths a rate of 12.2; the fatal cases formed 34.9 per cent, of the whole number. The
cold months of the year w'ere those of maximum prevalence: The maximum in 1864
occurred in March, when 8.04 cases per thousand men was attained; in 1865 a maximum
of 3.57 was recorded in February; in 1866 the highest rate, 9.73, was reached in March.
During the first winter the prevalence of the disease was due to the operation of causes
similar in character to those affecting the white troops; but the contagion had a wider diffu-
sion and found a greater susceptibility to its action among the negroes than among the
whites. The smaller rate of the second winter is the result of efforts to suppress the disease,
while its prevalence in the year following the war gives expression to the carelessness which
arose from anticipations of disbandment.
Xo case of small-pox or varioloid was reported among the 49,394 men of the Confed-
erate Army of the Potomac during the nine months, July, 1861-March, 1862, while 380
cases occurred during this period in the United States Army opposed to it. Small-pox may,
therefore, be considered as having invaded the South during the progress of the war.
The Confederate States Medical and Surgical Journal contains nothing on this subject;
but Surgeon W. A. Carrixgtok, Medical Director of the General Hospitals in the Depart-
not apply to intttanccs in whieli fresb vacciue lrmi<li was used. Surfjeoii General S. Oaklev V.\nderp<»f.l, of Xuw York State, issued an or<K*r, May 12,
18»"il, reijuiring regimental surgeon:? t^» vaccinate their men irrespective of the existence of scars of previous vaccinations. In his report to the Governor,
January S, ISf..!, he states that the spirit of this onler hail Ik'cu generally cumplieil with, and that up to Decemher 1, 1861, n,'i48 men had lieen revacci-
nate«I. His statistics show that 25.0 per cent, of the whole number were fiunit susceptible to the virus. In other worth, one man in jour was liable to
puffer from the contagion of small-pox.
• The previous attack did not in all cases exhaust the susoeptibilitj- of the individual. Surgeon .1. Mi rbav Rocebs. Inspector of tlospit-ils, C. S.
.v., states that his destroyed reconls contained the details of five cases of the disease in nurses who bad suffered from ooutlucnt small-pox in childhood ;
two of t!ie five <i\n\ of the second attack.— .Vo/i™; .oi.l f^ur.jinl MuiMhi, I, Mempliis, Tenn,, ISCO, p. 101.
628 THE EKUPTIVE FEVERS.
ment of Vir"-inia states'-' that the Armv of Xortliern Virginia received the contaoion wliile
in Maryland during the campaign wliich cuhninated in the battle of Antietam, Sept. 17.
1862. In the hospitals under his charge there were treated from October, 1862, to January.
1864, 2,513 cases of variola with 1,020 deaths, giving a death-rate of 40.58, and 1,196 cases
of varioloid with 39 deaths, giving a rate of 3.26 per cent. — the fatal cases thus constituting
28.5 per cent, of the total number. Surgeon Carrixgton says:
From actual observation and investigation at tlie time I can definitely pronounce upon the origin and progress
of small-pox in these hospitals. On Oct. 18, 1862, the first cases were brought to Eiclmiond from Fort Delaware. Up
to that time no cases had been rejiorted here for some months in the army or among citizens. By the 31st of October
twelve cases bad been reported. In carefully tracing each it was determined tliat those from Fort Delaware did not
disseminate the disease, being quarantined and avoided by all : but that soldier.s from the Army of Northern Virginia
had brought the disease to the hosjiitals, aud being unconscious and unsuspected, had exposed many to it before the
diagnosis was made. The army had just reached the vicinity of Winchester after evacuating Marylaud, subsequent
to the battle of Sharpsburg. There were but few cases from the army, and those had not been prisoners, nor had
they seen any returned prisoners. These cases went to Charlottesville, Lynchburg and Richmond, at which jioiiits
the malady spread, but much more rapidly aud extensively at Richmond.
Surgeon J. T. Gilmore of McLaw's Division, corroborates Carriis'gton's account of
the outbreak.f The first case occurred in Anderson's Georgia Brigade, while the armv was
reorganizing in the vicinity of Winchester, after having fallen back from Antietam. The
disease did not show itself in McLaw's command until toward the close of October, wlieii it
appeared in a soldier of the 10th Miss.; but the epidemic did not make much headway until
after the battle of Fredericksburg in December. 'No record of its prevalence has been pre-
served; but that it spread extensively among the troops and the civil population is evident
from its frequent importation into our prison depots by recently-captured soldiers, and par-
ticularly from the facts that have been reported by many Southern medical men concerning
the efforts to suppress the epidemic. Indeed, one medical officer has stated that the Confed-
erate Army was panic stricken by the spread of the disease. |
iSmall-pox was not a prominent disease in the Confederate prisons. The register of the
prison hospital at Andersonville, Ga., covering the period Feb. 24, 1864, to April 17, 1865,
shows the presence of 62 cases of variola, one-half of which were fatal, and of 63 of vario-
loid, 31 of which were fatal. Most of the cases occurred shortly after the establishment of
the prison, the disease having been brought from infected Richmond prisons by transferred
prisoners. The fatality of the cases of so-called varioloid may be- explained b}' the enfeebled
condition of the patients when attacked and their exposure to cold at night during the progress
of their sickness. The subsidence of the disease after its introduction into this crowded pen
must be attributed to the protective influence of antecedent vaccination and revaccination.
Table XVII§ shows the prevalence of the eruj^tive fevers in the tobacco warehouses of Dan-
ville, Ya. Of the 880 cases mentioned 818 were due to small-pox; 144 of these were trans-
ferred to other hospitals, and in 110 cases no disposition is recorded, leaving 564 cases, of
-which 159 or 28.2 per cent, terminated fatally. The number of prisoners confined at this
depot is unknown.
The occurrence of small-pox at Alton, Camp Douglas, Rock Island and other depots in
tlie Xorthern States has already been mentioned. || Some of the difficulties encountered in
attempting its suppression have also been instanced, as the want of facilities for effectino-
isolation, the inefficiency of virus furnished for the control of the epidemic and its rein-
* As reported Ity Joseph Joxes in the Medical Vohtme of the V. S. SioiUarrf Covtnttssiott Memth-s, p. 009.
+ Letter to Professor Pavl F. Eve, .S(. Louis Meilical Ileporler, III, ISCS, p. 466.
X Dr, Bolton, of RiehmoiKl, Ya..— see Stishvillf: Mcdittil Jottfital, I, 1S(j7, p. 277.
^Snpra, page 44. |i .Sf/.m, p.ige 4(j cl .'e-/.
S^MALL-rOX.
629
troduction by successive importations t'roiu tlie Confederate ranks. The following table
summarizes the statistics of the prevalence and fatality of the eruptive fevers among tlie
Confederate prisoners at the principal prison depots:
Tahle LIII.
Showinff the number of cases of (he Eruptive Feccrs and of deaths caused by them among the Confederate
prisoners of war at the principal prison depots for the period covered by the records of each prison.
l^r I fi^L Alton, III., iRocklslnml,; C«ii.p Mor- ( .lohnson's ' Camp CImso. Elmirn, N. Fort Dok- '""'l',"?'''
I r .f .V.'Jvv ^''l'''''"'''''' I11-,F«'I>™- I ton. Iml., IsUn.1, (i., 0.,Fpljrniiiv. Y., .lulv, ' wiiic, D.l.. \."",'' ,"'
■ i,,.., , i.l.In •SW.Io.lnMc, ai-.v, 18i'.4, 10 Jnni-.ISIW. to .Tunc. isas. ism. to' ,18li4,t".lnnp, AuKiist, ISl«. '"''".'. "'"''■
""-''I.'"' lS(r., .Inni', isiifi. .111110.181:.',. tu.lMn.'.lSirv. .Tiiiii>, isr.". isi;:,. in.Iiin.,lsc-,.-. ,""■■'•'"
N,....l 1I1..1JI11- I.,. .1.1,, I...
Mfiin strength prL'sent —
■11
j;,,'ici
:;l 17
1,008 I 0,0311
Xo. tif pris iiuTsn'mniitti'l
o,;«o
7, 027
17
3,570
Sninll-pox
M™.<U-s
Scarlet fever..
Erysipelas —
2,218
8S0
G18
100
1,797
I P|
401 1,190
CO 134
T..T.1I - 4,671
2,032 I 537 il,797 | 436
54S
110 I 11
10,335
, JiW I 298
107 j 13
1
432
!l, 01 0
1,180 3(i» 11,537
130
J5
34S
341 { 40C
74 I 402
4 -.',
101 47
362 1, 308
:T2 I|.033 I
CONSOLIDATIOX OF THE STATISTICS OF THE DEPOTS.
T.it^il la.m-s. T.ital deaths.
Small-iKix .
Measles
Scarlet fevt
Eri'sipelas.
'J, 830
3,473
1.3
4,349
TOT.\L..
10,607
2,024
393
3,453
Average annual rate per ! ,
1,000 of strength. ^i^X'!^',^ Percentage
Deatli-
per I.IJUU
i(liiii.-sioiis.
of fatal
120.4
30.3
0.2
53.3
204.2
32.1
4.8
■20.7
I.").iJ
3.3. 3
9.9
42. 2 I 10. 5
20.8
Clixical and Post-mortem Records. — Notes of the history and progress of .small-
pox cases were seldom recorded. The medical descriptive lists merely identify the patient.
and give dates. Only nine cases appear on the clinical records. The first is one of recovery;
the others were fatal. Death occurred prior to maturation in cases 2 and 3, and during the
secondary fever in cases 4-7; in 6 and 7 there was sloughing of the skin and rdlulnr
tissue; in 5 fatal syncope while the patient was on the close-stool; a mild case of the
disease, 8, became suddenly fatal by implication of the larynx; in 9 the patient at the
time of the attack had the scabs of recent revaccination on his arm.
Case 1. — Private William Coy, Co. I,97tliOhio; age 32; was admitted March 2, 186-1, in the evenins- Xoxt day
he had hiy;h lever ami was somewhat delirious: pulse 80; tongue slightly furred and cracked and very red on the
margin: liowels constipated. The papules were sparsely scattered on the face and were less numerous on the liody.
According to the jiatient's statement three days had elapsed since their first appearance ; the rash aftccted the palate
and caused soreness of throat. A gargle containing acetate of lead and morphia was used frequently: a Seidlitz powder
was prescribed every three hours until the bowels moved : the body was sponged with a solution of three drachms of
acetate of lead in two pints of water. On the lltli the pul.se was 80 and the patient restless, although there was little
630 THE ERUPTIVE FEVERS.
fever and uo ilelirium or Leadacho; tliere had beeu no iiaiu in tbe back,bnt the hips and thighs were very sore ; the
tongue was cleaner but still cracked; the bowels had been moved three times; the ernption was vesicular ou the
face and the jiapules more abundant ou the body and extremities. The most i^rominent vesicles ou the face were
ciiuterized; an effervescing draught was given every few hours and seven grains of Dover's powder at bedtime.
Next day there was a little fever; pulse 88; tongue uearly clean and less cracked; throat still very sore; eruption
jiustular; bowels loose; he rested well during the uight. Two teaspoonfuls of the spirit of Mindcrcrus were given
every three hours : a gargle of thirty grains of chlorate of potash in four ounces of water was used freijueutly; half
diet was given instead of low diet as before. On the 13th he complained of having rested poorly during the niight;
tongue clean; pulse 82; some febrile action; face swollen; throatworse; muscular prostratiou. Seven grains of Dover's
liowder were given every five hours; the gargle and spirit of Mindererus were continued. On the 14th the tongue
was coated brown; pulse 92; eruption pustular; bowels regular; he had no appetite but was very thirsty, and had
not rested well during the night. Five grains of Dover's powder and three of camphor were given every six hours.
He had another bad night and next day some delirium but no headache; jiulse 92; tongue slightly coated; bowels
open ; maturation jiroceeding favorably; the patient had no appetite but was still thirsty; he was quite hoarse but
his breathing was easy. A gargle of a solution of chlorinated soda was used frequently; the eflervescing draught
was taken every two hours. On the 16th he was found to have rested well ; pulse 90; tongue covered with a curdled
whitish coat; less hoarseness; throat feeling better; appetite improved; bowels loose. The eft'ervescing draught was
given every three hours; Dover's powder at bedtime. On the 17th there was little change, — the eruption had quite
subsided on the face and had ,iust matured on the extremities. Two grains of quinine in two teaspoonfuls of whiskey
were given three times daily; the Dover's powder and eft'ervescing draught were continued. Two days later the
erujition was subsiding on the extremities; there was no fever. The patient was considered convalescent anel full
diet was allowed. — Fest-House, Camp Dennison, Ohio.
Case 2. — Private Orange S. Norton, Co. E, 113th 111.; age 21; wasadmitted July 17, 1863, from Lawsou hospital,
St. Louis, Mo., as a convalescent from tyjihoid fever. He was feeble and emaciated and had a jiersisting diarrhoea,
pain in the left side and mucous expectoration mixed with blood. After a time he began to improve, and in Septem-
ber was able to get out of bed. In December he could walk about iu the open air but was easily fatigued; he was
gaining in flesh, although there was still some diarrhwa and pain in the chest. On the 24th he was vaccinated. He
stated that he had never beeu successfully vaccinated and there was no evidence of protection. 29th: Chill; high
fever; jiaiu in head and back; nausea; prostration. 31st: High fever; less pain; slight indication of eruption on
face. Gave Dover's powder; low diet. Jan. 1,18134: Nausea: vomiting; great depression; eruption. 3d: Vesicles
in great number. 4th: Symptoms violent; delirium: indications of conlluence. Sent to small-pox hospital. 7tli:
Died comatose. — Hospital, Qtiincy, III.
Case 3. — Private George Roberts, Co. A, 121st Ohio; age 35; robust and of sanguine temperament ; wasadmitted
March 9, 1864, with the premonitory fever at its height and the eruption aljundant on the face but undeveloped on the
body or extremities. He passed a restless night and on the following day had high fever, headache and pain in the
loins, dry mouth, coated tongue, red and inflamed fauces and palate, and marked conjunctivitis ; pulse 104, full and
bounding. He seemed carcle.ss as to his condition although answering (questions promptly. The eruption on his face
was papular but confluent, the entire surface lieing involved: it was also well developed on the extremities. A
gargle of acetate of lead and morphia was given; an eft'ervescing draught every three hours; nitrate of silver eight
grains, in dist illed water one ounce, was applied by a eamel's-hair pencil over the whole of the face. 11th : Pulse 106,
fulland bounding; tongue disposed to clean; less conjunctivitis; bowelsopen: no appetite; eruption ou iiice becoming
vesicular; throat ulcerating. A gargle of solution of chlorinated soda a drachm and a half, and water eight ounces,
was used and the eft'ervescing draught continued. 12th: High fever and at times delirium; tongue clean but red;
pulse 104; face much swollen, closing the eyes; eruption on the body abundant and confluent, covering the entire
surface; vesicles on the face receding, leaving the surface uearly smooth; bowels loose; respiration deep and easy;
throat much swollen; voice inaudible. He was cupped on the temples and a blister was applied to the neck and
breast; Dover's powder at uight ; gargle and eft'ervescing draught continued. 13th: He had rested better; pulse 136,
feeble and soft ; tongue very red and with a whitish fur in the middle ; face much swollen ; mouth dry; all the mucous
luembrancs near the surface bleeding; troublesome phymosis; eruption stationary; some vesicles on the extremities
and body; tbe patient's voice was gone and he lay quiet. A mixture of carbonate of ammonia fifty grains, opium six
grains, whiskey five ounces and gum camphor a scruple, Avas given in tablespoonful doses every two hours; hot
pediluvia were applied; the body was sponged with lukewarm water and the blister was reapplied to the neck and
breast, it having previously refused to draw. 14th: He rested w-ell during the night; pulse 116, fuller; tongue
parched; lips dry; gurgling iu trachea; epistaxis ; constipation; eruption returning Avithout pustulation; phymosis
aggravated; the blister had not yet acted. The treatment was continued; Dover's powder was given at bedtime;
beef-tea, egg-nog and ice were also prescribed, loth: He had rested well; pulse unchanged; hemorrhage from the
mucous membranes; respiration difficult and stertorous; less fever; swelling of the face, though desquamation was
in progress, leaving a clean and smooth surface; pustules on the hands and feet slowly maturing; eruption on body
again becoming vesicular; the patient picked at his head and bed-clothes; the blister had not yet acted. The treat-
ment was continued. He died at 4 p. M. — Pest-House, Camp Dennison, Ohio.
Case 4.— Private Enos W. Bratcher, Co. I, 3d Ky. Cav.; age 2.5; was admitted March 19, 1864, with tonsillitis,
and transferred to the pest-house April 22 with a free and well-defined variolous eruption. He presented no evi-
dence of vaccination. His gener.al health appeared good, but he became aft'ected with a troublesome diarrhoea soon
after his admission. Dover's powder in repeated doses was prescribed. 2Gth: Eruption confluent upon the face. A
bottle of ale dailv, with chicken diet. 28tb: A mixture of one ounce of collodion and one drachm of tincture of iodine
SMALL-POX. 631
was bruslitnl over the face. May 1: I'ustules uiiiiioious over the entire body: face crusted: fever hiyh, although
the pustules were tilled. Ale, iuilk-i>uueli, egu-nog. chicken and beef-tea were given. 4th: Scab falling from face,
leaving surface raw and red. Stimulants and nutritious diet eoutinued. (>th: Amelioration of syniiitonis: appetite
fair. {<th: Piarrluea. delirium and high fever; toiigueand teeth blackened with sordes. .Stimulants continued. He
died on the lOtli. — .l/ii(/i.««H Uvajyiltil. Iiid.
C.\SE 5. — Private Saul M. MilUiollin, Co. K, 4th Minn., while ou extra duty as cook was attacked Dec. 3, 1862,
with fever and headache. Quinine and Dover's powder were rejected as soon as swallowed. 5th: Severe lumbar pain;
variolous eruption upon face and hands. Gave cathartic pills, followed by (luinine and soda, (ith: Eruption fully
developed. Gave Dover's powder in five-grain doses every four hours; low diet. 7th: Fever subsiding; pustules
forming; heavy feeling in head. 8th: Sore throat: slight tumefaetiou'on right side of neck near angle of jaw: erup-
tion well developed, distinct ; bowels costive. Gave a gargle of two scruples of alum and two grains of sulphate of
morphia in four ounces of water: to be used four times a day. !1th: Right side of face much swollen : eruption nearly
conlluent: pain slight: bowels unmoved. Gave oil. lOtli: Swelling lessened; some pustulation; throat still .sore:
bowels open. Gave acetate of au\iuoiiia, sweet spirit of nitre and ])aregoric. 11th; Swelling subsiding but patient
very restless. Lowdiet. 12th: Patient m<ue comfortable: throat tilled with tenacious mucus ; bowels costive. 13th:
Pustules tilling well; swelling subsiding slowly: no severe pain: bowels costive. Gave senna and rhuliarb; soup
andsagc-tea. 14th: Uowelsopen: pustules running together. IGth: Fainted whileou theclose-stool. and died within
half an hour. — nos}>itiil, (Jiiiiic;/, III.
C.\SE 6.— Private Addison E. White, Co. G, 1st Mass. Cav.; age 28; was admitted April P, 1864, suffering from
diarrhoea contracted while a prisoner after the fight at Bristow Station, Va., Oct. 14, 1863. Ou April 10 he had
fever, headache and pain in the back. 12th: Eruption of variola'; patient very feeble. Gave effervescing draught :
tamarind-water; beef-tea. 14th: Extreme thirst : unable to rise from bed. Gave citric acid water: applied calamine
ointment, l.ith: No passage from bowels for two days; weaker: pustules no fuller than on the 12th. Gave Seidlitz
powder with a double allowance of Kochelle salt : milk-punch; Dover's powder at night. 18th: Pustules umbilicated.
some of au unusually large size. 20th: Secondary fever; delirium; scrotum swollen ami glistening. Gave a lotion
ofacetateof lead. 21st : Scrotum as large as an infant's head, its under portion gangrenous. The patient was rational
for a few hours on this day. He died at 10 i-. M. — JIoD/ulal, JiiiiiqioUsJitnclioii, Mti.
C.vSE 7.— Private AVilliam T. Blackwell, Co. C, IGthMe., was received April 9, 1864, from Belle Isle, Va., where
he had been imprisoned since his capture at Gettysburg, July 1, 1863. He was etnaciated and weak, having lost forty-
five pounds of body-weight during liis captivity. He had sufl'ered from cough, with thick offensive sputa. After
having complained of pain in the head and back for several days he became feverish and a papular eruption appeared
on his face and hands on the 16th. Gave eft'ervescing draught, milk-punch and gargle of chlorate of potash. l(>th:
Eruption fully out, confluent: no fever; patient so weak as to be uuable to talk above a whisper, .\pplied oxide of
zinc ointment. 20th: Dyspnoea. 21st: Dvspnrca increasing; expectoration scanty; tongue dry: lips black ami
parched: sordes on teeth; has refused everything but milk-punch for three days. Added syrup of squill to treat-
ment and Dover'spowder at night. 22d: Respiration and expectoration improved. Took milk-punch and soft boile.l
egg. 24th: Eruption on face drying up; arms and legs swollen; no itching: pustules livid at base: respiration less
embarrassed but patient delirious. 28tli: Gave fluid extract of cinchona. 30th: Cough troublesome: slight diarrhu>a.
May 1: Cough harassing; eight or ten offensive stools during night; expectoration muco-iniruleut and fetid.
Gave of sulphate of moriihia one grain, muriate of ammonia, powdered acacia and white sugar of each half an ounce,
syrup of S(juill two ounces and water six ounces, — a teaspoonful every six hours: also tincture of opium and tincture
of rhubarb of each one ounce, tincture of catechu and compound spirit of lavender of each two ounces, — to take a
teaspoonful every six hours. 2d: Swelling of arms subsiding: skin itching and desquamating; ou each arm were
two dark-colored and boggy patches which, on the right, had run into each other. Applied simple cerate to the limbs.
4th; Patient weaker: patches on arms becoming white in centre. Applied lotion of permanganate of potash. 6tli:
Constantly delirious. 8th : Sloughs of skin and cellular tissue removed from t^w arms. Otli: Rational at times but
unable to speak. Died at 10 .\. ii.—IIosjnlal, AnuapoUs Jiinciioii, Md.
C.\SE 8.— Private ?:zekiel Pounders, Co. E, G4tli 111.; age 24 : was admitted Xov. 20, 1864, from hospital at Camii
Butler, 111., where he had a history of erysipelas, pneumonia and phthisical tendency. On Jan. 31, 186."), he became
aft'ected with modified small-pox, and died February 8 of laryngitis. Until twenty-lour hours before death there
was no reason to a-iprehend a fatal Yc^nlX.—Hmpitu}, Quiiicy, III.
e.\SE 9.— Private Xathan Clingan, Co. A, 125th III.; age 22; was admitted Dec. 2, 1863, from hospital at Louis-
ville, Ky., with an abscess iu the ischio-rectal space, which breaking left an incomplete external fistula. While
under treatment for this he, on the 27th had a chill, followed by fever and pain in the back and limbs, apparently
indicating an attack of varioloid. At this time the patient had on his arm two fully-formed scabs from revaecination
after his admission into hospital. On the 29th the eruption appeared ou the face and the febrile symptoms became
relieved. Next day he was sent to the small-pox hospital. The symptoms were not violent nor was the eruption
confineut. but the patient was depressed. On January 5, 186-t, congestion of the lungs was indicated by increasing
dysputea. Death took place on the Srh.—Hoapitul, Quiiici/, III.
In another case it is claimed tliat successful vaccination failed to protect against a sub-
sequent exposure to small-po.\ ; but the separation of the vaccine crust, which is instanced
in proof of the success of the vaccination, occurred at so early day as to suggest a doubt
concerning its true character.
632 THE ERUPTIVE FEVERS.
Private Joseph T. Bates, Co. E, 24tliX. J.: age 23; ivas admitted Dec. 18, 1862, with chronic rheumatism, from
■n-bich he had partially recovered -vvheu, on Jan. 11, 1863, he was taken with an acute attack of articular rheuma-
tism. On the 16th. beiu," considerably relieved from pain, he was vaccinated along with the other inmates of the
ward. He continued to improve in health. The virus took well in his case and in seven other cases. He was exposed
to small-pox two or three days after vaccination. On the 28th he was taken Avith all the premonitory symptoms of
the disease, and ou February 1 was sent to the small-pox hospital. The seven other successful cases had a similar
exposure to the variolous poison hut have thus fiir escaped. That the case was one of successful vaccination there
is not the least doubt, the scab falling off on the first day of the attack.* — Satterlee Rospital, PMladelphia, Pa.
Post-mortem appearances were noted in the two cases wliicli follow:
C.\SE 1. — Private Henry C. Thurman, Co. C, 6th Iowa; age 2G; was admitted Feb. 4, 1865, with coryza. cough
and slight fever. During his stay in hospital he had some obscure symi)toms which, culminated in a chill followed
by suppuration in the glands of the left groin. These were open and discharging when, on April i, he complained
of great pain in the back and loins. An eruption appeared on his forehead on the 10th and spread during the next
two days over his abdomen, back, legs and arms: his pulse was accelerated and weak; stomach irritable and general
condition low. On the 11th there was epistaxis and vomiting of blood, sordes on the teeth and increased frequency
of jnilse, 130. He died next day, the vomiting continuing to the last: blood was passed from the bladder shortly
before death. Fost-moylem examination fifteen hours after death : Eigor mortis slight ; cellular tissues full of serum ;
eruption slightly umbilicated. The lungs were congested posteriorly. The heart was flabby, its right side and large
vessels filled with liquid blood and some soft and reddish-brown clots. The liver and spleen Avere softened. The
solitary follicles were iirominent and on puncture exuded a whitish serum; those near the ileo-csecal valve presented
a distinct black spot in a central depression. The kidneys appeared normal but the bladder was filled with blood. —
Doiiylas Hosjtital, Washinyton, D. C.
C'.vSE 2. — Private Oliver Conkling, Co. H, 1st N. J. Admitted Feb. 15, 1868. Diagnosis: small-pox. Died on
the 17th. rost-mortem examination five hours after death: Xo rigor mortis; age about 25; body completely covered
with pits. About half an ounce of pus was found under the arachnoid on the left side, and this membrane ajipeared
thick, white and opaque over the pons Varolii. The bronchial tubes and parenchyma of the posterior parts of the
lungs were congested. The-heart was firm and contained white fibrinous clots in all its cavities. The liver weighed
ninety-four and a half ounces and was firm and mottled ; the gall-bladder contained scarcely a drachm of dark bile;
the spleen was flabby and light-colored. The stomach was slightly contracted; the duodenum congested and its
mucous membrane thinned; the jejunum healthy; the valves of the ileum were thin and in some places nearly
destroyed, its solitary follicles slightly enlarged and its agminated glands somewhat congested in the upper third : the
large intestine was dilated. The kidneys weighed each eight and a half ounces and were dark and firm: the left
contained a small cyst. — Lincoln Hospital, Washington, I). C.
References to small-pox in special sanitary reports are of rare occurrence.
Snri/eon W. W. Brown, 7th N. H., St. Augustine, Fla., May 1, 1863.— -We were obliged to keep our small-pox
patients in tents on the island (Tortugas), exposed to the rays of a hot sun during the day and to the heavy dews
which were always present during the night. No doubt the fatality was much greater than it would have been under
more favorable circumstances and in a cooler climate. In the treatment the supporting plan is the only judicious
one. During the filling of the pustules, in all severe cases, the drain from the system is so great as to cause serious
apprehension of the sinkingof the patient from exhaustion : during the stage of maturation he needs an abundant and
nourishing diet, with a liberal allowance of good wine, ale, porter or brandy. This disease, when uncomplicated,
requires no medication except an occasional anodyne to allay nervous irritation and procure rest.
Surgeon Xi.i.B'S i'. Peck, 1st X. AT. Mounted Vols., Fort Stanton, Xew Mexico, Dec. 31, 1862. — The idea occurred
to me that if the initiatory fever could be subdued it might possibly have the effect of les.sening the subsequent erup-
tion. I therefore resolved to treat the cases with tonics from the connnencement and cut short the fever if possible.
Twelve cases were treated ; bnt of this number only four were seen at the beginning of the attack. The first patient
I saw had suffered from a confluent eruption for many days before he was brought in, so that I had no opportunity to
test the method in his case, which terminated fatally. The jecond was seen about two hours after the commencement
of the fever; he was suft'eriug from intense pain in the head, back and extremities; very high fever; pulse strong,
full and frequent; skin hot and dry; tongue slightly coated and bowels confined. I at once gave him fifteen grains
each of sulphate of quinia and compound extract of colocynth. In the evening he was free from both fever and pain.
At this time there was no appearance of eruption, nor was it developed until nearly twenty-four hours later. As the
eruption advanced I gave small doses of quinine and a cayenne gargle, with good nourishment. The case jirogressed
favor.ably. This treatment was adopted in the three other cases and similar results followed; it was used also in the
cases that were not seen at their inception, — a number of these were confluent but all jirogressed favorably.
Medical Inspector F. H. Hamilton', T. S. A., Xashvillc, Tvnn., April 30, 1863. — Erysipelas, abscesses and mumps
are common sequehe of variola, and the two former comiilications often jirove fatal.
* Ass't Surgeon T. C. W.illace, 033 N. T., has recorded— jlmericon Medical Times, TV, K. X., 1SC2, p. 122— the case of a man in his command who,
although showing the scars of two successful vaccine operations performed in childhood and again in ISoS, was successfully revaccinated Dec. 24. 1801.
The vesicle was fully formed, large and well tilled ; yet on Jan. 8, 1SG2, high fever was developed aud two days later the pjitient was covered with the
eruption of variola. The matter used in his case came from the Eastern Dispensary, 2vew Tnrk City, and ^^-as perfectly good, as shown by its effects oa
otlier members of this man's company.
SMALL-POX. 6
Surgeon Thomas M. Cook. lOlst Ohio, ttcar MiirJ'recsboro, Tcnn.. Jan. 12, 1863. — Into ,a solution of the virus
ilip the end of a double thread already in a coininou sewing or surgoon'.s needle, and introduce the needle as dee]) as
the cutis vera, drawing it through till the part wet with the vims conies into the wound, in which it is left to admit
of absorption. The irritation of its presence increases the circulation to the part as well as absorption from it. This
made the virus eli'ective iu many cases which had previously resisted the common modes of insertion.
Charles P. Lute, Act. Ass't Surgeon, Satlerlce Hospital, Philadelphia, Pa. — On Dec. 20, l«(i2, a case of small-
pox occurred in my ward. Headache, pain in the back, high fever aud sore throat were followed on the 23d by the
eruption. I vaccinated the patient along with !<3 others present in the ward. The virus from a primary vaccination
was used and not, as I fear is too fretjuently the case, that of a rovaccination, which should never be used. The
small-pox case was removed from my ward. I believe his vaccination'was unsuccessful. Of the remaining 83 cases
(! primary vaccinations and It revaccinations were successful. Twelve of the successful revaccinations occurred in
men who presented well-marked scars of the primary operation. From this it will be seen that revacciuation is
essential, and that the existence of a genuine vaccination scar is not a sufficient guarantee against small-pox. None of
the inmates of the ward contracted small-pox from the case in question.
Surgeon Ezka Read, 2l8< Incl., Locust Point, near Ballimorc, Md., Oct. 7, 1861.— One case of variola occurred during
the mouth, *ontractcd from exposure while on detached duty at Washington. At the time the patient cauu) into
hospital it was not known that he had l)een exposed to the contagion of variola, and con.sequently no precautionary
measures were adopted. Nausea, vomiting, pain in the head and other premonitory symptoms were not sufficiently
pronounced to arrest attention or indicate the character of the disease; and as the wards of the hospital were much
crowded at the time, he was assigned a bed iu the main hall leading to all the wards, where he remained during the
febrile stage and until the appearance of the eruption removed all doubt concerning the nature of the case. In this
location he was constantly passed by convalescents, hospital attendants and visitors, most of whom were unprotected
by vaccination. After that he was removed to a separate room in the hospital, where he remained for thirty-six
lioujs: thence to a tent in a secluded spot and subs<'t|uently to the Marine hospital on t lie opposite side of the Pa tapsco
river. He is now convalescing and thought to be out of danger.
It is an interesting fact that no one thus exposed to the disease w,as infected. This may be regarded as indicat-
ing the absence of contagious qualities during the stage of pyrexia aud incipient eruption.*
Treatment. — Tlie records of the treatment of small-pox are meagre. Iu mild cases
little was done other than to protect the patient from injurious influences. Laxatives, salines
and Dover's powder were generally used during the period of pyrexia, with tonics, stimu-
lants and concentrated nourishment after the subsidence of the socondarv fever. Surgeon
D. W. Hand, U. S. Vols., reported from Xew Berne, N. C, in 1S64, that the Sarmce.nia
purpurea, whieli grew in great abundance in the vicinity, had been faithfully tried during
a period of two months, and that no beneficial effect could be ascribed to its use. Some
external applications were employed to allay cutaneous irritation and prevent subsecjuent
pitting. Generally these consisted of cooling or astringent ointments; creasote in olive oil
and iodine in glycerine were also used for this purpose. Intercurrent laryngitis, pneumonia,
erysipelas, abscesses and gangrenous sloughs were treated on general principles, having in
view the condition of the patient's system as well as that of the affected tissues.
John E. McGirk, of Latrobe, 111., in a communication, Aug. 21, 1863, invited the
attention of the Surgeon General to the success which attended his use of chlorate of potash
in preventing suffocation during the maturation of small-pox. This subject liaving been
referred for investigation and report to Act. Ass't Surgeon R. T. Thomas, in charge of the
small-pox hospital at Washington, D. C, the following was rendered:
I have found great difficulty iu aflbrdiug relief to the syiuptoms of suffocation during the maturative stage of
the disease arising from the presence aud formation of pustules on the tongue, cheeks and fauces of the patient. For
this unpleasant aud dangerous condition I have been in the habit of using the chlorate of potash as a gargle, with
no precaution against swallowing it. I have at the same time given it internally in eight-grain doses every four
hours. In every case 1 have directed the free use of lemonade, and when the patient preferred it, I have ordered a
lenmu, which has been sucked with apparent satisfaction. The result of this treatment has been to afford relief in
almost every case.
I am not prepared to ascribe prophylactic powers to the chlorate of potash in the treatment of the kind of cases
referred to by Ur. McUikk. It has been undoubtedly beneficial taken internally in small-pox when the patient had
* Surgeon S.vxford B. IlrxT, U. S. VoK, is reported by Dr. El,isi[.i H.\RRi!i, in his article on Vaccination, V. 5. S<tiiitarii Commisfioii Memoirs, p.
149, .IS bavins written. —"^niaU-pox is not contagious in its early stages. If tiie patient be secluded at tlie earliest perioil when the disease can be recog-
nized by the scientific eye, another and an unprotected person can sleep in the same bedding with very little danger. We have seen this tested on a
large scale.''
Med. Hist., Pt. Ill— 80
634: THE ERUPTIVE FEVERS.
been ijreviously reduced to a low condition by other causes, as rbeuinatism, typhoid fever and dysentery; but while
such has been the case, I have been compelled by the urgency of the symptoms to resort to the frequent use of the
probang, moistened with a strong solution of nitrate of silver, for the purpose of removing the accumulated and
tenacious mucus which immediatelj- endangered life and which the patient bimself was unable to remove, — this
state of things occurring frequently when the chlorate of potash had been used internally as above stated.
The result of my observation of the etticiency of this salt has led nie to the conclusion that, like saline cathartics
and stimulants, it is a reliable adjuvant in the treatment of small-pox and nothing more.
UNTOWARD RESULTS OF ATTEMPTED VACCINATION.
The 231'eseiice of small-pox among the troops raised a demand for vaccine virus ■\vhich
was supplied in the form of crusts by the medical dispensaries in the Northern cities. This
stock was wholly from infants, and each crust was accompanied by a certificate bearing the
name of the dispensary, that of the child from whom it was procured and the date of its
removal. A small percentage of the virus used was furnished by Dr. Ephraiji Cutter of
Massachusetts, who raised crusts from the calf by vaccinating with humanized virus.
Dr. Cutter, indeed, appears to have claimed that some of his crusts were propagations from the natural or
spontaneous cow-jjox. The following report of an inspection by Surgeon J. J. Milhau, U. S. A., April 4, 1865,
describes the methods by which the animal virus was procured;
I reached Woburn, Mass., March 30, and called upon Ephr.\im Cutter, M. D., who expressed his readiness to
afford me every facility for investigating the siibject. As my visit was entirely unexpected there was no opportunity
to make preparations that might have given me wrong impressions. I accompanied him in his rounds and vfsited
stables in Lexington, Lincoln, North Woburn, Jamaica Plains and Brookline, personally inspecting the condition
of over lifty head of cattle: twenty-nine, mostly cows, had been vaccinated and the loosened crusts were collected
by Dr. C. in my presence, after which I assisted him in vaccinating fifteen other cows. All the cattle vaccinated were
of good stock and healthy appearance, well fed and kept in clean, dry, well-ventilated barns.
The ''natural spontaneous kine-pock" occurs but seldom in the cows of that district of country. Occasionally
the doctor's attention has been called to vesicular eruptions on the teats of cows with their second or third calf: he has
vaccinated other cows with the virus taken from these vesicles, but, until recently, he has failed in producing the
vaccine disease in this way. He is led to believe that cows are subject to eruptions on the teats which are not always
kinepox, or that the vesicles are broken in milking and rendered too imperfect to communicate the disease. The virus
which he has been using in vaccinating cattle for the propagation of crusts was originally taken from a child.
Some three weeks ago Mr. Jewett, a farmer near Lexington, noticed a vesicle on the teat of one of his cows with
her third calf. Dr. Cutter being informed of it took virus from the vesicle and introduced it into another cow, pro-
ducing a characteristic vaccine vesicle, and with the lymph from this second cow Mr. Jewett and a heifer were vacci-
nated. I saw them both. The fanner had two fine vaccine vesicles on the arm and complained of a little constitu-
tional disturbance; he had been vaccinated in early life. The heifer had a characteristic scab nearly ready to be
detached. I think there is no room to doubt that this was actually the },ine-2>ocl'. The original cow with the scar
on the teat, the second cow with a fresh cicatrix and the heifer with the scab were all in the same stable at the time
of my visit.
Early in March Dr. Cutter found a case of spontaneous cow-ijox in a cow with her second calf; the virus was
tested by vaccinating two cows on Tuffs farm in Lexington and obtaining characteristic vesicles and scabs. I
enclose herewith a specimen crust of the natural and spontaneous cow-pox. I examined twelve cows that had been
vaccinated with this matter, and the crusts on them had the same appearance as that on the heifer above referred to,
and did not differ from those on the cattle vaccinated with the virus reproduced from the child.
As the doctor now expects to furnish crusts produced by matter from the ''natural and spontaneous" cow-jiox,
I reconuuend that he should put them up separately and mark them so that they may be known to the department:
and I respectfully suggest that when received they may be issued to such officers as will give them a fair trial and
report tlie result.
In vaccinating the kiue Dr. Cutter uses the lymph taken on the eighth day, or the crust collected on the
twelfth or thirteenth day and rubbed down with a little water to the consistency of cream. He objects to glycerine
T)ecause a physician in his neighborhood had the misfortune to spread phlegmonous erysij)elas among tile jjatieuts he
vaccinated, a result which was attributed to some chemical change in the glycerine. In selecting matter for propaga-
tion he is necessarily very careful, as he holds himself responsible to farmers for the value of the cattle should they
be injured in the operation; — this I considered a good guarantee for the purity of the virus used, particularly as the
farmers are not entirely free from prejiidice on the subject.
In vaccinating, fifty to seventy-five insertions of virus are made in the hairless spaces under the tail, about the
perinipumand in the commissure between the hind legs; but more than half of these fail to take. A cow with seventy-
five punctures will probably not give more than fifteen or twenty perfect crusts ; indeed, in some cases I saw but four
or five good scabs. About 2 per cent, of all the kine vaccinated refuse to take the disease, being probably protected
by having had the natural pock. The crusts, which are fully formed and ready to be collected on the twelfth or
thirteenth day, fall off by the fourteenth. The scabs vary much in size not only in different animals but in the same
•SMALL-POX. 635
iiulividiiaL In collecting; the ci lists such as are perfeeily t'urnieil are taken ; those that have lieeu ruliheil or scratched
show a peculiar lustre ami are rejected: hence to obtain a nnnilier of jimnX crusts vaccination should be performed
during the season of the year when the cattle are kept quiet in stables and arc not annoyed liy insects. Each crust
is put up in wax; this is a nice operation, as the heat used to cause adhesion must be so moderate as not to injure
the virus. A tin canister tilled with water of the proper temperature answers the purpose.
Lymph is collected on the eighth day by means of a capillary glass tube which is afterwards hermetically sealed.
In conclusion I would state that Dr. Cl'ttek devotes much of his time and attention to the subject, and per-
sonally attends to all the details: the only assistance he receives is from his wife in putting tip the crusts.
About a year later, in April, 1866, a circular was issued from the. Office of the Surgeon General, U. S. Army,
requesting information on the extent to which vaccination had been practiced during the previous six mouths, the
source or sources of the virus used, and an expression of opinion as to the relative value of bovine and humanized
virus as well in their protective intlnence as in the degree of constitutional disturbance produced by each. Reports
were tiled by one hundred and four medical office rs, but the evidence obtained, particularly that bearing on the relative
value of the huuumized and liovine matter, was by no means conunensurate with the number of witnesses. ICiglil
medical officers stated definitely t heir want of experience of matter deri ve<l from the eow ; sii-ciity-foiir gave no opinion
ou the relative merits of the two kinds of vaccine crusts: eleven preferred matter from kine: »iiie from man, and (ico
had no predilection. Three of those who preferred the bovine vaccine acknowledged at the same time that the prefer-
ence was not based on personal experience: and few of the others who expressed a similar prelereuce could bo said
to have had a large experience. ."Surgeon Joiix E. .Sv.mmeks, U. S.A., was perhaps the only exception. While medical
inspector in IfSOo-ti.") he paid attention to this subject, and grounded his preference on the fact that sloughing ulcer-
ations and glandular suppurations had never been in his experience traced to the use of matter from the cow. Of the
nine otiicers who preferred humanized matter not one appears to have had more than a few cases of vaccination with
the cow-crust: thus. Act. Ass't Surgeon K. II. LoNOWii.i., Fort Wingate, New Mexico, who objected to the virus from
the cow ou account of the severity of the local and con.stitutional effects, had used it in only three cases. The two
officers who had no predilection appear to have based this opinion on tfie utter worthlessncss of the tested crusts
whether said to have been derived from the cow or from man. In fact the majority of these reports indicate a want
of success in vaccinating: eleven only speak of a reasonable ajnonnt of success attending their operations. This
failure was ascribed l)y some to the protection of previous vaccination and by others to a want of activity in the
matter. Those w ho arraigned the ijuality of the matter did so on account of subsequent successful vaccination with
matter from private sources; or, iu a few cases, on account of the subsequent occurrence of small-pox in those who
had been subjected to the operation. Ass"t Surgeon C. C. Gk.w, U. S. A., who distributed both kinds of crusts from
the office of the Assistant Surgeon General, considered that the results in both cases were equally unsatisfactory.
He was of opinion that much of the kine virus used was spurious. Ass't Surgeon C. 15. White, U. S. A., who, as
acting medical purveyor, distributed virus from New Orleans, La., regarded that from kine as less efficient, perhaps
on account of want of care in imtting it up.
Ill the Eastern armies during the war no bad effect followed the general use of these
humanized or bovine crusts; and, according to Surgeon Saxford B. Hunt, U. S. Vols.,
vaccination in over 16,000 cases in the I^orthern Department proved harmless or effective.
But in some of the "Western Departments there occurred unexpected and untoward results,
which were ascribed by some observers to a scorbutic or otherwise impaired condition of
system and by others to an impuritv in tlie virus, its contamination with the poison of
syphilis having even been asserted.
Medical Iimjieetor N. S. TowxSHEKD, U. S. J.. LouinriUr, Kij., May 9, 1861. — Vaccination had in a majority of
the regiments been thoroughly performed, but either from the bad character of the virus or the condition of the men
the sores proved to be exceedingly troublesome.
Surgeon C. Allf.x, \st Mo., Port Hudson, La., Feb. 24, 186L — Those men of the conimaiid not previously vacci-
nated were vaccinated at Benton Barracks in the month of January, 1861, with virus obtaijifd from the medical pur-
veyor at St. Louis. In at least one-half the cases a phlegmon of greater or less size was developed instead of the
characteristic vesicles: some are still sutVering from these irregular inllamniatory results.
Surgeon W. H. GniMKS, 13*/i Kansas, Fort Smith, .Irl:, August, 1861. — Owing to some peculiarity of constitution
or climate, or from filthy habits, a great many citizens of this part of Arkansas are afflicted with obstinate diseases
of the skin. Many of them have a kind of scabies or itch of an aggravated character which has aftected then: for
years: others have scaly eruptions ou dift'erent parts of the body; others again have old indolent ulcers or eruptive
diseases of an anomalous character. On the advent of our troops many of these persons were suftering from what
they called kinc-pock, having been vaccinated by some surgeon for that disease. Whether the surgeon who vacci-
nated them used the genuine vaccine virus or the old skin diseases so modified the vaccination as to change its char-
acter I am unable to determine. The result of this vacciaatioii or rather inoculation was in many cases a violent
erysipelatous inflammation with deep abscesses, destroying the subcutaneous tissues and burrowing under the muscles
of the parts aftected, producing serious constitutional disturbance. Nor was the site of the inoculation alone a fleeted;
the disease showed itself iu other parts with the same violence. Active antiphlogistic treatment usually subdued
(536 THE ERUPTIVE FEVEES.
the iuriamiiuition. leaving foul ami ill-comlitioned sores, which resisted almost every method of treatment fur inontlis.
A few of those thus afflicted became cripjiled in their arms.
- Many of the men of this regiment, without consulting the surgeon, had themselves inoculated with the matter
of these nondescript sores. The consequence is that all who have been thus inoculated have been unfit for duty for
weeks and mouths. When the disease did not affect the deeper tissues it spread over the surface, i)roduciiig ulcers
which in appearance and character very much resembled chancres. Indeed, so completely did they fill the charac-
teristics of this disease that several surgeons did not hesitate to say that the patients had been inoculated with syphilis.
Large and unliealtby ulcers, witli swelling and suppuration of the axillary glands,
observed in some of the regiments serving in the Department of the Cumberland in June,
1S63, were ascribed by Medical Inspector F. H. Hamilton to the existence of a scorbutic
taint. '■■ In the autumn of the same year similar results followeil vaccination in the encamp-
ments around St. Louis, Mo.; but in some of these, as in the 9th Iowa Cav., the men were
in vigorous health and free from scurvy. Surgeon Ira Russell, U. S. Vols., reported as
follows concerning tlie results of attempted vaccination in the wards of the hospital, Benton
Barracks, Mo.:
About the middle of December, 18G3, the patients were vaccinated in the following manner: The surgeon in
charge directed Dr. Kluber, the acting assistant surgeon in charge of AVard E, to vaccinate the patients of his ward
from the arm of a patient who appeared to have at that time — the eighth day from his vaccination — a genuine vac-
cine vesicle. The duty was performed as ordered and the vesicle was excessively drained. Next day the same man
was ordered into another ward for similar service, with his then irritated arm. and all the occupants of that ward
received a charge in their arms of what was jiresumed to be vaccine lymph. On the third day the same man was
taken into another ward and lent his intianied and now purulent vaccine sore to the patients there. This M-as the
tenth day after his vaccination. In successive days he was still kept moving through the remaining wards for the
same unfortunate service to his comrades.
No bad result followed the vaccinations in Ward E, and, as subseiinent inquiries proved, no abnormal result
was produced in any arm except in the men who received inoculation from the purulent matter which the constantly-
tea.sed vesicle and sore supplied after fifty or more arms had been vaccinated. The greater part of all who were vac-
cinated after the first day, or the eightli of the stock vesicle, suffered much from local inflammation, obstinate ulcer-
ations and lymphatic inflammations and swellings. Suppuration frequently ensued in the axillary region, and in
some instances there were severe constitutional symptoms resembling those of pyipmia. Ecthymatous eruptions
appeared upon the vaccinated arm and elsewhere, and when that class of pustules degenerated into open sores the
edges were ragged and the ulcerations were exceedingly obstinate. These characteristics led several of the surgeons
to conclude that the morbid phenomena were attributable to syphilitic inoculation.
Shortly after the occurrence of the events thus recorded sraall-pox spread through the
wards of this hospital, and while it spared all the inmates of AVard E, where the first day's
work of vaccination had been performed, the other patients — even those worst scarred and
ulcerated bv their recent inoculation — became nflfected and were transferred to the small-pox
hospital. Dr. Elisha Harris has published several of the eases that occurred at this time.f
The cases of spurious vaccination in the Department of Arkansas in 1864 were derived
from the outbreak at St. Louis, Mo. Medical Director Joseph R. Smith thus i-efers to them :
The vaccine virus furnished to the army was very unsatisfactory in its results. Very many vaccinations were
unsuccessful, and some produced spurious sores followed by constitutional effects. The first cases of spurious vacci-
nation coming under my notice occurred in the persons of recruits vaccinated at Benton Barracks and arriving in
this department in May. Soon after, however, vaccinations made in the regiments in the department were followed
by evil results, viz: Ulcers at the seat of inoculation and its vicinity varying in size from that of a dime to that of a
dollar, difticult to heal, with hardened edges and resembling, excejit in size, the indurated syphilitic sore. After one
or two months these ulcers were followeil l>y constitutional effects, sometimes glandular enlargements, always debility
and symptoms of a general cachexia.
I was at first of the opinion, from the appearance of the sores, that they were the result of syphilitic inocula-
tion. Further oViservation, however, failed to eonnrm this opinion. The history of the cases was not in detail the
histoi'y of syphilis, nor was the amenability to treatment identical : mercury was far from being a specific, and in my
observation the most successful treatment consisted in the use of iron, particularly in the form of iodide. Iodide
of potassium failed to cure, though in combination with iodide of iron it seemed to accelerate and add to the efi'ects
of the latter. In some cases change of scene and air alone seemed to have the desired effect, and cases that resisted
all treatment here si)eedily recovered on returning to their homes.
Owing to the reported svphilitic character of the vaccination sores at Benton Barracks
*/H/m, page 690. +I:i his Jiapcr oil I'accinafion in Oie Armif, in tlu- l\ S. Siinifury ComtriuisloH Memoir^ pp. ]45-14S.
SMALL- POX. 637
ti committee, with Dr. Hammer of St. Louisas chainnan. was aj^ijoiiited to investigate tliiMv
nature. The anouuilous results were not regarded as due to the infection of syphilis.
Dining tlip inogies.s of the investigation ninny ca-ses were examined — more than 200; they were stripped and
examined thoroughly and notes taken in eaoli case. Spreading and indurated sore.s existed in all ; hut none had any
symptom of secondary syphilis. The onl.v ahuornuil condition was swelling with induration of the axillary glamls.
In secondary s.vphilis the glands are indurated hut seldom suppurate. The sores existed in two forms, — abscess and
eczema. The latter is a disease easily produced; in some individuals slight causes will occasion its development.
The committee concluded, from the examination, that the condition of the patients was produced principally by
irregular and im))roper vaccination and exercise. Many of the soldiers vaccinated themselves, using for the purpose
rusty pins, irregular incisions, etc., and while the vaccination was progressing they went to drill, exercising the
arms. Eighty to one hundreil negroes under the charge of Dr. RrGE were affected in the same way; they werestout
and healthy, but the undershirts with which they were supplied were too narrow for the arms and kept upirritation
by friction. The treatuu^nt in these cases was simply to cut the undershirts and n.se lead-water: in eight days the
sores were healed ; yet these cases had been pronounced syphilitic. Many of the cases examined had been placed
under spccilic treatment; this was ordered to be discontinued and all got well.*
Ass't Surgeon Gkorge 0. Smith, 53d 111., reported the occurrence in December, 1863,
of thirty-one cases of vaccination presenting unusual characters at Convalescent Camp,
Fourtli Division, Seveuteenili Army Corps, Hebron, Miss. The virus was taken I'rom the
arm of a man of dissipated habits. The ulcerations on the arm and forearm had the appear-
ance of chancres; small, hard, red pimples were observed on the face and back; the axillary
glands suppurated, and most of the eases were affected with inflammation of the conjunctival
and Sclmeiderian membranes.f
Surgeon Utteksox. U. S. A'ols., recorded anomalous results in the ISth Ind.J Three
hundred men were vaccinated from the crust of a tardv and irre<i;ular revaccination on the
arm of a convalescent from typhoid fever and pneumonia. This man, subsequent to the
removal of his crust, had some rheumatic trouble and loss of power in liis arms, but no
cutaneous disease. Eighty of the men in whom this undesirable matter was implanted
suffered, after several weeks of latencv, willi ulcers of the arm, congestion of the i'auces and
painful affections of the joints and bones. Dr. Otterson attributed these results to syphilitic
inoculation, and in explanation assumed that the typhoid convalescent was suffering from
chancre while his revaccination was in progress; but, as the regiment, during the two months
succeeding its vaccination, marched three hundred miles in rainy weatlierand througli mud
and swollen streams, sore throat and rheumatic affections might have resulted from these
exposures, while the deteriorated condition of the men might be held to account for local
manifestations following the insertion of a non-syphilitic but morbific matter.
Surgeon George H. Hubbard, U. S. Vols., Medical Director, Army of the Frontier,
reported, November, 1863, the disablement of about five hundred men, mostly belonging
to the 1st Ark., by virus taken from the arm of a deserter from the Rebel army. A Board,
convened to investigate the nature of the inoculated disease, reported that —
Soon after the operation was performed the points at wliich the matter was inserted conuucnced (o itch and
inflame, and by the second or third day i)ustules were formed of a yellowish color, which rapidly increased in si/e
anil in a few days burst. In some a scab formed, but in all, by the tenth day, open ulcers yielding a thin ichorous
discbarge, were developed.
.\t the time we examined the patients some had well-marked llunterian chancre; some had large excavated
ulcers with elevated edges, Imt with little surrounding induration, — the centres, wlien not recently cauterized, were
of a brownish hue; — some, whose primary ulcers were about healed, liad secondary symptoms, such as swelling and
ulceration of the glands in different parts of the body, while otliers had pain and stiffening of the .joints.
The disease was brought to the 1st Ark. Vols, by deserters from the enemy, and in our opinion it is syphilis.
Dr. Hubbard concurred in the opinion of the Board, and reported as follows:
I have no reason to believe that in any one case did this virus produce a true vaccine pustule or had any of
•See hUciwinH o» Vticcinatioti^ St. Loiii:! 51wlical .Society, .S/. Lotm Metlirnl and StirtjictitJoiinmU 11, 18G.% p. 328.
f nicod': Mnlictil f>aiumiT. V, 1SI"4. p. 21S. } American MciUcal Timei', VI, New York, LSKi, p. 20".
638 THE ERUPTIVE FEVEKS.
the protecting power of vaccination. The ulcers all possessed, in a greater or less degree, the ■well-established pecu-
liarities of venereal chancre, being of a specific and progressive nature, spreading in some cases to the size of a dollar,
but generally about half that size ; commonly round in shape, Imt often irregular and usually of the depth of the true
skin. All had ragged, elevated, indurated and overhanging edges, little sensitive to the touch or even to caustics,
while the bottom of the ulcer (especially under these, indurated edges) was excessively sensitive. All discharged
dark ill-conditioned pus, which in many cases caused painful excoriation of the surrounding skin, and when trans-
ferred to other parts of the body reproduced ulcers like the original ; in this way chancres were developed on the
penis in several eases.
Cases precisely similar occurred in the Indian Brigade stationed at Fort Gibson in the Cherokee nation. Act.
Ass't Surgeon Miller, on duty at that post, reported as follows: — A private of the 1st Indian Home Guards, who had
been successfully vaccinated by me in March, 1863, and afterwards taken prisoner by the rebels, was. in spite of his
protestations, inoculated by a rebel surgeon, producing a syphilitic ulcer. Private Johnson, of the same regiment,
who had previously had small-pox, was inoculated, at his own request, with the same virns, and his ulcer presents
the same characteristics, except in extent, as those not so protected.
Moreover, these ulcerations have spread among the people to an alarming extent by .self-inoculation. In a large
proportion of the cases consecutive symptoms have appeared, — suppuration of the lymphatic glands in the axilla,
sore throat, exanthematous eruptions, &c. The cases occurring among the troops have received the ordinary treat-
ment for syphilis and generally with excellent results.
The mischief was widespread before the true character of the disease was recognized, so that few cases have
had prompt abortive treatment, and many are, in consequence, permanently disabled. Nearly every case has required
constitutional treatment in addition to local treatment of the chancre. The milder caustic applications proving
insufficient in many cases, acid nitrate of mercury was used to clear away the indurated edges, when the ulcer usually
healed rapidly under mildly stimulating applications.
But when these cases are considered in connection with those at Benton Barracks, and
particularly with those common at that period in the South, some hesitation is naturally felt
in pronouncing them to have been of a syphilitic nature.
Untoward results of vaccination appear to have been at one period the rule rather
than the exception among civilians as well as soldiers within the Confederate lines, — so much
so that for some time after the war the people, and in some instances even physicians, mani-
fested a fear of resorting to this protective measure.* The subject was investigated by a
number of medical officers whose reports were unfortunately destroyed at the capture of
Richmond, but much valuable material has been preserved in journal articles published since
the war by Jones, Habersham, Greene, Gilmoee, Stout, Bolton, Ramsay and FuQUA.f
When small-pox broke out in the Army of j^orthern Virginia at Fredericksburg, Va.,
in 1862-63, a general vaccination was ordered. In its progress the number of cases of
spurious vaccinia became alarming as affecting the strength of the army. It was reported
by General Lee's Inspector General that when the battle of Chancellorsville was fought in
May, 1863, as many as 5,000 men were unfit for duty because of disability arising from
vaccination. Numbers of these were sent to general hospital; many of the lighter cases,
retained with their regiments, continued in a disabled condition for several weeks, the ulcera-
tions Avhich followed the insertion of the virus showing no disposition to heal. Surgeon
Etheridge of Dale's Brigade, reported 332 cases. Inflammation began within twenty-
four hours after inoculation; a vesicle appeared in two or three days, but in some instances
* Wm. a. Greene, in his paper cited in next note, says : ''In the large cities provision is made for the Taccinatiun of tJie inhabitants, but in the
smaller cities and villages and in the country thei;e is not only no such provision made but the people, and in many instances the physician, manifest a
total disregard for, and even fear of, applying this only sure preventive of the disease. It is not uncommon to hear people say, when urged to be vac-
cinated, that they 'prefer small-pox to the risk of vaccination with spurious matter'; and they refer you, perhaps, to our soldiers, who sntfered so much
from vaccination ; and that they knew such an one who had contracted small-pox when vaccination had produced a tretnetidous sore!"
t Researches vpoii "Spurious TWci/ifl/iOH," or the Abnormal Phenomena accompainjing and foUotring Vaccination in the Confederate Army daring the recent
American Ciril War, 1S61-G5 ; by Joseph Jo.necJ, XitxhriUe Jonntal of ^edi*:ine and Surgery, N. S., Vol. II, p. I. Report on Spurious Vacemalion in the Confed-
erate Army, by S. E. Habersham, formerly Surgeon in the Provisional .\rmy of the Confederate States. — Southern Medical and Surgical Jourttal, Third
Series, Vol. I, Augusta, Ga., l,SC0-6", p. 1. Vaccination and its llesults, by Wm. A. Greexe. of .\niericus, Ga., Atlanta Medical and Surgical Jounml. VIII.
1807-68, p. 241. Spurious Vaccination in the Confederate States Army, by J. T. Gilmore, Mobile, Ala. (formerly surgeon C. S. A.) — St. Louis Medical lieporter,
III, 18G8, p. 405. Outlines of the History of Variolous Inoadation and Vaccination, tcith remarks, by S. H. Stout, Atlanta Medical and Suryical Journal, Vol. VII,
18CG-67, p. 1. Spurious Vaccination in the Confederate States Army, by James Bolton, Xashrille Journal of Medicine and Surgery, N. S., Vol. II, p. "277. Abnor-
malities of Vaccination, by Frank A. Kamsav, formerly Medical Director C. S. A. — Medical and Surgical Monthly, I, Memphis, Tenn., 1800, p. 110. On the
Commvnicabilily of Syphilis by Vaccinaiion, by Wm. M. Fvqva, Appomattox County, Xsl.— Richmond Medical Journal, I, 1SC6, p. 508.
SMALL- POX. 639
tlie eruption was pustular from the lirst. The ulcers which resulted closely resembled the
Hunteriaii chancre. After several successive scabs granulation took place and purplish
cicatrices were formed. Two hundred and twenty-seven cases occurred in the 44th Ga.;
the virus which occasioned these was derived from a man who stated that be had been vac-
cinated from his wife's arm while at home on furloucrh. The cases in the 12th Ga., and
most of those in the 21st, originated in virus furnisbed by the 44tb. The popular impression
that these sores were due to syphilitic inoculation was not entertained by the medical
officers wbo treated them. Cold-water applications, with the occasional use of nitrate of
silver, yielded the best results; antisyphilitic treatment failed entirely, having served to
prolong ratber than cure tbe disease. Secondary symptoms were not observed. Nor did
these oificers consider that scurvj- was concerned in the production of the anomalous results.
There was some tendency to scurvy in the army, but no connection could be traced between
these sores and tbe scorbutic condition ; tbe subjects were generally in robust and vigorous
health, many having just returned from furlough. The evidence indicates as the cause of
the ulcerations an inoculation with animal matter which was neither syphilitic nor vaccinal,
but derived from a degeneration of the latter. In nineteen out of twenty cases tbe matter
was taken from the arm of a comrade by some soldier or officer irrespective of tbe period after
vaccination. Matter was often taken from beneath a scab; and large sores were in request
by the men, in the belief that the size of the sore was a measure of the protection afforded
against small-pox.
The Chimborazo hospital. Division Xo. 2, Richmond, Va., was appointed to receive
cases of this kind that might be sent for treatment from the field, and its medical officers
were called upon to investigate and report upon their nature. Some of the records of this
hospital have been preserved, and among them are found the following cases:
1. — p. Daridson. E. lOlh Ga.; age 17 and in good health; was vaccinated from the arm of another man iVIi. 15,
18t)3. Ipy Ass't Surgeon WuKiiiT. His arm became very sore and in a week was useless, continuing so until he entered
this hospital, May 12. There were four elevated reddened scars about an inch apart on the right arm; the axillary
glands were enlarged: he had diarrhoea and his general health was bad; he had no syphilitic taint. He was given
one grain of opium, five of iodide of potassium and one drachm of syrup of sarsaparilla three times daily. 15y July
8 bis diarrhoM had subsided, but as he was exceedingly debilitated iron and quinine were given. He was returned
to duty August li.
2 — J. S. AlJ'onI, E. Wth Ga.; age 33; had good health until Marcli 1. 1863, when he was vaccinated by a friend
from the arm of a soldier. In three days his arm became sore and continued unhealed until his admission, July 23.
There was an indMent ulcer one and a half inches in diameter at the point of vaccination, and several cicatrices on
the left breast; his general health was good. He was given acetate of zinc as a wash; vegetable diet, with meat
once daily. He was returned to dnty August 16.
3. — E. Davidson, E, IGth Ga.; age 18; was vaccinated March 1, 1863. About a week later the arm became very
sore and remained so until his admission, June 5. He improved till the 29th. when, having^ volunteered with others
til defend the city from the enemy's expected attack, the marching to which he was subjected caused a relapse, and
a copious eruption appeared upon the body similar to that ujion the arm. Full vegetable diet was given. On July
8 abics excelsa was given three times daily. He improved. Diarrlma. on the 28th, was treated with subnitrate of
bismuth and tannic acid. By August 8 he was convalescent; on the 15th a furlough was granted for forty-five days.
4. — G. L. Young, E, IGth Ga.: age 20; was in good health when vaccinated in April, 1863. His arm became sore'
in aboat a week and remained so until June 15, when the eruption disappeared. Simultaneously, however, an erup-
tion appeared upon the left leg. At this time he was admitted with chronic diarrhoea. Cod-liver oil was administered.
On August 8 the characteristic eruption of rupia appeared. He was transferred to Camp Winder on the 17th.
5. — C. JTothop, E. '20th Ga.: age 23; was vaccinated several times during the winter of 1862-63 by the regimental
surgeon, but without success. He was admitted to this hospital March 29 for continued fever, and was vaccinated
.\pril 10 on the left arm. When returned to 'duty on the 25th he had a small scar on his arm. The virus was taken
from a soldier who had chronic diarrhn?a. .Vbout the middle of May Wolhop contracted diarrhtea, for which he was
admitted June 16. He was emaciated and anaemic and his arm was very sore; at the point of vaccination there were
two large elevated scabs, discharging pus, and a large secondary scab upon his forearm. He was given iodide of
potassium fiv-j grains, syrup of sarsaparilla one drachm and subnitrate of bismuth ten grains three times daily, with
640 THE ERUPTIVE FEVERS.
full diet. On the 18th he -was given syrup of iodide of iron, ten drops in water, three times daily. [The disposition
of this case is not stated.]
G. — J. T. Tliiirman, C, 2\st Ga.; age 29 and in good condition; was vaccinated March 3, 1863, by a medical stu-
dent, from a scab. He stated that every man vaccinated from this scab suffered with a sore arm similar to his own,
and that nearly the whole regiment was aftected. He was admitted July 3 convalescing from fever and diarrhoea.
There was a large dark elevated scab about twelve lines in diameter. The usual treatment was prescribed. He
improved. On the 28tli vitiligo ajipeared. He continued to improve and on August 16 was returned to duty.
7. — James M. Futlillo, K, '2'2d Ga.; age 28 and subject to diarrhoea : was vaccinated March 20, 1863, in the left fore-
arm from a recent pustule on the arm of another soldier. A pustule appeared, which soon became an ulcer. In May
other pustules were developed on the arm and continued to discharge until July 10, when they began to dry up. He
was admitted on the 20th with chronic diarrhoea ; the eruption was nearly well. He was given subnitrate of bismuth
ten grains and opium one-half grain iu a little water three times daily, with farinaceous diet,— fried bacon once daily
and a soft-boiled egg at dinner. He improved and was transferred to Camp Winder August IT.
8. — B. F. Adams, G, 26th Ga.; age 19; healthy; was vaccinated April 1, 1863. In three days the arm became
sore and remained so about twenty days, when it healed. The sore, however, secondarily affected the axillary glands,
which discharged pretty freely and remained open until he was admitted to hospital, May 9, with intermittent
fever. The usual treatment was employed and full vegetable diet given. On July 8 he was given abies excelsa three
times daily. He improved. On the 2"-th he had diarrhcca and enlarged inguinal glands. The treatment was con-
tinued. He was returned to duty August 12.
9. — A. M. Crow, H, Zoth Ga.; age 23; was vaccinated about the middle of February. 1863, at which time he was
convalescing from typhoid fever. The arm became sore and discharged for four months. He was admitted, Juno 7,
with diarrhiea. His arm was very sore. The diarrhoea improved and the arm healed. An ulcer formed upon the
left leg, which alternately became better or worse as the weather was cold or warm. The treatment was as iu pre-
vious cases. On July 12 cod-liver oil was prescribed. On September 2 he was transferred to Camj) Jackson.
10. — J. IT. Donald, K, Zbth Ga.; age 22 and iu good health; was vaccinated Feb. 1, 1863, and iu about two
weeks the arm became very sore anil remained so until March 1. Several pustules then appeared upon the right leg,
all of which healed by May 1. On June 1, after much fatigue and loss of sleeji. the wounds reopened and remained so
until he was admitted, July 10. On August 8 he was given nitrate of silver ten grains, in water one ounce, to use as a
wash. On the 12th, there being no improvement, cod-liver oil was prescribed. On October 5 he was put upon the
syrup of iodide of iron, the stomach refusiug to retain the oil. The condition of the ulcer had not improved but the
patient's general health was good. Treatment was continued till the 15th without improvement. He was then
furloughed for thirty days.
11. — J. Tromerhauser, K,iith Ga.; age 31: was vaccinated early iu March, 1863, being at the time in good health.
The arm became very sore but ultimately healed. About May 3, while at Chancellorsville, the sore reopened. When
admitted, July 20. 1863, for a wound of the leg received at Gettysburg, his arm was still sore. His general health
was good. Vegetable diet was given but no medical treatment was required. He improved and was returned to
duty August 16.
12. — G. J. Beddinij, E, Htk Ga.: age 1^; had good health up to the time of vaccination, March 1, 1863. Tho
virus was taken from the arm of a soldier. Shortly afterwards his arm became painful and a large scab formed, dried,
fell off and left a deep ulcer. A new scab formed and fell off", leaving a running ulcer, and the process of scabbing
■went on to the time of admission, July 4, when an elevated scab was found on the arm and a number of pustules on
the left shoulder and back. He was given iodide of potassium and syrup of sarsaparilla, with vegetable diet. He
improved and was returned to duty August 12.
13. — J, A. Tomhn-Un, E, 49//t Ga.;. age 20; was vaccinated Feb. l.T, 1863, and the arm became sore in a few days;
he at the time had chronic diarrha-a and tonsilitis. Being attacked with pneumonia the vaccine disease became
much aggravated. When admitted, June 12, there were three scars upon his arm and one large pustule on the left
leg, all having the characteristic appearances of the disease. The treatment was as in the previous cases. The diar-
rhoea not improving by July 9, Fowler's solution in live-drop doses was given three times daily. On the 28th two
additional pustules made their appearance. He was transferred cured to Camp AViuder August 18.
14. — A. A. Ireland, I, M N. C.; age 17; was vaccinated on the left forearm Jan. 15, 1863, from the arm of another
man ; his health at the time was good. After four days a pustule was formed, which assumed a malignant character
and by the tenth day had enlarged to a diameter of fourteen lines. At the end of a month seven other similar pus-
tules appeared upon the arm nearer the body. He was atlmitted June 30, 1863, having eight ulcers upon the left arm
with dark elevated and firmly adhering scabs. His general health was bad and he complained of lumbar pains. He
was given iodide of potassium and sarsaparilla, with full vegetable diet ; a poultice was applied to the arm. He was
furloughed on the 16th. The man from whom Ireland was vaccinated sufl'ered afterwards with malignant pustule.
15.— H. If. Smith, A, GOth Ga.; age 19; was vaccinated about the middle of June, 1863, while suffering from
dyspeptic symptoms. The arm became sore in about three days. When admitted, July 5, with debility, he had an
intlolent ulcer at the seat of vaccination and pain in the axillary region. The usual treatment was employed, with
full vegetable diet. He improved and was returned to duty August 16.
IG.—E. TV. Fei-ree, I,\Gth X. C; age 33; was vaccinated Feb. 14, 1863, from the arm of a soldier who appeared
to be in perfect health. Ferree stated, however, that the soldier's arm became quite sore at the expiration of fifteen
days. When admitted, June 30, he was much emaciated from diarrhoea, which hatl affected hinr from before the time
sMALL-ro.x. (541
of raccination. There were three scars on the left arm from pnstulos and two recent pustules in the formative stage ou
tlic left elbow; there was also a pustule on the left lej;;. Simulianeously with the recent pustules upon tlie arm
appeared an indistinct papular erui>tion upon the right leg. He stated that several soldiers who had been vaccinated
at the same time sutiVred in lik<' manner. Iodide of jiotasium and syrup of sarsaparilla were administered, with veg-
etable diet. On July IS syrup of iodide of iron was ■jiven, and on the 2Tth the ulcer of the leg was washed wit li a weak
solution of acetate of zinc. On October.") he was taking cod-liver oil. — the ulcer and the patient's general health were
both improving. Ou the 21th there was some eulargemeut of the lymphatics of the left arm. He was returned to
duty November 23.
17. — C. P. Green, K, 16(A X C; age 23: was in good health when viiocinated in February. 18G3. His arm con-
tinueil sure until April 1, when it healed. After several weeks of severe fatigue duty the eruption reappeared on the
arm and persisted. AVhile ou the march to Chancellorsville an eruption appeared upon the right leg. Ou August 8
the characteristic eruption of rupia occurred. He was put upon cod-liver oil. By the ISlh ho was convalescent aud
was transferred to Camp Winder.
18.— J. B. Coffee, A, 22(? X C; age 21: had good health until he was vaccinated Feb. 1, 18G3. The virus was
taken from the arm of another soldier who appeared to be in good health. About four days afterwards tlie arm
became intiamed aud the pustule increased iu size to two inches: the scabs which formed were continually rubbed
off by the friction of the clothing. Ten days later the axillary glands became intiamed and livid and di.scliarged
a large iiuantity of matter. An abscess, lanced iu May, healed up in Jnnc. Wlieu admitted, June 30, there were
two scars, one healing, the other discharging pus from l>eneath the scab. The ))atieiit's general appearance was
healthy. Iodide of potassium and syrup of sarsaparilla were given three times daily, with full diet. On July 28 the
right axillary glands were discharging. Iodide of iron was given, aud on August 18, being convalescent, he was
transferred to Camp Winder.
19. — J. E. iriifia, J, 22(1 X. C: age 21; stated that when an infant his mother vaccinated him with a needle
coated with lymph from the arm of another child. The family health was good. He refused to he vaccinated by the
surgeon of the regiment : but having lent his knife to some of his comrades who used it to cut the rags binding their
vaccinated arms, aud himself afterwards using it to open small pimples on his leg, he became inoculated. He was
admitted June 30, l-G'S, with a declining impetiginous eruption on the right leg: there were many scars. The muscles
were well developed, but the patient complained of general weakness in the joints and there was a slight diarrhira.
The eruption returned during exercise in warm weather. He was given iodide of potassium and syrup of sarsaparilla.
Ou July 13 he was improving.
20. — LimUay McDowell, I, 22(1 X C; age 21: was vaccinated in January, 1863: the arm hecauie sore at once,
aud healed only on the approach of warm weather. When admitted, June 30, 1>63, there was a large elevated scar at
the place of vaccination aud several small ones below it: he was scorbutic. Chlorate of potash iu teu-grain doses
was given three times daily, with vegetable diet. On July 0 lemon-juice and a mouth-wash of tincture of myrrh in
water were added to the treatment. On Augnst 8 the disease was cured and the scurvy im]noving. He was returned
to duty ou the 17th.
21. — rr. D. Cantirell, E, Hth Ga.; age 22; was in good condition until vaccinated in February, 1803. A few days
afterwards his arm became sore aud the axillary glands swollen. He was admitted July 2. His ;-eueial health was
then good aud the sore ou the arm had healed, but the axillary glands discharged copiously. He was ordered iodide
of potassium five grains and syrup of sarsaparilla a drachm three times daily. Ou the 8th tincture of iodine was
applied to the enlarged glands and repeated daily. Ou the 18lh he was given the syrup of iodide of iron five drops
in water three times daily. On the 28tli the glands were still discharging aud he had taken cold. Brown mixture
was given with Dover's powder at night. He was returned to duty August 16.
22. — J. H. Uunleij, B, 22d X. C; age 29: continued well, but for some relaxation of the bowels, until the last of
February, 1863, when he was vaccinated. Twenty-four hours afterwards the arm began to be painful and a pustule
was formed which discharged pus, aud in three weeks developed into a deep excavated ulcer which continued
unhealed until the middle of June. When admitted, June .SO, there was a dark, slightly elevated scab sixteen lines
iu diameter. He stated that the soldier from whose arm the virus was taken suffered much from the disease, and
that when he left cam)i his arm was still very sore. Full diet was given, with syrup of iodide of iron. By July 28 he
had recovered except that he was troubled with jules and diarrhcea. He improved under treatnunt and was trans-
ferred to Danville August 20.
23. — T. S. Uaiglcr. A, 22f? X. C; age 20; had good health until about the time he was vaccinated, Feb. 1, lt-G3,
when he had rheumatism. By the loth his arm was very sore. Ou admission, June 30, to this hospital from General
hospital Xo. 21, where he had been under treatiucnt for diarrhoea, his appetite was good and complexion florid, but the
left parotid gland was enlarged and there was a purulent discharge from the left ear: ten distinct reddish^scars were
clustered around the place of vaccination on the forearm aud there was a similar scar above the elbow. He was
treateil with iodide of jiotassium and syrup of sarsaparilla; tincture of iodine was applied to the enlarged gland and
warm water injected into the ear several times daily. He was returned to duty August Hi.
24.— T. J/. Iliirris, C. 23(1 X. C; age 23: had good health until he was vaccinated from a crust in March, 18G3.
About a week afierwards erysipelatous iutlainniation supervened, with implication of the axillary glands. In another
week the erysipelas subsided, leaving three pustules on the arm, which were healing, when, on April 25, the char-
acteristic pustular eruption appeared upon the left leg. When admitted, June 30, the muscular system was well
developed: there were three scars upou the left arm and upon the anterior asjjeet of the left lecwas au irritable ulcer
Med. Hi.«t.. Pt. Ill— 81
642 THE ERUPTIVE FEVERS.
twelve lines in diameter, with an inflammatory areola and three impetiginons-lookinn; pustnles. He was treated with
iodide of jjotassinni and sarsaparilla, a lotion of sulphate of zinc and full diet. On July 8 turpentine was applied to
the ulcer and twenty drops three times daily were given internally. On the 18tb, as he did not improve, he was
given the syrup of iodide of iron in ten-drop doses in a little water. He was returned to duty August 18.
25. — J. y. Adams, E, 3'fh X. C; age 33; was vaccinated March 1, 1863, at which time he had a slight diarrlio?a.
The vii-us was taken from the ann of a healthy soldier. In from four to six days a pustule formed and ulceration
progressed beneath an elevated scab. In about a month otlier pustules formed on the same arm, which on healing
left dark cicatrices, but the primary ulcer continued to discharge. Erysipelas set in June 1 on the arm. When
admitted, July 17. his general health was not good: there were two suppurating ulcers on the right arm. Cod-liver
oil was given, with vegetable diet and meat once daily. He was returned to duty August 16.
26.— Jho. L. Turner, G, 5th Va. Car.; age 27: was vaccinated by Ass't Surgeon Moses from the arm of a soldier
v.liile in hospital at Farmville, Aug. 10, 1863, suffering from the effects of a blow and from chronic nephritis. He
had been vaccinated during the winter by Ass't Surgeon J. C. Vaidex without effect. He was admitted to this hos-
pital September 5 with pustules resembling impetigo on the left arm and leg; the pustules appeared in successive
crops. Generous diet was prescribed, with cod-liver oil. On the 19th the oil was discontinued and iodide of potassium
substituted. He was furloughed on the 23d for twenty days.
Suro-eon S. E. Habersham communicated the result of the investigatiou into this anom-
alous vaccinia to Medical Director Careiis'gtoj^' under date Isox. 21, 1863. His first expe-
rience of the diseased condition appears to have been obtained not from the Georgia cases
above mentioned, but from the revaccination of patients already in hospital for other diseases.
In some, without much inflammatory redness, a scab was formed which left an indolent
ulceration. In more malignant cases the pustule became surrounded by an erysipelatous
redness, a scab formed over a phagedenic ulcer, the matter from which affected other parts
of the cutaneous surface, and occasionally the axillary glands became swollen and suppu-
urated. Many of these cases were cachectic and some decidedly scorbutic. Dr. Haber-
sham ascribed these results to the condition of the men rather than to the qualitv of the
inoculated matter; for, to test this point, he obtained a fresh crust of known purity and
efficacy and found that in three of ten cases it occasioned anomalous manifestations. This
testimony shows that such results may sometimes be referred to the condition of the indi-
vidual. That vaccinia mio;ht run an irreo-ular course in broken-down constitutions can
readily be understood. Cutaneous ulcerations as a result of inflammatory processes were
to be expected in soldiers convalescing from typhoid fever, debilitated from chronic diarrhoea
or cachectic from scurvy. But although these results occurred in three of ten cases under
treatment in tlie Chimborazo hospital, Surgeon Habersham's generalization as to the caus-
ation of the sores in cases of so-called spurious vaccination, must.be regarded as inadmissible
in view of the many cases on the Chimborazo records in which it is stated in definite terms
that the patient was in good health at the time of his vaccination, and the equally definite
testiraonv to the same effect given bv the medical officers on dutv with the affected regi-
ments. The records of this ho.«pital are strongly opposed to the theory of a syphilitic origin
of the sores under consideration; manv of the cases remained in view for a lonii' time but
no history of secondary developments was recorded.
Dr. Habersham's report was as follows:
I have the honor to inform you that, in accordance with your order of June 2!1, 1863, I have received all the
patients sent into this division with a ''peculiar eruptive disease," supposed to be the consequence of vaccination, and
herewith forward you the results of mj' investigation into this anomalous affection.
In compliance with an order issued from the Surgeon General's office in the month of Xovember, 1862, general
vaccination was practiced upon all soldiers as soon as they were admitted into this division, and in order to insure
the full protective intiuence of vaccination (not anticipating any evil consequences therefrom) the order was strictly
obeyed and all the patients, even those having recent scars upon them, were revaccinated. A few days after the
insertion of the virus, and in many cases within twenty-four hours, the seat of puncture became very much inflamed,
with a deep inflammatory blush around it, which gradually implicated, in severe cases, nearly the whole of the
affected limb. A pustule rapidly formed instead of a vesicle, which very soon discharged an ichorous fluid. This
fluid was, in the course of forty-eight hours, converted into a dark, mahogany-colored, irregularly-shaiied scab,
SMALL-POX. 643
prominent ami firmly attachod at its liaso. A dark-red areida of several lines in diameter, measuring; from the edge
of the seah. was then developed, w'lieh in turn seemed to exude an ieliorous serum. This was soon convi-ited into
a scab surrounding^ in juxtaposition the first and i)resentin<; the apjiearaneeof a siti!;le seal). This process continued
for several days, and tliere was often a sealj one inch or two and a half in diameter. Pari ])a8aii with the increase
of the scab the erysipelatous Idnsli on the limb diminished, and when the blusli bad disappeared tliis scab ceased
to enlar-io. As this inllammatory process subsided the discharge lost its serous character and seemed to be con-
verted into pus, which exuded from under the seali, loosening its firm attachment at its base, and tlius rendering it
liable to be removed prematurely by the patient in his sleep or even by the friction of his clothing. Wlieu this
occurred a foul, bleeding, irregularly shaped iJiagedeuic ulcer was r»vealed, with everted edges and presenting the
a]>pearance of a syphilitic phagedenic ulcer, involving the subcutaneous areohir tissue, exposing, in many cases, the
muscular tissue below. The process of destruction did not cud here, for the ulcer continued to increase and from the
loosened eilges an ichorous discharge continued to pour out from under the skin, which seemed to destroy the edges
of the ulcer, thus increasing its dimensions. Wherever the ichorous pus from this ulcer touched the sound skin
another pustule of a similar cliaracter was formed, in some cases reaching the size of tlic primary sore. This, how-
ever, was seldom the case, l>nt a smaller nicer generally resulted, which often healed and cicatrized before the first.
The axillary glands when the arm was aftected, and the inguinal glands when the leg was the seat of the dis-
ease, sometimes became intlamed and discharged pus, presenting the niicr<iscopic characters of healthy ]ms. This
enlargement of glands, however, did not occur in a sufficient ntimber of cases to make it a natural seijueuce of the
disease. Attending the early stages of the formation of the nicer, before pus was discharged, there was always more
or less pyrexia, with furred tongue and loss of appetite, these symptoms disappearing as soon as ulceration was estab-
lished. In these highly aggravated eases successive crops of pustules made their appearance on the affected limb,
often also upon the lower limb of the affected side, but seldom crossing the niesian line and never developing them-
selves upon the trunk or head.
The less malignant form of the disease resembled the first in character but not in degree. For a few days after
the insertion of the virus merely a small intlamed spot was discerned, which seemed to be more the result of the
injury done to the skin by the prick of tlie lancet than any inflammatory action resulting from a specific cause.
About the fifth or sixth day a minute pustule was discerned upon a scarcely larger intlamed base. This jiustule
and areola gradually increased, but the diameter of the areola was not as great and there was no deep inllammatory
blush upon the arm. merely a difl'used redness of several inches in diaimttir. The sanu' process, however, took place —
an exudation of serum from the areola — which, in turn, became a crust, and which gradually increased in size, but
it never reached the diameter of the more malignant type; and when it was detached by the process of ulceration,
which occurred at an early period, the revealed ulcer was neither as deep nor as malignant in its appearance. The
edges were not everted and there was no discharge of pus from under the edges of the ulcer; it only jiresented the
appearance of an ordinary ulcer, showing no tendency to increase and but little to heal. Pyrexia seldom attended
this form nor was the appetite impaired.
The third and mildest form of the disease made its appearance as a small pimple in from two to ten days after
the introduction of the virus, which gradually formed a pustule; a dark-brown scab succeeded in from three to four
days, which remained attached sometimes as long as two weeks, and when it became detached a livid or brown spot
was revealed, the size of which was ecjual to the scab. This scar, however, was very sensitive to the touch and liable
to bleed from the least friction of clothing, and when this occurred it would exude serum or blood and another scab
would surely form. If the system became suddenly depressed from any cause it would almost always assume the
ulcerative process and become a sloughing ulcer, which only healed with the general improvement of the system.
As thus described this disease has prevailed in the Army of Virginia, both in field and hospital. The surgeons
of the Army of the Southwest report its prevalence there. It was developed in the early part of the year in a cavalry
regiment in the monntains of Virginia, the colonel commanding sufl'ering severely from the disease. In every case
its origin has been traced to the introduction of vaccine virus into the system. How far an epidemic cause may have
exerted its intluence in its early development it is impossible even to surmise; we know, however, that it originated
in Virginia at a time when our army was upon very short rations, and that many of the soldiers sent from the field at that
time presented a decidedly scorbutic appearance. Many had been reduced and were broken down by exposure to the
ipclemeucy of a cold winter and the de[iressing intluence of low diet, want of clothing and many other prolific
causes of disease calculated to deprive the blood of its healthy constituents, particularly of its fatty matter. Hence,
this may have jiroduced a predisposition. In verification of this fact I will state that when it was found how fre-
quently the disease in cimsideration su|iervcned ujion vaccination in this hosi>ital in broken-down and depraved con-
stitutions, it was deemed prudent to postpone the introduction of the virus until the patient was restored toa healthy
cou<litiim by improved diet and medical treatment. At the first apiiearance of the evil conseijuences of vaccination
I was inclined, with other surgeons, to believe that the virus was impure, and because of this suspicion, I threw away
the matti-r we then had and obtained a vaccine scab from Dr. Kxox, a practitioner on Church Hill, who assured me ho
had used it in several cases with a perfect result.
The introduction of this virus into the arms of some ten patients resulted in the development of the disease in
question in three of them, while in the remainder it produced apparently a true i)ustnle. From this fact, and the
immunity which healthy-looking men enjoyed, I was led to believe that the predisposing cause existed in a vitiated
and impoverished condition of the blood and so rejiorted in my first report, and that the introduction of pure virus
into the system was the exciting cause of a latent disease. This view, I see, is also held by Surgeon Fhank A.
E.\MSKY of the Department of F.ast Tennessee, in a communication on tile in the otlice of the .Surgeon (Jeneral. This
view 1 have never had reason to change, though I am aware that many men, apparently in health, have suflered from
644 THE ekuptivp: fevers.
the effects of vacciiiatiou. lu one case, -n-liich I here (juote. the iufluence of a good couditioii of the general system
seems to have exerted a wonderfully modifying influence. *
The search for parasitic or cryptogamic vegetation, -nitha good microscope, revealed none. The pustule was
seldom developed where parasites make their habitation, namely, in the hulbs or at the roots of the hair. The pus
presented microscopic characteristics of pus globules floating in a homogeneous fluid. These globules were not as
abundant as in laudable pus and not so distinctly nucleated, and were irregular in outline in some of the cases exam-
ined. This appearance of pus globules, however, often exists in healthy or laudable pus when it has been exposed
to the air any length of time. In the many cases I have examined I have yet to find a patient who will acknowledge
that he has had any syi>hiiitic disease at any jieriod of his life, though many of them have had gonorrhcea. This
exemption from syphilis, however, is not strange, since it is a very uncommon disease in the rural parts of our country,
tiie inhabit.ants of which comprise the very large majority of our army. We also know the tendency of the secondary
form of syphilis is to develoji itself on the forehead, chest, back and trunk generally, and yet no cases developed
npon these parts of the body have presented themselves to my oliservation. Many of the patients, also, have sutfered
long enough to liave had the tertiary form of syphilis developed, nodes, etc., and yet no such'symptoms have been
seen by me.
From what I can learn the army of the United States has so far escaped these evil results of vaccination. A
few cases, however, originated among Federal officers in the hospital of Libby Prison. They were vaccinated in
the prison by one of their surgeons from his own arm some weeks after their confinement, and presented all the
characteristics of the disease as it appeared in our army. I was assured by these officers that they had neither seen
nor heard of such a result of vaccination in their army. Does not this fact alone lead us to infer that its cause or origin
may be traced to some abnormal condition of the blood in these cases, induced by confinement in a vitiated atmos-
phere, without the means of eliminating the mutcrUs niorhi from the system by exercise and care to the function of
the skin ?
The classification of this disease is difficult and unsatisfactory, since it commences as a pustule and assumes
often the outward form of rupia, which by all dermatologists is classified among the bulhe. If we classify it among
the pustuhr we find no disease there describing it accurately, some cases resembling ecthyma, others impetigo.
Inasmuch, however, as it often assumes the characteristics of chronic ecthyma, either in a mild or aggravated form,
according to the healthy or imhealthy condition of the patient, I propose to name it vaccine ecthyma. Like all chronic
cutaneous diseases it shows a decided tendency to return whenever the system becomes reduced from any cause, or
when the patient is exposed to causes which produce an undue action in the circulation of the capillary system. An
irndue amount of exercise in warm weather seems to excite its appearance. This was illustrated in those soldiers
supposed to be perfectly cured, and who were about to be ordered to their regiments for duty when a raid was threat-
ened, in the month of July, upon the city of Richmond, These men were among the volunteers from the hospital
to defend. the city, and were marched through a hot sun some four miles to the lines at the extreme limits of the
v.estern end of the town. They returned with a new croi) of xmstules, which, however, healed by resolution in a
short time.
Tre:(tiiwnt. — There is every reason to believe that the disease results from a blood disease, only to be eliminated
from the system by enriching the Ijlood and supplying its deficiency of fatty matter with rich nutritious food and
the judicious use of alteratives. It is vain to treat the ulcers locally, for without alterative treatment with nutri-
tious diet all the local applications which were tried seemed to aggravate rather than improve them ; but as soon as
the general condition began to improve so did the ulcers. The milder cases began to improve a, few weeks after
admission without any treatment except dietetic in conjunction with the iodide of potash, syrup iod, ferri and sarsa-
parilla: in others merely applying simple dressing to the ulcer was found sittficient to subdue it. Under this treat-
ment all the cases gradually but slowly improved. In the early part of August we received a large supply of cod-
liver oil, and I was thus enabled to test fully the treatment which the supposed cause of the disease naturally sug-
gested. Some few of the patients could not digest the oil, but those who could began rapidly to improve, and many
were well enough on the 18th of August to return to their regiments, whilst others were thought well enough to be
transferred to their respective State hospitals, in compliance with an order issued at that time. Those who were
unable to digest the oil continued the syrup iod. ferri, which was thought the best alterative indicated in their cases.
Their improvement \.as scarcely percejitible. In the early part of September, however, another ettbrt was made by
them to take the cod-liver oil, which they were enaliled to do in a little whiskey; their improvement soon became
• very evident to themselves, and though not yet entirely well the ulcers are rapidly granulating. No new ])ustules
are being develoiied and the patients are in a fair way to recover. I have no doubt that the best remedy has been
found in the cod-liver oil; and this, locally applied and internally administered, with an entire change of air and
nutritious diet, will remove and eventually eradicate this obnoxious and filthy disease from the system.
From the above-mentioned facts I am led to draw the following conclusions: That the disease is pustular at
its first appearance; that it resembles ecthyma in its general character; that it is but a local manifestation of a gen-
eral disorder or vitiated condition of the blood; that this vitiated condition resulted from improiier aud spare diet,
together with inattention to cleanliness, thus impairing the eliminating functious of the skin; that syphilitic virus
has had no influence in producing the disease; that the morbid ert'ects have in most of the cases resulted from a
deficiency in condition, independent of any imperfection in the vaccine virus; that the disease can only be removed
by those means c?,lculated to improve the general condition and restore the healthy play of all the functions.
* See case 2G of the Chimbonizo records, submitted on page 642, mpra. Dr. Habersham, in citing this case, fails to state why the man was in hos-
pital at F.tnnville at the time of his vaccination. *'This patient," he says, "was young, vijrorous and comparatively ht-althy when he received this
vaccine into his syatem," — yet the records of the Chimborazo hospital represent him as having been at that time under treatment for chronic nephritis.
SMALL-POX. 645
]\Icanwliile cutaneous ulcerations, erysipelatous inflammations and occasional swollin'^
and suppuration of the lymphatic glands appeared in the 8outh and Southwest as frequent
results of attempted vaccination. The attention of the profession became aroused by reported
instances of the inefficiency of the protection atlbrded by these false vaccine sores and the
suspicion of syphilitic infection associated with them, together with the spread of the small-
pox epidemic. A belief in the doctrine of an epidemic constitution of the atmosphere was
generally accepted; but the more the subject was investigated the more apparent it became
that the undesirable and unprotective results were due to impurity in the virus used.
Thus Bolton, who was engaged in growing crusts on healthy children for the use of
the Confederate authorities, tested his stock by nearly 1,300 vaccinations without an abnor-
mal result, and when, after this, it was employed by a Tennessee physician in five cases, in
four of which it proved inert and in one produced a succession of scabs, he attributed this
to decomposition of the crust from a faulty method of preservation. Subsequent to this
he collected about eight lutndred crusts from healthy children. These were distributed
throughout the army, and no further reports of abnormal results were forwarded. Stout
has recorded that soldiers were vaccinated from the arms of soldiers, in many instances by
themselves and even by medical officers, with no care as to the normal appearance of the
vesicle or dried scab employed in the process. In many cases the operation was followed
by extensive erysipelas of the arm; sometimes by phagedenic ulceration. A few lives
were sacrificed, and in one instance reported to him, amputation was resorted to for the pur-
pose of saving life. He prohibited the use of virus obtained from the arms of soldiers or of
any person supposed to be in bad health. Pure virus was distributed to physicians in pri-
vate practice with the request that they furnish scabs from healthy children to be used in
the army. A medical officer was detailed at every hospital to scour the neighboring country
in seai'ch of children on whom to propagate the virus, that a sufficient ci"op might be secured
to avoid the necessity of using that obtained from adults.* Gases of sjxu'ious vaccination
became less frequent after this, and were almost unknown during the later months of the war.
Many of the unfortunate cases he regarded as dissecting wounds, putrefactive matters having
been inserted along with or instead of the vaccine lymph. But he did not attribute the
gradual disappearance of the anomalous results wholly to the purity of the virus; for, coinci-
dent with its use, there was in the hospitals near Atlanta a diminished tendency to erysipelas
and gangrene, which led him to believe that during the previous period, when such tenden-
cies prevailed, bad eflfects may have followed the inoculation of perfectly normal lymph.
Greene, as the result of his observations, considered that much of the trouble was due to
vaccinating with the matter of bruised crusts. Soldiers crowded in small tents and exposed
to injury from handling their muskets and accoutrements in drilling, guard and jDolice duties,
had the vesicle damaged and its natural progress interfered with by inflammatory processes
which could not fail to alter the constitution of the crust. He subscribed, however, to the
theory of an atmospheric influence predisposing to a morbid condition of the tissues and fluids
of the body.
» C. n. TEBArtT. in an article on ModlJUd Inoailalimi — Xeic Orltaut Med. mid Siirj. Jour., XIX, 18G6, p. 3ft— rclati-s that while ho wa» Stiprrintondent
of Vaccination at the po*t of Macon, Ga., in 1SG4, the iirevalence of small-pox and the scarcity of reliable vaccine crusts kxl him to have recourse to inocu-
lation with variolous matter taken from the pock in the vesicular stage and mixed with an equal (luantity of cow's milk, as practiceil by certain physi-
cians in 3Iarseilles and Lyons as early as 1832. From an experience of five hundred cases he concluded that the modified in(>cnIation is as mild in its
manifestations as vaccine,— few of his cases having had more than a single vesicle and none more than six in addition to that at the site of the puncture ;
that the higraftcd disease is, like vaccinia, not eonimuuicabic by mere contact ; that the immunity confcrreil is more lasting and otherwise su|>erior
to that obtained by vaccination, and that, with the occurrence of small-pox, we are immediately supplied with an all-potent means for its repression.
646 THE ERUPTIVE FEVERS.
Scurvy was generally exonerated by these investigators, as the civil population, living
at their homes on vegetable diet, were also affected by these anomalies of vaccination. The
people were as careless in their methods of vaccination as were the soldiers; matter, fresh or
dried, from a sore arm appeared to have been the desideratum rather than ripe vaccine from
a lymph-vesicle or the crust of a primary vaccination from the arm of a healthy child.
The impurity in the virus was held b}' some physicians to consist of a syphilitic con-
tamination; but of the many cases that passed under the observation of medical men not
one has been recorded in which the constitutional symptoms of undoubted syphilis have
been shown as tlie result of the j^riniary sores. Bolton insisted on the presence of syphilis
in some of the outbreaks, and asserted that many of the cases were so situated that their
history could be preserved, and that, in these, secondary symptoms appeared, followed in due
time by tertiary symptoms. " In short," his paper says, '" the disease was genuine syphilis."
According to his account the disease prevailed most extensively among troops from the State
of Georgia, and was thought to have been traced to a soldier from that State who had been
home on furlough and was said to have vaccinated himself from his wife; but although he
makes positive statements concerning the syphilitic nature of the ulcerations, it does not
appear that he saw any of the cases in the aftected Georgia regiments, — he was engaged at
the time in propagating vaccine virus on the arms of negro children on the plantations of the
South. GiLiiORE, however, who had an opportunity of observing the cases in the Georgia
brigades of Semmes and Cobb, considered that he saw enough of the disease to convince him
thoroughly that the virus owed its impurity to syphilitic contamination. . He accounted for
the introduction of the specific impurity bv a soldier who, while on furlough, was vaccinated
by a woman, an inmate of a house of bad repute in Augusta, Ga. The man denied having
had syphilis previous to his vaccination, and the condition of the woman who vaccinated him
is acknowledged to have been unknown.
On the other hand, the testimony of the regimental medical officers, and of those on
duty at the general hospital, where the more aggravated and persistent cases of this Georgia
epidemic were treated, together with the yet extant records of the hospital, show that not
one of the cases developed the secondary manifestations of syphilitic disease, and that, in
fact, the disease was not s\'philis.
The strongest evidence of the transmission of syphilis by the operation of vaccination
was reported by Surgeon WiLLiAii M. Fuqua, 7th Fla. In this instance it is said that the
virus employed was obtained from a sailor who was suffering from primary syphilis at the
time of the vaccination. Fifty-two of the men had offensive and freely-discharging ulcera-
tions with, in some instances, swelling and suppuration of the axillary glands. Copper-
colored spots appeared in two cases, the hair began to fall off in a third and a bubo, regarded
as syphilitic, was developed in a fourth. Most of the patients were returned to duty after
specific treatment; a few were sent to general hospital, one of whom died. The regiment
was in bad condition at the time of its vaccination, one-seventh of its membership being on
the sick-list with diarrhoea and malarial fevers.
Whether these cases were really syphilitic or the result of a putrefactive animal matter
in cachectic individuals, some of whom may have been the subjects of syphilis irrespective
of their vaccination, appears immaterial to the settlement of the general question relating
to the causation of the ulcerations and occasional glandular swellings following attempted
SMALL-rOX. 64"
vaccination in the Soutli. The weiylit ot" the testimony throws the responsibihty on the
matter used in tlie inocuhitions but frees it from the suspicion of syphiHtic infection.
Further light is shed upon the causation of tliese ulcerations by the efforts of our
medical officers to protect from small-pox the Rebel soldiers held in conlinement at our
jirisoii depots. Isolation and vaccination were employed; but at some of the prisons, as
Alton, tlie spread of the disease was so rapid that the former could not be effected until after
the construction of a special hospital, and the latter was unavailing from the inefficiency of
the virus used.* Most of those committed to the Rock Island prison had large ugly scars
which afforded no protection from the infection of small-pox. These scars were the result
of attempted vaccination while in the Southern ranks. f Virus which produced no bad
effects on the United Slates troops stationed at Camp Douglas, occasioned phagedenic, irrita-
ble or indolent ulcers when inserted into the arms of the Confederate prisoners. J It is
evitlent from these results that the debilitated condition of the men, whicii was a subject of
constant remark by our medical inspectors, was the essential in the ]3roduction of the unusual
sores that followed their vaccination. A report bj- Medical Director Charles S. Tkipler,
Northern Department, gives interesting testimony on this point:
Facts of interest have l^een developed in regard to bad results obtained fiom vaocinft matter supposed to be
impure. At an early period iu tlieevents embodied iu this rei>ort rumors of virus said to be contaminated witb syph-
ilis became prevalent. These were calculated to excite serious alarm, as the evidence seemed to sliow that much of
the virus issued by tlie purveyors caused larj;e, painful and obstinate ulcers, exhibiting many of the marks of syph-
ilitic disease. Whether the purveying department sliould on these facts be accused of carelessness as to the source
of its supply of vaccine, or whether the evil existing might have some other explanation, became a question 1 sought
at once to solve.
It was evident at the outset t)iat a few localities — Camp Douglas, Roek Island Barracks and Camp Butler — all
prison depots in the State of Illinois, furnished most of the causes of complaint. Those who sutieied from the
so-called impure virus were rebel prisoners of war. It was at once suspected that by no chance could all the impure
virus, if any there was. concentrate in these localities: that our own troops ought also to suffer somewhat in the same
way; and that probably the evil might be found in the constitutional condition of the subject rather than in ihe vac-
cination itself.
Reports were called for to state the facts in full as to the probable poisoning by syphilis or other infection, and
also to inform me as to dietetic and other causes which might tend to explain the unfortunate results. An informal
and hasty report from Rock Island stated, iu general terms, that the same virus used indiscriminately on prisoners
sutferiug from scorbutus and on United States troops iu ordinary health produced very ditt'ereut results. With the
latter it acted kitully and in the usual manuer; with the former it produced largo iudolent and occasionally slough-
ing ulcers, sometimes indurated at the margins and chancroid in appearance.
The report nuide May 31, 18Ij4, by Surgeon .loiix H. GuovF., U. S. Vols., in charge of Camp Douglas, embodies
an amount of evidence which seems to pre .e conclusively that there was no fault in the vaccine furnished (further
than its deterioration l)y age), but that the cause of the evil lay in the cachexia of the subjects of the vaccination.
He states in brief that while a large number of the prisoners were vaccinated with ordinary results, 1,580 cases were
followed by bad ulcers. These commenced on the third day with a vesicle, not umbilicated, which tilled with pus;
this speedily became an open irritable sore, with diiVuse redness, and finally degenerated into an irritable and indolent
ulcer varying from one to three or four inches iu length. In some cases the ulcer was limited to the cuticle, in others
it was phagedenic, and iu some a deep gangrenous slough occurred. Evidently this was not syphilitic. Of the whole
number 6<j8 had healed at the time of the report; 912 remained obstinately open. Those which had healed left an
extensive smooth, red, shining cicatrix. It is noteworthy that 816 prisoners of -war who had been vaccinated while
in the rebel service had cicatrices of this character. On these results vaccination was suspended at that post.
Surgeon (.Jrovk further reports that the vaccine virus used was obtained upon requisitions from tlie medical
purveyor and used at about the same time upon the United States troops (men and oflicers) at the garrison, without
any uupleasant effects excepting in one case of an othcer's wife, who was iu a chlorotic couditiou. In this case an
irritable ulcer followed, which, after about three mouths, yielded to treatment.
Here we have in the same locality some thousands of vaccinations made with the same virus at the same time.
In one class a large nuijority had ulcers: in the other only one experienced any uni>leasant eftect. It is plain that
the men and not the virus furnished the onyo inali. From other localities the same history came.
Isolated instances occurred iu which patients suffering from chronic diarrho'a had niters, and subsequent to
the reception of Surgeon Gkove's report, the eases of three recruits vaccinated at Camp Butler and then forwarded
to Arkansas were referred to me for report. In these cases as in others the same jiheuomena were observed. The
same crust that acted kindly on some produced nlcers on the three recruits.
• Dr. Wails report, tiijira, lage 07. f *'» Uf' lIoxLEvs' statcmuut, tupra, jiagc 53. % Dr. Uvmpusevs' report, nij>ra, i»gc CT.
G48 THE ERITPTIVE FEVERS.
The cause of this cachexia must be attributed to the previous exposures of the subjects. Many of these pris-
oners were poisoned by malaria; many more had and still have scorbutus. The prison diet in this department is
sufficient in quantity, but it lacks those component parts which are essential to health. Aside from soft bread the
only vegetable issued is thirty pounds of potatoes to one hundred men per diem. This is not sufticient to ward otl'
scurvy, and so long as it is continued a mortality not creditable to our Government may be expected among our pris-
oners of war.
To conclude, the facts before me authorize me to report: —
1st. That the vaccine matter furnished by the purveyor is good except when rendered inert by age.
2d. That the condition of prisoners of war is so cachectic as to produce bad results from healthy vaccine virus,
results which do not obtain from the same virus in healthy subjects.
3d. That the ration now issued to prisoners of war is calculated to produce and continue scurvy and other
cachectic conditions.
4th. That the ration can be modified without increased expense so as to bring about a healthy condition among
the prisoners.
Undoubtedly, also, at Anderson ville the condition of our men sufficed to explain the
evil results even if the equality of the virus emj^loyed had been beyond question, — for at
this prison mosquito bites, aljrasions, pricks froin wood-splinters and other slight accidental
injuries were in several instances followed by gangrenous ulcerations that necessitated ampu-
tation, as in cases in which a reputed vaccine was inserted. The hospital register of this
prison shows that four deaths occurred in six cases of vaccination admitted from the pen,
fifty deaths in ninety-six of ulcer and sixty-one deaths in one hundred of gangrene.
In conclusion, ifmay l;>e said, that the anomalous results of vaccination developed during
the war originated in one or both of two causative influences, — first and chieflv, an impure
virus; and, secondly, a deteriorated system. The one was demonstrated by tlie production
of evil consequences in sound and vigorous men, the other by similar consequences in
cachectic individuals although the lymph used was of normal character. The impurity of
the matter may be ascribed mainly to the general practice of attempting to propagate vac-
cinia from the crusts or inflammatory products of a re vaccination sore on the arm of an
adult or even, as shown by the observations- of Surgeon Ira Russell at Benton Barracks,
from a genuine vaccine vesicle when changed by injury into a purulent sore. The impair-
ment of the constitution was due to a scorbutic tendency and the prostrating influences of
over-fatigue, exposure, mental depression and antecedent disease.
This experience teaches the value of the army regulation requiring the vaccination or
re vaccination of men at the time of their enlistment, before the privations and exposures of
active service have had an opportunity to affect their health. It teaches also the necessity
at all times for a vaccine lymph of good stock and unimpeachable history, free from the
products of abnormal vaccinal inflammation. Fortunately, since the introduction of the
Beaugency stock into this country by Dr. Henry A. Martin, large armies may be protected
from variola without the use of crusts. So long as this virus is preserved, charged points
free from inflammatory products, and from any possible taint of syphilis, may be prepared
at short notice for vaccination on a large scale. It ia needless to. say that the preparation
of the points on which an army relies for its protection from small-pox, and from the some-
times severe effects of spurious vaccination, should be conducted under official supervision.*
* Anomalous results may attend the use of bovine virus when tlie crust is employed. This should never be used on account of its tendency to
decomposition and liability to contain inllammatory products. T. S. Hopkins of Thomasville, Ga., speaking of vaccination with virus in the form
of cones, gays, in the Bidletin of the Xaliomd Board of Healthy March i, 1882 : " The result has been fearful. Nearly every one vaccinated has snflfereJ
severely from erythema or erysipelas, the arm swollel] from shoulder to wrist, and the point of puncture presenting the appearance of a sloughing ulcer
discharging freely sanious pus. Many of the cases have been confined to bed with high fever from five to ten days, reijuiriug the constant application
of poultices and the free use of morphia for the relief of pain." Even ivory points or quills, ostensibly coated with bovine lymph, may induce spurious
results, if by pressure or other means the vesicle on the calf be made to exude an inflammatory serosity or be transformed into a purulent matrix.
During variolous ejiidemics, when tlie demand for bovine virus is greatest and the necessity for pure vaccine is most severely felt, there is the greatest
danger of an unprincipled and disastrous vitiation of the supply. AVlieii vaccination is compulsory, whether by law or public sentiment, citizens as welJ
as soldiers require official protection from the dangers of impure inoculation.
MEASLES. 649
II.— MEASLES.
Prevalence and fatality. — During the years covered by the statistics 67,763 cases
of measles, with 4,246 deaths, were reported among the white troops, the rate of fatahty
having therefore been 6.27 per cent. Probably but a small part of this mortality was directly
referable to the disease. In many of the regiments not one death was caused by its epidemic
occurrence. Most of the mortality was tlie result of secondary pulmonary affections; but
the mortality-rate does not express the whole of these consec|uences, for many deaths were
placed to the account of the pneumonic lesion without a reference 'to the primary cause.
The average annual rate of cases per thousand of strength was 30.41, — the maximum, 77.57,
during the first year, the minimum, 1.98, during the last j^ear. But these numbers repre-
sent only a part of the prevalence of the disease, for many regiments suffered while at the
recruiting rendezvous before they had been mustered into the service of the United States.
Among the colored troops 8,555 cases, with 931 deaths, or 10.88 per cent, of fatal cases,
were reported. The average annual i-ate of cases per thousand of strength was 46.65, — the
maximum, 121.54, in the first year, the minimum, 5.11, in the last year of their service.
The regiments in the Confederate service also suffered from measles during the early
period of their history. According to Professor Paul F. Eve* —
Measles prevailed extensively in the new regiments, especially in those fron\ the country, anil gieatly impeded
their organization. It so diminished the etiectiveni-ss of the troops and proved so fatal in camp that companies,
battalions and whole regiments had to be disbanded for a time and the men sent home.
Tliis statement is fully corroborated by the records of the Confederate States Army of
the Potomac, which show that during the months of July, August and September, 1861, 8,617
cases of measles were reported in a maximum monthly strength of 58,360 men. One man
in everv seven of the command became affected durino; these months. After this the disease
subsided; 430 cases were reported in October, 241 in November. 79 in December, 34 in
January, 1862, and only 8 in February.
lu examining the monthly prevalence of measles among the white ami colored troops
of the army the irregularity of its progress among the colored regiments appeal's to indicate
a succession of epidemic waves involving the susceptible material of successive additions to
the strength of the command. As the new men came within the influence of the contagious
foci the disease spread, giving a sudden elevation to the line of prevalence, which thereafter
fell until fresh additions occasioned a corresponding rise in its level. The highest rates
occurred in the early months, when the command was small and unprotected by a previous
attack. In subsequent periods of increased prevalence the rates, if calculated on the strength
of the new regiments only, would probably have been ecjually high, but, calculated as they
have been on a mean strength, jjart of whii-h had lost its susceptibility to the disease, they
are necessarilj'- lower than those of the earlier epidemic periods. Thus, in April, 1864, 851
cases gave a rate of only 12.66 per thousand of a strength partly protected by previous
attacks, while in July, 1863, 327 cases gave a rate of 27.63 per thousand of newly-recruited
men. The injury to the new regiments was as great at one period as at the other, although
the rates indicate a progressive decrease of prevalence in the colored command as a whole.
The decline of the disease toward the close of the year 1864-65 corresponded with the ces-
sation of recruiting and the commencement of disbandment.
•Qnoted bv Boberts B.vstholow in his [apcr on Cnnip 3[e<ulca—r. S. Sanilari) Commimm Memoirt, N. Y., 1867, p. 231. Tlio article cited is an
excellent priwntation of the clinical hi^to^J■, latholocj- and trcatmiiit uf the disease, based on an anal.vsis of one hundreil coses observed at the field hos-
pital, Chattanoopa. Tenn.. and Ito9|>itaI Xo. 1, Nashville, Tenn. Its substance was reported to the Surgeon General's Office April 21, 1804.
Med. Hist., Pt. HI— 82
650 THE ERUPTIVE FEVERS.
Among the white troops, however, the hne of prevalence shows a seasonal influence as
■well as that due to the aggregation of susceptible individuals. The white troops were levied
en viasse instead of by gradual recruitment, as was the case with the colored regiments. The
highest rate of prevalence occurred during the early period of the war as the newly organized
commands were beini;; mustered into service. But while recruitinsi; continued active in the
summer of 1862, under the call of the President for more troops, as stated in discussing trie
irregular waves of prevalence of typhoid fever, measles declined in prevalence almost to a
minimum. During each of the following summers a similar decline was observed, while
each winter was marked by an increase of the disease, largest in the early months of 1864,
when veteran troops were to some extent being replaced by fresh men. This influence of
season, unnoted in the case of the colored troops, appears among the white troops to have
outweighed that of individual susceptibility. To explain this it may be assumed either that
the colored men were more susceptible to the disease or that the influence of the warm season
operated less favorably on them. The annual rate of cases per thousand of strength was
30 among the white and 46 among the colored ti-oops; but this difference, even if it indi-
cated a greater resistance to attack on the part of the whites, is too small to account for
their immunity from the disease during the summer months. The influences of the warm
montljs must therefore have operated in a special manner for the protection of the white
troops. The milder temperature was evidently not the cause of the decline of the disease,
else the colored troops would have been equally benefited. It was due probably to a change
in the environment of the soldier, the free ventilation and open-air life of the summer camp
diluting the virulence of the specific exhalations to a degree inconsistent with the retention
of contagious cpialities. On the other hand, the ignorance and helplessness of the colored
recruits, with a want of care on the part of those in authority over them, rendered over-
crowding, defective ventilation and other insanitary conditions as common in their camps
of organization in summer as in winter, and conduced to the spread of the disease among
susceptible individuals ii-respective of season.
The reports of medical officers show, in some instances, the manner of the introduction
of the poison of measles into their commands, — tlie rapid development of the epidemic, its
maximum having been attained in about a month and its subsidence having occupied a
similar period, — its extent proportioned to the number of susceptible individuals in the
camp, for efforts at isolation were seldom competent to restrain the disease, — -the mild char-
acter of the epidemic when the men were subject to favorable influences, — and its severity
when they were, as was too often the case, exposed to the inclemencies of the weather
before, during or after the attack. In a few instances where the disease occuri'ed among
troops housed in crowded and badly-ventilated buildings it became deadly in itself, the
patients becoming listless or stupid and the eruption dusky or failing to appear distinctly.
The virulence of the morbific agency seemed to liave been intensified by concentration and
the resisting powers of the system enfeebled by ochletic influences. But generally it was
dangerous only from its complications or sequelae. These usually affected the pulmonary
organs, and were due to exposure to cold and wet during transportation or in poorly heated
or leaky tents or quarters, to insufilciency of clothing or bedding or to sudden changes in
the weather for which no adequate provision had been made. Bronchial inflammations,
pneumonic congestions and solidifications, laryngeal congestions and oedema were the most
prominent of the dangerous conditions; but sometimes the diseased action was manifested
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MKASLES.
651
on the intestinal mucous membrane. Exposures during and after convalescence were also
prone to be followed by pulmonary disease, which augmented the death-rate from pneu-
monia and the number of discharges for disability resulting from chronic bronchitis and
consumption. Moreover, in subsequent epidemics of other diseases, as of ty[)hoid fever,
those who had been prostrated by measles became more severely aflfected tlian tlioso who
liad escaped the rubeolous infection.
Act. Ass't Surgeon Alfrf.r JIl'i.i.Eif, Fort liUIgih)/, J/i««., Jj»iM, 18(52.— In Fibiuaiy measles aiipranil in tlio ^ar-
xison -with the return from furlou;;!! of two soldiers from the lower part of the Minnesota valley, where the disease was
jirevailing at the time. Successively nearly all the men of the command here, who had not previously sutlered from
the disease, were takeu sick. Most of the patients (including a great many children at this post) passed through
the attack with hut Utile treatment other than the exorcise of needful c-iution against exposure to cold. No secondary
alfeetions commonly following this eruptive fever came under my observation.
Siir(iiou W. W. Uuowx, llh X. If., St. Aii<iu-<tine, J'la., May 1. IWiS.— Our first case of measles occurred at ilivn-
chester, N. It., in the person of a middle-aged man in whose family that disease existed at the time of his enlistment.
He a-iserted that he had t he disease in early life. About twenty men became infected by him. These had as mild an
attack as could bo desired and fully recovered. Our next lot of cases was larger and of a more severe type, as the
-weather was much colder. Nearly all of them had pneumonia, more or le.ss severe and alarming according to the age,
constitution and habits of the patients. All were innnediately removed from our hospital tents to the warmer atmos-
phere of a house in the city; also all new cases as soon as they nuinifested the premonitory symptoms of the disease.
Several of these assumed a typhoid character and died notwithstanding our efl'orts to save them. After arriving at
Kcw York and being subjected to the close quarters assigned them there, our men suffered from measles in a form
that is never seen in New Hampshire in civil life. Some patients affected in the ordinary way until the eruption
fully appeared, and concerning whom we were not at all apprehensive, would suddenly become listless and stupid ; the
eruption over the whole surface of the body assumed a dusky hue; the pulse increased iu frerjuency and the respira-
tion became more rapid and labored. On auscultation and percussion we found signs of congestion or hepatization.
"We saved some of these by active stimulation with brandy internally and rubefacients externally. In others, con-
stituting a more hopeless class of cases, the purple color of the skin was present from the very onset. In this variety
the eruption did not appear very distinctly or not until near the close of life. In all these cases a decidedly stimu-
lating course of treatment was adopted from the first, and by great exertion some were saved that would have been
lost had any other view been taken of the character of the disease. External rubefacients, such as nmslard, with
internal stimulants, constituted the main features of our treatment in this form.
SiirffcoH E. J. BoxiXE, 2rf J/ic7i., I'pton'.'i Hill, Vo., Oct. 4, 1862.— The only epidemic we h-.tw had was measles of
a very mild type. It uuide its first appearance in the beginning of July and ceased about the end of August, 1861.
We had altogether fifty-three cases and no deaths. There was nothing peculiar about the course or appearance of
the disease; the characteristic eruption on the fauces was present in the beginning of nearly every case, and iu a
majority there was a slight diarrluva. The treatment was generally diaphoretic, with laxatives when re(iuired. Iu
some cases, probably teu, the eruption appeared after the first day's fight at IJuU Run. The men walked back to
Arliugton through heavy rain: they suffered much from fever for some days, and, though they all recovered, eli'ects
•were left which required their subsequent discharge from the service.
Surgeon C. N. CiiAMUKHL.ux, 10/7i JTnss., Wasldhgton, V. C, Oct. 1, 1861.— I am gratified in being able to state
that no patient died of uu^asles, although umny of those affected were very sick and had entailed upon them the ordi-
nary se.iuehe of the disease, rendering their convalescence slow and tedious and making thiMu peculiarly suscejitible
to disease uuder the unavoidable exposures of a soldier's life.
Surgeon M. R. Gage, 2r,lh Wis., Camp BandaU, Wis., Dec. 31, 1862.— Rubeola has been somewhat prevalent ever
eiuce the organization of the regiment, and although many cases have assumed a considerable degree of severity but
little difficulty has been met iu conducting them to a hai>py termination hy mildly antiphlogistic measures. Nau-
seauts and expectorants were the remedies nmstly administered, with sometimes counter-irritants over the chest.
Surgeon J. M. CuYLER, T. S. A., Medical Director, Fortress Monroe, Ta., Jan. 28, 1862.— I have also to report
another invasion of rubeola, brought here by the troops of General Butler's expeditiou on board the transport Const i-
tution, A ward at the general hospital has been specially prei>ared for cases of measles ; and in order to circumscriljo
the disease as much as possible, all the cases brought on shore are treated there. Generally the disease is of a mild
character and thus far unattended with those sequelie which have heretofore rendered it so troublesome.
Snrgeon EZR.v Keed, 21«/ Ind., Locust Foinl, Baltimore, Md., Oct. 7, 1861.— During the month of September rubeola
in a mild form was very prevalent; but no death was occasioned by it. Pulmonary and intestinal irritation gener
ally coexisted, manifested by troublesome cough and diarrhiea; but in the convalescence there were no accidents
and no supervening structural derangements. Altogether the recoveries have been more satisfactory than I have
ever known in a like number of adults. Iu the treatmi'ut but little medicine was required with the excejitiou of
anodynes and astringents. The epidemic is now decliuing and but few cases are reported.
Ass't Surgeon H. >r. Sprague, C. S. J., Alton, 111, March 31, 1862.— In the 13th U. S. Infantry no case of measles
was severe in its primary eflccts. Mauy, however, suffered from bronchitis with marked debility, and a few seemed
6.52 THE ERUPTIVE FEVERS.
to develop tuberculosis. I found the latter class to Ije of plitUisical families and usually young and undeveloped
physically. They have been discharged. In no case did pneumonia supervene upon the disease.
Suryeon John G. F. Hoi-STEN, U. S. Vols., Orerion. Hospital, Memphis, Tenn., JS'ov. 20, 1862. — All the new regi-
ments comiu"- down the river are aftected with measles of a somewhat severe type. I find it impossible to effect
l>erfect isolation, yet hitherto no ca.se has been developed here.
Surf/eon C. J. W.VLTOX, 21st Ky., Marcli 31. 1862. — At the beginning of the (juarter the regiment was encamped
about half a mile southeast of Green Kiver bridge, in Taylor County, Ky., in a bend of the river making three-quar-
ters of a circle one mile in diameter, on low swampy land, with a tough, clammy clay underlaid with slate-stone.
The soil and clay were so impervious that, after a light shower or snow, the water stood in any little l^asin upon the
surface for some hours, and but very little walking over the streets nuide a mortar sufhciently toui,'h for building
purposes. The soldiers were occupying bell tents : using water from a swampy spring ; living principally upon bacon,
salt pork and badly-cooked beef, with tough, heavy, hard bread, few vegetables and a good supply of cotfee badly
served up. They were well clothed and each had a pair of blankets. They slept upon a scanty supply of straw on
the ground, without brush or boards under them. The season was unusually wet — so much so that there was scarcely
one day in the week that any drilling could be done. In a word, pearly every circumstance was against the health
of the camp. Our regiment was composed of about an equal number of recruits from Lexington, Ky. and vicinity,
and from the Green River country. The latter, with few exceptions, had not had measles. This disease broke out
among our troops at Campbellsville. Ky., before we moved to the bridge in the month of Xovember, and rag'ed with
fearful violence, but was attended with but little mortality, leaving, as is always the case in the army, those who
had had it very much debilitated and open to the invasion of such diseases as are occasioned by exposure to cold,
the results of which may still be seen in abundance about our camp. Eight hundred and sixty-eight men were
treated during the quarter, besides a large number of coughs, colds and trivial aft'ections that were not entered on
the record.
Siirr/co)i LorLS W.\t.sox, IGfh III., Post Surgeon, St. Joseph, Mo., Dec. 31, 1861. — ^Most of the cases of rubeola have
exhibited a typhoid tendency and have been followed by bronchitis, with loss of voice, pneumonia, otitis and abscesses
under the jaw. These sequehe Cave been troublesome and have protracted recovery several weeks.
Sm-geoii J.vmes M. B.vtes, I3th Me., Shij) Island, Miss., March 31, 1862. — During the first half of the quarter the
regiment was encamped at Augusta, Jle.. in the '-Harding'' tents, each of which was provided with a stove, with
good hard dry wood as fuel. During December and January many of the men were attacked with measles, there
havijig been during the two months one huiulred and twenty-six cases. The contagion was brought into camp by
one of the recruits. Many of the cases were of a severe type, accompanied with acute bronchitis and some with
congestive conditions of the lungs, owing probably to exposure in camp prior to admission into hospital.
Surgeon Willijim Henry Thayer, lith X. H., CarroUton, La., May 4, 1864. — Measles commenced in February,
1863, and lasted till the removal to ^Vashington in April. Some of the early cases were very severe, of typhoid char-
acter, and two were fatal. The attendant bronchitis in many lasted for weeks. It has been recently suggested that
this disease arises from a cryptogamous plant growing on the straw used for bedding. Whether this theory will
stand the test of further investigation may be questioned; nevertheless it is proper to state that during the winter,
from December to April inclusive, straw was used for bedding, but it has not been used since then.*
Surgeon George A. Spies, i'th Ohio, Gauley Mount, Va., March 31, 1862. — The regiment became infected with
measles, January 16, by a soldier who had visited a friend in hospital at Summerville, where the disease was prevail-
ing. Fifty -nine men became aftected. The attack was characterized by great prostration of strength and putrescent
tendency, and was complicated with bronchitis, pneumonia, diarrhoea and dysentery. At the beginning the fever
was asthenic in the feeble and inflammatory in the more robust. It is remarkalile that all the patients were Ameri-
cans; no European was affected, although the regiment consists of Americans and Europeans in equal number.
Probably most of the latter had already suffered from the disea.se, as the exanthem in Europe is chiefly seen among
children and young persons.
Medical Inspector G. K. Johnson, U. S. J., Buliimore, Md., April 23, 1864. — .\n unusual mortality from measles
occurreil in February in the Mansfield hospital, Morehead City, N. C. There were thirty-seven admissions for this
disease in that month and the latter part of January. All the cases progressed favorably until February 17. At that
time the weather became intensely cold, and, as the supply of wood was deficient, the wards could not be kept prop-
erly warm. A number of cases at once assumed a bad character and eight died soon after. Autopsies revealed in
two instances pulmonary congestion and inflammation, and, in four, intense iuflanmiation of the intestinal mucous
membrane, extending from the pylorus to the rectum. t
About thirty-seven cases of measles were admitted into the Hammond hospital in March. At the date of my
visit four of them had died of pulmonary complications and several others were then suffering from like causes.
These patients were in a poor ward, — the poorest in the hospital. It was cool, damp and not very comfortable; and
to this I was inclined to attribute, in part at least, the proneuess of the disease to these accidents. Exjiosures to
* It is needless at this date to do more than refer to the views of S-ilisburt, vrho attributed the disease to a fungus on the bed straw used by the
troops. See American Jour. Med. Scimce^, Vol. XLIV, N. S., 1862, pp. 17-23 and pp. 3ST-394.
I Surgeon J. B. Bellanger, V. S. Vols., in charge of this hospital, has reported these occurrences — Amer. Med. Times, VIII, N. T., 18G4, pp. 258-9.
The thermometer fell suddenly from 60° to 18° Fahr., ^s-ith a cold northwest wind. The bad effects of the low temperature were soon manifested by the
occurrence of a dry husky voice and distressing cough in the rubeolous patients, soon followed by diarrhtea, attended in a few days with bloody dis-
charges, very frequent in some cases and quickly fatal. Br. Bellanger puts the number of cases at thirty-nine, of which eight died, — six of enteritis,
one of acute bronchitis and one of sudden pulmonary congestion.
MEASLES. G5:^
dampness, to a low ami fluctuating tcnipevaturr ami Id vitiatt-U air iluriii;; the pro-jress of tlie ilisea^ art-. I am eon-
vincetl, fruitful causes of serious ami often fatal visceral eoUijestions ami iullauunations.
Surffcun \y. M. Gates, 22</ Mo., Die. ol, ISlil. — The rejiiment is principally conii>cise<l <if men wlio have been
ennjaKcrt iu agricultural pursuits, owning their own farms anil living in their own houses in reasonalilo comfort.
Thev have been accustomed to a life of labor Avithout undergoing any great hardships or privations, their food jilaiu
and frui;al and their hahits correct. A smaller proportion of the men of the regiment, enlisted in towns and villages,
principally foreignei-s, have lived more irregular lives and their habits are much less correct. The latter have suf-
fered somewhat fixim diseases to whicli such subjects are always liable, which diseases, however, have been cither
lessened or prevented by proper disci]iliue. The location of the camp in Macou t'ity was well selecteil from the sani-
tary point of view, being upon an elevated plateau which atl'orded drainage: but as the tents were of the smallest
size and without flies tliey were inconvenient and often crowded. Under these circumstances it was diliieult to
enforce that desirable degree of neatness and cleanliness favorable to perfect health. Tho tnmps remained in camp
until the cold season was far advanced, and suffered much in conseiiuenee of some severe storuis which occurred pre-
vious to their removal to winter ijuarters. Tho evil etFects of their exposure were heightened by the fact that their
clothing was not supplied in jiroper time and when furnished was found to be of poor quality. Tliey suffered espe-
cially from the want of overcoats, which were not jirovided until sometime after tho winter had set iu. Their coals
were of too light a fabric to afford sufficient warmth and protection and were destitute of cajies. Tliey have never
yet beeu fully furnished with boots, although greatly needed. In consequence of these causes, the inlluenco of which
has been much increased by the severe duties iu which they have beeu engaged, and which consisted in almost inces-
sant scouting over a wide extent of country iu northern Missouri, a large proportion of the men have suffered from
those forms of disease which result from exposure to cold and atmospheric changes, as catarrh, bronchitis, pleurisy,
pneumonia, etc.: from the continuance of their causes these diseases were difficult to treat successfully, and relapses
were of frequent occurrence. While the health of the regiment was in this unfavorable condition, measles nuide its
appearance on October lli, comuiunicateil by the S.id Missouri regiment, which, returning from St. Louis, reuuiiued
some days at this station. Notwithstanding all efforts to isolate tho earliest cases the disease soon became general,
seizing upon every one not protected by a former attack. The number of these was large, as the regiment wasrecruilcil
from a scattered rural population. The disease presented no difficulty iu its treatment when uncomplicated, but from
the causes mentioned, many cases were complicated with bronchitis andcata'-rhal pneumonia, lleuco the largo number
of deaths reported asdue to pneumonia. As a number of our patients were suffering from catarrh and bronchitis on
the accession of measles, and, as might be feared under the circumstances, pneumonia woulil soon supervene, our
troops went inunediately into winteriiuarters. These consisted of unoccupied houses iu the town, generally in imper-
fect repair, many of the windows being broken, doors gone, plastering knocked down from the walls and tho buihl-
iugs otherwise injured. They were for the most part destitute of fire-places, and the troops without stoves, which,
up to this date, have been but partly supplied. The quarters, owing to these circumstances, were uncomfortable and
nufavorable to the health of the men, — so much so that it has been found dangerous to return convalescents to quar-
ters for fear of relapse. By the labors of the men and etforts of the oflicers the quarters are now iu much better
condition, and we have reason to hope that iu a short time they will be further improved,
J»«'( Siirgcon>: CoMPTON .«:mitii, ilh V'h. Cat-., Bilay House, Md., Sej}!. 30, 1861.— At Racine rubeola maile its
appearance anmng the troops, and when, on July 2. the regiment was mustered into the service of the L'nited .States,
there were two hundred cases of that disease. Kacine is situated on the west bank of Lake Michigan, where, until
the time we left for the South, cold easterly winds prevailed which greatly aggravated the sequehe of rubeola, par-
ticularly congestion of the lungs. The disease continued to spread through the regi-uent to such an extent that
during our trausportatiou to Harrisburg I had two and part of the time three passenger cars filled with rubeolous
patients, and was obliged to leave about twenty at Elmira, X. Y.
.!»»•( Surgeon W.vlteh B. Morrisox, 3d J/u7i., EdwariTs Fei-ry, Md., Oct. 25, 18l>2.— Rubeola made its appearance
in the command, previous to mustering into the Tnited States service, while at the recruiting rendezvous, Grand
Kapids, Mich. The disease spread rajiid'.y, seizing upon all who had formerly escaped the lualady, and indeed, a few
suffered a second attack. Tlie acme of the epidemic was reached in about twenty days, after which its decline was
rapid, the disease having become nearly extinct when the command was ordered to Washington two weeks subse-
quently. Occasional cases were developed, however, during the succeeding two months. Four deaths occurred iu
one hundred and thirty-four cases. Secondary pulmonary affections were of frequent occurrence, owing to exi>osure
during cold and damp weather. Many men were permanently disabled and discharged from tho service.
Act. Ass-I Surgeon A, 15. Sh.vi.er, yeuport Barrackn, Ktj., April 3, 1862.— There were thirty-four cases of measles.
Many of these were treated in Sibley tents with board floors and a stove, without a single complication; others
were cared for in a new temporary hosjiital consisting of two airy rooms. Every case iu the hospital wiis more or
less complicated, and the only death from congestion occurred in this building. This was in part due to deficient
v.ntilalion at night and iu part to want of proper water-closets. Convalescents were exposed iu going from the
wards to the sinks in rear of the hos-jiital building.
Surgeon H. W. KexdaM.. .50/7i UL, Ike. 31, 1861.— Rubeola occurred late in Xovend.er while tho regiment was
quartered iu tents on an elevated and bleak prairie near Chillicothe, Mo., and was followed in a majority of the cases
by pneumonia and freciuently relapsing catarrhs. The removal to St. Joseph, a distance of eighty miles, in open cars,
while most of the cases were only yet convalescing, produced another list of pneumonic sequehe.
Surgeon L. H. AXGELL. 52rf TU., Dec. 31, 1861.— About December 1, while in camp at Benton Barracks, measles
began to make its appearance. The exposure of the men the first few nights iu cold and damp quarters iu a filthy
654 THE ERUPTIVE FEVERS.
camp left bat few of the regiments unaffected with bronchitis or some form of inflammation of the air passages. The
tjuarters of the men were poorly or not at all ventilated, and were warmed by stoves burning soft coal (after stoves
were procured), which permitted a large amount of gas to escape into the atmosphere, so vitiating it as to act most
perniciously upon the mucous membrane of the air passages. * » * Each orderly sergeant was furnished with a,
bottle of expectorant medicine which was administered to the men in quarters. At St. Joseph, ilo., after Decem-
ber 11. many cases of rubeola were accompanied or followed by pneumonia, which is probably attributable to the
exposure of the men at the time and previous to the attack. Cases of pneumonia are occurring from exposure while
guarding railroads and bridges, and I have to excuse from duty a large number of convalescents, especially from
measles, who would be sure to return in a few days with renewed attacks were they ordered to active service.
Surgeon William H. Palmer. 3d X. T. Car., PoohsriUe, Vd., Dec. 31. 1861. — ^Jlan'y cases of rubeola occurred
during the present winter, and the disease is still on the increase. Tlie type is mild. The precursory symptoms are
attended with little febrile action: but the pulmonary aflection consecutive to the eruption has been cjuite severe,
and in many cases associated with great and persistent dyspntea and complete aphonia. Xotwithstandiug these
complications, recovery has been in every case of that degree which forbids application for discharge. Some of those
attacked afiirm that they have had the disease before, but their assertions require confirmation.
Surgeon J. K. Bigelow, Sth Ind., Indiauola, Texas, Feb. 20, 1864. — Rubeola, which occurred as an epidemic during
the autumn and winter of 1861, was unusually complicated with pulmonary lesions which frequently ended fatally
or incapacitated the soldier for further service.
2f(dicnl Inspector E. P. Vollum, V. S. J., Wasliin/iton, D. C, Dec. 1, 1862. — There broke out among the 1st U. S.
Sharpshooters, while at the camp of instruction near this city, a form of measles which directly or by a subsequent
congestion of the lungs, caused a large number of deaths. Many, supposed to have recovered from tlie disease, are
stUl suffering from pulmonary affections and persistently applying for their discharge. In January of this year
the 1st Mich., while stationed at Annapolis Junction, became subject to an epidemic of measles which prevailed
during that and the following month; but the disease required little attention except when complicated with pul-
monary affections, which, as usual, were more formidable than the disease itself. One hundred and ninety-two cases
were reported, only one of which was fatal. At Fortress Monroe, during March and April, while this regiment was
in tents, pneumonia and bronchitis prevailed to some extent as the sequel* of measles, and seemed to be induced by
the change from an inland to a marine climate.
Of the recruits for the loth K. Y., received about the beginning of January, twenty-eight were taken down
with measles soon after they joined. Four died of pneumonia and two others succumbed to the disease in general
hospital. » * * Many cases of measles in the 2d Jle. were complicated with congestion of the lungs, five proving
fatal. During the winter nine deaths occurred in the regimental hospital, all of which were directly or indirectly
attributable to measles.
Surgeon L. M. Slo.vs'.\ker, Wth Iowa, Broicnsrille, Texas, April 20. 1864. — An outbreak of measles occurred in
September, 1862, and prevailed until the beginning of December. About thirty men contracted the disease. Usually
it was of a mild form and when uncomplicated required l>ut little treatment. Some of the cases transferred to general
hospital proved fatal: two of those retained in the regimental hospital died from pulmonary complications.
Surgeon J. M. Mekrox, '2d X. H., Portsmouth, X. H., June, 1861. — There were about fifty cases of measles, many
of them complicated with pneumonia: yet a rapid recovery was the rule; no case terminated fatally. Treatment
consisted chiefly of mild febrifuges and diaphoretics, with a mixture composed of antimonial wine, syrup of squill,
sweet spirit of nitre and paregoric.
Surgeon HEXRYM.4:xFRED,22(f .STy., Baton i:ouge,La., March 29, 1864. — In December, 1861, while at Camp Swigert,
Greeuupburg, Ky., the entire legimeut was attacked with rubeola, two or three hundred men being sick at one time.
The winter was very wet and cold and many chronic affections of the lungs were engendered by this epidemic.
Jet. Ass't Surg. B. R. Palmer. Sauk Centre, Minn., Jan. 2, 1863. — Rubeola, which took its course through the camp,
wa.s introduced by Wisconsin troops. Severe pulmonary irritation, pneumonia, diarrhoea and dysentery accompanied
or followed the disease.
Snrgeon A. J. McKelw.^y. Sth X. J., Camp Van Lear, near Alexandria, Va., Oct. 20. 1862. — Toward the end of Feb-
ruary and through the month of March rubeola to the extent of about thirty cases prevailed in the regiment.
Although the disease was of a severe type no case proved fatal : but in several cases tubercular and bronchitic devel-
opments necessitated the discharge of the men.
Ass't Surgeon J. W. JIasox, l'2th Corps d'Afrique, Fort Hudson, La., Feh. 23, 1864.— In September, 1863, the camp
was visited with measles, mild in itself, but followed by acute bronchitis and pneumonia, which either proved fatal
or left the system in an adynamic condition.
Surgeon Jotham Doxxell, loth Me., CaroUo Fass, Texas, Feb. 9, 18(>4. — Measles and catarrhs were very preva-
lent at Augusta, and quite severe both in the regimental camp and the surrounding country. A few cases resulted
in severe bronchitis and pneumonia. Xo great mortality occurred at that time, three men only having died during
the winter. * * » The numerous cases of phthisis pulmonalis during the first season at the South may. I think,
be attributed in part to the measles and the exposures of the men at Augusta.
Surgeon Madisox Reese, llSth III., Fort Hudson, La., Feb. 21, 1864. — Two-thirds of all the pulmonary diseases
were caused by measles.
Surgeon William Berry, 1th Ky., Baton Fouge, La., April 27, 1864. — During the latter part of September and
all of October, 1661, measles prevailed as an epidemic. Nearly four hundred cases occurred. Much of the subsequent
mka>;lks. 655
disease from which the vogiiiifut siiffi-reil is attiilnitahle to this epidemic. Its sequehv atlVcteil the men iu two ways:
Some sii tVe red from lironcliial irritation or liroiiehitis; others from irritahility of the howels. In snlise<|ueiit epidemicH
of tyjdioid tVveraiul pneumonia, those patients who had measles during the period mentioned were more danijerously
artVeled than tlieir more fortunate conira<les.
Skiiicoii II. F. Vaxi>ei;veer, alh .V. J., Alexandria, fa., Od. 21, 1862. — .\n epidemic of measles appeared ahout
the cud of Fehrnary and sul)sided in May. Twenty-three cases occurred in the regiment and one death resulted in
division hospital. The disease was severe, the eruption often becoming livid and receding on the second or third
diy, which was sure to lie followed liy dangerous pulmonary congestion. This change was often exceedingly sudden ;
two hours sometimes changing the symptoms of rulieola to those of typhoid pneumonia. Emetics and stimulants
were the means of cure employed in this condit ion. Tubercular disease appeared in several instances as a sequel.
Siirycon A. AV. McC'Ll'ltK. 4//i fown, Sprinfithld, J/o., J^»n7 2, 18(i2. — About December 20 measles broke out in camp.
.\ large number of men were attacked. Consecutive pulmonary troubles disappeared only when the wealhi'r breanu)
warm, so as to permit the patients to get into the open air. All the fatal cases of pneumonia except two resulted
iVom measles.
Siiigcuii C (i. Pease, 2il iris.Cur., Cussville, Mo., Juhj 1, 18G2. — While at Milwaukee we had a large number of
c.tses of rubeola. To an enfeebled condition of the lungs, consequent on this disease, 1 attribute the frei|ueney of
diseases of the respiratory organs that has since occurred; nearly all the cases of tubercular disease observed in the
regiment since the first of March appear to have originated iu the previous attack of measles.
Siinjion FUANKI.IX R. HofGll, !'7f/i .V. Y., Mircirsrillc, Mo., Oct. 5, 18t)2. — While recruiting in winter ipiarters at
Dooneville. X. Y., during the winter of 18(51-02, rul>eola prevailed as an epidemic, attacking some lifty or sixty men,
of whom thirteen diedt Many who recovered traced lasting pulmonary ditUculties to this disease.
Tlie CUBICAL KECORDS of measles show a return to duty three or four we^Ks aib, r liie
onset; but in many cases the stay in liospital was prolonged for as many months by the
continuance of bronchial inflammation or the supervention of broncho-pneumonia or diar-
rluea. In some cases the specific agency manifested its virulence by a dark-purple color of
the eruption and symptoms of internal congestion. Generally, however, the point of interest
in the record is the consecutive disease rather than the progress of the eruptive fever. Some-
times pneumonic congestion was suddenly' developed by exposure while the skin v\^as affected,
but more frequently pulmonary disorders, including consumption, appeared to be engrafted on
the patient during convalescence. Laryngitis in some cases caused sudden death and in
others a temporary or even permanent aphonia. Cerebral meningitis sometimes occurred,
and intercurrent or sequent attacks of erysipelas were common. Conjunctivitis was a fre-
quent sequel, and deafness followed the invasion of the middle ear V'V way of the Eustachian
tube; occasionally the ear became involved in the suppuration of the glands in its neighbor-
hood. OEdema of the feet, orchitis and abscess of the ischio-rectal space, inducing fistula in
ano, appeared among the sequelae.
Case 1.— Private James W. Simmons, Co. E, 50th 111.; age 22; was admitted Feb. 28, 18G3, from his regiment
near the city, with high fever, the eruption of measles, sore throat and hoar.seness. tiave Dover's powder and ])re-
scribed rest in bed and low diet. He iiiiproved speedily, but some cough persisted until March 10. He was returned
to duty on the 22d. — Ilu'iiitii}, (Juincy, III.
Case 2. — Private Nathan li. Jloore, Co. H, 137th 111.; age 18; was admitted ,Iune 9, 18(11, from regimental can\p
in this city with the eruption of measles, some febrile excitement and cough, pain in the bowels, constipation and
coated tongue. He improved under treatment by sweet spirit of nitre and syrup of ipecacuanha, with rest in bed
and low diet. He was returned to duty on the 28th. — IIosji>itat, Qainci), III.
Case 3. — Private Charles H. Moulton, Co. D, 22d Mass.; age 27; was admitted from guard duty Jan. 22, 18fi.^,
with measles. He had slight fever: his face and the upper part of his body were covered with the eruption, which
was also discovered on the roof of his mouth; there existed also slight bronchitis and conjunctivitis. Flaxseed tea
was prescribed iu large quantities, with a tablespoonful of Mindererus' spirit every three hours; the diet was
restricted to milk and farina. On the 2.-)th his bronchitis was aggravated; two days later he was much better in
every respect, siiuill, wild cherry and morphia having been substituted for the acetate of ammonia. Chicken was
allowed. l?y February 6 he had only a slightly inflamed condition of the bronchial and conjunctival membranes.
Oh the l?<th he resumed his duties as a member of the hospital guard. — Sailerhe Hospital, riiiladelphiu, Pa.
C.tSE 4. — Private Lewis Walters, Co. B, 39th Mo.; age 28; was admitted Dec. 17, 1864, with alternate sliiver-
iMLis :ind heat, anxiety, lassitude, pain and weight across the forehead and eyes; skin hot and studded with tho
characteristic eruption of measles: appetite poor. Gave cantharides and stimulants. Jan. 20, 18(i.5: Still weak;
coughing severely. February 20: Improving slowly. March 20: Still weak and with severe cough. April I: Dis-
charged.—Z7o«i>i((iJ .>'o. 23, .V.isAnV/e, Tenn.
656 THK ERUPTIVE FEVERS.
Case 5. — Private Frank P. Heniau, Co. C, IGtli I'. S.lnf.; age 21; ivas attacked with measles Jau. 16, 1863. and
transferred to Fort Ontario, where he remained sutl'ering from fever till late in February, when he was returned to
duty with his regiment, then serving in the Army of the Cumberiaud. In a sliort time he was again seized witli
fever, and after staying abont a month in hospital at JIurfreesboro', Tenn., he was transferred to tliis hospital May
22. When admitted he was scarcely able to walk; tongue coated; pulse 124; pain in chest; cough; slight expectora-
tion; appetite impaired; urine scanty and high-colored. Gave tepid bath; Dover's powder at lied time; also sweet
spirit of nitre, syrup of squill and Norwood's tincture of veratrum viride, with counter-irritation to the chest. 29th:
Cough; slight expectoration; but little pain ; pulse 7.5; unable to walk. Gave paregoric, syrup of squill and fluid
extract of senega. June 3: Pain in the bowels for several days, relieved by paregoric. Improving; able to walk.
8th: Stools frequent and watery. Gave nitrate of silver and opium. 14th; Severe chill at night followed by fever,
great thirst and pain in the bones. Gave quinine and Dover's powder. He was transferred next day to Xo. 1 hos-
pital, Louisville, Ky., whence he was returned to duty June 20. — Hospital Xo. 23, XashrilU; Tenn.
Case 6. — Corporal Aaron Mnnsell, 2Gth Mich.; age 29; enlisted Feb. 20, 1864. He contracted measles on
April 13, and was admitted on the 26th to Third Division hospital, Alexandria, Va.. where he became convalescent.
On May 6 he was transferred to this hospital. Gave compound tincture of cinchona and full diet. Eeturned to
duty March 21, 1865. — SatlcrUe Hospital, rhlladclpliia, Pa.
C'a.se 7. — Private John Edeus, Co. A, 13tli West Ta.; age 19; was admitted March 16, 1865, with diarrhiva. He
was convalescing slowly when, on April 27, the eruption of measles, dark purple in color, appeared on his face. He
complained of great oppression about the chest, and had subsequently nausea, persistent vomiting and profuse
diarrhoea. He died May 8. — C umherland Hospital, Md.
C.\SE'8. — Private Alfred Lord, Co. G, 20th Ind.; age 22; was admitted Feb. 8. 1865, with chronic diarrhiva. On
March 15 he had a severe chill, which was followed on the 17th and 18th by the eruption of measles over the entire
surface. On the 19th the patient sat at an open window, and in the evening the eruption had almost disappeared,
while a dull pain in the right side of the chest, aphonia, fever and pain in the head were developed. Gave diapho-
retics and apjilied cups. Kext day the pain in the ehesl was increased and there was duluess on percussion over the
lower lobe of the right lung; pulse 100. Repeated cups and ajiplied sinapisms; gave expectorants, stimulants and
beef-essence. The pneumonic complication assumed a typhoid character, and on the 24th erysipelas attacked the face.
He died two days later, retaining consciousness to the last. — Mouer Hospital, Philaddphia, Pa.
Case 9. — Private G. P. Foster, Co. B, 26th Mich.; age 19; suffered with measles while in camp. Pneumonia
supervened, and the patient was admitted March 12, 1863; Skin hot and dry; delirium at times; breathing hurried
and oppressed; cough with viscid, rusty sputa; bronchial respiration and slight dulness over the lower lobes of the
lungs. He sank gradually, dying on the 16th. — Third Division Hospital, Alexandria, Va.
Case 10. — Private C. L. Brocket, Co. G, iiOth 111.; ago 19 : was admitted Feb. 23, 1864. in a condition of typhoid
delirium due to pneumonia, which had supervened on an attack of measles. He was treated with opium eneuiata.
beef-tea, brandy and cordials; but he grew worse and died March 4. — Hospital, Quinci/, III.
Case 11. — Private Matthew Dyson, Co. G, 72d 111., had measles in September, 1862, but did no duty after his
convalescence, as he continued afi'ected with cough and occasional diarrha>a. When admitted. April 17. 1863. he was
greatly debilitated and had bronchial breathing on both sides. A chill on the 25th was followed by violent pain in
the right and afterwards in the left side: the respiration became hurried and the diarrhtea aggravated. He died
May 3. — Lauson Hospital, St. Louis, J/o.
Case 12. — Private William A. West, Co. G, 7th Vt.; age 18 ; enlisted Jan. 23, 1865, and had measles in February,
followed by pain in the chest. After treatment at \ew Orleans, La., he was admitted to this hospital June 17, with
diarrhiva and dull pain in the region of the liver; skin hot; pulse full but not strong; respiration on right side
diminished, on left side increased. Gave cod-liver oil, syrup of wild cherry and extra diet, with neutral mixture as
required. On the 20th a sharp pain with well-marked friction sounds and dulness was developed on the right side.
Beef-essence and wine-whey were given and mush poultices applied to the chest. 28th; Removed poultices. He
improved by July 1, but there was still much ett'usion in the chest. He was discharged on the 20th because of chronic
diarrhtea and pleuro-pneuniouia. — Satttrhc Hospital, Philadtlphia, Pa.
Case 13. — Private Alvin C. Evitt, Co. I, 99th 111.: age 22; was admitted Sept. 23, 1863, with diarrho'a and pneu-
mouia following measles. He had severe cough with pain in both sides, headache with nausea in the morning:
severe umbilical pain when at stool. — about twelve passages daily. Gave turpentine emulsion and milk diet. He
improved slowly. By December 5 the diarrhcea was reduced to five or six passages daily and by Jan. 10, 1864, to
three or four. He was returned to duty March 9. — Hospital, Quincy, III.
Case 14. — Private William Tibby, 18th Pa. Cav., was admitted March 9, 1864, with measles and Inonchitis.
Gave an expectorant mixture during the day, Dover's powder at night; nutritious diet. On the 25th the eruption
was almost gone and the bronchitis nearly cured; but dysentery had supervened: Tormina; tenesmus; stools fre-
quent, bloody and slimy; pulse full and bounding; tongue red, dry and thickened. Gave emulsion of turpentine
three times a day and an opiate enema at night ; milk and farinaceous diet ; rest in bed. On the 29th the cough had
ceased and the dysentery was relieved; a cutaneous eruption of doubtful character had appeared. The patient was
returned to duty April 4. — Second Division Hospital, Fifth Army Corps.
Case 15. — Private Hiram Steanbrook, Co. D. 97th 111., was attacked at Memphis, Tenn., Dec. 19, 1862, with
measles, which left him with a bad cough and so weak that he was unable to walk. When admitted. March 21, 1863,
he was emaciated and had slight diarrhcea; pain in left side; no dulness; edges and tip of tongue red, dorsum coated;
MEASLES. 657
pulse weak and rather fieriiient. Ou tlie 26tli bo was taken with erysipelas of the face. Iron, <|iiinine and brandy
were prescribed. Hy April 1 his condition was much improved. On the 10th the alidomeii was observed to be dis-
colored by a snbentaueous extravasation of blood. Lemonade was jiiveii. This symptom disappeared by the irith.
The patient was returned to dnty April 29. — Liiuxon Hospital, Si. Louis, Mo.
C.\SE 16. — Private Joseph AV. Conrad, Co. K, 1st X. Y. Eng'rs: age 17: enlisted April -1, 1804, and was taken
with measles on the 2itth. He was admitted. May G, from Harewood hospital, Washington, D. C, with bronchitis.
Ou the 15th the tongue and submaxillary glands became inllained; jileurisy was developed on the 19th, with a large
effusion on the 27th. Ou June 11 the patient's symptoms became aggravated on account of the floor of the ward
having been scrubbed. On July 18 he was evidently failing: theetfusiou was being absorbed gradually, but gurgling
was heard in the apex of the left lung posteriorly and respiration in the subclavicular region was harsh and prohmged.
On August 3 the symptoms of phthisis were considered uneiiuivocal. Death took place on the IGtli. — Stiltirlee Hos-
pital, riiilathlphia, I'a.
C.\SE 17. — Private George Damon, Co. C. Mth Vt.: age 21: was taken sick Feb. 20, 1862, with jaundice. AVhile
convalescing he was admitted, March 6, with headache and a dry cough with bronchial rales. Next day the eruption
of measles was apparent over the whole surface; pulse lt)0; thirst; cough dry; throat sore; bowels confined; urine
liigh-colored. His case progressed favorably until the 14th, when the velum palati and arches became swollen and
red and the voice whispering. Later in the day laryngotomy was performed and artificial respiration kept up for
£umo time without success. — Surgeon E. 11. Sprague, Uth Vt., liratthhoro', J't.
Case 18. — Private George A. Boyce, Co. B, 11th Vt., had a severe attack of measles Jan. 1, 1864, at Washington.
a few weeks after his enlistment. Ho lost his voice and became much debilitated. While under treatuu-nt at Hare-
wood hospital he was taken, June 4, with dysentery. On his airival in Vermont via David's Island, New York
Harbor, he was in a very low state. Treatment has relieved his diarrhoea and improved his general condition, but
liis voice has not been restored. He was transferred to the Invalid Corps Aug. 21, 1864. — Hospital, Burlington, 17.
C.\SE 10. — C. H. Flury. 8th Mich. Bat'y, was admitted March 27, 186.3, with aphonia, cough, pain in the chest
and diarrhoea following an attack of measles in .Scjitomber, 1862. He was treated with alteratives, turpentine emul-
sion and milk diet. He recovered his voice and was sent to his regiment Aug. 20, 1863. — Hospital, Quincy, III.
C.\SE 20.— Private Milton H. Beecher, Co. M, 15th N. Y. Cav.; age 20; was admitted May 23, 1864, from field
hospital. He had been attacked with measles, April 5, at Burlington, Vt., and had been treated in hospital at Spring,
field, Winchester and Martinsburg. At the last-mentioned place he had a relapse and was sent to this hospital. He
became delirious while en route. On arrival he was wild and unmanageable. He was sponged at once and given a
Dover's powder. Next day his appearance was wild; pulse rapid and thready: tongue moist and natural; face flushed;
slight dry cough. A cathartic was given; also an antimonial cough mixture; evaporating lotions were applied to
the head and blisters behind tl:e ears. Ou the 2.5tli the delirium continued. The patient's head was shaved and
douched with cold water. On the 26th there was much jactitation with subsultus and dysuria. Sweet spirit of nitre
was given three times. On the 27th there were clonic spasms and rigidity of the muscles of the arms, muttering deli-
rium and partial coma : pulse 120 and wiry, with occasional remissions. Fluid extract of veratrum viride was given
in three-drop doses every three hours and the ice-water to the head was continued. Next day the pulse fell to 75,
with increase of volume and softness. After this the coma deepened and the pujiils dilated. Iodide of ijotassiuui was
giveu with wiue and beef-tea. He died June 1. — Hospital, Cumberland, Md.
C.\SE 21. — Private James M. John, Co. I, 8th Pa. Reserves: age 19: was admitted July 6, 1864, on accouut of
inflatuinatiou of the eyes, with purulent discharge and photophobia following measles. Gave full diet; applied a
lotion of borax. He improved; was furloughed August 26 and returned to duty September 6. — Satterlee Hospital,
Philadelphia, Pa.
Case 22.— Private William Martin, Co. B, 33d Wis.: age 20; was admitted Aug. 26, 1863, with slight congestion
of the conjunctiva and photophobia, the result, according to the patient's statement, of an attack of measles in Jan-
nary. Gave cinchona and iron at each meal: full diet. September 3: Photophobia distressing; appetite good:
bowels regular. Applied laudanum diluted, but as this proved too irritiiting, an infusion of tea was prescribed.
7th: No better. Gave small doses of extract of conium, sulphate of cinchonia and citrate of iron at each meal; the
«yes to be kept shaded, October 1: Improving. Xovember 16: Returned to duty, — Hospital, Quincy, III.
Case 23. — Private George Tinker, Co. K, 2d Wis.: age 23 : was admitted Sep. 25, 1861, with lumbago following
an attack of measles and intermittent fever. He had pain in the loins, aggravated by motion, and a slight swelling
over the seat of pain; conjunetiv;e inflamed; pulse 72: tongue natural. He was treated by a blister to the loins,
Dover's powder, quinine and an eye-wash containing sulphate of zinc. He was transferred. October 1, to Annapolis,
Md., whence he was returned to duty December 2. — Seminary Hosptital, Georgetown, D. C.
Case 24. — Private George W. Gill, Co. F, 4th N. Y. Art'y : age 21; enlisted Dec. 14, 1863, and contracted measles
"vrlxile with his regiment at Fort Ethan Allen, Va. He was treated in regimental hospital, in the Carver hospital,
Washington, and the Mower hospital, Philadelphia, before his admission to this hospital May 13, 1864. He had
catarrhal ophthalmia, granulations, purulent discharge and photophobia. Applied sulphate of copper daily; full
diet. July 20: Lids mnch inflamed and closed; profuse juirulont discharge. Applied cold compresses soaked in a
solution of borax and atropia. 31st: Di-scharge abated; inflammation subsided. August 5: Furloughed. 21st:
Betnrned. December 20: Slight fever. 31st: Much better. Jan. 1. 1865: Pneumonia. February 1: Improving
lapidly. Gave iron and quinine three times a day and applied locally a solution of boras. March 25: Furloughed.
Mep. Hist.. Pt. Ill— 83
658 THE ERUPTIVE FEVERS.
April 13: Returned: eyes somewhat iutlamed: still feeble. Coutiuued former treatmeut. May 19: Discharged. —
Satterlee ITosjiital, Philadelphia, Pa.
Case 25. — Private Alvin P. Barnaby, Co. 11, 1st Mich. Cav.: age 43: was admitted Aug. 18, 1861, from Harris-
bum-, Pa., with conjuuetivitis consequent on an attack of measles. The membrane -was loose and swollen, and small
yellowish-red vesicles appeared at the margin of the cornea; there was also a frequently recurring ocular hyper;i'mia,
with retinal irritation and asthenopia: his general health was fair. Blisters were applied over the mastoid process
and saline jiurgatives occasionally given ; pediluvia were also used : a green shade was put over his eyes ; a lotion of
corrosive sublimate, three grains, laudanum two drachms and distilled water four ounces was applied lukewarm on
rafs for a half hour three times daily; full diet was given. He improved steadily. The treatmeut was afterwards
changed for an eye-water of borax six grains, cherry-laurel water fifteen drops, decoction of quince seeds a drachm
and distilled rose-water three and a half ounces. Jan. 26, 1865: Furloughed. February 25: Returned. He had fre-
quent relapses till March 23, after which he improved. May 20 : Discharged. — Satterlee Hospital, PhilatUIphia, Pa.
C.\SE 26. — Private James A. Munck, Co. G, 100th Pa.; age 18; enlisted Feb. 25, 1864. He contracted measles
and was admitted, March 27, to Division Xo. 1 hospital, whence he was transferred to Mower hospital, Philadelphia,
and on May 13 to this hospital. Diagnosis: Deafness of the right ear. Warm water was used by syringe and a
few droiis of a weak solution of sulphate of .^iuc were instilled daily into the ear. Improvement followed and the
patient was returned to duty August 6. — Satterlee Hos2>ital, Philadelphia, Pa.
Case 27. — Sergeant Robert Myers, Co. I, 1st East Tenu. Cav.; age 21; was admitted May 25, 1863, having been
treated in various hospitals for measles and its sequelse since Dec. 5, 1862. On admission he was much pros-
trated, and had pain in the chest, fever, nausea and irregular abdominal jiaius. Gave calomel, quinine and Dover's
powder every three hours, with sinapisms to the abdomen. 26th : No fever ; stools frequent and copious ; epigastric
pain. Gave powders of subnitrate of bismuth, persulphate of iron and opium. 30th: Fever; pulse full; tongue
white; pain in right hypochoudrium. Gave powders of quinine, Dover's powder and ipecacuanha every three hours,
with ten grains of blue mass and five grains of Dover's powder at bedtime. 31st: Very weak; fever; twenty stools.
Continued powders and gave pills of nitrate of silver and opium. June 3: Caught cold from kicking away the bed-
clothes during the night ; lymphatic glands of face much enlarged ; severe cough with thin glairy sputa. Continued
medicine; applied hot fomentations to face: expectorants. 9th; Rested badly; delirious; pain in the face from enlarged
glands; diarrhoea persisting. 10th: Purulent discharge from ear; stupor. 8 P. .m: Unconscious; extremities cold;
profuse suppuration from both ears; involuntary stools; died at 8.30 r. M. — Hospital Xo.23, Xushville, Teiin.
Case 28.— Private William H. Shultz, Co. B, 30th 111.; age 24; -was admitted March 18, 1865, from David's
Island, New York Hai'bor, with a?dema of the feet, following an attack of measles in December, 1864, Both feet
were swollen and pitted on pressure. He was treated with cream of tartar, squill and iodine, but without success.
He was discharged from service May 9. — Hospital, Quincij, III.
Case 29. — Private Rector Cornwall, Co. K, 130th 111.; was admitted April 13, 1863, with orchitis, resulting from
exposure to cold while convalescing from measles. His left testicle was very painful and enlarged to three or four
times the natural size. Treatment consisted of strapping and small doses of mercury and chalk. Improvement
followed and the patient was returned to duty July 20. — Lawson Hospital, St. Louis, Mo.
Case 30. — Sergeant William Litter, Co. K, 4th Va. Cav.; age 26 ; was admitted May 4, 1863, with broncho-pneu-
monia and diarrhoea after mea.sles. He was treated with blisters and mercurial alteratives. A large abscess on each
side of the anus developed into fistula. He was discharged from service June 27. — City Hospital, St. Louis, Mo.
PosT-MOETEM Recokds. — The frequency of tlie pulmonary affection in fatal cases of
measles may be appreciated from the many instances submitted among the post-morteni
records of pneumonia.''^ In addition to these there are but seven recorded cases: In case
1 the blood was black and un coagulated ; iu 2 and 3 there was cerebral congestion; in 4
pleurisy; in 5 pericarditis; in 6 sudden death, probably from heart failure, and in 7 an exten-
sive consecutive inflammation of the knee-joint and femur.
Case 1. — William D. Eraberg, prisoner of war, was admitted May 23, 1864, with measles. Desquamation was
in progress, and, as the patient was debilitated, tonics were prescribed. On May 26 he had chills followed by fever,
with frequent feeble pulse, constipation and sevei'e pain in the head, back and limbs. A low form of delirium super-
vened, and he died June 4. The attending physician supposed the case to be one of typhus. Post-mortem examination:
The blood was black and tluid and the tissues tlabby, but no actual lesion was anywhere observed. — Third Dieision
Sosjrital, Alexandria, Va.
Case 2.— Private S. Hammock, Co. H, 13th Ky.; admitted Feb. 28, 1865. Diagnosis— Rubeola. Died March 16.
Pos<-mo?-/em examination: There was serum effused between the membranes and the brain. The gall-bladder was
collapsed; the spleen enlarged; the bowels congested. — Act. AssH Surgeon J. E. Brooke, Hospital, Pock Island, III.
Case 3.— Private Abel W. Taylor, Co. B, 32d Me.; age 16; was admitted April 22, 1864. He had been sick for
about three weeks, having suffered during a part of that time from an attack of mumps. On admission there was no
parotid swelling, but the face was dusky-red, the body covered with the eruption of measles; the pulse was rapid,
130; the breathing hurried, 30 ; and there was frequent expectoration of rust-colored mucus, with dry rales over the
* See lu/vti, page 783.
MEASLES. 659
chest anteriorly aud subcrepitaiit rales posteriorly but no marked duluess ; low delirium was present. Ho died on the
24th. rost-inortem exaraiuatiou: There was venous congestion aud fiuo arterial injection of the pia mater, with inter-
stitial congestion of the brain aud some etl'usiou of bloody serum in the ventricles and subarachnoid space. The lower
lobe of the right luug was hepatized, the jileura of the att'ected part covered with masses of lymph and the pleural
cavity iilled with liquid. The heart was healthy and contained suuill red and white clots in its ventricles. The liver
was somewhat granular; the spleen a little softened; the other organs healthy.— C«i;/(r HuKinttil, rhilmldpliia , Pa.
Case 4.— Private Thomas Thompson, Co. H, 20th Me.; age 20; was admitted April 0, l^Cyl, presenting the gen-
eral appearance of one alfected with tubercular disease of the lungs. On the 22d the eruption of measles appeared,
liefore it faded the patient was attacked with pleurisy, aud died May 1.. J'osl-Hiorlim examination: The ape.'c of the
right lung contained tubercle in the inllammatory stage; the right pleura was thickened, adherent in places and cov-
ered with lymph ; the sao contained a large effusion. The liver was fatty.— T/iii-(? Diiision nospital, Ahiumlria, Va.
C.\SE 5. — Private Jefterson Marsh, recruit, 28th JIass.; ago 24 ; was admitted May 8, 18G4, with measles. On the
\'>\\i pneumonia of the left side was developed, and five days later the physical signs of pericarditis were observed.
On June 1 the tonsils, base of the tongue and epiglottis were found to be extensively ulcerated. He died on the 3d.
Post-mortem examination : The blood was liquid. The trachea was much inflamed and denuded of mucous membrane.
The lower part of the left lung was consolidated. The pericardium was nearly filled with serum. The abdominal
viscera were healthy. — Third Dirision Hos^ntal, Alexandria, fa.
Case 6.— Private James E. Walker, Co. A, 3d West Va.; ago 20 ; was admitted April 30, 1865, convalescing from
measles. He was weak and had a slight cough with mucous expectoration ; but his appetite was good and his tongue
moist. He improved and was feeling finite well wlicu, on May 11, while sitting on his bed and talking ho suddenly
put his hand to his heart, fell over on the bed and died without ennvulsious or apparent pain. Poxt-mortcm examina-
tion: liody but little emaciated. The upper lobe of the right lung was studded with tubercle and its apex contained
a small cavity. The walls of the left ventricle of the heart were hypertrophied and softened. — Cumberland Hospital, Md.
C.vSE 7.— Private Chester Morse, Co. E, 2d Colo. Cav., was admitted Jan. 30, 1864, with measles. As convales-
cence progressed the left knee aud thigh became affected with pain of a rheumatic character, and in time a true syn-
ovitis of the knee and periostitis of the femur were developed. Large opiate doses were required to alleviate his
suft'eriug. By March 31 the thigh aud knee were much swollen and the intermuscular spaces distended with sero-
purulent matter, which had established an external communication for its discharge. Hectic supervened, aud death
occurred May 1. Post-mortem examination: Bony spicula were found in the diseased periosteum; the outer condyle,
and the shaft of the femur at the junction of its middle and lower third, were honey-combed ; the cavity of the knee-
joint was filled with sero-purulent matter: the outer part of the head of the femur, the great trochanter and the
digital fossa were involved in the disease.— Hospital, Kansas City, 2Io.
Treatmext. — According to the medical records of the war the treatment of camp
measles, whether in the individual or in the command, appears to have involved measures
of sanitary supervision rather than cHnical instructions or pharmaceutical formulte. An
epidemic of measles in a susceptible command subject to the exposures of active service was
often as disastrous in its consequences as a severe engagement with the enemy. Men and
regiments of men insusceptible to the poison of this disease are by so much the more efficient
as a military machine. Recruits from the city are more likely to have passed through the
disease in childhood than those from the rural districts, — city regiments are therefore to he
prefeiTed in this connection. But when the call to serv'ice is urgent this becomes a sec-
ondary matter; the liability to disease under exposure to its causes must be accej^ted as a
part of the danger to be faced. Measles will thus continue to be a subject of interest and
anxiety to army medical men until the discovery of a means of protection against it inde-
pendent of subjection to its influence in previous epidemics.
The mildness of the disease when running its course under favorable conditions, as
compared with its virulence in crowded quarters and hospitals, and the disability and death
resulting from its complications and sequelae in commands exposed to the vicissitudes of the
weather, suggest the propriety of an attempt to divest it of its gravest dangers by an inten-
tional infection at a time when the sanitary environment of the men may be absolutely
controlled. Inoculation for small-pox was practiced before the discovery of vaccination.
Of late years, however, the efforts of sanitary officers have been so successful in controlling
the spread of communicable diseases that few medical men would counsel the intentional
propagation of measles among large bodies of newly organized and susceptible troops. The
660 THE ERUPTIVE FEVEKS.
military necessity whicli calls for the levy does not usually admit of this preliminary course
of hospital treatment; nor does the experience of our recruiting depots and camps of organi-
zation indicate this early period of the history of a regiment as propitious for an encounter
with disease: Men and officers are alike ignorant of military methods and of the ways of
•camp or barrack life. Privations are endured which a larger experience would have rendered
wholly unnecessary, and many needless exposures are entailed upon the men. There is,
moreover, in time of war an excitement in tiie atmosphere of a recruiting camp which would
render the propagation of this disease a hazardous experiment, even if conducted under the
supervision of veteran medical officers.
After some months of active service the troops become sobered down to the stern reali-
ties of war. They are better disciplined, better qualified to protect themselves and to appre-
ciate and cooperate with efforts for their j^rotection. They may possess fewer facilities than
at an earlier period for meeting the attacks of disease; but they are able to utilize all that
are available. They are perhaps, except in cases of unusual exposure and privation, better
able to protect themselves against the accidental introduction of measles into their camp
than they were formerly to submit to its intentional conveyance.
The aim of the medical officer is to jirevent his men from becoming sick. Measures
should be taken to exclude all known sources of infection; but should these fail and a
man become affected with the disease, he should be promptly isolated fur tiie protection of
the others, and carefully guarded agamst the dangers that threaten his own safety. Blankets
and articles of clothing used in common by the sick man and his intimates should be
removed with him. Those men that have been most in contact with him should be restricted
to open-air communication with others of the command until time has been afforded for
further developments. The patient should be well sheltered in an ecpiable and temperate
atmosphere, warmly covered and attended with care and intelligence for tlie avoidance of
unnecessary exposure.
Should a regiment or a portion of a larger command become affected arrangements
should be made for its relief from duty, its isolation from the remainder of the troops and
the appropriate treatment of its sick. In this way onlv may the epidemic be circumscribed
and the affected men preserved for future service. The extracts that have been submitted
show conclusively the evil consequences of injudicious management during the prevalence of
measles in a command. The duty of the affected regiment should be to take care of itself
tmtil again fit for military service, guarding, meanwhile, against the extension of its con-
tagion beyond the lines of its isolated camp. If the cases are numerous adequate accom-
modation should be provided lest, by overcrowding, an increased virulence be developed.
On the subsidence of the epidemic the men who have escaped attack may be returned to
active service, while the convalescents are retained or furloughed until restoi'ed to their
normal condition.
Isolation proved inefficient in restricting the disease during the war; but there is no
record of its having been systematically carried out. The disease was generally considered
trivial by our medical officers, who realized its disastrous consequences only after it became
too late to effect its suppression. Nevertheless it subsided among our white troops during
the warm months of 1862 while new ree-iments were beino; oro;anized and mustered into
■service. Fresh air apparently controlled its spread. Hence, in winter-camps exposed to
the disease, efforts to prevent or quell an outbreak should be directed to tlie removal of con-
MEASLES. 661
tagious foci auJ the dilution and disinfection of suspected atmospheres. In fact the sys-
tematic isolation and protection of the sick in hospital, with free ventilation and sanitary
supervision for the as yet unaffected members of the command, may be regarded as the only
trustworthy measures for the limitation or suppression of the disease and the mitigation of
its possible consequences.
The following from the report of Ass't Surgeon Bartholow, U. S. A.,'-' relates to the
therapeutic management of the disease:
Many cases of measles, if left to themselves, terminate favorably. An increase in the excretion of urine, a.
smart (liarrbiva, are the phenomena which mark the crisis and decline of the disease. \Ve may have the opportunity,
when the proper time arrives, of producing, imitating or favoring the occurrence of these critical discharges ; hut it
would he idle to attempt to cut short an attack hy such ineans at other periods of the disease.
In those cases where, from malignity of the poison or peculiar states of constitution, patients do not recover
from the first impression of the morbid cause, and death is imminent from cerebral disease, intense pulmonary con-
gestion or hypera'uiia of the kidneys before the eruption appears, remedial measures have little power to avert a fatal
issue. Congestion of organs essential to life is the chief source of danger. How are we to treat it? Coma and
delirinm are produced hy engorgement of the vessels of the brain, by extravasations of blood on the hemispheres,
hy iutlammation of the meninges and by exudation of lymph; coincident with these phenomena is, in many cases,,
suppression of urine. I have seen these symptoms ranch improved by a copious bleeding, but the patient died iir
every instance. Whiskey, no matter how freely administered, had no great efficacy. The true way, in my opinion,
to treat this condition of the brain, is to excite the action of the kidneys by saline diuretics, to relieve the vessels hy
local cupping, being careful not to extract too much blood, to produce counter-irritation by hot sinapisms to the
extremities and by saline cathartics, and to remove a portion of the blood by ligatures to the thigh, applied tightly
enough to arrest the superficial venous circulation. It is not worth while to give calomel and antimonials in the
vain hope of subduing indammat:on; if these agents possessed this power time is not aflbrded for its manifestation.
The most important s- /nptoms and the largest mortality are due to pulmonary complications. The morbid
anatomy of the disease laows that a capillary bronchitis, accompanied by copious exudation, lobular pneumonia, an
intense congestion of the vessels of the lungs and a gorged condition of the right cavities arc the sources of danger;
the left side of the heart is found empty. These pathological facts, if they mean anything, teach that stimulants are
not indicated. In practice they produce only injury when administered in this state. Bleeding gives temporary-
relief, but the patients die if bled. Mercurials and antimonials do not relieve but only add complications: mortality
is increased by their use. •! think we ought to rely on counter-irritants and cups to the thorax, counter-irritants
and derivatives to the inferior extremities, ligatures to the thighs to control the venous circulation and on remedies
to maintain and increase the renal secretion. The best counter-irritant in these cases fs turpentine ai)plied as a stupe,
but not permitted to remain long in one place, followed by warm applications. These remedial agents may be assisted
by sinapisms, hot pediluvia and small doses of opium. Active diuretics should be avoided not only on account of the-
hyperiemia of the kidneys Init of the irritable state of the mucous membrane of the intestinal canal. Bitartrate, bicar-
bonate and citrate of potassa are the proper remedies of this class. They should be given in small doses largely
diluted. If the aftection of the kidneys be a prominent symptom, cups and sinapisms should be applied to the loins.
Remedies to control diarrhcea are saline cathartics with tincture of rhubarb, followed by astringents and opiates.
When increased heat of the abdominal walls and increase in the number of dejections evidence increase in the hyper-
ipmia of the submucous tissue and enlargement and thickening of the solitary glands and follicles of Lieberkiihu,
then dry or wet cups, turpentine stupes and sinapisms, followed by warm moist apjilications, are indicated.
The diet should consist of nutritive matters which may be taken up in the stomach and duodenum. Animal
broths and small doses of wine are proper. If the intestinal lesion be not decided, milk, eggs, butter and fresh, ripe,
acid fruits may also be added. In the stage of desquamation the skin is excessively sensitive to change of temper-
ature; it is during this stage that pneumonia is developed out of lobular pneumonia and pulmonary engorgement,
and diarrh(i>a and dysentery out of intestinal congestion. Olive oil, lard or glycerine is useful when applied to the
desijuamated surface. Carefully-prepared nutriment and stimulants become necessary, but the stimulation should
not be excessive. With the decline of felirile action there is a progressive lowering of the vital powers; the kidneys
resume their activity and diarrhtra usually supervenes, — and these phenomena, although often critical, may still.
further reduce the patient, and therefore require watching.
During this stage, also, lesions of various organs commence and progress without the knowledge of the physician-,.
if he is not awake to the probability of such accidents; daily examination should be made of the organs likely to
become affected. The typhoid state, which results -when the intestinal lesion goes on unchecked, and when chronic
pneumonia follows the lobular attack, should be treated by appropriate remedies. This state will be less alarming
if proper nutriment has been supplied from the beginning, and if the excessive use of brandy or whiskey has not so
impaired the process of digestion as to prevent the primary assimilation. It is constantly necessary to obviate the
tendency to death. The physician should study this tendency, whether by the brain, the lungs or the intestinal canal,.
and be prepared to counteract it. In camp measles, more than in almost any other disease, is the physician's duty on&
of care and watchfulness.
* See note wjjra, page C49.
662 THE ERUPTIVE FEVERS.
III.— SCARLET FEVER.
Scarlet fever was rarely seen during the war. A few cases occurred at intervals in
most of the large military commands, but the disease does not appear to liave spread in
any instance from the primary case. The records do not -show whether this immunity was
due to antecedent attacks or to insusceptibility developed by age and independent of pre-
vious exposures. Among the white troops 578 cases were reported, 70 of wliich, or 12.1
per cent., were fatal; among the colored troops the cases numbered 118, with 2 deaths,
equivalent to a fatality rate of only 1.7 per cent. This was therefore one of the exceptional
diseases less fatal to the negroes than to the white men.
The medical records contain only the following: 1 and 2, undoubted scarlet fever; 3,
entered as a case of j^v.rjyura, and 4, perhaps a sequel of measles, although regarded bv the
medical officers in attendance as a sequence of scarlet fever.
Case 1. — Private Dominic AVeyland, Co. C4, 4th Minn.; age 25; -n-as admitted May 10, 1863, -n-ith a sprained
ankle, and was next day transferred to the convalescent ward, where he assisted as nurse. On June 1 he was read-
mitted and on the 2d scarlatina ^^•as diagnosed ; pulse 120 ; skin hot ; temiierature 102° Fahr. Prescribed tartar emetic
two grains, chlorate of potash eight grains, nitrate of potash one scruple, Flemming"s tincture of aconite twelve
drops, camphor mixture eight fluid ounces ; to take a tablespoonful every four hours; the throat to be swabbed with
a strong solution of nitrate of silver; chlorate of potash to be used as a gargle; gave also a full dose of castor oil and
sponged the surface with tepid water. He was convalescent on the 7th, but had a slight weakness of the eyes.
Returned to duty July 29, — Lawsoii Hospital; St. Louis, Mo.
Case 2,— Private Charles H. Witham, Co. D, 31st Me.; age 21; was admitted May 7, 1861, with high fever and
delirium; sore throat and a scarlet rash covering the whole of the body. Neutral mixture and muriate of ammonia
in three-grain doses every four hours, with alum and chlorate of potash as a gargle, were used in the treatment. In
four days the rash disappeared, the fever abated and the throat imi^ioved, but, as the patient was much prostrated,
milk-punch was administered. On the 13th he was seized with great dyspncea, excessive irritability of the stomach
and extreme prostration. He died on the 16th, Post-mortem examination: The lungs were healthy. The pericar-
dial sac contained eight ounces of colorless serum. — Mower Sospital, Philadelphia, Pa.
Case 3. — .Sergeant J. P, Taylor, Co, G, 5th 111, Cav,; age 23; was admitted March-15, 18fi3, with purpura, A
scarlet rash covered the lower extremities from the lower third of the legs to above the nates, excejit an irregular
narrow strip on the inner aspect of the legs and thighs. It was most intensely developed anteriorly, but presented
no tumefaction, vesication or other unusual characteristic except a little cuticular corrugation with much itching
and a slight burning sensation. There was but little accompanying fever, although -the patient was extremely pros-
trated and had headache with furred tongue and constipated bowels. Gave tincture of iron in thirty-drop doses in
water every six hours ; also ten grains of calomel and eight of Dover's powder to be taken at night and an ounce of
Epsom salts iu the morning; applied locally a solution of acetate of lead every four hours. The medicines operated
well and next day there was no fever, pain or itching; the rash, which seemed indisposed to spread, was changing
color by the deposition of a whitish or grayish pseudo-membrane in irregularly -shaped and sized blotches under the
cuticle. This involved the entire extent of the rash except a few lines in widtli on the inner aspect of the tliighs and
legs around the margins of the strip above mentioned. On the morning of the 18th the fever assumed a typhoid
character, the mouth and fauces becoming dry; a rough grayish elevated eruption with red ar-eohe appeared on the
upper extremities, chest and face, extending into the mouth and fauces and covering the conjunctivie. Added qui-
nine and turpentine, with Dover's powder at night and an occasional aperient, to the treatment. The patient sank
gradu,ally, dying on the 2Ut.— Hospital, 5th III. Car.
Case 4, — Private James M, Myers, Co, C, 144th X, Y,; age 25; was received June 19, 18G3, having been unfit
for duty since December, 1862, and under treatment most of the time in the Fairfax Seminary hospital. He had been
injured by a fall, and while suffering from its effects was taken with an eruptive fever which he says was measles,
Ijut, as it appears that his thro.at required cauterization and the glands of his neck were enlarged, the disease was
probably scarlet fever. His feet and legs began to swell about April 15, The urine was scanty and contained only
a trace of albumen, although showing under the microscope a few blood corpuscles and pale clots; no oil globules
were present. He was treated with compound jalap powder, tincture of muriate of iron, bitartrate of potash and
tincture of digitalis; but as his condition failed to improve he was discharged August 1 for debility, — Satterlce Hos-
pital, Philadelphia, Pa.
lY.— ERYSIPELAS.
Prevalekce axd Fatality. — Among the white troops 23,276 cases of ervsipelas were
reported during tlie war period, equalling an average annual rate of 10,45 cases per thousand
of strength. But these numbers do not correctly represent the frequency of the disease.
ERYSIPELAS.
663
Xo doubt tliey give witli I'uir accuracy the number of cases reported from the lield, but ery-
sipelas was a scourge of the hospital wards rather than of the regimental camps. How
many cases were developed in the hospitals cannot be ascertained, nor, for this reason, can
tlie fatality of the disease be learned. According to the reports the fatal cases constituted
8 per cent, of the total, but this Is necessarily an exaggeration.
The disease prevailed to a greater extent in the camps of the Western than in those of
the Eastern armies; during the four years, July 1, 1S61, to June 30, 1865, the average
annual rate per thousand men in the latter was 7.8, in the former 13.2. It was also more
common or more fatal in the hospitals of the Central region than in those of the Atlantic
commands.; for during the period mentioned the deaths in the former constituted 10.2 per
cent, of the cases and in the latter only 4.4 per cent. During these four years 924 deaths
from erysipelas were reported from the AVestern hospitals in an average population of 19,456,
and only 194 from the Eastern hospitals, which had an average population of 26,137.
Similar results were observed among tlie colored troops. During the three years of
their service the cases of erysipelas numbered 1 ,536, or 8.38 annually per thousand of strength,
and the deaths from the disease 247, or 16.1 per cent, of the cases. In the Atlantic region
the cases averaged 5.4 per thousand men annually, with 12.1 per cent, fatal, while in the Cen-
tral region the rates were 9.1 per thousand, with 17 per cent, fatal. Enquiry into the cause
of these difl'erences appears to point to insanitary conditions, mainly arising from over-
crowding in the camps and hospitals of the Western commands.
Like small-pox and otlier diseases which owe their propagation in part to a concen-
tration of organic emanations, erysipelas was somewhat more prevalent during the winter
months, when warmth was sought at the expense of ventilation. See diagram facing page 624.
So far as can be ascertained the Confederate surgeons had an experience of erysipelas
similar to that of our own medical officers. During the nine months, July, 1861, to March,
1862, 390 cases were reported from the Army of the Potomac, wliicli numbered 49,394
men. This is equivalent to an annual rate of 10.5 cases per thousand of strength. The
records of the Chimborazo hospital, Richmond, Va., make note of 22 deaths among 236
cases treated, a mortality of 9.3 per cent.
The prevalence and fatality of the disease among the rebel prisoners may be gathered
from the figures of Table LIIL*
Sometimes erysipelas, as seen in the wards of our general hospitals, was connected with
traumatism; in cases 1 and 23 of the subjoined series an injury of the knee or leg appears
to have determined the attack. Generally, however, the disease was developed independent
of a pre-existing lesion. To give emphasis to this fact Surgeon Alexander McBride, in
charge of the hospital at Camp Wallace, Columbus, Ohio, mentions a nurse, who, having
received some injury to the face, was attacked four days later by erysipelas, which was mani-
fested primarily on a feature that had escaped injury. Occasionally the trunk or the extremi-
ties were affected, as in cases 2 and 20-24, given below; but the face was the usual site,
the ridge of the nose, the ear and the infraorbital region being the more common points of
attack.
The contagious nature of the disease was regarded as undoubted by those medical
officers who had the best opportunities for its study. In some hospitals where cases of ery-
sipelas were treated in the general wards the disease affected a large number of the patients
*S«i»ra,' page C29.
664 • THE ERUPTIVE FEVERS.
under treatment for other maladies, particularly tliose debilitated by typlioid fever, measles'
or pneumonia. To relieve the. inmates from this source of danger special wards were pro-
vided for the treatment of erysipelas. Few of the nurses in these wards escaped attack.
The freedom of the surgical wards from erysipelas, a§ compared with the frequenc}"- of the
disease in the medical wards, points definitely to communicability. In the Third Part of
the Surgical Volume of this Work* it is stated that only .4 per thousand of the whole num-
ber of wounded had a record of erysipelatous complications. This statement, of necessity,
underrates the frequency of traumatic erysipelas, as the records in many cases may have
failed to note its occurrence. It indicates, however, the infrequency of the disease in the
surgical wards. It is impossible to determine what proportion of the medical cases suffered
from erysipelas ; but, as suggestive of its frequency, it may be observed that eleven of the
three hundred cases forming the post-mortem records of lobar pneumonia were thus compli-
cated.f Again, of the forty cases herewith presented, nineteen were received into hospital
with erysipelas, while twenty-one occurred in patients already in hospital. The surgeon
dreaded the presence of erysipelas among his wounded and had every case at once isolated;
the physician was less alive to the contagious nature of the so-called idiopathic erysipelas,
and permitted cases to remain in the general wards until a larger experience demonstrated
the necessity for their isolation.
Symptoms. — A chill ushered in the attack. This was followed by febrile reaction^
sometimes accompanied by inflammatory and even diphtheritic appearances in the fauces.
A few hours later an erysipelatous blush on some part of the cutaneous surface showed what
was in prosjaect. In other cases, however, which generally ran a mild course, the disease
began without premonitory symptoms of a character to attract notice; in case 8 the patient
said he had never felt better in his life than he did a few minutes before the development
of the local manifestatioiis. Spreading gradually from the jDoint of attack on the nose, cheek
or ear the inflammatory blush extended, without abatement of the associated fever, over
more or less of the face and scalp, subsiding, j^erhaps, on one side as it invaded the other.
In cases of greater severity the pain and febrile excitement culminated in delirium; the
tumefaction blotted out the patient's facial expression; the eyes were hidden by the swollen
lids and bull« rose ujoon the inflamed surfaces. This condition of aggravated suffering
occurred at a time when the case, if mild, would have been ending in convalescence. It
sometimes lasted for many days; in case 6 five days elapsed before signs of amelioration
were observed. The disease terminated in desquamation and scabbing; yet occasionally, as
in ca.ses 2, 4 and 6, convalescence was delayed by the occurrence of a diarrhoeal or dysen-
teric attack. Circumscribed purulent deposits were found in some of these cases, as in 7^.
which was prolonged for several weeks by su23i:>uration in the lower eyelids, under the chin
and in the superficial tissues of the posterior cervical region. The fever in the milder cases
was generally sthenic; but when the disease was prolonged, severe, or occurred in a debili-
tated subject, the familiar symptoms of adynamia were rarely absent. Relapse, as in case
8, sometimes followed an injudicious exposure to the weather. Relapses or recurrences
were generally less severe than the primary attack.
As contrasted with these rnild cases the disease sometimes assumed a malignant or
typhus-like aspect, characterized by the rapid development of coma and the appearance of
petechial spots, which, as in 40, became quickly resolved into sero-purulent depositories,
* Page 851. f See infra, page 773.
ERYSIPELAS. 665
Otorrlioea and deafness were frequent results of severe attacks. Parotid abscess, as in 25,
not unfrequently found an exit through the external auditory meatus, and death, as recorded
in 26, was sometimes to be feared from hemorrhage into the site of the disorganized aland.
In 9, a convalescent with consecutive aural disease, died from the effects of a cold douche
indulged in as a luxuiy during oppressively hot weather.
In dangerous cases, characterized by deeply seated inflammations, the brain and its
membranes frequently became involved. In 27 the cerebral structures were attacked by
way of the orbit. Cases in which the scalp was largely tumefied were generally associated,
as in IS, with pronounced cerebral symptoms, due, according to the post-morte77i records of
28, 29 and 30, to congestion or some excess of effused liquid; death by coma was the usual
end of such cases. In 31, which was complicated by meningeal inflammation, death was
hastened by a fall during the patient's delirium.
Sometimes, instead of the cerebral membranes, the serous lining of the pericardial sac
became implicated; in 32 the heart was covered with fibrinous deposits and the cavitv of
the pericardium distended with purulent liquid. ^
The gravity of the erysipelatous attack was in many instances intensified by a concur-
rent inflammation of the fauces. In 33 the tongue was much swollen; in 7, 13, 17, 20
and 29 the fauces were inflamed and in 14 and 34 diphtheritic sloughs were formed. Tume-
faction of the epiglottis by congestive or inflammatory infiltrations leading to occlusion of
the rima glottidiswas occasionally the immediate cause of death, as in a case mentioned by
Surgeon Shubal York, 54th 111.'-= Act. Ass't Surgeon DeWitt C. Day, who had a large
experience at the special hospital for erysipelas, Nash-ville, Tenn., observed that in the
majority of cases the disease was first manifested on the mucous membrane, as is always the
case in measles and scarlet fever; he inferred from this that a striking analogy existed
between these diseases in their formative stage.f
In some cases, as 21 and 35, pneumonia appears to have been the immediate cause of
death. Day believed the pneumonia to be a result of the erysipelatous influence, and as aa
illustration of many cases that might be adduced, recorded that of a soldier who, after the
amputation of his arm, was attacked with erysipelas at the site of the operation. In a few
days the inflammation faded at the stump but spread rapidly over the chest and back. He
had been carefully nursed in a ward kept at an equable temperature, but nevertheless pneu-
monia supervened and became intensified as the diseased action subsided on the surface.
A determination to the mucous membrane of tlie intestine was also observed in some
instances. This, which occasionally caused death, as in cases 17 and 19, not unfrequently
prolonged the period of convalescence in mild or favorable cases of the disease. Dr. Day
was of opinion, as the result of his observations, that the disease, when originating from or
by extension involving the mucous membranes, was of a more dangerous nature than when
confined to the skin and cellular tissue. So long as the skin alone was its seat its exten-
sion over a larger surface was not. attended by a corresponding aggravation of the constitu-
tional disturbance. J
•S«e his report, iiifra, page C72. t Americati Metlical IHmei, VI, New York, 1863, page 268.
1 lu A hrirf account of Kptdeinic Erijulpchig ax it appeared at Hlotiiio del Jley^ near the C'ilij of Mexten, daritig the mottthe of February and Mareh^ 1848, —
Charle/toii Mt'tii.d Journal and Jlerictr, IV, i84I», p. 27, — Surgeon J. P. Evaxs, V. S. Vol. Sen-ice, Btates that a cutaneous inflammation was present only io
about one-fifth of the cases. Internal parts, as the fauce:*, the salivarj* glands, the inner ear, tlie lungs or their jileural niemhranes, were seized at the
onset ; and almost complete relief to these i>arts followed the external manifestations of the disease. On the other hand, the sudden retrocession of the
external inflammation always cnhancetl the severity and danger of the malady. Fortunately not many such cases were witnessed. Ono is mentioned
in which erj-?ipelns of the face disapiK>ared suddenly, anrl diurrhcea, with constant tormina and extreme tenderness of the alMlomen, ensued and provwl
fatal in a sliort lime. The erjsiis-Iatfm-* fever that affected the troops near the City of Mexico and the inhabitants of the surrounding countrj', appeaiB-
Med. Hist., Pt. 111—81
666 THE ERUPTIVE FEVERS.
Mild or erytliematous cases affecting tlie limbs or trunk ended in desquamation in four
or five days. In the higher grades of the disease abscesses were formed in various parts,
or the subcutaneous and intermuscular tissues became infiltrated with jjurulent matter; in
some cases gangrene was developed; occasionally the joints were involved and destroyed.
Great emaciation and prostration resulted from the profuse and prolonged discharges in such
cases. Bedsores aggravated the suffering, and the patient ultimately died exhausted by the
continued drain or carried off by intercurrent diarrhcea or pulmonary congestion. Ery-
sipelas of the head and face was generally regarded as more dangerous than an attack involv-
ing the trunk or extremities; but the accuracy of this opinion has not been established.
Facial erysipelas was common, and in the majority of cases ran a mild and rapid course.
Act. Ass't Surgeon Washington Matthews, who had favorable opportunities for observing
the disease in the erysipelas wards of the Rock Island hospital, 111., considered that while
cases involving the extremities were infrequent their course was usually prolonged by the
progressive invasion of contiguous regions and their danger heightened by consecutive sup-
puration in the underlying cellular tissue. The progress of such cases to a fatal issue is
illustrated by cases 20-24 of the following series :
CLINICAL REPORTS OF ERYSIPELATOUS CASES.
Case 1. — Private Samuel Gruniger, Co. A, 41st N. Y., was admitted July 28, 1861, with erysipelas of the left
leg, which was of a fiery-red color aud swollen to twice the natural size; it was jiurplisli for eight inches above aud
six inches below the knee and vesicated largely over the purplish parts. He had sprained the knee four days before;
the resulting pain aud swelling had been treated by bread poultices. On admission a tepid bath was given, nitrate
of potash and tincture of iron prescribed and acetate of lead lotion applied. Next day the swelling had subsided a
little ; a dose of sulphate of magnesia aud tartar emetic was administered and cold water was substituted for the lead
lotion. On the 31st the cuticle around the joint separated en masse, and there was a general improvement in the
patient's condition. On August 1 there was a slight blush on the knee, but mobility was perfect and there was no
pain, swelling or constitutional disturbance. Next day pain with some stillness returned on account of using the
joint too freely. On the 3d there was much cedema, with pain along the inner aspect of the knee. A cathartic of
calomel, jalap and gamboge was given. The patient was transferred on the 9th and was discharged from the service
November 25. — Seminary Uospitat, Georrjetoien, I). C.
Case 2. — Sergeant David W. Thomas, Co. H, 29th Ohio, was admitted Sept. 16, 1863, with erysipelas atfecting
the anterior tibial region; pulse lUG, feeble; tongue moist but coated; appetite poor; skin natural. Gave Dover's
powder every six hours, muriated tincture of iron before meals and tincture of iodine in water for topical use. On
the 18th sulphate of magnesia was given for constipation. The iuflammatiou subsided on the 19th and next day full
diet was allowed. Convalescence was interrupted October 2 by an attack of diarrhoea, which lasted four days.
The patient was returned to duty November 14. — Second Division Hospital, Alexandria, Va.
Case 3. — Jackson L. Marsh, a rebel prisoner, was admitted April 15, 1865, with erysipelas. He had been in
prison since December of the previous year and had suft'ered from chills and vaccine sores. He had scorbutic stains
on his limbs and was subject to constipation, seven days sometimes passing without a movement of the bowels. The
erysipelatous attack began, without premonitory symptoms, by a swelling of the lower eyelid of the right side on the
morning of the 14th. He was treated with castor oil internally and resin ointment as a local application. The
swelling never exceeded two and a half inches in diameter. It subsided in a few days and was followed by desqua-
mation. He was returned to barracks on the 28th. — Act, Ass't Surgeon Washington Matthews, Eock Island Hospital, III.
Case 4. — ^Private Frederic O. Johnson, Co. E, 35th Ala.: was committed to prison Feb. 18, 1865. He had been
suftering from chills and diarrha?a for a long time previous to his capture. He was admitted on April 6 for cough,
debility aud diarrhoja. On the 20th he was seized with lassitude, chills, fever and pain in the glands of the neck.
Next day erysipelas set in, aud on the 22d he was transferred to Ward C for treatment. One drachm of saturated
to have been a manifestation of an epidemic that bad prevailed extensively in the Tnited States from the j-ear 1S41. Dr. H. N. Bexxeit of Bridgeport.
Conn., has described the disease in an article entitled A Ti-eatise on the Epidmnic Erysij>elatous Jtrcr of Ihe United Slaies, — New York Jonmal o/ Medicine, IX,
1853, pp. 9 et seq. It was regarded as a communicable disease, aflfecting especially the old, the infirm, those afflicted with other maladies and persons of
aniemic appearance and lax fibre. The febrile action, which speedily assumed a typhoid character, was associated with inflammatunr- lesions of various
parts. Sore throat was generally present. In mild cases the mncous membrane was of a bright-red color and but little tumefied. In the malignant
form the pharny,x assumed a dark-purple color, which spread graduallj- over the palate, tongue aud sides of the cheeks, the tougue becoming mucb
swollen and ultimately of a dark-brown color, from which was derived the popular aijpellation of the disease— i>/aci- Tongue. Ash-colored sloughs were
formed, which, ou their separation, left ulcerations of considerable depth aud unhealthy cast. The breath was horribly offensive. The lymiiliatic
glands became swollen and sometimes suppurated. In about one-sixth of the cases erysipelas appeared on the cutaneous surface, sometimes erythema-
tous and fleeting, sometimes phlegmonous and dangerous in its results. The lungs, pleurse and cerebral membranes were occasionally the site of the
inflammatory developments. But the most formidable lesion of the malady was peritonitis in the post-puerperal state ; of 30 cases in Caledonia county,
Vermont, only one recovered.
KKYSIPhiLAS. 667
solution of cliloruto of potash was given internally three times a day, and the same solution was used on lint as a
local application. On the 2ltli the intiannnation began to snlisido and the patient's eyes became visible. By the SlJth
he was convalescent and complained of nothing but weakness. Desiinamatiou was completed on May 2, after which
his strength was slowly regained under nourishing diet, tonics and stimulants. For a time a slight dysenteric attack
delayed his recovery, but by the 12th he was able to return to barracks. — Jet. Ass't Surgeon Washiiiglon Matthiirs,
/I'ocA" laland Uonpital, III.
Case 5.— Isaac B. Eeid, a rebel prisoner: age 27: was admitted April 12, 1865. He had always been in good
health but for an occasional lit of ague and an attack of varioloid, the latter having occurred subseijuent to his cap-
ture. A swelling, mistaken for mumps, began April i and increased for a week, during which time he became very
weak, as lie was nnable to eat anything. At length an erysipelatous blush appeared on the surface, when the swelling
became reduced in size. Castor oil and turpentine emulsion were prescribed for internal use and resin-cerate with
turpentiue as a local application. His tongue was dry, brown and cracked on the IGtli, on which day a pint of ale
was prescribed for daily use. Ou the 18th milk-punch was sul)stituted. The tongue at this time continued dry and
brown and was protruded Avith dirticulty; the inflammation had moved from the right to the left side of the face;
de.s<iuaniation was in progress ou the right side; pulse rapid but soft : appetite poor; two or three evacuations from
the bowels daily. The erysii)elas did not entirely subside until the 28th, when the tongue became clean and moist
and the appetite, strength and pulse improved-, but some injection of the conjnnctiv:e remained and there was com-
plaint of pain in the ear. The internal use of turpentine, which was somewhat experimental, seemed neither to
aggravate nor alleviate the symptoms nor to affect the condition of the tongue. He was returned to barracks May
8. — Act. Ass't Surgeon Washingiot ilaitluuf, J!ock Island Ronjnta!, III.
C.\SE 6.— Private Hiram Michael, Co. C, 1st Pa., had a chiU April 12,1864, while at Camp Cadwallader. This
was followed by headache and sore throat, and on the 16th by redness and swelling of the right side of the face,
which led to his admission on the following day. Tincture of iron was prescribed with full diet : the atVected parts
were painted with tincture of iodine and a lead solution was applied. On the lOtli the whole of the upper part of
the face was involved: the eyes were swollen and closed and several bulhe appeared on the left ear and side of the
face. Quinine in two-grain doses hourly was added to the treatment, with beef-tea and egg-nog. Delirium super-
vened ou the 20th, when anodynes were given, but the symptoms did not begin to show amelioration until the 2uth.
He was convalescent ou the 28th and was returned to duty May 24.— ri()-ne;-'« Lane Hospital, PliUuMpMu, Pa.
Case 7. — Private Andrew ,^. Morter, Co. E, 115th Ohio; age 32 ; a man with a history of chills, chronic diarrhoea,
recurring sore throat and injury to the loins by a fall from a mule, was admitted Xov. il, 1862, with hot and dry skin,
full pulse. 100, furred tongue, constipated bowels, anorexia, great thirst, headache and drov.siness. Gave every three
hours two grains each of calomel and bicarbonate of soda and one grain of ipecacuanha, to be followed next morning by
a small dose of castor oil. Kext day the febrile symptoms continued and the tonsils were swolleu. Gave a saturated
solution of chlorate of potash as a gargle. A slight blush was observed under the eyes in the evening: several stools
were passed after taking the oil. The fever continued ou the 11th ; the blush under the eyes was accomi)anied with
a tingling pain in the cheeks; the throat was very sore and there was some delirious muttering. The calomel was
discontinued. On the 12th the cheeks, eyelids and forehead were of a deep-red color and the eyelids closed, swollen
and doughy; bulhe had formed on the checks; delirium; aphonia; tongue furred ; pulse 90 and soft. Gave beef-
essence and stimulants; applied cotton lightly over the swolleu parts, but towards evening this caused pain and
flour was used iustead. By the 14th the ears were involved, but the swelling around the left eye was subsiding; the
bnllie had burst and were forming scabs; the delirium continued. Gave tincture of iron, brandy and egg-nog, and
replaced the flour by glycerine. Next day persulphate of iron, ten grains in two ounces of glycerine, was used locally.
The delirium did not subside until the 18th ; an enema of castor oil, turjientine and soai> was given with benefit on
this day. Xext day desquamation was progressing, but the eyelids remained iuflamed; the pulse was weak, com-
pressible and intermittent. On the 20th the patient was able to sit up; the iron was omitted: poached eggs, toast
and chicken-sou]) were allowed. The spots under the eyes became putiy; they were painted with iodine on the 25tli
and lanced and poulticed ou the 27th, after which they continued to discharge for several days. On the 28th a hard
lump was felt beneath the chin near the anterior belly of the digastric muscle. This was poulticed and on December
2 oiiened, liberating a iiuantity of pus. From some impropriety in diet the patient was attacked ou the 8th with
diarrhd-a, headache and hoarseness, which lasted four or live days. After this some large abscesses formed ou the
back of the neck and discharged freely w^hen opened. He was returned to duty Jan. 30, 1863. — TTest End SospHal,
Cincinnuti, Ohio.
Case 8— Private Benjamin F. Cobbs, Co. B, TVood's Missouri Batt., was admitted from prison May 2, 1865,
■with idiopathic erysipelas. The patient said he never felt better than he did ten minutes before the attack began
by a stiffness or cramp-like feeling in the cervical muscles of both sides. From these localities a painful cutaneous
inflammation spread over the face. He was treated with one drachm of turpentine eumlsion and ten grains of bicar-
Iwnateof soda three times a day. After a course of four days the inflammation subsided and thepatieut was returned
to barracks ou the 9th quite well and strong. Next day, having been exposed to the vicissitudes of the weather, he
relapsed and was readmitted. On the 16th he was again well and able to go out on release. He received i" tiint-
meut during the second attack.— Jc^TJ**'/ Surgeon Washington Matthews, Eock Island Hospital, III.
Case 9. — Private Richard Smith, Co. A, 4th N. J. Cav.: age 24 ; contracted erysipelas and was sent to the liild
hospital for treatment June 16, 1864; was transferred to White House Lauding on the 18th; to Mount Pleasant Hos-
pital. Washiiigtim.on the 21st and to this hospital on July 22. Ou admission he was delirious and much prostrated;
pulse frequent and feeble; excessive discharge from both ears; scalp swolleu; bowels loose. Gave morphia, half a
668 THE ERUPTIVE FEVERS.
grain, at bedtime; extra diet. Next day iron and quinine -vrere prescribed, with porter, milk-punch and ice-cream.
He improved under this treatment. On the 25th he was able to sit up and on the olst to walk about the ward. At
this time, while suffering from the oppressive heat, the patient went into the wash-room and held his head for several
minutes under the hydrant. He had then to be carried to bed; pulse 120; skin very hot; severe headache: great
distress. Gave one drachm of brandy every half hour. He died early next morning. — Jilower Hospital, Philadiljyhia, Pa.
Case 10. — Private Michael Brown, Co. L, 25th N. Y. Cav.; age 30; admitted Nov. 26, 18C4, with prolapsus ant
and piles, was taken on the 29th with a chill followed by fever, pain in the bones, nausea and an erysipelatous
swelling of the right side of the face, closing the right eye completely. Gave tincture of iron, opium, calomel and
ipecacuanha; applied sugar of lead to the face; special diet. He was discharged March 2, 1865, because of chronic
ulcer over the left tibia, piles and strabismus. — Finley Hospital, WasMiigton, D. C.
Case 11. — Private Patrick Firney, Co. B, 31st N. Y., while under treatment for scrofulous ulcers of the neck, had
a chill Nov. 15, 1862. Next day he was feverish. A saline purgative was ordered, with small doses of acetate of ammonia
and low diet. On the 17th the left ear was affected with erj'sipelatous redness. Tincture of iron was prescribed. Next
day, as the disease evinced a tendency to spread, a broad line was painted with tincture of iodine around the scalp.
The inflammation began to subside on the 22d ; a nutritious diet of eggs, chicken and oysters, with an allowance of
milk-punch, was prescribed. He was able to sit up on the 26th, and was transferred December 2 to another ward to
await discharge. — Sattcrlee Hospital, Philadtlphia, Pa.
Case 12. — Private Michael Euft', Co.M, 8th N. Y. Cav.; age 33; was placed on duty in the kitchen Aug. 30, 1863,
while under treatment for opacity of the cornea resulting from an acute conjunctivitis. December 30 : Pain, swelling
and redness back of left ear; constipation. Gave five grains of calomel and ten of rhubarb at once. Jan. 1, 1861:
Copious stools ; pain and swelling increased. Gave syrup of iodide of iron three times a day and applied flaxseed
mucilage. 2d: Erysipelas well marked. Continued the iron and applied cranberry poultice over the entire face;
gave brandy, milk-punch and extra diet. 3d: Inflammation increased on right side of face; constipation. Gave
castor oil. 4th: Easier; stool; slight delirium. Gave small doses of Hott'mann's anodyne every hour. 5th: Slight
delirium; tongue dry and heavily coated ; pulse 140. 6th: Tongue cleaning; pulse full and soft, 98; skin moist;
features more natural. 8th: Removed cranberry iioultice; reapplied flaxseed mucilage. 9th: Pulse small and quick;
delirium. Gave half an ounce of brandy every hour. 10th: Easier; inflammation subsiding. 15th: Improving
slowly; abscesses at back of head. Api^lied poultice. 21st: Opened two abscesses. 30th: Improving steadily: able
to sit up. February 10: On light duty. April 23: Returned to duty. — iloKfr Hospital, Philaddphia, Pa.
Case 13. — Private Floridan Covert, Co. 1, 86th N. Y.; age 27; was admitted Dec. 14, 1862, deaf from disease of
the middle ear. Nothing of interest occurred in his case until Jan. 29, 1863, when he was seized with chill followed
by violent fever, rapid pulse, intense headache, pain in the back and sore throat. Small-pox was anticipated, as
some cases of this disease were in the house at the time; but about twenty-four hours after the chill a red erysipe-
latous spot appeared on the nose. The inflammation spread so rapidly that in thirty-six hours it had overspread the
face, closing the eyes entirely. The patient was so prostrated by the violence of the attack that stimulants were
necessary to keep him from sinking. Tincture of iodine and afterward collodion were applied to the aft'ected surface
and appeared to act beneficially. He was transferred to another ward two weeks later somewhat weak but wholly
recovered from the erysipelas. — SatterUe Hospilul, Philuilclphia, Pa.
Case 14. — Private Henry Webber, Co. C, 31st N. Y., while under treatment for granular lids was taken, Nov.
23, 1862, with erysipelas of the face and complained of pain in swallowing. On examination the throat was found
extremely swollen externally and internally, and the tonsils and posterior aares covered with a whitish pultaceous
membrane, portions of which could be wiped off with a sponge; the pulse was rapid and unequal; eyes red and
injected and the patient much prostrated and alarmed at his condition. The treatment consisted of twenty drops of
muriated tincture of iron every two hours in a tablespoonful of a saturated solution of chlorate of jjotash ; the tonsils
and throat were well brushed with an eighty-grain solution of nitrate of silver and the erysipelas circumscribed with
tincture of iodine; the diet was stimulating and nourishing. The mixture was continued in gradually decreasing
doses for ten days, after which the jiatient was considered cured. — Satlirlte Hospital, Philatldphia, Pa.
Case 15. — Private Fred. Bachman, Co. D, 1st N. Y. Art'y; age 35; while under treatment for rheumatism, or a
lameness of the right side from injury, was seized, Jan. i, 1863, with erysipelas of the face, attended with much fever,
severe headache and drowsiness. On the 18th the blush extended over the forehead and anterior portion of the
scalp, pitting on pressure and developing bulhe. A solution of sulphate of iron, half an ounce in a jiint of water,
was applied by means of compresses; tincture of iron was given with Dover's powder at night; milk diet. The
inflammation subsided by the 21st; but fetid matter came from the left ear, which was immediately washed out with
a solution of nitrate of silver. The patient was delirious on the 25th, but by the end of the month he was able to sit
up. The discharge had nearly ceased, leaving deafness on that side. A blister was applied behind the ear. He was
discharged March 30 because of deafness of one side and lameness from injury occasioned by a horse falling on him. —
Sutterke Hospital, PJiiUuhlpliia, Pa.
Case 16. — Private Lewis J. Russell, Co. B, 87th 111.: age 21; was admitted April 17, 1863, with an abscess of
the parotid gland, which was opened on the 27th. The gland of the opjiosite side became aft'ected, and on May 1
erysipelas set in, involving the whole of the face and scalp. A severe diarrho?a supervened on the 17th, and death
occurred on the 20th. — Lawsoii Hospital, St. Louis, Mo.
Case 17.— Private William W. Paxton, Co. H, lUth Ohio, was admitted March 21, 1863, with diarrhoea follow-
ing typhoid fever. On the 25th he had a chill which ushered in an attack of erysipelas of the face. Iron, quinine
EKYSTPELAS. 669
and lii',inily were administered and iodine applied to the surface. Tlie erysipelas disappeared next day. Imt the
patient's strength failed, and he died on the 28th. — Lauson Hospital, St. Louis, Mo.
Case 18. — Private Asa Fry, Co. K, 83d Ind., was admitted March 21, 1863. in a weak condition resulting from
typhoid fever and diarrha'a; he was unable to speak louder than n whisper. On the 25th he had a had cough and
his throat was red and congested. Applied a strong solution of nitrate of silver. On the 28th tincture of iron and
I'hlorate of potash were prescrilicd. A chill on April 3 was followed by erysipelas of l!» face, beginning on the nose.
Symjitonis of iutlammation of the brain attended the rapid extension of the disease to the sja'.p. l>eatli took jilace
on the 9th, after thirty-six hours of coma. — Lawson y/«»j)i((if, St. Louis, Mo.
C.^SE 19. — Private Robert Vantesseu, Co. E, 12th Va. Cav.; age 59^ was admitted Oct. 15, 1863, on account of
an injury to the chest by a fall from horseback. In December he was attacked with phlegmonous erysipelas, which
first atli'ted the head. In January, 1861, the eyelids were anlematous and the neighboring subcutaneous tissues
infiltrated with serum. Treatment at this tinu' was palliative and expectant, but, the disease extending, tincture of
iron, ciuinine and dirt'usible stimulants were administered freely, with generous diet and Dover's powder at night;
strong tincture of iodine was aii)>lied frcciuontly to the affected parts. Pus was dischargi'd copiously — as much as
eight ounces daily — the inllammation at this time involving the legs, arms and chin. Colliquative diarrhiea super-
vened: a large bedsore on the back caused much sutfering. He died March i. — Ciimbcrlunil ffosjiital, Md.
C.vSE ?0. — Private Jno. Thornton, Co. E, Kith Iowa; age 23; was admitted Oct. 4, 18G3, pale and feeble from
malarial fever, with torpid bowels, pain in the region of the spleen and some cough with white ropy expectoration.
On December 2 he was so much improved as to be able to assist as nurse; but on the 7th he had a chill, followed next
day by fever with heat and soreness in the left axilla. Laxatives, quinine and low diet were prescribed. On the 9th
the throat was sore and the tumefaction about the left shoulder extended upward into the neck and downward along
the trunk. On the 10th the breath was offensive and swallowing was accomplished with difficulty. The quinine
was omitted and eight-grain doses of iodide of potassium substituted ; tincture of iodine was applied to the inllamed
parts. On the 12th tincture of iron was given in place of the iodide of potassium; port wine, two ounces daily, was
also prescribed, with special diet and morphia at night. The fever abated somewhat on the l.")th, but the patient
was greatly prostrated; pulse 120: the swelling extended from the axilla to the ileum. A chill, with other indica-
tions of suppuration, was noted on the 18th: on the 20th the inflammatory redness extended as far as tlie knee and
on the 22d to the foot. At this time the ]iatient was greatly emaciated; he slept but little and had no ap])etite: an
opening. just below the iliac crest gave exit to a purulent discharge. Incisions above the crest on the 28th liberated
a pint or more of pus. By Jan. 5, 1861, his condition was considerably improved; he rested better and was able to
sit up in bed. Aromatic sulphuric acid and the sulphates of iron and cinchonia were administered. On the 12th an
opening made on the outside of the thigh permitted a large quantity of pus to escape. Three days later an opening
was made on the shoulder. Matter was, meanwhile, discharged freely from all the apertures. Peer or wine was
taken at desire; but the patient was much depressed. He continued to lose .strength until the 2Jth, when the dis-
charges became somewhat reduced and the appetite improved : but on the 28th diarrhoea supervened and persisted,
with occasional remissions, to the end. Apertures for the escape of pus had to be made along the leg and foot. He
died exhausted April 1. — Hos2>ilal, Qniucy, III.
POST-MORTEM OBSERVATIONS.
C.tSE 21. — Robert Sparks, a citizen of Missouri, was admitted Jan. 11, 1865, with erysipelas of the arm and fore-
arm. The skin and cellular tissue became destroyed, exposing the muscles for three-fourths of the circumference of
the arm from the insertion of the deltoid to the wrist-joint. The patient was treated with quinine and niuriated
tincture of iron and did well for seven or eight days, but pneumonia set in, the ulcer assumed an unhealthy appear-
ance and death occurred February 7. Posl-mortim examination : The upper and lower lobes of the right lung and the
lower lobe of the left lung were hepatized gray: the middle lobe of the right lung appeared to be healthy; the upper
lobe of the left lung was highly congested. The heart was normal. The liver was healthy; the spleen twice its nor-
mal size and an:emic: the intestines healthy: the mesenteric glands enlarged. — Act. Ass't Surt/con James McCoitiirii,
Sock Island Hosjiital, 111.
Case 22. — Private John Farlow, Co. C, 28th Pa.; age 44; was admitted March 29, 1864, with erysipelas of the
right lower extremity. He had been taken sick while at home on furlough. On admission the limb was red and
swollen to the middle of the thigh, its color livid and its temperature lower than normal. About April 10, as the
erysipelatous inllammation subsided, the knee-joint was found to be swolle'n and distended with liquid: this disten-
tion increased for a week and then gradually diminished, the pain also ceasing. At the beginning of May the left
knee became swollen and painful, and on the 11th, when it had attained the size of a man's head, it opened sponta-
neonsly and discharged abont a pint of sanions pus. At this time a bedsore formed over the sacrum and rajjidly
enlarged; another appeared shortly after over the right hip. Death took place June 3, rost-morttm examination:
Body much emaciated : both lower extremities greatly swollen. There was some hypostatic congestion of the lungs,
and the cavities of the heart contained fibrinous clots. The liver was fatty and slightly larger than normal: the
other abdominal viscera were healthy. An incision into the right knee-joint gave exit to a pint of pus; the articular
surfaces of the femur and tibia were much eroded, nearly the whole of the cartilages having disappeared, A similar
condition was fouml on the left side. The veins were carefully examined without the discovery of anything abnor-
mal,— Jet. Aes't Surgeon VTm. S. Diinton, Cuyler Hospital, Philadelphia, Pa.*
* \n account of this case, submitted by Pr. John .\siicbst, jr., was publisbi'd iu the Pritceedin/jg of Ihe Patiwtogical Scdeti/ of PhUadttiiliia, /Vi., Vol.
n, 1867, page ITi
670 THE ERUPTIVE FEVERS.
Case 23. — Johu W. Eosers- age 22: a rebel couscript: was admitted Ajnil 1, 1865, -n-ith erysipelas and gan-
grene of the right lower extremity. He had suft'ered much from bilious and intermittent fevers followed by dropsy.
For seven years his legs and feet liadljeen more or less anleniatous. A week before admission he fell over a chair and
the injury thus inflicted on bis leg aggravated the chronic swelling and developed erysipelas, which was preceded
by a chill. A saturated solution of chlorate of potash was ordered to be applied copiously to the limb. Delirium
came on dnrin" the night and continued until the morning of the -Ith; duriug this time he would rise from bed and
run about the ward. Nitrate of silver was applied around the limb to confine the erysipelas, but it proved useless.
Bromine was then used and milk-punch and tincture of iron ordtred. Large blood-blisters formed on the leg, which
began to look yellow, black-spotted and gangrenous. Labarraque's solution was used as a dressing. After the deli-
rium subsided the patient became comatose and died on the 9th. Post-mortem examination revealed nothing but the
gangrene of the limb. — Act. Ass't Surgeon Washimjton Matthews, liocl' Island Hosjntal, III.
Case 24. — Josiah E. .Small, a rebel couscript from Missouri, was admitted Dec. (5, 1864, with acute pneumonia.
The patient had an attack of pneumonia in 1863 and has sutfered more or less since then with pain in the left side.
On admission his tongue was coated except at the margins, which were red: bowels regular; pulse 90; respiration
hurried; he had cough with some expectoration; pain in the right side, which was dull on percussion and yielded
crepitant rales over the mammary region. He improved under treatment, and when. Jan. 6, 18G5, he was taken with
erysipelas all signs of the lung disorder had disappeared. The erysipelas ran its course in four days, but was imme-
diately followed by an abscess in the hip, which was opened on the 25th, discharging about a pint of pus on that day.
On the 27th ha was transferred to the surgical ward in good spirits, with a fair share of strength and a good appetite.
The treatment while in this ward consisted of flaxseed poultices with quinine and Dover's powder, and afterwards,
for six days, simple dressing, with a powder given every sis hours consisting of tliree grains of tannin and one and
a half each of opium and camphor. On February 5 poultices were again ordered and the face and hip directed to be
painted with tincture of iodine, which treatment was continued until his return to the medical ward on the 9th,
when his tace was found to present the desquamating cuticle consequent on a recent erysipelatous attack. He was
emaciated to a great degree, exhaled an exceedingly offensive stench from his person aud had deep bedsores on his
sacrum and on each iliac crest; his left lower extremity showed almost every process of bone in consequence of the
emaciation, while his right limb was swollen to a large size throughout its entire length in consequence of pui'ulent
infiltration. This sivelli.nr/ was comjiletely reduced in the course of tu-inty-four hours by the application of a tiglit l)audage
from the toes to the hip, with the further effects of causing a large C|uantit}" of fetid pus to be discharged from the
old aperture and of entirely relieving the excruciating jiain whicli the patient formerly experienced in the swollen
limb. The baudage was readjusted twice daily. The position of the jiatieut was frequently changed by an attendant
for the purpose of taking the pressure off the Ijedsores; his surface was cleansed once daily and disinfectants freely
used about the bed. Ale, milk-punch and whiskey were successively used as stimulants; lead lotion was applied
to the bedsores and an astringent pill given when needful. He died on the 20th. Post-mortem examination: The
body was extremely emaciated, the abdomen concave ; the integument abraded over nearly every bony prominence ;
the course of the purulent deposit among the muscles of the hip, thigh, leg and foot was distinctly marked ; the bed-
sores had not increased to any noticeable extent since his admission. There was some congestion and blueness of the
bowels, particularly of the large intestine; a part of the ileum, three inches long, was invaginated. — Act. Ass't Sur-
geon H. C. Xewkiri, Pocl: Island Hosjyital, III.
Ca.se 25. — Private William P. Bracken, Co. O, 86th N. Y.; age 22; was admitted Oct. 2, 1864, with chronic rheu-
matism. About May 1, 1865, lie had an attack of erysipelas of the face, which gradually extended to the scalp and
back of the neck. He was treated with tincture of iron internally and a lotion of half a drachm of sulphate of iron
to the pint of water. The case progressed favorably and by the 6th the erysipelas had altogether disappeared; but
the patient was feeble and had some irritability of stomach, which was cheeked by hydrocyanic acid in effervescing
draughts ; after which stimulants and a nutritious diet were ordered. On the 8th he complained of pain over the left
parotid, where an abscess, opened next day, discharged a quantity of fetid pus; there was also a discharge of pus
from the left ear. From this date lie refused nourishment and sank rapidly, dying on the 15th. Post-mortem exam-
ination : The cerebellum was softened, but no abnormal effusion was observed beneath the membranes. Both parotid
glands were enlarged. The lungs and abdominal viscera were normal. — Third Dirision Hospital, Alexandria, Va.
Case 26. — Private James Montgomery, Co. E, 110th Pa.; age 27: was admitted March 29, 1864, with erysipelas.
He was delirious and in low condition, his face and scalp swollen and doughy. One grain of quinine and five drops of
tincture of iron were given every two hoi»rs, with milk-punch and beef-essence ; mucilage of slippery elm was applied
to the face and scalp and flaxseed poultices over the parotid glands. On April 11 the left parotid became swollen
and on the 15th the right submaxillary gland; the swelling of the latter subsided on the 23d, but the parotid con-
tinued much enlarged, indurated aud painful. On the morning of the 24th blood and pus escaped from the left ear;
an hour later an incision was made into the softest part of the swelling, about one and a half inches below the angle
of tlie jaw, giving free exit to a quantity of pus. At midnight a pint of blood issued from the ear and the incision,
and thereafter, for four days, hemorrhage occurred at intervals notwithstanding efibrts to suppress it by tents satu-
rated with solution of persulphate of iron. Meanwliile the erysipelas reappeared aud diffused itself over the entire
face. Pus continued to be discharged and the tumor became much reduced in size; but at 5 .\. M. of May 2 twelve
ounces of blood came from the ear aud abscess, and a further loss occurred while readjusting the styptic plugs on the
giving way of part of the wall of the abscess. At this time the patient became inclined to stupor aud there was much
jactitation, which was equal on both sides, but after 11 p. M. motion on the right side ceased and clonic spasm was
developed on the left side: the right eye became glassy audits pupils dilated, while the left continued bright and
had its pupil contracted ; the left radial pulse was absent during the spasm, the right radial pulse was constant. He
ERYSIPELAS. 671
flicd r.t 2.30 .\. m. of the 3il. Fost-mortcm examination: Rigor mortis well marketl; skin blanched. The brain was
liealthybut pale: the thoracic and abdominal viscera aiiifniic. The integnmeut on the leftside of the face and neck
was swollen, softened and discolored. There was an openins; throngh the lower wall of the external auditory canal
and an orifice below the ear large enough to admit four lingers, leading into a large cavity filled with soft coagula
and the disorganized remains of the parotid gland. The arteries in this cavity are supposed to have been intact, as
no extravasation took place from them upon injecting from the arch of the aorta. The ramus of the lower Jaw was
denuded of periosteum: a probe was passed readily from the lateral sinns through the .jugular forauuMi into the
abscess: the external jugular vein was healthy below the .abscess but not traceable through the cavity. (The jioiiit
of special interest in the pathology of this case is the suppuration of th^ parotid gland, a most rare occurrence, aud
pridialily dependent on the condition of constitution induced by the erysipelas. Death was the result of unavoid-
able heniorrlmge. probably from the internal jugular vein, it having been involved in the disorganization of the gland,
rhe identity of the cerebral symptoms immediately before death with those of compression is worthy of mention,
the actual pathological condition of the brain being that of aua>niia.) — Cuijler Hospitul, Philueldphia , Pa.
C'a.sf. 27.— Private Kobert Work. Co. D. 8.Sd Ohio; age 27: admitted March 21, 1863, with diarrhre-a. He was
very weak, had a slight bronchitis and an ulcer on the cornea. Erysipelas of the nose and right cheek was developed
on April 12. l^ninine and iron were given freely and iodine applied locally. He died on the 24th. rosi-moilem exam-
ination: There was pus in the anterior chamber of the right eye, traceable along the course of the optic nerve to
the brain, which was congested. The lachrymal gland was softened. The bones forming the orbit were denuded
by purulent intiltration. — Lairson ffos2)iliil, St. Louis, Mo.
C.vsE 28. — Private Solomon Osborne, Co. F, 10th East Tenn. Cav., was admitted Jan. 27, 1864, with measles.
On February 6. before the eruption had entirely disappeared, he was attacked with facial erysipelas. He died on the
11th. I'litl -mortem examination: The scalp was o?dematous, the calvaria thick, the brain and its membranes much
congested. There were slight pleuritic adhesions on the right side: the lungs weighed forty-nine ounces and were
congested posteriorly: the bronchial membrane was injected. The inner surfiice of the pericardinm was yellowish and
softened : the heart soft and easily crushed between the fingers : the arch of the aorta atheromatous. The peritoneum
was congested. The mucous uieiubrane of the stomach was injected and thickened : that of the small iutestfne some-
what injected, of the large intestine thickened and softened. The liver was cirrhosed: the gall-bladder full; the
spleen soft : the kidneys much injected, the left showing a cyst with a drachm of liquid. The blood in the veins was
dark and semifiuid, — Act. Ass't Surgeon C. S. Merrill, Hospital W, yashville, Tenn.
C.\SE 29. — Private Charles Agugo, Co. K, 1st Mich. Sharpshooters, was admitted May 16. 1864, with rheumatism.
There is no record of his case until Jan. 7, 186,5, when he was attacked with erysipelas, ushered in by a decided chill.
^ The fauces and right side of the face first became affected ; the iullammation then crossed the nose and involved the
entire left side of the face; there was much swelling and both eyes were closed. He was treated with tincture of
iron. <iuinine. stimulants and a nutritious diet. Delirium set in on the 17th. He died comatose on the 19th. I'osl-
iNorffiii examination: The membranes of the brain were highly congested. Other organs normal. — Act. Ass't Surgeon
Leiris Heard, L'Oiirerture Hospital, Alexanilria, Va.
C.\SE 30. — Private Xathan Sprechor, Co. A, 99th Pa.: age 21: was admitted Xov. 30, 1864, with pneumonia,
from which he had recovered sufficiently to do light duty, when, on Feb, 23, 1865, his right ear became inflamed, A
blister was applied behind tlie ear and opium and blue-pill administered. On March 8 he became aftected with nausea,
and an erysipelatous inflammation spread from his right ear to his neck. Ipecacuanha was given and afterwards
reratrnm viride, and the inflamed parts were covered with cold flaxseed tea; but the inflammation extended to the
side of the face and delirium came on. Tincture of iodine was applied and a lotion of sulphate of iron, with quinine
and iron internally: but the disease spread rapidly over the head, neck and upper part of the chest, and the patient
died ou the IGth. Post-mortem examination : There was a slight eftusiou in the ventricles of the brain and two ounces
of serum at the base: the cerebellum was softened. — Third Division Hospital, Alexandria, Va.
C.\SE 31.— Private Felix Kennedy. Co. 15, 10th Vt., was admitted Xov, 25, 1863, suffering from facial erysipelas,
more marked over the left frontal region, where the disease encroached upon the scalp: pulse frequent and feeble;
tongue furred: skin dry and rough. The patient's aspect and general condition indicated habits of intemperance.
Stinmlants aud cold-water dressings were employed. There was much gastric irritation during the progress of the
ca8e,^ven liquid nourishment given in small quantity was occasionally rejected. On the night of December 4 there
vras a tendency to low delirium; but on the following day the mind was apparently clear. The inflammation of the
face and scalp was not at this time so marked as on admission, but his pulse continued weak and frequent and his
stomach rejected everything. Xext night the delirium returned, and during its continuance the patient opened a
window and fell to the ground, a distance of twenty feet, broken, however, by striking the roof of an adjoining
piazza. When brought back he complained of pain in the lumbar region and in the right ankle, also in the left side
of the chest near the angles of the sixth and seventh ribs. He died on the 8th. Post-mortem examination: In the
brain were evidences of meningitis: the lungs were crepitant; the heart, liver and kidneys fatty: the stomach con-
gested and its mucous membraue thickened. — Central Park Hospital, Xew York City.
C.vSE 32. — William H. Rushing, a citizen of Tennessee; age 42; was admitted March 5, 1864, with erysipelas,
Diecl 15th, Post-mortem examination: The face was swollen. There was some congestion of the bronchial tubes in
the left lung. The pericardium was distended with purulent liquid: the heart covered with fibrinous deposits; the
endocardium normal. The liver, spleen and kidneys were healthy: the intestines slightly inflamed.— £ro»j>i/a/ So. 1,
yathrille, Tenn.
Case 33.— Private Francis Xoolin, Co. H, 110th Ohio; admitted Xov. 23, 1863; died Jan. 12, 1864, of erysipelas
672 THE ERUPTIVE FEVEKS.
and glossitis. Post-mortem examination: Tongue much swollen and completely filling the mouth: spleen very large
and soft. Other organs healthy. — Ass't Siirffeon Harrison Alli'ti, V. S. A., Lincoln Hospital, Washington, D. C.
C.\SE 34. — Private Peter \V. Bradburn, Co. A, 9th N. Y. Heavy Art'y; age 52; -was admitted Ilec. 8. 1864. with
intermittent fever. He recovered, hat on Jan. 27, 186.5, Tvas attacked by erysipelas of the head. Tincture of iron
■was administered internally and a lotion containing acetate of lead and laudanum was applied. On the 29th the
patient's head was greatly swollen, pulse 120 and very weak: he was unable to swallow and his throat and tonsils
■were extensively ulcerated; he was delirious at night. Beef-tea and brandy were given freely by injection; the throat
and mouth were mopped with a solution of the chlorate of potassa and muriatic acid; a solution of half an ounce of
sulphate of iron in a pint of water was applied to the erysipelatous parts and morphia administered at bedtime.
During the following day the patient expelled a large amount of pseudo-membrane from his throat. On the 31st an
aqueous solution of bromine, containing a half drachm to the pint, was substituted for the iron solution as a local
application. Death occurred on February 7. Post-mortem examination: The raucous membrane of the small intestine
•was much injected and softened; Peyer's glands were prominent, as in the early stages of typhoid fever. [The con-
dition of the throat and respiratory organs is not recorded.] — Act. Ass't Surgeon E. I!. Ould, Hospital, Frederick, l[d.
C.\SE 35. — Private George Washington, Co. M, 10th 111. Cav., was admitted March 24, 1864, with erysipelas, and
died on the 27th. Post-mortem examination: The scalp and neck were greatly swollen. There were recent pleuritic
adhesions on both sides, and about six ounces of serunr with some broken-down lymph in the right pleural sac : the
lungs were much congested. The heart contained large light-yellow clots. The liver was fatty and weighed eighty-
two ounces: the sijleen, thirteen ounces, was pulpy and of a dull purplish color. The stomach and kidneys were
healthy. — Hospital Xo. 1, Jiashville, Tenn.
C.4SE 36. — Private Benjamin Barnes, Co. K, 5th Md.; age 59; was admitted from Slave Pen prison Jan. 3, 1865,
■with pleurisy. The acute symptoms had subsided under the use of anodynes, diaphoretics and sinapisms to the chest,
■when a swelling of the under lip and right cheek and a gangrenous condition of the mouth were discovered, the tiesh
hanging in black shreds. Nitrate of silver ■n'as applied and a mouth wash used containing chlorate of potassa and
creasote. On February 1 erysipelas of the face set in and 'was treated with tincture of iron internally and locally,
milk-punch and nourishing diet. He died on the 9th. Post-mortem examination: The salivary glands were enlarged.
The anterior portion of the left lung was coated with pseudo-membrane and adhered to the thoracic parietes; the left
pleural sac contained a considerable quantity of effused liquid ; the bronchial mucous membrane was of a dark-purple
color. The pericardium was full of clear yellow serum and the heart distended by a soft yellow clot. The liver was
large but otherwise normal; the spleen large and pale; the kidneys granular. The stomach was pale and contained
several black masses, apparently clotted blood ; nothing abnormal was observed in the rest of the alimentary canal. —
Act. Ass't Surgeon Tf. C. ilinor, Third Division Hospital, Alexandria, Va.
C.\SE 37.— Private General Denning, Co. G, 12th Tenn. Cav.; age 18; was admitted March 25, 1864, with con-
tinued fever, and died April 3 of erysipelas, /"osf-moi-ftm examination: The bronchial tubes of both sides were inflamed.
The heart weighed eleven ounces and a half; the endocardium was discolored. The liver weighed seventy ounces;
the spleen sixteen; the kidneys five and a half each. The intestines were healthy. — Hospital Ko. 1, Xashville, Tenn.
C.YSE 38. — Private Charles A. Eowell, Co. M, 1st Vt. Heavy Art'y, was admitted April 24, 1865, with erysipelas,
and died on the 28th. Post-mortem examination: The thoracic viscera ■nere normal but for extensive adhesions of
the right pleura. The spleen was much enlarged: the other abdominal viscera healthy.— Z)fj)0( Field Hospital, Sixth
Army Cocjm, City Point, Va,
Case 39. — Private James M. Brown, Co. H, 11th N. H.; age 18; was admitted March 26, 1864, with erysipelas,
and died April 3. Post-mortem examination: The mass of the left lung was healthy, but there were some superficial
abscesses, one of -which adhered to the thoracic -wall; the bronchial tubes were slightly inflamed. The heart and
the abdominal organs appeared healthy. — Hospital Xo. 1, Xashrille, Tenn.
Case 40.— Private Thomas Sarfas, Co. E, 19th Y. R. Corps, was admitted June 8, 1864, with erysipelas of both
■wrists. Tincture of iodine was applied and citrate of iron and qainine, whiskey and beef-tea prescribed. On the
11th the face was attacked, the scalp becoming speedily involved. On the 13th the tongue was dry and brown.
Coma supervened and the body became covered with a dark-blue petechial eruption which rapidly filled with sero-
purulent matter. Death occurred next day. Post-mortem examination: The lungs, liver, kidneys and arch of the
aorta were filled with small abscesses resembling those on the skin. [See Specimen 323, Med. Sect., Army Medical
Museum.] — Sheriurn Barracks, Washington, D. C.
Surgeon S. York, 5ith III., Jaclxson, Tenn., April 30, 1863. — In one of the cases which terminated fatally the
disease attacked the throat to a limited extent over the parotid and submaxillary glands. The skin was not
extensively aftected, but the fauces soon became considerably swollen. The patient died in a few hours, after a short
difficulty of breathing, from redema of the glottis ; the epiglottis was about half an inch in thickness and the entrance
into the larynx nearly closed. In the other fatal case the eruption made its appearance between the cheek bones
aud the nose, extended over a small surface only, and after a duration of two days became suddenly translated to
the liver, stomach and diaphragm. The patient had severe pain in the right hypochondrium and epigastrium, bilious
vomiting and singultus. He died in about six days thereafter with plain indications of gangrene of the organs
involved. In this case \io post-mortem examination was held.
I have used in the treatment of this disease saline purgatives in cases where there was biliary derangement,
mercurials as indicated, and emetics of ipecacuanha in those attended with gastric disorder; chlorate of potash,
tincture of iron, quinine, iodide of potassium and wine, whiskey or brandy have also been given. The best diet after
ERYSIPELAS. * (373
the acute stapce hail suhsided somewhat was found to be soft-boiled eggs, beef-tea and good wlieiiten bread. The
local remedies in which I have placed nm.st conlidence are tincture of iodine, acetate of lead and vinegar. In one
case of phlegmonous erysipelas, in which the head was greatly swollen, I api>lied a leTuon poultice ajiparently with
bcnetit. This was suggested by the virtues ascribed by some writers to the cranberry poultice. I sui>posed the
virtues of the latter to be due to its acidity, and as the berries could not be obtained I tried the lemon,
SiirgeoH AV, 11. White, 22rf 7iiir<i, nettr Jf'cst Plains, .1/o., Feb. 1, 18G3. — The disease which gave us most an.\iety
was erysipelas. The face was chiefly attacked. Most of the cases were severe and associated with marked derange-
ment of the liver and digestive organs. They generally yielded to active cathartics in conjunction with tonics and
local applications of nitrate of silver or tincture of iodine.
Surtjeon J. COOI-EU McKek, V. S. J., Cunq) lliilhr, near Spriiinfiihl, IU.,JhUi 1, 1802.— I can sjieak with the
highest satisfaction of the use of muriated tincture of iron in the treatment of erysipelas. Alternated with (juiniue
it controlled the disease in all its forms. I found local applications, as of iodine and nitrate of silver, unsatisfactory
iu their results; as they failed to limit the spread of the disease I abandoned their use and applied emulsions of
flaxseed, thereby relieving my patients from much unnecessary suffering.
Extract from the RecortU of thv ChimVorazo Hoxpilal, Itichmoiid, Va. — Erysipelatous cases have occurred within the
last mouth [March, 18G1], none grave. They are treated with iodine or muriated tincture of iron topically, and
tlie latter internally with saline purgatives as reriuired. In the case of Hicks, who entered March ,5, this treatment
was changed on the 9th for the sulphate of iron, there being no iodine iu the jiharmacy. At this time the erysipelas
was leaving the hands of the patient and invadiug the upper arms. Velpeau says that sulphate of iron arrests the
malady sooner by two days than any other agent. His formula for the lotion was employed. It arrested the disease
in thirty Lours. At the same time the patient took quiuiue three times daily. On the 12th he was convalescent,
Tee.viment, — Tlie essentials to success iu the management of erysipelas comprised the
prompt isolation of the affected individual, the dissipation of causative miasms by free ven-
tilation and the disinfection or cremation of articles known or suspected to be dangerous.
The gradual establishment of special wards and hospitals for erysipelatous cases during the
progress of the war gave a practical recognition to the contagious cjualities of the disease
and to the other intimate analogies which classed it for prevention and treatment among
tlie eruptive fevers, Tliis view held good, however, only in hospital practice. Erysipelas
occurred in the field independent of the infection of a pre-existing case. Sometimes it
appeared due to atmospheric exposures; sometimes no apparent cause could be assigned for
its development. Here it presented no analogy to the erupitive fever save in its course in
the individual, — a self-limited febrile action with an associated inflammatory condition of
the skin, and frequently of the internal surfaces, constituting the cerebral, tonsillar, laryn-
geal, pulmonary or dysenteric complications of the disease. There was no inherent suscepti-
bility which, until exhausted by an attack of the malady, made victims of those subjected
to contact with the affected individual. There was, therefore, no apparent coinmunicability.
But when this same case was transferred to the crowded ward of a general hospital a dis-
tinctly contagious quality was manifested. Defective ventilation seemed to concentrate the
causative exhalations to a degree of virulence that overwhelmed the conservative powers of
those exposed to their influence, — or the inmates, as a result of previous disease, had these
powers so weakened as practically to have developed susceptibility to attack. Probably
both of these conditions were concerned in the spread of the disease. Overcrowding was
generally regarded as a predisposing factor, and the susceptibility of enfeebled convalescents
was shown by the experience of every hospital.
Bromine vapor in quantity sufficient to be perceptible in the atmosphere of the wards
was used in some of the western hospitals for the prevention of erysipelas. Surgeon M.
Goldsmith, U. S, Vols., published directions for the use of this agent,* with a communica-
tion from Dr, B. Woodwakd, in which it is stated that since the use of the vapor in the
crowded wards of the Park Barracks Hospital, Louisville, Ky,, not a single case had occurred,
although prior to its use from five to eight cases had been developed every week. In wards
• AmericaH MedUal lima, VI, New York, 1863, p. HI.
Mei>. Hist.. I't. 111—85
574 ' THE ERUPTIVE FEVERS.
containing' as manv as sixteen cases at a time, side by side with other sick and wounded
men, the disease did not spread after the use of this disinfectant, and nurses who formerly
dreaded the danger of having erysipelas in their wards lost all fear of the disease/^'
Clinicallv, treatment was directed to the constitutional state of the individual to mod-
erate the violence of the local inflammation, limit its spread and control its results. When
the constitutional disturbance was of a stlienic character salines, laxatives and diaphoretics
were administered; but these were seldom continued for any length of time, as the disease,
if mild, speedily subsided, and if severe, as speedily induced a state of prostration which
called for careful nursing, support and stimulation. Emetics were rarely used at the com-
mencement of the attack; laxatives or purgatives were, on the contrary, freely prescribed,
particularly in the presence of cerebral symptoms. Dr. D.-iY has, however, entered a protest
ao-ainst the use of the latter on the ground of their liability to induce prostration and increase
the tendency to diarrhoeal complications ; he claimed that constipation was a favorable con-
dition in the erysipelas cases of Hospital No, 10, Nashville, Tenn. Tincture of iron appears
to have been regarded in the light of a specific: In most cases, as soon as the inflammatory
blush indicated the nature of the attack, this remedy was administered, many medical officers
considering that it controlled the disease and others acknowledging benefit from its use but
doubting v'hether the duration of the attack was in any case shortened. Chlorate of potash
was also largely used by some practitioners. As soon, however, as the pulse became weak,
the delirium muttering or the general prostration notable, beef-essence, milk and eggs, with
wine, whiskev or brandy were freely administered. Convalescence was promoted by c^uinine,
iron and extra articles of diet, and to these stimulants were added during the tedious pro-
gress of consecutive suppurations.
Local treatment was rational or empiric. The aim of the one was to relieve suffering
and allay local inflammation, — of the other to exercise a controlling influence on the cutaneous
manifestations. The feelings of the patient invariably testified to the efficacy of soothing
methods, seldom to that of the empiric measures, the repute of which was sustained chiefly
by the favorable dictum of the medical men who applied them. Protection from the air
afforded relief. This was best effected by smearing the surface with oil, fresh lard, glycerine
or some unirritating unguent. Dusting the parts with flour or. lightly covering them with
cotton answered the purpose at first; but these substances generally became a source of
irritation afterwards by forming incrustations with the exudations from the affected sur-
faces. Lead and other cooling lotions proved of value in many cases. Flaxseed emulsion
and glycerole of starch were also regarded as useful. Collodion had its advocates as forming
a light protective and equably constringent film.
The empiric methods consisted of the application of tincture of iodine or nitrate of silver
to the inflamed surface with the view of favorably influencing the local action. Occasion-
ally the attempt was made to limit the spread of the inflammation by circumscribing it with
an application of one or other of these agents to a strip or band of the sound adjacent skin.
The tincture of iron and solutions of the sulphate or persulpliate of this metal were also
employed on the affected surface to subdue the violence and arrest the progress of the inflam-
matory action. The repute of the cranberry poultice was such that one medical officer, in
the absence of this acid fruit, made use of lemons, and in his opinion with benefit to his
patients. A saturated solution of chlorate of potash was sometimes used as a wash to the
*Joururtl last cited, p. 239,
O
MUMPS^YELLOW FEVER. 675
suri'rtce by ineJieal men who prescribed this salt for internal administration. Unguents of
resin and turpentine appear to have been used extensively in the erysipelas wards of the prison
hospital at Rock Island, 111.
Abscesses, diffuse suppurations and other local results of the acute inflanimation were
treated in accordance with the general principles of surgery.
CHAPTER VII.— OTHER MIASMATIC DISEASES.
I.— MU-MPS.
This disease occurred to a notable extent, jiarticularly in the first year of the war, wnen
40 cases were reported among every thousand men. The rate of prevalence fell to 23 in
the second and third years, to 14 in the fourth year and to less than 3 per thousaml of
strength in the fifth year. Suppurative inflammation of the parotid glands was not unusual
in the advanced stages of the continued fevers,* but the tumefaction of the glands, I'eported
under the present heading, generally subsided at the end of a few days. Of 48,128 cases
reported 72 died. The following case probably illustrates the character of those having a
fatal termination :
Sergeant Joseph B. Brown, Co. E, 3d Ky.; ago 20: was admitted Maicli 21, 1863, with sliglit dianha'a and
pain, redness, heat and swelling in the region of the parotid. A poultice of arnica leaves and flaxseed was applied,
and in a day or two the abscess commniiicated with the external auditory canal. Ou the 27th a free incision gave
exit to six ounces of pus. On April 2 he was restless, but became quiet after the administration of hyoscyanius and
opium. He was found dead in bed on the morning of the 3d. PoHl-inortciii examination: The mastoid portion of
the temporal bone was denuded and carious and its cells iilled vrith pus. The deep vessels and nerves were com-
pletely dissected by the progress of the suppuration. The right ventricle of the heart contained a tibrinous clot.
The left lung, its apex especially, was studded with miliary tubercle. The liver was large but healthy; the gall-
bladder full; the bowels filled with llatus. — Lawson Hospital, St. Louis, Mo.
II.— YELLOW FEVER.
Our armies fortunately escaped visitation from epidemics of exotic origin. Cholera did
not invade the country until after the war period. Yellow fever was imported, but by
timely conservative action most of the troops in the invaded or threatened departments
wore preserved from the disease. The regiments stationed in the Department of the Gulf
wholly escaped.
The freedom of Xew Orleans from visitation while garrisoned by unacclimated men from
the North has been asaibed to the institution of active measures of local sanitation and the
strict enforcement of quarantine regulations by General Butler's military government. The
following remarks by Surgeon T. H. Bache, U. S. Vols., who was Medical Director during
the first summer our troops spent in the city, bears on this point :
Was the exemption from yellow fever due to ((uarantine or to the cleanly .condition of the city, or to both?
Following La Kocue and otliers I was not originally in ftivor of establishing a (luarantine to keep out yellow fever.
By originally I mean prior to the summer of 1862. My views were changing about that time, chiefly on account of
the exemption of New Orleans from the disease during the summer of 1861. This I was inclined to attribute to our
blockade, which was the strictest sort of a ijuarantine. During that summer the city was as dirty, if not dirtier than
usual, owing to the war; the ditches for artificial drainage were obstructed ou our arrival. Moreover the epidemic
was "over due," as they say. I relin'iuished the position of Medical Director on August 15, 1862. About the .3th or
* Supra, page 434.
(376 OTHEK MIASMATIC DISEASES.
6tli of September a man, who airi^etl on a vessel wliich }iad passed quarantine a day or two before, sickened and
died of black vomit on the fifth day of the disease. I never heard, however, of any other case following it.
The quarantine established during the summer of 1862 was kept up with unremitting
care during the following season, with the effect of excluding the fever from the city, although
many cases were treated at the quarantine station. Ass't Surgeon George M. Steekberg,
U. S. Army, says on this subject:
On the fourth of July, 18G3, the Spanish man-of-war Pizarro arrived at quarantine, and the vigilant resident
physician iu his examination discovered cases of yellow fever on board of her. Every etfort was made by the com-
mander of the vessel and the Spanish Consul at New Orleans to obtain permission for the vessel to come to the city;
Init they were assured that it would be allowed to come no further until at least thirty days had elapsed after the
last case of yellow fever had occurred and the vessel was thoroughly fumigated. The Pizarro therefore put to sea
again with yellow fever still on board, after having remained at the station three weeks. There were fifteen cases
lauded from this vessel and treated in the hospital at the station; of these three died. About October 5 cases of
yellow fever occurred on some vessels of our navy which had recently communicated with infected vessels at Pensa-
cola and ofi' Mobile. The fact that the disease was then prevailing in the blockading squadron was not known at
this time to the authorities in New Orleans, and the first intimation of it was received when it made its appearance
in the Holyhock, which was then lying in front of the city. The vessel was at once sent to quarantine. When she
arrived there were three dead bodies on board ; and four afterwards died out of twelve cases. The disease soon after
made its appearance in the Fear-not, the Pensacola and the Estrella, all of which were sent to quarantine. Fortu-
nately it was so late in the season that it did not spread any further in the navy and not at all in the city. The last
case occurred late iu October on the Estrella.
The Department of the South was visited in the autumn -of 1862 and again in 1864,
when also some of the stations in the Department of North Carolina became infected. On
the first occasion 382 cases were recorded with 100 deaths; on the second 783 cases with
309 deaths among the white and 190 cases with 27 deaths among the colored troops.
On June 20, 1862, the bark Adventure, three days from Havana, Cuba, put into Key West, Fla., in distress. She
was quarantined for ten days and lay at the station for three days longer than the official terra. About this time
four of her crew, sick with fever, were taken into the Marine hospital, where one died and the others recovered. On
July 27 a soldier of the 90th N. Y. was attacked, and the disease afterward.s spread through the garrison, which con-
sisted of 448 men, yielding 2 cases iu July, 153 iu August, 137 in September and 39 in October, or a total of 331 cases.
71 of which proved fatal. It is thus seen that this garrison furnished 87 per cent, of the cases and 71 per cent, of the
mortality occasioned by yellow fever during the year 1862.
Surgeon E. S. Hoffman, 90tli N. Y., in an able repiort of his experiences at this time,
states that yellow fever in Key West has always been traced to direct importation from
Cuba. Ass't Surgeon Cornick, U. S. Army, denies this and suggests a local origin. How-
ever this may be, the weather in 1861 was similar to that prevailing in 1862, and in both
years the island contained a large number of unacclimated men, but in the latter only did
the disease aj^pear. Some local conditions no doubt favored its spread and added to its
virulence, such as a large amount of decaying vegetation resulting from the clearing of land
for military purposes, the breaking of ground for gardens, the excavations involved in the
construction of fortifications, and during the progress of the last, the opening and removal of
about three hundred graves which is said to have occasioned an intolerable odor. The clin-
ical features of the disease are thus depicted:
Premonitory symptoms for the most part were wanting throughout the epidemic. In a few cases the patient
complained for some days of slight headache and constipation, with trilling pains iu the back and loins. In two cases
diarrhoea was followed on the second or third day by the sudden appearance of black vomit and a similar black matter
in the stools. Death by coma took place soon after; but both these men bad been weakened by typhoid fever, from
which they were convalescing at the time of their fatal seizure. A similar case, remarkable from its bearing on
the question of fright and nervousness, was that of Private George Cornwall of Co. I, who was admitted August
21 with diarrhcea of five or six stools daily. He had no fever nor headache. Appropriate medicines relieved the
diarrhoea, and the patient was preparing to leave the hospital ou the third day when a soldier was brought in with
fully-developed yellow fever. The complaints aud evident alarm of the latter frightened Cornwall, and within one
hour of the admission of the new patient he was himself seized with violent fever, headache, intense injection of the
conjunctiv.'e aud distressing pain in the back and lower extremities. Next moi'uiug suppression of urine came ou,
soon followed by vomiting, — the fluid at first waterv afterward showed the coffee-ground sediment. — and a strong
YELLOW FEVER. 677
nriuons oilor was percept iWe in the perspiration. The other case now improving, Cornwall's spirits rose, hope returned
to him, anil tor six days lie strn^ijled uuavailingly against the disease.
Nearly every case presented a dittereut series of symptoms, iullucnced by the constitntion, temperament and
idiosyiicracy of the patient. In opposition to observations made in most other epidemics of this disease there was
no particular time during the twenty-four hours when the attack occurred, the patient being seized at all hours both
of day and night. In most the onset was sudden. The patient was seized with a severe pain in the head, generally
supra-orbital, and often preceded by a regular chill. The pain soon extended to the back of the neck, the lumbar
region, the knees and calves of the legs, and with this were associated intolerance of light and deep-seated pain in
the eyeballs. In a few cases the head symptoms reached a high degree at once, delirium setting in almost from the
tirst, but I found that these yielded more readily to prompt measures than where meningitis manifested itself at a
later period. The eyes were injected and watery; the skin generally hot and dry, but sometimes, particularly in
fatal cases, cold and covered with clammy perspiration. The pulse varied from 85 to lUO and was full and incom-
pressible save in the cases of cold skin, where it was small and gaseous. The tongue was usually covered with
white fur, its tip and edges red; but sometimes it was perfectly clean, with or without the red tip; the edges and
tip corresponded exactly with the pulse and febrile excitement — the higher the fever the redder the tip and edges.
Only in two cases was there a dry tongue and in hut one a brown or dirty coat. The bowels were generally con-
stipated—sometimes diflieult to move, hut usually readily affected by cathartics. In many cases after the administra-
tion of calomel the patients continued to have inky and frenuent stools for some days. The nrine was mostly nornuil
at the onset, but in severe cases scanty, and the little that passed was dark-colored and threw down a copious sedi-
ment. Xausea freiiuently was present at first and the stomach easily rejected its undigested contents, — sometimes
accompanied by bilious matter.
These symptoms continued for a longer or shorter period. Sometimes the fever lasted from twelve to forty-
eight hours, and in a few fatal cases to seventy-two hours. During the fever the headache, pain in the back, legs
and eyes, with nnsatiable thirst, were the most distressing symptoms. Generally, after treatment, perspiration was
speedily established and continued through the fever; but in some all available and known means failed to induce
moisture on the hot, dry surface. In a few cases there were distinct remissions, and in five patients who had passed
through the second stage and were convalescent the fever returned on the ninth day and the whole programme was
repeated as if an original attack.
At the beginning of the second stage the patient was free from headache aud jiaiii, but still complained of
weakness in the back. The stomach, mostly irritable, often rejected its contents without effort, while in some there
was constant retching without emesis. Pain, more or less acute, according to the severity of the attack, with tender-
ness on pressure, was manifested in the epigastrium. Patients apparently convalescent and desirous of getting up
would show great uneasiness on pressure at this point, and before long black vomit revealed to them the desperate
nature of the disease and its treacherous character. As a rule the worst symptoms came on after the patient had
lieeu from six to twelve hours in the second stage. The pain in the epigastrium increased and burning thirst accom-
panied it; vomiting followed, at first of the fluids ingested, often clear aud transparent, but sometimes mixed with
chyle or more or less colored with bile; in three or four hours the tluid assumed the appearance of water, with a
tuownish-black sediment. On closer examination this black matter was found to he in ropy feculent masses, some
of lighter specific gravity, suspended in the Ihiid, others sinking to the bottom and adhering witli considerable
tenacity to the containing vessel. The quantity of li(inid ejected was sometimes very great, and the stomach relieved
itself in some cases by, as it were, involuntary muscular action, casting the vomit to a distance of several feet by a
single spasmodic act. The matter thrown u]> resembled chocolate, aud on settling deposited a griimous coli'cc-ground-
like mass, which, when expressed through filtering paper, lost much of its dark color. It effervesced with bicarbo-
nate of potash and turned blue litmus paper red. Heated in a test-tube the duid, if previously transparent, became
opaque and curdy like alliurainous urine. In those cases in which t:riemia was present the vomit when heated gave
olf ammonia, as shown by the white fumes that were developed when a rod that had been dipped in muriatic acid
was held over it. The urine was invariably albuminous and sometimes largely mixed with blood. I observed as one
of the characteristics of the epidemic that the matter was not ejected in large quantities at a time from the stomach ;
and only in a few cases did the quantity thrown up at once exceed two ([uarts. In these it was very dark, resembling
a mixture of soap and water, very acid, and accompanied by a sensation of rawness and extreme distress in tire epi-
gastrium; hiccough also troubled the patient considerably dnriug the intervals. The matter, from it.s acrimonious
nature, frequently excoriated the tongue, throat and lips; the stools also, being often of a similar character, caused
painful sensations in their passage. The period from the beginning of the black vomit until its term i nation in conva-
lescence or death was variable — sometimes it terminated fatally in twenty-four hours; sometimes it lasted longer, and
in one case was even protracted for four days, ending in recovery. I always considered its appearance a very grave
symptom, although twelve well-marked cases recovered out of fifty-two that presented it. During this stage of the
fever the pulse was generally from 50 to (>5, small and easily compressible, but in two fatal cases it reached 100 per
minute. The bowels became loose, particularly if they had been constipated in the first stage; the fa-ces of a dark
color and fetid odor. The color of the skin varied considerably — in some natural, in others presenting various shades
of yellow, but generally this color did not make its appearance until shortly before the closing scene. In two cases,
which afterwards recovered, I observed previous to convalescence a distinct third stage of the fever. The matter
thrown up changed its color — in place of a tarry appearance it became streaked with blood; the tongue cracked and
blood began to flow from it and from the gums, lips and nose; blood appeared in the stools also, and the yellow color
of the skin passed into a dark-orange color. The ha^matemesis in one case was checked with tincture of iron every two
hours, aud in the other the persulphate had an excellent efiect. The ten remaining cases of black vomit convalesced
678 OTHER MIASMATIC DISEASES.
rapidly on the subsidence of the vomiting, and resumed tlieir duties sooner than others -vvho, from a severe attack of
yellowy fever, i)assed from the first stage to convalescence without going through a second and third stage. Fatal
cases died generally on the second or third day. One ease died three weeks after being attacked with the fever. He
passed through all the stages, — the hot stage lasting forty-eight hours, the second with evident signs of the coffee-
ground vomit, the third with hematuria, hitmatemesis and bleeding from the tongue and lungs, after which he fell
into a typhoid condition, which ended in death.
Recovery was rapid. Ten days after the onset the patients resumed their duties.
Tlie treatment adopted in tliis epidemic is described by Ass't Surg. "W. F. CoRNiCK,
U. S. A., us follows:
As soon as the patient is attacked with symptoms of the fever he is placed to his chin in a hot bath containing
from four to eight ounces of mustard until he gets into a profuse perspiration or complains of being faint ; he is then
put in bed between blankets and fifteen to twenty grains of calomel are administered, followed in four honrs by an
ounce or two of castor oil. By the time the oil has had a good eft'ect his pulse as a rule becomes almost natural,
though in many cases quite frequent. I then give him ten grains of quinine every hour until he has talcen two
doses, after which five grains every two hours until he complains of ringing in his ears or other indications of the
action of the remedy. I also give sweet spirit of nitre to keep the kidneys in good working order, from the derange-
ment of wliich we have so much to fear. Should the patient after this complain of gastric uneasiness I give, as a
preventive of black vomit, one drop of creasote in the form of a i^ill : this has been attended with the liappiest results,
sometimes even after black vomit has made its appearance. If the patient complain of much uneasiness about the
stomach I generally resort to sinapisms, which will in most instances give relief. After this he is treated upon
general principles.
The other points affected during the year 1862 were Hilton Head, S. C, and Fort
Jefferson, Fla., both of which received the disease from Key West. Surgeon C. H. Crane,
U. S. A., Medical Director of the Department, placed on record the facts connected with
its appearance at the flrst-mentioued station.'''
The steamer Delaware, with General Terry and staff on board, left this place [Hilton Head] July 26 for St.
Augustine, Key West and Fort Jefferson. She returned August 26, bringing a detachment of the 7th N. H. that had
been left sick at Fort Jefferson when the regiment was relieved from that post in June last. These men had all been
invalids for a long time and were broken down in constitution.
This steamer left Key West on her return trip August 14, and on her arrival here was sent to quarantine at
St. Helena, about thirty miles distant. Among the passengers was Ass't Surgeon Coknick, U. S. A., who had been
on duty at Key West for some time and much exposed to yellow fever. Shortly after embarking this otiticer was
taken with what he supposed to be a mild attack of the fever; but he had completely recovered before the arrival
of the steamer at this place, and no case of sickness then existed on board. The vessel remained at the quarantine
station twelve days, when, as Surgeon Daltox, U. S. Vols., who was a passenger, reported to me that there was no
sickness on board, she was allowed to come to Hilton Head. Three days subsequent to the landing of the passengers
yellow fever appeared among the New Hampshire men, and to date (September 19) there have been eight deaths in
the detachment ; but the disease has not spread beyond it, and during the past three days there has been no new case.
As the remainder of the detachment has been sent to New York in the Delaware I am hopeful that no more cases
will occur. The other chartered vessels with Government supplies aboard, which have arrived here from Key West,
have also been sent to New York. I am satisfied that the only sure method of excluding yellow fever from this place
is to stop all communication with infected ports. In the instance of the Delaware twenty-eight days elapsed between
the time the vessel left Key West, the only infected port she visited, and the development of the disease after the
debarkation of her passengers at this place.
At this time there were about ten thousand troops at Hilton Head and Beaufort, but the
disease did not spread among them, although some cases occurred in October and November
in the vicinity of the wharf at which the Delaware had landed her passengers. In all,
including the men of the 7th N. H., there were forty cases at Hilton Head, twenty-live of
which were fatal.
During Octoljer eleven cases with four deaths were reported from Fort Jefferson, Fla.,
garrisoned by a detachment of the 90tli N. Y., the main body of which was then suffering
from the disease at Key West. Ass't Surgeon Chapman, of that regiment, denied the
importation of the fever, as a quarantine of seven to fourteen days had been imposed on all
vessels from infected ports. It is needless to advert to the weakness of this argument in
*See also Yelloic Ftfeer at P<jrt Itoijal, S. C, by Thom.is T. Smilev, V. S. Ho6pit.il, Hilton HnaA, S. C.—Bostnu Med. <w<t S,irg. Jniir.. LXVII, 18G3, p. 449.
YELLOW FEVER. 679
favor of the domestic origin of yellow fever. The cases of the Adventure and Delaware are
sufficient to prove its fallacy.
The reports of Surgeon D. W. H.\nd, U. 6. Vols., state that during this autumn the
disease affected the citizens of Wilmington, IN". C. and Charleston, S. C, attributing its intro-
duction in both instances to blockade runners from infected ports. The evidence appears
to throw the responsibility of the Wilmington epidemic, which is reported to have occasioned
1,200 deaths among the 3,000 whites and negroes who remained in the city, on an infected
steamer from Nassau, which ran the blockade on August 6.
The epidemics of 1864 affected the garrisons of Key West, Fla., and Xew Berne, N. C.
From the first-mentioned station 132 cases witli 12 deaths were reported as having occurred
among the 2d U. S. Colored Troops in May and June, and 78 cases with 21 deaths among white
troops in Julv and August; but no particulars of their origin were furnished by the medical
officer in charge. The fever appeared at Xew Berne about the beginning of September and
continued until the frosts of November. During this period 705 cases with 288 deaths
were reported among the white, and 58 cases with 15 deaths among the colored troops.
Eiglit medical officers, out of sixteen affected, fell victims to the disease. The origin of
this epidemic is involved in obscurity. The first cases among the troops occurred in the
persons of men attached to District Headquarters as clerks and orderlies. It is known,
however, that two citizens were taken sick on the same date as the earliest of the cases
among the troops ; and it is impossible to say how many cases, unobserved and unrej^orted,
raav have occurred among the civil population at an earlier period. It does not appear that
the infection was introduced from a foreign port, nor by refugees from Wilmington, for the
disease did not affect the citizens of the latter place until some time after its appearance at
New Berne ; but as the fever was at this time prevailing in Charleston, S. C, the infection may
have been carried northward bv refugees from that afflicted citv. Surgeon Haxd, wlio
investigated the outbreak, was so impressed with the difficulties besetting the proof of
importation that he referred the disease to local causes, and enumerated in his report the
various unfavorable hygienic influences which in his view contributed to its production.
It is needless to say that the history of yellow-fever epidemics in the South since tlxe close
of the war does not sustain the theory of their local origin.
When the presence of the disease was recognized at New Berne soldiers and citizans
were at once moved to Morehead City, Beaufort, Hatteras, Roanoke Island or other places.
Certain individuals who had become infected prior to their departure with these detachments
suffered from an attack at their new stations, but the disease did not spread, except to a
limited extent at Beaufort.
Surgeon C. A. CowGiLL, U. S. Vols., reported that 292 cases of fever were admitted
into the Foster hospital at New Berne during the progress of the epidemic, and that some
time after the first cases were received the disease spread through the wards, affecting first
convalescents from malarial diseases, then convalescents from other diseases, and finally the
attendants; of these 118 were attacked, giving a total of 410 cases and 181 deaths among
the white troops in the establishment.
Surgeon D. AV. Haxd, U. S. Vols., reported of this epidemic as follows:
Xew Berne is situated on a point of low land at the junction of the Trent and Jfeuse rivers and is almost wholly
surrounded by niar^h aud swamps. The liij;liest part of the town is only a few feet above the surface of the river,
and the streets, being without paving, have an imperfect drainage and in wet weather are a mass of mud. The elms
and maple trees, which in times past have been planted in every yard aud street without regard to taste or utility,
680 OTHER MIASMATIC DISEASES.
have grown into a perfect forest, and during the wet days of July last the dense foliage kept the whole town damp
and mouldy; during that month there were few days without a shower of rain. In the spring and summer lahorers
■were kept at work on the streets and sewers, and Government teams were sent regularly to remove such filth and
garbage as might be collected, the citizens being required by the commanding officer to deposit all such refuse where
the teams covild get it. The backyards were not, however, very closely examined, and the accumulations of years
were afterwards found in many places ; but with all this, I believe the general sanitary condition of New Berne when
the fever broke out to have been better than that of most Southern towns.
During the winter of 1863-64 and spring of 1864 several small docks, near the foot of Union street on the Neuse
river and Craven street on the Trent, were filled up, in part, it is said, with stable manure, for the purpose of exteiul-
ing the wharves. Between two of these docks thus filled up at the foot of Craven street was a row of old frame
buildings, several of which were built on piles, with the river-water formerly washing under them. Through care-
lessness or neglect no drainage was provided for the cavern under these buildings. In consequence the summer rains
made a pond under them, where dead rats and filth rapidly accumulated and where the intense heat of August gen-
erated fearful poison.
On the Neuse river front there was built in July and August an embankment to prevent the water encroaching
on the carriage-way between Pollock and Short streets. This was made of a solid wood front, tilled in for the most
part with clean sand: but during several days of excessively low water, sand and mud were thrown into it from the
exposed river bottom.
During July and August the weather remained steadily hot, the tlierniometer averaging at midday 83.2.5° in
July and 8.5° in August. The fall of rain in July was 9 inches and in August 4.3 inches. The prevailing winds
during both months were from the southwest. The continual showers of rain during these months and .September
kept the ground and air very moist without mitigating the heat. In July we had several thunder storms with heavy
winds, but in August the wind was steadily from the southwest or south and very light.
There is no regular ebb and llow of the tide in the Xeuse river, but these continual southwest winds drove the
water out and we had for many days the lowest tides that had been known for years. Many acres of sand and mud
on both river fronts were thus exposed to the hot sun. In the summer and fall the vicinity of New Berne is always
prolific of malarial fevers, and the warm season of 1864 was one of the worst known not only here but in all jiarts of
North Carolina. Each year since the occupation of New Berne it has been noticed that the regiment doing provost
duty, and remaining in town, has been almost exempt from intermittent and remittent fevers and much more healthy
than the troops encamped on the outskirts. It was noticed through the past August that the men in town — part of
the 1.5th Conn. — were generally escaping the malaria] fever, but early in September some bad cases of congestive fever
occurred among them.
On the 6th of this month yellow fever existed in New Berne, although not then acknowledged or positively
recognized, and this disea.se undoubtedly ori./huited in the town.
The Neuse being blockaded we are sure no vessel arrived at New Berne from an infected port at any time during
the summer. A few refugees came in during August, but none of them brought more than the clothing they could
carry themselves, and we can find none who came in about that time from Wilmington. No sailors or soldiers were
landed at Morehead City and thence transferred to New Berne from any Southern port. On August 25 thirty-four
men arrived at Morehead City in the steamer New Berne from the receiving ship North Carolina at Brooklyn Navy
Yard, and were forwarded by rail to New Berne for vessels in the sounds. No disease existed among them, and this
was the only shipment of sailoz-s through New Berne between August 15 and Sept. 10, 1864.
The first cases of the disease which came under my notice, and, so far as we can learn, the initial ones, were —
Private Orlando Pollock, 3d N. Y. Art'y, clerk at district headquarters, corner Union and East Front streets.
Admitted to Foster hospital Sept. 2, — died on the 6th.
Private Francis Coates, 3d N. Y. Cav., orderly at district headquarters. Adinitted Sept. 1, — died on the 6th.
Private G. C. Lillie, U. S. Signal Corps. Admitted Sept. 4 from signal otiice on o]qiosite corner from district
headquarters, — died on the 6th.
Jlrs. "Wilcox, a white refugee, corner of George and South Front streets; had chills for a month or more; taken
quite sick Sept. 1; had black vomit, turned yellow, and died on the 7th. This woman had lived in that house one
mouth and in New Berne eight months.
Mrs. Prudence Eice, whom I did not see, died Sept. 6, in the next house to Mrs. Wilcox, of what was probably
yellow fever.
Sergeant M. Rogers, 15th Conn., jailor at Confederate prison, corner George and Pollock streets, was taken sick
and admitted to regimental hospital on Sept. 7; had black vomit, and died on the 9th.
These occurred at two points widely separated, and preceded by nearly a week the irruption of the great ei)i-
demic. 1 could not at the time believe they were genuine cases of yellow fever; but on September 12 Lieut. A.
B. Johnson, street inspector, and two soldiers, died in the Fqster hospital with unmistakable symptoms of that dis-
ease. From this time cases began rapidly to appear in different parts of the town near the two rivers; but it was
soon found that the worst cases were among the Government emiiloyes in the vicinity of Craven street wharf. This
led to an examination, and on tearing up the floors of some of the old buildings used as storehouses by the quarter-
master and commissary, a pool of stagnant water was found the effluvium from which sickened the worknu-n. It
was at once decided to burn down the houses and fill up the pond. This was done, but the poison generated there
no doubt existed many weeks after.
The epidemic influence seemed to prevail with greatest force in the vicinity of the water, and for several weeks
was confined to a district two squares broad along each river bank. It was most violent in the rotten old frame
YELLOW FEVEK. 681
houses which, ou several streets, are built iuimediately on the >:rouu.l ami \vi.icli are always tlaiii)): but every house
in the infected district had more or less of the disease. Gradually the epidemic influence spread over most of the
town, and by Xovember 1 almost every white person in the place had suti'ered. The negroes were at first exempt ;
but after a few weeks the disease extended to them and nearly all in New lierne had it, generally, however, in a com-
paratively mild form. The epidemic prevailed violently for only forty-five days, but cases occurred from September
2 to Xovcmber 22. Between these dates eight hundred and sixty whites and one hundred and fifty-five negroes died
in New Berne from yellow fever. Children nearly all recovered, while with the aged and persons recently arrived
from the North it was very fatal.
During this epidemic it was clearly proved that no contagion existed. Soldiers from the Foster hospital and
provost guard, as well as citizens, were sent away as rapidly as possible to Morehead City. Beaufort, Ilatteras. Koauoke
Island. Bachelor's Creek and to the country about here, where many of them soon after sickened and died: but at no
place excejit Beaufort did the disease extend to any other persons. At Morehead City patients removed from Xew
Berne were placed indiscriminately in tlie wards of the Mansfield hospital, and citizens of New Berne thronged the
hotel. Twenty-oue soldiers and thirty-four citizens died of yellow fever: yet not a single person contracted the dis-
ease unless he had visited Xew Berne or Beaufort. At other points similar oliservations were made. Cases have
been reported as occurring in tlie country about here conflicting with this idea, but I have been able to trace every
one of them to a visit, often very short, to Xew Berne. The town of Beaufort was badly crowded with refugees from
Plymouth ;ind Little AVashington, and the policing was not good. The proper atmosphere for the spread of the
epidemic was found there, and from a few cases brought from New Berne the disease spread to a considerable extent
over the more crowded portion of the town. Fifteen soldiers and seventy-six citizens died there; but it should be
noted that at the Beaufort hospital, which is pushed out on the_ sea-face of the town, not a single case of the fever
occurred among patients or attendants who had not beeu exposed elsewhere.
The patients were generally taken in the evening with a slight chill, followed in a short time by fever and
severe pain in the sacral and lower i)art of the lumbar region. It was rare to have severe neuralgic pains, but the
patients were always restless and sleepless. Pain in the head was ahnost universal but not severe; it was generally
over the eyes, sometimes much worse on one side than on the other, and with a feeling of fulness and deep-seated pain
in the eyeballs. The conjunctiva was always more or less injected and often very red, with a yellow hue ol the scle-
rotic coat appearing through it and extending back over the eyeball. The face was not much flushed; but the skin
felt hot to the touch or else quite cool, tlie circulation being bad even' in the early stage. Profuse sweating often
continued for hours, the pulse remaining unaltered, from 104 to 120 as a rule, with a quick beat and often giving
the impression of air being in the artery; it sometimes had a thrill like an aneurism. The tongue was clean and its
character varied at dift'erent periods of the epidemic. During the first two weeks it was generally of natural size,
with a slight white fur in the middle and red tip and edges. Afterwards in almost every case it acquired a dull
leaden hue with no other unusual appearance. In only a few cases did we have the large •■ oyster tongue."' The
stomach was irritable and tender on pressure from the beginning; the bowels constipated or regular, with no sore-
ness or diarrhoea.
This first or febrile stage lasted from twenty-four to eighty hours, generally about sixty hours, and was fol-
lowed by a decided remission, the patient being left greatly prostrated but free from ]iain and often feeling that all
danger was past. In the second stage the circulation was feeble and tlie greatest care had to be taken to preserve
an even temperature. Mosquito bites at this time left purple, purpura-like spots, and the cuticle was harsh and dry.
The pulse became quite slow, often going down as low as GO-TO and easily compressed under the finger. The irrita-
bility of the stomach now often subsided and the tongue would get a slight coating of whitish fur or would swell
consideraldy. In this condition the patient would remain from twelve to twenty-four hours cheerful and confident.
The third stage then coming on our patients would be found with great restlessness, an anxious, often frightened
expression of countenance, increased irritability of stomach, with a feeling of uneasiness or oppression at the peri-
cardium and a tendency to belch or bring up wind from the stonmch, — a deepening of the yellow in the eyes and a
brownish-yellow tinge of the whole skin. An oft'ensive odor was at this time often exhaled from the body, and fre-
quently there was suppression of urine. This condition was often followed by black vomit and death, the fatal ter-
mination being generally on the fifth day— sometimes as early as the third, rarely later than the eighth.
Fortunately, however, many cases did not terminate in death. The symptoms above related gradually sub-
sided, and decided convalescence was established by the seventh or eighth day. A few recovered after having had
black vomit : but such cases were rare. No one was known to recover after having entire suppression of urine.
Retention occurred in only a few instances — in very nervous persons. Death was sometimes preceded by stujjor
with stertorous breathing: but oftener by great nervous irritability, with slight spasms, opisthotonos and jactitation.
.Secondary fever was not observed in many instances. It was found to be not unfavorable when it did occur. Con-
valescence was slow, and the yellow tinge of the skin and eyes did not disappear until the third or fourth week.
At the Ijeginuing of the epidemic we believed the disease to be of malarial origin and treated it with quinine;
but onr cases died. The disease was one evidently of blood poisoning. Quinine would not check its action on the
brain; the indications were therefore to eliminate it by the liver and kidneys. Calomel treatment, not pushed quite
to ptyalism. was adopted. A cathartic dose, followed by one-grain doses every hour or two hours, generally brought
a blue line on the gums between the second and third days, and we found it best then to stop the mercurial. In very
few cases was severe salivation produced. The medical ofticers who had any considerable experience in this epidemic
agree with me as to the utility of mercury. Besides this we gave as a drink ice-water acidulated with bitartrate
of potassa: ice and the smallest portions of animal jelly and beef-tea were employed: sinapisms and blisters were
useful over the stomach, and minute doses of ipecacuanha sometimes stopped the vomiting. We derived no benefit
Mkd. Hist., Pt. Ill— «6
682 OTHER MIASMATIC DISEASES.
from acetate of lead. Occasionally, in the third stage, small doses of opium of morphia were useful: and generally,
in that statue, mild stimulating drinks, such as iced sherry, were grateful and soothing to the patient. Prompt and
active treatment in the early stage was found to be necessary. Later, the expectant plan was as good as any; but
I should not dare trust it from the beginning. Several cases recovered after black vomit appeared, but in no case
could this result be attributed lo treatment. In no disease that I have seen is careful nursing so much demanded.
I cannot speak in terms too high of the noble conduct of the medical officers here. To Surgeon C. A. Cowgill,
U. S. Vols., Surgeon Nathax Mayep., lOtli Conu., Surgeon P. B. Rice, 132d N. Y., Ass't Surgeon J. H. Doughty, U.
S. Vols.. Ass't Surgeon E. F. Hendricks, 15th Conn., Ass't Surgeon J. M. Davies, 9th X. J., Dr. J. W. Page, U. S.
Sanitary Commission, and many other brave men who did their whole duty, soldiers and citizens alike are under
lasting obligations for their heroic labors.
The inefficiency of a quarantine, consisting merely of detention for a given number of
days, was so manifest in 1862 that the late Surgeon General Crake insisted on non-inter-
course for the protection of a threatened locality. Obviously this is the only sure method;
and wlien the conditions are such as to admit of its successful operation troops should always
be thus protected. Commercial intercourse, however, does not brook an interference of this
kind with its progress, and occasions may occur when even military command is incompe-
tent to control the conditions that may arise to render intercourse imperative. Fortunately,
recent progress in sanitary science and experience in the prevention of yellow fever have
demonstrated that protection may be afforded, not only without the promulgation of an
ordinance of non-intercourse, but even without the detention involved in the original accep-
tation of the term quarantine. Sanitary supervision and disinfection have been substituted,
and at the present time enable our health boards and quarantine officers to protect the com-
munity witliout materially interfering with the current of commercial enterprise.*
The depopulation of the city of New Berne in 1864 saved many of its garrison and
inhabitants from falling victims to the fever. After the disease had fairly broken out among
the troops most of them were removed from the town, and nearly all of those thus removed
escaped. This experience was repeated in the yellow fever epidemic of 1867: Where the
troops faced the pestilence, as at Galveston, Houston, Hempstead, New Orleans and Fort
* I'litil the e^tJiblishment of the National Board of Health in 1S70 the United States had no competent protective system against yellow fever.
For many years before that date the sanitarians of the country and the leading public health officials were well aware of the princiitles which underlie
such a system. The meetings and transactions of the American Public Health Association extended the knowledge of these principles and prepared the
way for subsequent concert of action by the health officers of threatened ports. A central health office, which should co-ordinate the efforts of the
various State and municipal health authorities, was regarded by all as essential to protection. The quarantine powers vested in the State and local
authorities were effeetiTely exercised by some, but their beneficial results were counteracted by the ignorance or carelessness of others or the imperfection
of their quarantine regulations. At that time the National Government took cognizance of the danger only by the provisions of an act passed in 17li8
authorizing the officials of the revenue service to aid the local authorities, when requested by them to do so,- and when such assistance could be rendered
without interfering with their own duties. Ass't Surgeon Hakvey E. Brown, L". S. A., in a Ileport on Quarauttne, submitted to Congress in 1S72, exj>used
the weakness of the want of system then prevailing, and indicated the geneiul character of the needful remedial measures. Touching national super-
vision, he held that in the administration of the "War Department alone is found that freedom from political influences and that authoritative manage-
ment which, while demanding absolute obedience, gives to the individual the largest liberty consistent with public safety. Hence he recommended
that the general management of affairs should be conducted by the Surgeon General of the Army, aided by inspectors detailed from his torjis of officers.
The Surgeon General, in forwarding this report to the Secretary of War for transmission to Congress, objected to this recommendation on the ground
that the Army SIcdical Corps as then constituted would be unable to furnish officei-s for quarantine duty without serious interference with its own military
duties and detriment to the interests of the service. No efficient action was taken by Congress until 1870, when a central body, the National Board of
Health, was organized to advise the National and State authorities on matters pertaining to the public health, and to co-operate with the State and local
health boards and officials in preventing the importation of foreign pestilence and in restricting its spread should it unfortunately succeed in effecting a
landing. On the recommendation of this board efficient and uniform regulations Wf re adopted by the various ports exposed to danger. By the co-opera-
tion of the Consular Service it was kept informed of the sanitary condition of all foreign ports having communication with this country, and was thus
enabled i)romptly to notify the local authorities when danger threatened. It endeavored, by medical inspection and disinfection at foreign ports, to have
all vessels bound for ports of this country in a satisfactory sanitary condition before beginning "their voyage. The certiticate of its agent at the port of
departure had weight with the authorities at the port of entry, who granted admission if the vessel was said to be entitled to free pratique and nothing
had occurred during the voyage to change her status in this respect. Tlie movements of a vessel suspected of infection, on accoilnt of having failed to
Bubmit to inspection prior to leaving the foreign port, were conmuinicated to the officers of the port of destination, who, on her arrival at their station,
applied such measures of disinfection as her condition required. Refuge stations were established at certain points on the coast to which infected vessels,
denied entrance to port, were sent for treatment. These fulfilled the role of quarantine stiitions for many small ports on the Gulf and Atlantic coasts, the
commerce of which, although as dangerous in this connection as that of the larger ports, was inadequate to equip and maintain the requisite quarantine
establishment. Here the passengers and crews were kept under observation or treated in hospital, according to circumstances, and the cargo and vessel
submitted to a thorough cleansing and disinfection. By this system infected vessels only were delayed,— and not for an arbitrary period but merely
until disinfection was satisfactorily effected. Under the auspices of the National Board of Health the pathway of commerce was freed from vexatious
restrictions and unnecessary obstacles, while the country was protected against the unanticipated arrival of the disease on its shores, and tlie people of
the exposed sections realized a feeling of security to wliith they had heretofore been iinaccustomed. Its experience has demonstrated that protection
may b'.* obtained without a recourse to non-intercourse or indiscriminating quarantini.'S of detention.
YELLOW FKVER. 683
Jeflerson, the great portion of those exposed were attacked. Where, en the other hand, as
at Indianoia, Mobile and Pass Christian, the commands were removed after the outbreak of
the disease, nearly all the men escaped. Since then the prompt removal of troops from
points threatened with infection has lessened the ravages of yellow fever at our Southern
militarv stations.*
CHAPTER VIII.— OX SCURVY.
Prevalence, etc. — According to the statistics of this office the average annual rate
of cases reported from military commands under the heading ^'orftwiiis, during the eighteen
years before the war, was 26.3 per thousand of strength, or, as will be seen directly, nearly
twice as large as that which prevailed among our white troops during the years of the war.
The medical otficers of our Regular Army, by virtue of their experiences at remote frontier
ix)sts, were well qualified to detect the existence of this diseased condition. Surgeon
Charles S. Tripler, U. S. A., who was Medical Director of the Army of the Potomac
when scorbutic symptoms were discovered in it during its operations on the Peninsula, had
already placed his experience and views, on record ;t and many references to scurvy are to
be found in the published reports of Army Medical Officers. t although descriptions of the
scorbutic condition itself are rare. §
•lu more recent epideDiics affet-liug tbe civil pujmlatiuii, as iu those wLicli scourged Memphis, Tenn., in 18TS and li*7'J, depupuhitiou, by the
establishment of cainis at some distance from the city, certainly savtil many lives. At Camp Marks, which was establis^hed July 2S and broken up Oit.
2s, l!*Ti>, the average nunibt-r of rations drawn was l,:i04. Xiue cases of yellow fever occurred, of which none were fatal. Two of the iiiliubitants of
this camp were taken with fever after their return to tbe city when the settlement was broken up. At Camp Williams, which was distant only fuur
and a half miles from Memphis, a large number of cases occurre«i, but invariably in ^w^rsons who had violated the rules by visiting the city or in refu-
gee who songlil the camp while already infected. As many as seventeen of the latter died in one night ; yet it is said that in no case was the fever
commanicate<l to those iu the camp. See |iaper by Col. John K. Cameron of Memphis, iu Heports ami Papers, American Public Health Association, V,
ISTit, p. 158, in which the author strongly urges deiioimlation as a saving me;isure in fever-stricken cities.
t In the Citi'-iitnali JUwcel and 06*wrfr, Vol. I, liOS, p. 131 t( se>j. His able article investigates the theories of causation and much of the recorded
ciitiTicucc on prevention and cure. He concluded that abstinence from fresh meat and vegetables, by diminishing the needful proportions of potash and
iron in Ibe blotwl, induces scurvy; and that in the aliseuce of a projier dietarj- the disease should be treated by salts of these bases, the potassio-tartrate
of iron being suggested as ca^table of fulfilling all the indications.
J .\ scorbutic tendency was developed at most of our military posts during the winter season, after the troops had been for some months confined
to Ihf use of the ordinarj- ration with desiccated vegetabh'S. Tlie latter in the quantities issued failed to repress the disease. At jvosts which could be
Tvadily supplied with potatoes only the taint was manifested, on account of a want of liberality in the issues; but at those in the interior, which were
rvftched by a tedious overland journey, the disease became one of the first importance. The capabilities of the soil had not been tested by the cultiva-
tion of i»ost gardens, but iu the spring and summer every plant of assumed anti-scorbutic value growing in the vicinity was carefully gathered for use.
Thr cunditious afTecling the dietary of the men at these stations may be appreciated by a perusal of the reports published by Ass't Surgeon R. H. Cool-
iiw.r, I'. S. A., iu his Medicul Stutiftic* of the Vuiled SttUei Anmj, I8o5-C0; Washington, 25. C, 18G0. For instauce :— Ass't Surgeon D. L. Magrider stated,
in a reiKirt from Fort Lookout on the Missouri river, iu Nebraska Territory, October, 1S50, that should any accident prevent the arrival of a supply of
flesh vrgetabK-s this fall, it wuuld be his misfortune to witness another scorbutic epidemic before the return of vegetation iu the spring. Surgeon T. C.
Mams<.'S wrote from Fort Randall, September, lSo7, that scurvy wjis the only disease about which the slightest apprehension was felt. During the pre-
vious winter tbe whole command was more or less affetrted before the arrival of a supply of Irish potatoes iu January enabled him quickly and effectually
to suppress the disease. These vegetables had been shippi-d from St. Louis, Mo., iu the fall, and had become frozen while en route, but their anti-scor-
butic pro|nTties bad not bet*n destroyed. They were used raw as well as cooked. At this post lime-juice, pickles, molasses and dried fruits were issued
along with the ration, but in the quantities furnished they did not prevent the appearance of scurvy. The wild artichoke, edible from the beginning of
.\pril to the middle of Slay, was eaten raw, gnitt-d or slicwl, with vinegar; later iu the season other greens wtre used. Ass't Surgeon E. W. Johns,
writing from Fort Larauii*-, ItecemU-r, ISoS, considered that thert? was little of interest to report except what relate<l to scorbutic disease. He used the
juice of cactus plants, which, in the absence of any other curativt- agent, effected a wholesome change in the system, as complete, although not so rapid,
•5 that resulting from the use of [wtatoes. The juice was prejvired by broiling the thick leaves slightly over a fire aud then slicing and digesting th m
in water until a thick greenish-brown mucilaginous mixture was obtainetl. A tumblerful of this mixture, with two ounces of whiskey, flavored with
csMDce of lemon, was given as a dose. At this i>ost stores of water-cresses were collecteti and used at the mt*s tables ; and so highly was the in port mce
of thia addition to the diet appreciated that the colonel commanding su|>erintend(.-d the search for the plant. Going Imck to earlier times, a severe out-
break of the disease occurred in 1j*20 at Council BIuRs and St. Peter's. The strength of the former post January 1 was 788, of the latter 228, making
In all l,(ilt;. The total of cases of all diseases rejwrted at these two posts during the quarter ending March 31 was 805. Of these 503 were of a scorbutic
cbamct^r; and the numlier of deaths from this cause was lt>8, of which lo7 occurred at Council Bluffs. According to Surgeon SIower, neither small-
poat n'.T .\siatic cholera, iu their most malignant forms, was so dreadful as this outbreak of scurvy. See Foruv — Ou Seorhiitus — Atnerican Jotr. liUd.
Scitwrt*, N. S.. Vol. III. Philadelphia, 1842, p. 77.
g R. S. Holmes, fonnerly uf the V. S. Army, has given in the S/. Loni* Medical and Sitrgicai JovmaJ. A'ol. V, 1847-8, p. 417 et ftq., some account ». f the
disease as it ^^rcurre*! among tht- troops in Florida. He also saw it elsewhere in this country and in Mexico, and from its diversified character aud the
abacDce of symptoms commonly considered diagnostic, ht is convinced that the disease is often overlooked, and that cases of true scun*}* are toipetimes
6S4: SCUEVY.
The majority of our volunteer medical officers had, on the contrary, at the beginning
of tiie war no personal familiarity with the disease; nevertheless few of them failed to
recoo-nize the possibility of its occurrence or to look closely after the health of their men with
the view of detecting its earliest manifestations. In fact, the first intimation of a scorbutic
tendency among the troops, so far as is shown by the records, came from a volunteer medical
officer. Surgeon David Woostee, 5th Cah, encamped near Sacramento, Cal. His reference,
which is dated Jan. 13, 1862, is as follows:
I have fouml chlorate of potash invaluable in the iirst symptom.s of scurvy: Tender gums harden as if by
magic under the use of a drachm a day in tvro ounces of simple syrup.
The figures submitted in the first part of this work indicate that scurvy was present in
our armies from the first month for which reports were forwarded. May, 1861, to the close
of the war. In the mouth stated 7 cases were reported in a strength of 16,161 men. These
mav be rep-arded as a contribution from the conditions that were in existence before the war.
The continuance of the disease after the cessation of hostilities was mainly due to a recur-
rence of these conditions.
Among the wdiite troops during the five and one-sixth years covered by the statistics
30,714 cases of scurvy were reported; and 383 deaths were attributed directly to that
disease. These numbers are equivalent to 71.2 cases and 0.82 deaths in every thousand
nien of average strength present during the period. The fatality of the disease was not
large, 1.25 per cent, or one fatal case in eight}', although nearly one-half of the deaths from
this cause occurred in general hospitals in the cases of men received from Southern prisons
and not recorded in the list of those taken sick with scurvy. This, however, may be con-
sidered ofl'set by the cases of diari'hcea which owed their persistence and fatal ending, perhaps
also their origin, to the scorbutic cachexia.
The prevalence indicated by these statistics might be regarded as suggesting the presence
of a very notable scorbutic taint in an army, but it must be remembered that these numbers
are the aggregate of a series of years, and that the average annual rate of cases amounted
only to 13.8 per thousand of strength, or to the development of scorbutic symptoms in one
man in every company of 72.5 men. Moreover, it seems probable that these rates greatly
overestimate the extent of the pervasion of our white regiments by the scorbutic taint. It
is usually considered that if one man in a command be affected with well-developed signs
of scurvy many other men in that command, all of whom have been subject to the same
dietary, will be more or less disabled, although they may not be borne on the sick-report.
Tliis assumption is indisputable; but it is questionable if all the cases that were reported as
scurvy by our medical officers actually presented the characteristic signs of the disease.
Medical statistics are of no value unless all the circumstances attending their collection be
mistaken for other diseases and treated as such. He holds it as an error to suppose tliat depression of spirits, loss of strength, affection of the gums,
sallow appearance and livid patches are present in every case of scurvy. In doubtful and obscure cases the only well-marked proof of the presence
of the scorbutic taint is found in the results of treatment ; If an ophthalmia, or an ulceration of the leg occurring in a person who previously subsisted
on salted provisions without vegetables, should persist under ordinary methods of cure and yield to acid drinks and a diet of vegetables, the presump-
tion is strong that the disease was connected with the scorbutic taint. The symptoms most commonly observed were liver-colored patclus on the arms,
legs and chest, and a puffy or tender and bleeding state of the giims, with a tendency of the teeth to become loose. A freiiueut sign of the disease as
observed in Florida consisted of extensive superiicial ulcerations following the rupture of bulla on the feet, ankles and between the toes. At first the
origin of these was not suspected, and cases were borne on the sick-list for three months, when their cure was brought about probably by the anti scor-
butic diet that was habitually used in the hospital as ftir as circumstances would permit. Subsequently the affection was cured in a few days by drinks
of lemonade, or what was considered better, a mixture of vinegar and nitrate of potash and a diet of vegetables. Ulcers on the legs, suiipurative inliam-
niation after woumls, a foul state of the socket after the extraction of a tooth, a peculiar susceptibility to salivation from mercury aud other medicine?,
were also among the more common effects of scurvy, and associated with these were muscular debility, derangement of the bowels, depression of spirits,
a sallow countenance aud bleeding gums. Soldiers suffering from inflammations complicated with the scorbutic taint formed a large proportion of the
iwtieuts in Florida. These were jironc to relapse,— a return to their former diet in quarters was followed in a week or ten Jays by the reappearance of
their complaints.
SCURVY. 685
clearly appreciated. The writer Knows, from lii:; local experience in the Array of tiie Potomac,
that after the first alarm of scurvy in the ranks of that army many medical officers continued
on the alert for a recurrence, and cases which, but for that alarm, would have been returned
as diarrhoea or rheumatism, found place on the Monthly Reports as veritable scurvy.
During the twenty-seven months, April, 1854, to June, 1856, inclusive, the French army
in the Crimea, averaging 86,740 men, reported 23,250 cases of scurvy and 645 deaths from
that disease irrespective of those that occurred among the large number of cases sent home
for treatment.* These numbers are equal to 268 cases, of which 2.8 per cent, were fatal in
every thousand of average strength present. The annual rate of prevalence amounted to
119 cases per thousand, or to one man with characteristic scurvy in every squad of 8.4 men.
To judge from the statistics of uncomplicated scurvy the English armv was compara-
tively free from the disease, as only 2,096 cases and 178 deaths were reported during the
whole period of twenty-seven raonths.f Most of these occurred during the seven months,
November, 1854, to Mav, 1855, inclusive, giving a rate of 55 cases per thousand men for
this period, or an annual rate of 94.3, equivalent to one man with marked scorbutic symptoms
in every squad of 10.6 men.
During the early months of the campaign in the Crimea both armies remained free from
scurvv, a result attributed to the quantities of grapes and cabbages gathered by the soldiers
while on the march from Kalamita Bay to Balaklava. But in Xovendjer, 1854, the disease
appeared in the ranks and increased rapidly in the English army until the following Feb-
ruarv, after which, under the free use of lime-juice and issues of potatoes, its threatening
aspect was immediately subdued. It continued, however, to furnish a few cases monthly
until the end of the camjxiign. In January, 1856, these numbered 58 and were equal to
one per thousand; in the other months they did not reach this rate and were not recorded in
the official table of sick-rates. In the French army, on the contrary, the disease was promi-
nent throughout the war.
The death-rate among the English cases shows decidedly that the same methods of
recording the statistics of scurvy did not hold good in the allied armies'; for while in both
the disease was clinically identical, a death-rate of 8.4 per cent, prevailed in the English
ho.spitals as compared with 2.8 per cent, among the French troops. English medical officers
have reported that although comparatively few cases of pure scurvy were noted in the returns
nearly every admission into hospital for other diseases exhibited unequivocal signs of the
scorbutic taint. Apparently French military surgeons sent their men to hospital when pre-
senting signs of scurvy, but in the English camp such cases were not taken on sick report
until the disease was in an advanced stage unless some intercurrent attack, to which the
morbid condition of the blood rendered the men peculiarly susceptible, called imperatively
for treatment. But even in the French practice, as stated by M. Baudens, soldiers were
rarely sent to hospital during the first stage of the scorbutic malady when the characteristics
were a hemorrhagic disposition, great muscular lassitude and pains, particularly in the legs
and feet, weakness of pulse, loss of appetite, a notable discoloration of the skin and a remark-
able dilatation of the pupil ; yet most of the men admitted for other maladies had these con-
stitutional evidences of the scorbutic affection.
• n-pport M.,nco-Chin<r,iioJ i«r la CampagHe U Orie„l, jar J. C. CllEXf, Paris, 1865. S«c his ErponlUyn Sommairc it> fniu priHcipanx (It la campaipu,
€l Mq. and Table 33,
t Mr'tU'al aud Surgii
tq. and Tablt^s A aad B.
p. 13 tl «.;. and Table 33, |>. oia.
t .l^*V<il Olid Surgical Uittory of Oie hrUUh Am,y in the Crimea.— Official Report to Parliameiil, LondoD, 1858. S« article on Scurry, Vol. II, I>. 171 It
686 SCURVY.
Our medical officers, perliaps from their unfamiliarity with the disease, paid much
attention to the early symptoms; and certainly of the 30,714 cases reported by them a large
majority were never admitted into hospital, but were excused from duty and treated in
quarters until the symptoms of the first stage, which gave them a place on the sick-report,
had subsided. In fact, a comparison of the records of our armies with those of the allied
forces in the Crimea shows that our Medical and Supply Depai'traents have reason to feel
gratified with the success of their efforts to banish scurvy from our ranks.
Ass't Surgeon E. S. Dunstee, U. S. A., on special duty as an inspector of hospitals
and camps, was the first to call attention to the probable presence of a scorbutic taint among
the troops operating in the East. His report is dated Xew Creek, Va., April 27, 1862.
The 8th, just from Parkersburg, is mider orders to proceed to Moorefield. I am decidedly of the opinion that
this regiment should be allowed more time to recover from the debilitating condition that ensued from the winter's
residence in Buffalo. You will remember in my report that I referred to the (as I called it) latent scorbutic condition
of the men; its etfects are still visible, though there has already been a manifest improvement; and I think a few
weeks camping in some healthy jilace like this would put the men iu fine condition.
Shortlv after this time rumors were current of the existence of scurvv in the Army of
the Potomac. These ultimately took official form, and indicated two brigades, one of which
consisted of regular troops, as the commands specially affected. Medical Director Tripler,
who was well informed concerning the dietary of the regular brigade, could scarcely believe
that these men should be the first to manifest scorbutic symptoms. Nevertheless he pro-
cured suitable supplies and, proceeding to the front on May 22, investigated the condition
of the suspected regiments. The men were found free from taint. Dr. Tkipler reported
to the Surgeon General as follows concerning this reported outbreak:
I received a telegram while I was at White House engaged in organizing a general hospital, informing me of
the appearence of scurvy in two brigades and directing me to send for lime-juice, etc. I telegraphed you, Jlay 21,
for lemons, in obedience to that order, expressing at the same time my doubt of the accuracy of that report. This
doubt was based on the fact that one of the brigades was that of the regular infantry. I knew that these troops had
been furnished with desiccated vegetables and that some of them had used them regularly. Orders for this issue had
been promulgated long before, with instructions as to the method of cooking to be adopted by the troops. I called
upon the Chief Commissary and learned that the men very generally refused to use the desiccated vegetables; that
he had abundance of them and could not get rid of them. Even potatoes had been suffered to rot upon his hands and
in the camps. A general order was again applied for, and issued on the 23d of May, requiring the troops to draw and
use the desiccated vegetables in soup daily, unless prevented by being actually on the march, prohibiting the frying
of meat and commanding it to be always roasted or boiled. Upon my arrival at headquarters I inquired into the
grounds of the report, and learned that it had been made by the Medical Director o-f General Fitz-John Porter's Corps,
Dr. Geokge H. Lymax. This gentleman, one of our ablest and most energetic officers in the volunteer service,
informed nie that he had not seen any cases, but he had considered it his duty to make known, for prudential reasons,
as soon as it was mentioned to him, that it had been reported to him by Brigade Surgeon Waters and by some young
assistant surgeon of the Regular service. I sent for Dr. Waters and found he had seen no cases; that it had been
reported to him by some volunteer regimental surgeon. I directed him to have the men brought to me immediately
for inspection. He subsequently reported to me that the patients had been sent to the general hospital at the AVhite
House. A short time afterwards I visited this hospital and then found two cases set down as scurvy. I examined
these: one had no sign of scurvy, and the other was a robust man with an erythematous patch upon one shin, swell-
ing of the leg and knee, discoloration of the ham without hardness, and no swelling or sponginess of the gums. The
aftection came on, according to the account of the patient, in one night from sleeping without shelter after a hard
day's march through deep mud. I could not consider this case scorbutic under the circumstances, and accordingly,
feeling relieved as to the fact, I reported that no sctirvy existed in this army. About that time the lemons arrived
and were distributed among the several corps.
But three weeks later, on June 14, there were discovered in the 19th and 20th Mass.
six men showing symptoms of scurvy and others "acquiring a predisposition to the disease."
Surgeon J. F. Hammond, U. S. A., Medical Director of Sumner's Corps, to which these reg-
iments belonged, stated that the 19th had become generally, indeed almost universally,
affected with scorbutic symptoms, and reported on medical authority that similar cases had
been observed in another brigade of the corps. As explanatory of the outbreak he was
SCURVY. 687
informed that the desiccated vegetables were so disagreeable to the taste that the men would
not eat them. Ass't Surgeon A. K. Smith, U. S. A., was immediately despatched by Med-
ical Director Tkipler to inspect the men said to be affected. He confirmed the truth of
the report, whereupon the commissary of subsistence at White House was telegraphed to
send potatoes, dried apples and pickles to Sumner's Corps. At the end of the month Sur-
geon J. F. Dyer, 19th Mass., furnished a report of the condition of his command, showing
IS cases of pronounced scurvy, 100 of the scorbutic taint, and many of diarrhcjea which he
attributed to the causes of scurvy, inasmuch as it was controlled when the patients had
access to a free suppily of vegetables.
Duviii<r the (Quarter just eiuletl tlie legiiiicnt has beeu on the peninsula before Yoiktown ami Kiclimoud. The
labor of the men has lioen arduous and their exposure great. These causes, with an almost total deprivation of fresh
vegetables and fruits for three months, have in my opinion laid the foundation for serious disease, which has in many
cases made its appearance in the form of scorbutus. Eighteen eases of this disease, in the form of ulcerations, hem-
orrhages and eruptions, have been noticed during the past month, and nearly one hundred have been found with
spongy and bleeding gums, Diarrhiea has also been apparent, depending, it appears to me, upon the same cause,
and disappearing whenever the patient could have access to vegetables in any considerable quantity.
Surgeon Xathax Haywart), 20!;h Mass., rendered a similar report:
In addition to the number of cases reported as taken sick during the month, some two hundred and forty men
of the regiment showed more or less decided marks of scorbutic disease, and were treated as far as practicable by the
administration of raw potatoes and vinegar. These cases were in most instances too slight to warrant putting the
men in quarters, and hence they do not appear in the report. In many other instances the scurvy taint was only
apparent in its moditication of other diseases. Thus a large number of the diarrhwas were characterized by passive
hemorrhage and a peculiar intractability when treated by ordinary methods, yet they yielded readily to vegetable
acids and anti-scorbutics when they could be procured.
The usual marks of the disease — swollen and ulcerated gums, painful swellings of the muscles, languor, nos-
talgia, petechial eruptions and ecchymoses — were observed. The cause of its appearance can readily be found in the
exiwsure of the regiment to the depressing iutlueuces of cold, wet, hunger and miasma during the ten or twelve days
following the battle of Fair Oaks, combined with the absence of vegetables. The ditiiciilty of obtaining even the
nsual ration of fresh vegetables has placed an insurmountalile obstacle in the way of the efforts of the medical officers
to arrest the spread of this disease, and unless potatoes, onions and other vegetables are soon supplied in liberal
quantities there is reason to apprehend its manifestation in more serious forms.
Various other medical officers noted in their reports for June the presence of a scorbutic
taint, which in some instances in July became developed into unmistakable scurvv.'-'
Surtjeon H. F. V.vx Derveeh. 5(/i .^". ./., Camp near Alexandria, Va., Oct. 21, 1862. — Scurvy commenced in the reg-
iment towards the close of June. The causes of this epidemic were — 1st, a want of vegetable food: 2d, exposure to
wet and cold at night : 3d, an impure atmosphere, and 4th. the aggravation of all these causes by mental de])ression.
The disease exhibited its usual symptoms — si>onginess of gums and spots of purpura: contraction of joints and stiff-
ness and pain of limbs were especially frequent and severe. Xo fatal case occurred. The epidemic reached its height
about the first of August. During its prevalence diarrhiea and all other diseases were complicated with scorlnitic
symptoms. The means employed to combat the disease were fresh vegetables, a free supply of lemons, the salts of
potassa and tincture of the chloride of iron. The use of these remedial agents was attended with considerable ben-
efit, and the disease was diminishing when, on the 15th, we marched out of camp on the way to Yorktowu. The
change of air, the exercise of marching and foraging on the cornfields and orchards soon put an end to the epidemic.
Surgeon A. J. McKelwav, 8(/i X J., Camp near Alexandria, Va., Oct. 20, 1862. — In addition to the diseases speci-
fied as having affected the men of this regiment since their landing at Yorktowu scorbutus made its appearance. Few
escajied without showing some manifestation of the disease. The general symptoms were feelings of languor and
debility: fatigue on the slightest exertion; the face presented a pufty appearance in many instances; the gums were
spongy and swollen, the breath ofteusive, the legs in many cases mottled with purpuric spots; cases not so well
developed nor so distinctly marked were attendeil with wandering neuralgic pains, at times attacking the spine and
at other times producing pain or constriction of the chest with difficulty of breathing. One well-marked symptom
in some cases, where the disease did not manifest itself in purplish spots, was rigidity of the muscles of the leg, spoken
of as chronic rheumatism in the description of their feelings given by the sutferers. In some of these cases purpura
shortly appeared, but in others who suftered precisely in the same way, malaise and debility included, the^e spots
were never exhibited. The exciting causes can be easily found in the continued deprivation of proper vegetable
* Dr. Fbascis R. Lyma.v, house pbrsiciao, Bt-lftvue hospital. New York, remarks ia the American Jfe<fi™t Time^, Vol. V, 18G2, p. 125, tlmt of about
one handrej «olJiers of the Army of the Potomac ailmitted during July and .\ngust, 1S62, thirty-five per cent, were affected with gcurvy. Some of tliese
men bad l>een in Richn:ond hospitals. Deljilily and wandering shooting pains were sometimes the only grounds for a diagnosis. The diarrhcea, fre-
quently present in these cases, alated as the general health became restored. Many after gaining in flesh, strength, appetite and spirits, continued to
suffer from stire gums, excruciating i^iins and stiffness and sT.clling of the liml>s.
688 SCURVY.
food under which the men had suffered siuce their huuliiig on the I'euiiisuhi. Doubtless other causes coutrilmted to
its iM'oductiou, — exposure, fatigue, exhaustion and other depressing influences; but the want of fresh vegetables and
meat and the use of salt meat for months no doubt gave origin to the disease.
Ass't Sui-gi'oii C. S. Wood, 6G//1 X. T., Sept. 30, 18G2. — At this time scurvy manifested itself in the most unmis-
takable manner. Nearly oue-half of the regiment suffered from it during the month of June. Fresh vegetables were
ordered, but, owing to the want of trausportation, the quantity received was so small that its effect was hardly per-
ceptible. Lemons, however, of which we soon had an abundance, controlled the disease.
Siiriiioii Hexky McLe.\^, 2d N. ¥., Camp near Alexandria, Va., Oct. 30, 1802. — The water was impure and the
men for the greater portion of the time [at Harrison's Lauding] scantily supplied with fresh vegetables. Symptoms
of scur%-y made their appearance. These cases, as well as those of associated diarrhoea, were benefited by the exhi-
bition of dilute sulphuric acid.
Sarijeo)! A. P. FiaCK, W3(l Pa., Xcw Berne, X. C, Feb. 25, 1803. — At this place [Harrison's Landing] scorbutus
oiade its appearance, but this was speedily repressed by the liberal use of fresh vegetables, lemons, etc.
Durino; the advance on Ricliinond and the retreat to Harrison's Landino- tliere liad
been a constant strahi on the mental and physical energies of the men, for their excitement
had been as intense as their labors were severe. ISTo fresh vegetables had been supplied. The
desiccated vegetables were not liked, and there was seldom time to prepare them properly.
Even the ordinary components of the ration were not always fully supplied, nor was time
allowed for cooking. The men frequently ate their rain-soaked hard bread while under
arms awaiting orders. Sleep was obtained by snatches on the muddy roads and fields and
was broken by the call to arms. The troops marched by night, raanoeuvered and fought by
day, and they were gloomy and despondent withal, because en route to the landing a series
of harassing and deadly conflicts served only to secure the safety of the array. The hard-
ships, privations and exposures of the seven-days' fight, added to those of a campaign wliich
had already produced scurvy in some of the regiments, sufficed for a more extensive devel-
opment of this disease. One of the first cares of Surgeon Jxo. Letterman, U. S. A., who
relieved Surgeon Tripler as Medical Director on the arrival of the army, July 4, at Har-
rison's Landing, was to promote its recuperation by eradicating the scorbutic disease. Requi-
sition was made for large supplies of potatoes, onions, cabbage, tomatoes, squash, beets and
fresh bread. The first shipment of anti-scorbutics was received on the 7th; potatoes and
onions reached the Landing on the 20th, and thereafter supplies were so abundant that they
rotted at the wharf for want of some one to take them away. Li addition to the vegetables
and Ijread issued by the Subsistence Department, fifteen hundred boxes of lemons were
procured by the Medical Purveyor for the various regimental hospitals. The beneficial
eftects of these issues soon became perceptible in the improved health of the men, and when
the army left the Landing, August 16, scurvy had disappeared from its ranks. According
to Letterman a true idea of the improvement that took place could not be conveyed in
writing, as there was so much in the appearance, in the life and vivacity exhibited by the
men in their slightest actions, even in the tone of the voice, which conveyed to one's mind
the impression of health and spirits, of recovered tonicitv of mind and body and of the pres-
ence of vigorous and manly courage.
After this scurvy was no more seen in the Army of tlie Potomac except m isolated
cases, although at times, especially after the conditions of an active campaign had prevented
the issue of fresh vegetables and soft bread, a scorbutic complication of other diseases was
considered by some observers as noticeable, and by others tlie increased danger attending
diarrhceal attacks was attributed to the same cause. Thus Ass't Surgeon John S. Billings,
U. S. A., in his account of the condition of the array in June, 1864, the second raonth of
its advance from the Rapidan to Petersburg, Ya., reported the existence of several cases of
■SCURVY. 689
well-marked scurvy and of a sccrbutij fuiaeiit complicating other diseases;* and the present
writer, when reporting the condition of the Second Army Corps in March and April, 1865,
attributed the obstinancy of the diarrhoeas which were then prevailing, and the great and
rapidly-increasing prostration with which they were associated, to the absence of fresh veg-
etables from the diet of the command, although the only well-marked cases of scurvy present
in camp were known to have contracted the cachexia while in Southern prisons. f The
statistics of the army show that during the month of June, 1S(U, when Dr. Billings made
his observations, only 22 cases of scurvy were reported, or .22 per thousand of streno-th for
the month ; and in March and April, 1S65, when a possible scorbutic condition of the Second
Army Corps was suggested, there were reported from the whole army onlv 36 and 20 cases,
or .33 and .26 cases per thousand respectively for each month. Practically that army was
preserved from the scorbutic influence from the suiipression of the outbreak in June and
July, 1862, to the conclusion of its history. Medical Inspector John Wilsox, U. S. A.,
refers thus to its freedom from scurvv during the siege of Petersbnro-:
The ample supply of fresh and nourishing vegetables had an excellent effect in guarding the men from scoibiitic
taint. Xever was so large an army so entirely exempt from this form of disease. This fact increases in sanitary sig-
nificance when we consider that the depressing and exhausting influence of life in the trendies grc.itly favors the
development of adynamic diseases. The demoralizing tendency of an almost unremitting sharpsliootingfi reproduces
under any circumstances mure or less of thai moral depression and physical depravation so favorable to dyscratic
disease: yet notwithstaiKling this the most marked exemption from scorlintic disease has been enjoyed, and tha
health of the Army of the I'otomac, during the months of Septemlier and October, has been of a most gratifying
character.
About the time of the suppresvsion of the epidemic in the Eastern army scurvv was
observed in other portions of the U. S. forces. Brigade Surgeon Charles H. Rawsox, 5th
Iowa, Acting Medical Inspector of the left wing of General Pope's command, adverts to a
species of land scurvy- as the most irregular and insidious of the diseases affecting the troops,
and as, in his opinion, complicating many other complaints. J The following reports indicate
its presence in detached commands:
Siinjton B. F. Stkvensox, 22d Kij., Portland, Ohio, Oct. 8, 1862.— During the month of July we had a number of
well-marked cases of scorbutus. They were sent to hospital without the lines, where a vegetable diet could be pro-
cared. Under this regimen they rapidly improved and were returned to duty. The prevalent opinion that attributes
scurvy solely to the absence of vegetable nutriment will derive but little support from a history of the cases that
occurred in this regiment :^ We had in all eleven cases of scurvy; ten of these were men of foreign birth, whoinduln-e
more freely in vegetable diet than do our native Americans. As these had for years been addicted to a free indulgence
in spirituous liquors, may not the withdrawal of the long-accustomed stimulus have had a material inlluence in pre-
paring the system for the inroads of the di.sease ?
Siirgioii John W. Scott, in(;i h'ans. — During the month of July, 18i)2, the regiment was, with other troops, in
the Cherokee country, and, owing to the absence of fresh vegetables, was compelled to subsist mainly upon the army
ration, in con.seqnence of^hich a scorbutic tendency began to manifest itself in the shape of cutaneous eruptions
and intractable ulcers in the mouth; but, owing to the promptness of the commanding olficer in carrying out the
recommendations of the medical ollicers, a supply of desiccated vegetables was procured and the unfavorable
symptoms speedily disappeared.
Aan't Surgeon Jon. C. B.vily, ''. .S. A., Paralta, X. ^fex., Oct. 6, 1862.— An abundance of grapes, green cori.,
beans and ouious were immediately furnished the troops, with such good eft'ect that by Seiitember not a sign of scurvy
remained. Chlorate of potash was prescribed internally for the worst cases with unmistakable lienefit.
Surgeon B.vsiL Xokkis, C. S. A., Fort Craig, X. Mex., Sept. 6, 1802.— The character of the paiu in incipient
scnrvy is so like that in rheumatism as I have seen it in this Territory, that I am inclined to the opinion that a fair
• Sec his ;i'.j)ort, |agc 100, T'lirt First of Diis work. f Ibid, page 210.
{ 111 a litter dated Corintll, Miss., Juue 21, 18C2,— .tin«-ica>i Med. Timvs, Vol. V, lSn2, p. 42 : Some of the men aftectcd had pale, waxy, (mfry and
an»mic faces; increasing dehility; soreness, ecchymosis and swelling of the feet and lej^s; pains in the bones, muscles or any and every portion of the
body; diarrheea or irregular bowels and capricious appetite ; comparatively few had the gums ulcerated. Sudden death in men apimrently healthy was,
by Dr. Raws*>s*, attributed to an insidious scorbutic taint. He had no opportunity of making a ^orf-mortem examination in any of these suddenly-fatal
cues, but was satisf d that death did not result from heart disease.
g Surgeon Steveksox does not apjiear to have noticed the support given to the prevalent opinion by the rapid imi)rovemcnt of h:s cases und^-ra
Tegetable regimen.
Med. Hist., Pt. Ill— 87
690 SCUEVY.
proportiou of all the cases of rheumatism occurring in this department may he successfully treated liy fresh vege-
tables, fruits, lime-juice and other remedies adapted to the cure of scurvy.
Subsequent to this period occasional references to scurvy were made by various otiicers:
Ass't Surgeon A. K. Rice, 1st Muss. Car , Beaufurt, S. C, Oct. 2, 1862. — In September we were much troubled
with scorbutus; but with an abundance of fresh vegetables, I am happy to say, the disease is declining. I have
found that painting the sores with tincture of muriate of iron promoted a healthy action.
Ass't Surgeon A. A. Woodhull, U. S. J., 2d and Wlh U.S. Inf., Cam]) near Sheijhcrdstowit Ford, Md., Oct. 9,
1862. — I have observed, not so much iu mj' own command as iu other regiments with which I have been casually con-
nected, the signs of latent scorbutus. That diathesis in a number of cases, especially after long-continued fatigue,
was exhibited veiling itself chiefly under the garb of obstinate chronic rheumatism. I attribute it to dejiressing
influences at work upon systems that had been more or less debilitated by the privations of life on the frontier.
Surgeon W. W. BuowN, 7th N. H., St. Augustine, Fla., May 1, 1863. — AVhen the regiment left Fort Jeffer.son many
of the men were beginning to manifest symptoms of scorbutic disease, such as spongy and bleeding gums and ulcera-
tions of the legs. Slight scratches of the skin became, in some cases, ulcers, showing a cachectic condition, which
no doubt would have assumed aii. alarming aspect had we continued as destitute of fresh vegetables as while at that
post. [The regiment had been stationed at Fort Jeft'erson for three and a half months, and this service had been
preceded by a sea voyage lasting nearly a month.] Ou our arrival at Beaufort, .S. C, corn, watermelons, sweet
potatoes and other garden vegetables soon arrested the progress of the disease, and its removal was completed by the
oranges, lemons and limes which we obtained iu abundance on reaching St. Augustine.
Surgeon Charles T. Southworth, 18(/i Mich., NaahvilU, Term., June 8, 1863. — Notwithstanding the advantages
derived from rest, a clean and desirably situated camp, well-cooked rations, good tents, etc., I daily found the men
becoming less susceptible to the action of remedial agents. With few exceptions all were suftering from scorbutic
disease. Vesicants were surelj- followed by erysipelatous inflammation ; scarifying and cupping had similar conse-
quences, and iu many cases a peculiar erui>tion existed. I immediately substituted fresh beef, soft bread and corn
meal for the salt ration, beans and hard bread; vinegar, pepper and a few vegetables were also used. From that
time to the present but little medicine has been employed. Now we nave less than thirty sick in quarters. No dis-
ease assumes a malignant form, medicine has a happy effect, and the men are in good sjiirits, instead of being torpid
and sluggish. » » * I consider beans the most indigestible of all vegetables, and if this be true they are of course
the most injurious. The bean, let it be cooked as it may, ferments in the stomach before it is digested, and an irri-
tated alimentary canal is the necessary consequence; it also gives to the system a vast amount of carbon, which is
not required in this warm climate, nor in any climate with the thermometer at 90° Fahr. Corn meal, on the contrary,
is generally grateful to the stomach, atfects the liowels sufficiently to maintain them solvent and thereby prevents
the accumulation of irritating substances. It has as much nutriment as the system requires, and it can be jirepared
in many difl'erent ways. I have known 7,000 men march for twelve successive days (in the Mexican army iu 1852)
with no other ration than one quart of parched corn daily, and without five sick in the whole division to which I
belonged. Scurvy is a disease almost unknown in that army; and corn is at all times the principal article of food
and at many times the only one the soldiers can obtain.
Lieut. Col. F. H. Hamiltox, Medicallnspector, U. S. A., June, 1S63: Inspection of troops at yushville and Murfrees-
horo\ Tenn." — The ilh East Tenn. Inf., nearly 800 strong, is composed almost entirely of refugees from Eastern Tennes-
see. Nearly all of these men have been hunted by their enemies and have lived for a time among the mountains
before they were able to get within our lines, subsisting by chance, aud in most cases unable to procure vegetables or
indeed food of any kind except in small 'C[uautities. The regiment has been organizing for several months by com-
panies which were filled up gradually as the men came in. Since their eulistment until recently they have had no
fresh vegetables. « * » They need especially fresh vegetables aud water-proof bl.aukets. * » » Vaccination,
which has been practiced pretty generally among the men, has in most cases made large and unhealthy ulcers, caus-
ing swelling and suppuriition of the axillary glands. Several of the cases were brought to my notice. There have
also been some cases of idiopathic erysipelas. It will be fortunate if, in this condition, the meu are not called into an
engagement; their wounds would generally no doubt prove fatal. ^
The itk East Tenn. Car.; 600 men; refugees. Five companies have been organized since the middle of Decem-
ber, 1862. Up to the first of April last they had received almost no fresh vegetables, — since that date about one ration
of potatoes every two weeks. From April 25 to May 10 more than one hundred men were vaccinated, of whom many
are still Buttering from ugly ulcers and suppuration of the axillary glands. About seven cases of idiopathic erysip-
elas have occurred. These men need vegetable food.
The 1st Middle Tenn. Inf. was organized in April, 1862. The regiment has been in no battle and has not done
"much marching. It was recruited mostly from Nashville and its vicinity. The men have had very few fresh vege-
tables since their entry into the service. A good many cases of scurvy have appeared, and slight wounds have not
healed kindly. The whole regiment was vaccinated four weeks since, and about cue-third became afl'ected with
intractable ulcers, — many not yet healed. In several cases the axillary glands suppurated. There have been several
cases of idiopathic erysipelas lately, with diarrhcea. This regiment is still sutt'ering for want of vegetable food.
The 22d Mich. Inf.; 640 men; organized July 31, 1862. Up to April 1 almost no issues of fresh vegetables were
made; since then about one ration of potatoes every two weeks. Vaccination has left large and obstinate sores iu
a great many cases. These men need more fresh vegetables.
* Dr. Hamilton refers at some length to these exp.rienees in his Ti-eulisc on Military Snnjer/i aud lii/giene, Jsew Yorli, Ibtio, p. 8U e( «'^.
SCURVY. 691
Tlie ISIh Mivli. Inf.: 43(5 iiien. This re-iiment has been iu service for about nine months; (luring the first seven
months it received almost no fresh vegetables, bnt since April 1 five full rations of potatoes per man have been
issued. [Here Inspector H.\.Mii.TOX quotes at length from a report by the surgeon of this regiment, the substance of
which, as relating to scurvy, has already been submitted.]
The lOlh III. Inf.: olii men. This reginu'iit has been in service nearly two years, and until .\|)ril 1 last the
colonel does not recollect that an issue of fresh vegetables was ever made. There has been a great deal of scurvy but
it is now disappearing.
TheSolh III. Inf.: ISO men. The regiment has been in service about nine mouths; it received almost no fresh
vegetables until April, 1863. The men have been scorbutic but are now improving.
ThcSaih III. Inf.: 000 men: in service nine months: first vegetables received April 1, 18G3. Scurvy, which was
present, is disappearing and all diseases are becoming milder.
Thf Virtlli III. Inf.: in service eight months: first issue of fresh vegetables Ajjril, 18(>3. The men have been
scorbutic but are now improving.
The GOIh III. Inf.; 588 men ; mustered into service Keb. 17, 1862. The colonel says he has received for his men
more fresh vegetables from the Sanitary Commission than he ever received from the Commissary, and that he does not
know what he should have done without that aid.
77(f ,")2(f Ohio Inf.: ."i32 men: in service nine nmntlis. Fresh vegetables received in April and May. but very
seldom before that.
The 5th Ki/. Cue.; 397 men. There is a slight tendency to scurvy among the men, and a little intermittent fever.
They are now receiving about one ration of potatoes per week. They were mustered into service eighteen months
since, but until within the last few mouths have had very few fresh vegetables.
T/it 16(A //(. Inf.; 583 men. The reginu-nt is encamped on the north side of the Cumberland river, opposite
Nashville, on rather low sandy soil. The health of the command is excellent. There is not a man in this regiment
but can read and write; one hundred and sixty are members of a temperance society; they have a schoolmaster and
a gymnasium. The colonel assures me that his men all use desiccated vegetables when they can get them, but they
cannot draw them at present. L'ntil lute in April they had drawn but one ration of fresh potatoes iu sixteen months;
since then they have drawn four full rations. They have only 15 men sick iu hospital and (juarters ; not one iu hos-
pital in X.ishvillo, and only about 15 men absent in auy hosiiital, and these are mostly detained as nurses. The good
health of this regiment 1 ascribe to their good habits aud discipline and to their free use of desiccated vegetables.
The troops at Mnifrceahoro'. — The scorbutic taint continues slowly to disappear; but a good many well-marked
eases remain iu the field and general hospitals. Potatoes continue to arrive, and the commissary has been able during
the month to issue three full rations per week, aud lately one full ration per day; but the enlisted men do not gen-
erally get more than one-half or one-third of the rations issued. The last arrivals of potatoes are all sprouted and
many are decayed; it is probable, therefore, th:it very few more will be received in a condition proper to issue. .Suf-
ficient attention is not paid by the buying and shipping commissaries to the ventilation of the barrels. A subsistence
officer at Murfreesboro' informed .Surgeon Pkkin and myself that he had to open the sides of all the barrels after
their arrival. The conseijuence is that when opened they are already decayed or nu>nldy. Those forwarded by the
Sanitary Commission are opened before being shipped, aud they arrive in a much better condition than Government
potatoes. • ' • The sick at this post, with the exception of those affected with small-pox, are now gathered into
the General Field Hospital, where 300 hospital tents have been pi.tched, giving a capacity of 2,075 beds. The hos-
pital garden is already beginning to supply onions, lettuce and other early vegetables iu great abundance. The
Invalid Camp, established also iu teuts inside the fortifications, is a model of neatness and order. To Medical
Director I'khin too much credit cannot be given for his increasing vigilance aud attention to the wants of all
portions of this conuiiand, but especially for what he has accomplished for the troops both iu hospitals and iu the
field in and about Murfreesboro'.
Appended to Dr. Hamilton's Inspection Report are two special reports, one by Sur-
geon R. J. Farquhakson, ith East Ttnn., and the other by Ass't Surgeon N. B. SissoN,
92d Oliio, to illustrate the conditions that developed the scorbutic taint in these commands.
Surgeon FAK(jvnAR.sox says: — The men are almost entirely refugees from East Tennessee, and for some time
previous to their enlistment were subject to many hardships from exposure to the weather, scanty clothing and imper-
fect, meagre and luonotonous diet. Indeed, after having subsisted for i)eriods varying from a few months to a year
upon com bread and bacon, they entered the regiment during the past winter and have since been upon the army
ration for a longer or shorter period. The most immediate aud obvious consequence of this has been the development
of that scourge of armies, scurvy, in some of its protean forms. To account for its production one needs but consider
the composition of the army ration, abundant in carboniferous and nitrogenous principles but almost entirely defi-
cient in auy manifestly antiscorbutic agent. Three items of the ration only partake of this nature, viz: vinegar,
molasses and potatoes: of these the first, to be etlicacions as a preventative of scurvy, would have to be issued in
larger quantity, aud to be cider or wiue vinegar instead of that prepared from spirits by the (Jeriuan method; the
second is in small t|uantity and of doubtful virtue: the third would be of much importance if it were issued regularly >
and also if the men could be induced to eat it iu its most powerful anti-scorbutic state, viz; raw.
Some two or three months before I joined the regiment, in June, many of the men were vaccinated iu Louis-
692 SCURVY.
ville, Ky., by the assistant snigeon. with matter fiiviiislied ^<y authority, and whic'.i in a few eases produced the
ordinary ettects, leaving behind the apjiroved scar; but of its strange and dire etfects in tlie great majority of cases
I can best give an idea by stating the condition of these men when I joined. The scar was, in some instances, broad,
smooth and flat, witliout the slightest a])i)earanee of pits; in others it was raised above the surface and lacerated,
presenting the appearance of a large wart. Abouf the period of cicatrization two seiinehe generally appeared, .some-
times separately, but often in the same patient : a particular erujition, resembling ecthyma, in the innuediate vicinity
of the scar, and an inflammation of the lymphatic glands of the axilla, those of the lower part of the neck just above
the clavicle being in a few instances also afl'ected. These enlargements were, as a rule, cold and indolent, ending by
resolution in most eases, in a few by suppuration and open abscess. In other cases the arm presented two or three
sores, corresponding to the points of vaccination, covered by thick scabs of a dirty-white or yellowish color, with
dark jius oozing from breaks in the crust at the edges or on the surface. In some persons the sores coalesced, form-
ing an ulcer embracing all the points of vaccination. When these scabs came away or were removed by poultices
the well-defined scorbutic ulcer presented itself, with raised edges, smooth or jagged, and the cup-like cavity filled
with dirty sanies when the ulcer is ijhagedenio or extending, or with large flabby granulations when showing a dis-
jiosition to remain stationary or to heal. These ulcers were indolent or irritable in different patients. Ulcers of this
kind resulted not only from vaccination but from slight abrasions of the skin ; examples may be instanced as result-
ing severally from a slight burn of the finger, from a scratch of the forearm by a pin and from a wound of the hand
by a thorn.
Upon a general examination of the men the following conditions were observed: In most cases a complaint of
malaise or debility, which prevailed to such an extent and in so marked a degree as to present to a. casual observer
the appearance of confirmed laziness, the men sitting down even when you were talking to them, and exhibiting,
when api)arently well, the greatest lassitude and indisposition to duty, indeed to exercise of any kind. They were
not anannic, but rather dark and ruddy. Headache was common, as were also dysjieptic symptoms, loss of appetite,
gastralgia, vomiting and eructation of food. The pulse was smaller and more rapid than in health. The tongue in
almost all cases presented the same appearance — broad, flabby, smooth and without the slightest appearance of fur
no matter what might have been the immediate disease for which the jiatient presented himself; in a few cases in
which the stomach was implicated the tip was red and papilhe prominent. The gums were preternaturally red, and
in most instances retracted from the teeth and inclined to ooze blood upon pressure. Though in many cases there
was complaint of pain in the bones, in none have nodes or the flatness and hardness of the muscles of the calf of the
leg, so often described as a peculiarity of marine scurvy, been observed.
Finally, attention should be called to the most prevalent and the most important consequences of the cachexia
present, viz., dysentery. Three causes may be assigned, and probably all had an agency in the production of this
disease: exposure to rain, with imiierfect protection and sleei)ing on the wet ground; the use of hard limestone water
from a well near by, and, lastly, the scorbutic taint. This dysentery is of an acute character, with bloody stools from
the beginning, but no typhoid symptoms; it seems to be more of the nature of bloody diarrhoea, easily checked by a
laxative followed by an opiate, but soon returning, as might be expected, the causes remaining in full force.
Ass't Surgeon N. B. SissoN reports: — The regiment was moved from the mouth of Coal, on the Kanawha river,
in West Virginia, to Carthage, Tenn., by way of Nashville, about the 25th of January, 1863. It consisted of 855
privates and 35 officers, and although it had been in the service a little over five months the health of the men had
been such that we had lost but one man from disease; and yet we had been much exposed, had often bivouacked in
moving from Marietta, Ohio, to the mouth of New Kiver, in West Virginia, and had done much hard work in build-
ing, flooring, roofing, bunking and comi)leting about GO houses for winter barracks which we had occasion to use.
At the time we moved measles and mumps were making their appearance in the regiment. We were transported in
three small steamers, the "Cottage," " Victor No. 2" and "Leslie Coombs," with'one company on the "Odd-Fellow."
These were all old steamers, narrow keels, narrow guards, old models, fueled to run from the mouth of the Kanawha
to Nashville and back to Fort Donelson, and carrying ordnance stores, regimental horses and a full sujijily of tents
and camp and garrison equipage. During the two weeks occupied in moving to Nashville the soldiers were so much
crowded that food could not be well cooked nor clothing washed or changed; personal cleanliness was impracticable,
and the air was impure and poisonous. These insanitary conditions so undermined and debilitated the constitutions
of the soldiers that they could not resist or sustain future severe attacks of disease.
Having reached Nashville, the regiment encamped three miles south of the city, during rainy weatlier, in old
and leaky tents, with cases of measles occurring daily until the number ran up to 8U. These were left in hospital
at Nashville after having remained in camp thirteen days.
After this we were placed on the steamers " Fitzhugh " and " Glenwood '' for transportation to Carthage, Tenn.
On these vessels we were more extremely crowded, for, in addition to the troops, they carried ordnance stores, fuel,
tents, camp and garrison equipage and forty mules. Six days were occupied in reaching Carthage, and the crowding
was such that some of the C(unpauie« were compelled to sleep in the hold of the "Fitzhugh." On February 28 the
regiment disembarked and marched to a camp two miles south of the Cumberland river and the same distance from
Carthage, a sloping piece of ground covered with a large growth of beech trees and apparently a healthy location.
At this time the ration was very defective in variety, there being no potatoes, mixed vegetables, salt, acids,
subacid fruits or fresh meat. The ration in the early part of March consisted of hard bread, poor bacon, beans,
coft'ee and sugar; but in a few days rice, salt, tea and molasses were added. Medical Director F. S.i.i.TER, U. S. Vols.,
was informed of the necessity of having the regiment supjilied at once with fresh meat, potatoes, etc., and was
urgently requested to use his influence in having these articles furnished. From day to day and week to week I
u-ged the necessity of fresh meat and a vegetable and anti-scorbutic diet. 1 stated that the present camp was healthy
SCL'RVY. 693
anil well selettctl. anil that due diligence was given to eutbrce the laws of military hygiene, as far as in my power,
to eradicate the scorbutic and typhoid elements of disease from the command. Thorough cooking, cleanliness, ven-
tilation night and day, striking tents twice a week and oftener when practicable, efficient ditching and draining of
tents and camp and daily disinfecting of kitchen-sinks anil latrines have been recommended and in a great measure
carried into effect. I am informed by the Commissary that during the period Jan. 25, 1863, to June 3 following,
lie issued about twelve rations of fresh beef. Xo fresh or desiccated potatoes, mixed vegetables or subacid fruits
were issued to the counnand until the close of May. As soon as weeds and grass began to grow the men were encour-
aged to procure, cook and use them.
These numerous debilitating causes and elements of disease operating on a regiment unseasoned to the service
has made a large sick-list and mortality report. Typhoid fever was developed by crowded transportation and made
malignant by the long absence of vegetable diet and the presence of scurvy among the soldiers thus deprived for a
long period of proper rations. The scorbutic taint increased the number of diarrha>al cases and made the disease
intractable, .\bout 120 cases of measles occurred ia the regiment, of which 33 died during the disease or from its
effects. There were about 150 cases of typhoid fever, of which 43 died.
This hasty statement is, I believe, correct, and covers most of the causes that have so severely afflicted the regi-
ment and destroyed so many valuable lives. To what extent these causes were avoidable I am not prepared to say;
yet it is a great misfortv"\ue that scurvy should have affected American troops and given a malignant character to
other diseases.
Snrgeoii Ja.mks Huyax, V. S. roh.,02>}>osite Tick^burg, June 27, 1863. — Scorbutic diseases in their several forms,
without much external development, were not uncommon both among our patients and convalescents. The free use
of fresh animal food, togetlier with vegetable acids, acetic, citric and tartaric, was resorted to with advantage in
these cases. Sponginess of the gums would sometimes continue a long time after the other symptoms had disappeared.
Surgeon N. W. LEii;nTOX, 17o(? .V. Y.. Fi(iiiklin,La., Fcb.l2, 1864. — Xumerous cases of boils and cutaneous erup-
tions have improved under anti-scorbutic remedies.
Ass't Surgeon Henry Manfred, 22tlKy., Baton Eougc, La., March 29, 1864. — Several cases of scorbutus occurred
from a deficient supply of vegetables and fresh meat. Every effort was made by the medical officers to remedy these
deficiencies. Recovery under improved diet and appropriate medical treatment was speedily effected.
Surgeon A. W. Gray, 24<A Ind., ilorgama, La., Sept. 17, 1864. — The surgeons of the affected regiments are unani-
mous in the belief that this scorbutic condition is owing to the inhalation for a lengthened period of an atmosjihere
strongly impregnated with salt, and the entire aVisence of fresh meat and vegetables from the diet of the men while
much exposed to the heat of the suu and doing excessive fatigue duty.
Ill July and August, 1864, the line of jM'evaleuce of scorbutic disease among tlie wliite
troops became somewhat iDrorainent, although it failed to reach the level of the outbreak in
the Army of the Potomac. This increase chiefly affected the forces operating against
Atlanta, Ga. These trooj^s constituted only 20 per cent, of the armies then in the field, Imt
they furnished 55 per cent, of the scorbutic cases. Their rate for July amounted to 6.6
cases per thou.sand of strength. Surgeon H. E. Goodmax, U. S. Vols., 2d Division, 20th
Corps, in his report on the condition of his command during the Atlanta campaign, states
that 150 marked cases wore admitted to division hospital during the months of July and
August, and that during the campaign fifty per cent, of the division, which numbered 7,000
men, had been sent to the rear sick, two-thirds of whom were, in his opinion, suffering from
scorbutic aflections.* But, on the other hand, Surgeon W. Grixstead, U. S. Vols., of the
3d Division of the same Corps, states that his command did not suffer much, although there
was an insufficiency of vegetables.^ The number of cases in the Department of Arkansas
was at the same time above the average; and a similar increase in the Department of the
Gulf prolonged the increased prevalence in the army as a whole into September of that year.
Towards the close of the year ending June 30, 1865, a slight increase in the number
of scorbutic cases was mainly due to conditions aflfecting the diet of the troops in the Central
region. Xo special reports relating to these outbreaks are on file.
The annual rates of prevalence, calculated from the cases reported by medical officers
oi white troops during the four years of the war and the year following the war, were:
• S«e his Seporl, p. 307, Part First of this work. t Ibid, page 300.
694 SCURVY.
Per 1,000 of strengtli.
For the year ending June 30, 1862 4.7
For the year ending June 30, 1863 12.6
For the year ending June 30, 1864 — 9.0
For the year ending June 30, 186.5 22. 4
For the year ending June 30, 1866 28. .5
Average annual rate from the statistics of the five years 13.8
But the prevalence of tlie disease among tliese troops will be better appreciated bv a
reference to the diagram facing this page, on which it is represented by the light red line.
The maximum dm'iug the war, 4.0 per 1,000 in July, 1862, was occasioned by the outbreak
in the Army of the Potomac. At that time this army, which constituted only 25 per cent.
of the forces in the field, furnished 68 per cent, of the reported cases. Tlie maximum
monthly rate, shown by its reports, was 10.7 per 1,000 men.
The unexpected, demonstration of a more extensively diffused scorbutic taint among
the white troops in the year following the war than at any time during its progress must
be referred to the conditions attending the disbanding of large masses of men, and especially
to carelessness on the part of officers and men whose thoughts were perhaps engaged on
their own future plans rather than on current affairs. The monthly rate of 5.6 was recorded
towards the end of the SDring of 1866, when the return of vegetation repressed the epidemic
tendencv.*
The same diagram illustrates, by means of the heavy red line, the prevalence of the
disease among the colored troops of the armv, while the orange and green lines submit for
comparison the monthly rates that prevailed in the British and French armies in 1854-56,
during the Crimean campaign.
Scurvy had a much greater prevalence and fatality among the colored than among tlie
white troops. During the three years covered by the statistics 16,217 cases and 338 deaths
were recorded, — equivalent to an annual average rate of 88.8 per thousand of strength, with
2.08 per cent, of the cases terminating fatally. The rates were:
Per 1,000 of strength.
For tlie year ending June 30, 1664 68. 0
For the year ending June 30, 1865 65.1
For the year ending June 30, 1866 -. 141.6
The causes which increased the prevalence among the white troops in the summer of
1864 and in the summer and autumn of 1865 appear to have operated with great intensity
on tlie colored troops. In August of the latter year the monthly rate, 33.9, was higher
than the maximum attained by the disease in the French ranks, 32.9, in February, 1856.
Even in July, 1863, the first month for which returns were received, and when only 12,000
* During the fiscal years 1SGG-G7 and 1867-GS the rate of scurvy continued higher in the U. S. Army than it bad been during the years of the war.
lu the former year the rate was 25.0 — in the batter 21.1— among the white troops per thousand of strength. This was undoubtedly owing to the re-estab-
lishment of those conditions already indicated as having been in existence before the war, — the garrisoning of military posts in localities remote from
vegetable markets and other sources of food supplies. The following, from a report on tlje condition of Fort Stevenson, Dakota, by Ass't Surgeon W.\sit-
INGTOS M.VTTHEWS, U. S. A., published in Circular No. 4, "SVar Department, .Surgeon General's Office, "N^'ashington, D. C, December, 1&70, p. 39G, slmws
the prevalence of scurvy at that post, and, as this is not an isolated instjiuce, the high rate of scurvy in the army during those years is readily under-
stood : — "During the summer of 18G7 the Sioux made three raids on the camp in force and one attack iu a small party. The troops were compelled to
labor very hard after the building of the post was commenced, and as their food was deficient in variety, and being lodged in tents during the severest
weather, tliey suffered greatly in health. Acute dysentery was the first prevailing disease. This reached its height in September, 1SG7, when there vcTe
some fifty-five cases on the report, besides a number of mild attacks not recorded. After this scurvy prevailed. This reacheil its height iu April, 18G8,
<lurin.G: which month there were sixty-one cases reported among the enlisted men alone, besides forty or fifty able to perform light or partial duty, whose
names were not taken upon the sick-list. The scorbutic tjiint was, however, even more widespread than these numbers would seem to indicate. The
men were prone to contract diseases, slow to recover and little able to bear their hard labors and the rigors of the climate ; frost-bites were common.
The troops were not completely housed until Jan. 3, 1SG8." In the mean time the lessons of the war were not forgotten by medical and company
officers and post commanders. Efforts were made to raise such vegetables as were adapted to grow in the soil of the garrisoned localities ; and at posts
where the soil was arid and sterile a larger allowance of flour or bread was authorized to admit of the purchase of articles to vary the diet by means of
the money-value of the uuconsumed portions cf the ration. In September, 18G7, the Subsistence Department was required to keep on hand liberal sup-
plies of canned fruits aud vegetables for sale to officers for their personal use and company messes. The effect of these measures was seen in the year
1SG8-09 in the reduction of the annual rate of scurvy to 4.8 per thousand of strength. Since that time the disease has been practically excluded from
.1
s-
g I
^
■^
IS- ;i,
^-^ ^yy
scuKVY. 695
men had been enrolled, the rate of scurvy was 7.7 per thousand, or nearly double the rate
of the white troops when the epidemic in the Army of the Potomac raised it to its maximum.
From this a cachectic condition must be inferred as having been in existence at the time of
their enlistment; and this seems the more likely when it is considered that most of them
had endured many hardships in those disturbed times before their admission into the service
gave them a position and resources. The tendency of the colored men to succumb under
morbific influences, a reference to which has already been made,''' might be suggested in
explanation of the extension of scorbutic disease among them, and the remarks of Sui'geon
H. W. Brown, 4th Corps D'Afrique, submitted below, might be cited in support of this view;
but this is manifestly inconsistent with the fact that during the last half of the year ending
June 30, 1866, the number of scorbutics in the colored ranks was relatively less than among
the white troops. Tlie very great prevalence at the period mentioned must therefore be
attributed to a deficient dietary operating on the system of a race having perhaps a special
predisposition to be harmfully affected by the deficiency. Unfortunately the only special
reports on this subject, two in number, relate to a- period when the general rate of scurvy
was nearly at its minimum.
Surgeon H. W. Buow.v, Vh Corps D'.tfrique, Port Huihon, La., April 5, 1864.— Tliere is a kiiirt of scorbutic taiut,
a want of vitality, wliitli .stciiis to lieloii^ to tlie ncj;io, and is observed iu him both in and out of tlie military service.
It uianilVst.s itself in soft and swollen ;i,'ums, tumid bellies and oft'cnsive breath. The swelled belly is found mostly
among the contrabands and iu their children: but the negro soldier is constantly applying to the surgeon for alum
for a sore mouth. These appearances are frequent when scurvy cannot be said to exist as a disease. Diet — that is to
say, a proper diet and constantly supplied — would, perhaps, remedy this; as it is, the tendency no doubt has a great
influence upon the cause and termination of inflammatory complaints.
Surgeon Joiix Fisn, 17(/i Corps D'Afrique, Port Hudson, La., Feb. 25, 1864. — Scurvy certainly exists, but is gen-
erally associated with and masked by other diseases. It works insidiously, and while few are attacked with uncom-
plicated scurvy, the constitutions of many are so undermined that they yield with scarcely a struggle to the (juick
onset of more ojrmi foes, such as pneumonia and other acute diseases. My slender experience inclines me to think
that scurvy often jialms itself otf upon the surgeon for chronic rheumatism. At any rate I am treating some cases
of chronic rheuuuitism ('.) with chlorate of potash, iron and Irish potatoes.
Surgeon S. Hemenway, 41st Colored Troops, has placed on record some interesting
particulars concerning the epidemic in the 25th Army Corps,f which, in the months of July,
August and September, 1865, raised the rate of prevalence of scurvy among the colored
troops to 19.7, 33.9 and 18.3 per thousand of strength. These troops had been engaged
during the previous winter in the operations against Richmond and Petersburg, Va. Sup-
plies of fresh vegetables had been exceedingly limited, and it is said that the articles of the
regular ration — the pork, hard bread, beans and rice — had not always been in good condition
when issued. Fatigue duty was arduous and continued, fuel insufficient, and the quarters of
the men dark, damp and cold. Many became despondent and would not exert themselves
to improve their condition. Distinctly marked cases of scurvy had already appeared in
May, 1865, while the corps was at City Point, Va., and many medical officers, in reviewing
their practice at this time by the light of their subsequent experience in Texas, concluded
that cases which they had reported as rheumatism had been in fact manifestations of scor-
XhoK- which the anny surgeon has been called upon to treat. Exceptional cases have occurred iu instances of individual privation, sometimes the result
of an indi8|H»ition on the part of the man to m.-ike usi' of the available vegetable supplies. The extension of railroad transportation and the niadriai
increase uf the cannol-goods trade have co'jtributed largcl.v to remove the taint of scurvy from tbc military service of the United States. The intro-
daction of sti.-am into the navy, by shortening the voyage from port to port, the use of fresh provisions while in port and the issue of a ration of six
ounces of cannc<l vegetables twice a week when fresh vegetables are not available, have banished scurvy from the navy under the ordinary conditions
of senice. The disease was observed by Dr. Gtliox in 1SC8 on the Idulio during a voyage which lasted two hundred days. Few of the men sought excuse
from duty, but their general condition was below par ; they performed their duties listlessly; they last strength and appetite ; their bodies were covered
with marked discolonitions ; their gums were tender and bled easily, causing those who chewed to attribute it to the tobacco, for which they lost taste;
ecratches. wounds and bruises healed slowly or not at all : and men, often of the fment physique, succumbed readily to trifling causes of disease. (See
PnuiKal Sit^jexOfmn on Xaral Uygimf, by ALBEBT L. GillON, Surgeon, U. S. Navy, Washington, D. C, 1871, p. T-1.)
* Snjmi, (jage 14. - f CJicojro aferfica* Bnimtner, Vol. VII, 18CG, page 582 cOej.
696 SCURVY.
Ijutic disease. During the voyage from City Point, Va., to Brazos St. lago, Texas, scurvy
made rapid progress. As soon as the troops ettected a handing at the latter place the worst
cases were sent to the post hospital, at which, within a week, five hundred cases had accu-
mulated. Two or three hundred, for whom no hospital accommodation could be procured,
were sent to New Orleans, La., but this relief was only temporary, for within three days the
patients at the post hospital again largely exceeded the accommodations. About sixty per
cent, of the corps suffered from the disease. Most of the cases had to be treated in quarters.
As soon, however, as the troops moved into the interior and fresh vegetables, even in limited
quantities, were obtained, the disease began to decline.
A del)ilitatecl state of the system ivitli emaciation cbaracterized the disease, jiarticularly iu cases accompanied
b.y dianliceal or dysenteric discharges. Extensive nlcerations of the gnms with frequent bleeding were universally
present. The swollen gnms projected in the form of bulbous enlargements of & dark-red or purplish and often of a
perfectly black color. These sometimes completely hid the lateral view of the molar, bicuspid and canine teeth.
Extensive ecchymoses ou the extremities and other portions of the body and a dropsical condition of the feet and legs
were attended with severe pains in the joints and bones of the lower extremities. Vesications and foul ulcerations
were also freiiuently jiresent. The muscles of the calf and thigh were often indurated, and the joints, particularly
the knee and ankle, anchylosed. The patients were usually much dejected, and death ensued after muscular exertion,
from hemorrhage during the process of digestion and sometimes from pulmonary redema. Dr. Hemexway used with
some degree of satisfaction the juice of the Afjare Americana ; but ho did not feel warranted in affirming that the good
results depended entirely upon this remedy, for most of the scorbutic patients were supplied at the same time with
small allowances of raw potatoes and onions sliced in vinegar, and pickled cabbage — and when thus supplied improve-
ment was always more rapidly eft'ected.
Tlie greater prevalence of scurvy among tlie soldiers of the Confederate armies and the
prisoners of war on both sides than among tlie United States troops in active service has
already been indicated. '"^
Tlie CLINICAL KECOEDS of scurvy are exceedingly meagre. The case-books of the gen-
eral hospitals contain notes of only seventeen cases in which the disease occurred in United
States soldiers while on duty with their commands; 1-11 are from the records of the hos-
pital at Quincy, 111.:
Case 1. — Private John Geisbiihler, Co. H, 82d 111.; ago 38: was admitted July 0, 1864, from Jefferson Barracks,
JIo., having sufiered more or less from scurvy for five months. He was emaciated and had purple spots on the right
leg. Gave nitric acid, sour krout, fresh vegetables and full diet. He improved for the first few weeks of his stay,
but after this there was only a very gradual change iu the swollen limb. C)n October 1 it was still considerably
enlarged and the patient had lost some teeth. He was discharged from the service Feb. 8, lS6.j.
Case 2. — Private Peter Reynolds, Co. H, 8-lth 111.; age 27 : was admitted July 2T, 1864, from Jefferson Barracks,
Mo., where he had been treated for a month for scurvy. He was feeble and his legs were swollen and covered with
livid spots. Gave cinchona, sulphate of iron and anti-scorbutic diet. Improvement was slowlj- effected. He was
discharged March 29, 1865.
Case 3. — Private Dennis Crowley, Co. I, 96th 111.: age 21; admitted July 27, 1804, from Jefferson Barracks,
Mo., having been somewhat troubled with scurvy for two months. His left foot and leg were swollen, discolored
and ulcerated. He was treated with special diet and vegetable acids, but improvement was not rapid. In November
there was still some swelling of the leg, although the patient was able to do duty not requiring activity or strength.
Ho suffered from palpitation in going up stairs or iu making any special exertion. On Feb. 13, 1865, he was trans-
ferred to the Veteran Eeserve Corps.
C.vSE 4. — Private James Blair, Co. A, 34th 111.; age 2S; was admitted Aug. 17, 1864, from Jefferson Barracks,
Mo., with chronic rheumatism. He had pain in all the large joints ; the gums were almost totally destroyed and the
roots of the teeth carious. Colchicum was given with a mouth-wash of chlorate of potash. In about three mouths,
during half of which period he was on furlough, the rheumatic paius were relieved, but, as he was unable to eat solid
food, he was discharged from the service Jan. 26, 1865.
Case 5. — Corp'l Thomas Lenuard, Co. I, 39th Iowa; age 49; was admitted Sept. 25, 1863, with scurvy. Body
emaciated; skin livid; purplish spots on legs; gums spongy and bleeding; feet and ankles somewhat (edematous;
pulse and appetite normal. Gave lemonade and fresh vegetables. October 20: Constant pain iu large joints.
November 20: Gave guaiacum and iodide of potassium. Scurvy better; rheumatism better. December 25: Skin free
from discoloration; paius in hip aud knee joints. Jan. 10, 1864: Scorbutic symptoms returning; gums swollen and
-inability to eat animal food. 25: Iodide of potassium discontinued.
'See siqim, pp. 37, 40, 40, 61, 52, 54, 55, 5S, 00, 01, 04 iiml 07 i( seq.
SCURVY. 697
Have uitiic acid three times a day. Febniaiy 10: Xo iiinnoveiueut; patient cannot walk without onitches. Dis-
charged from service ou the 25th.
C.\SE 6. — Sorg't Andrew Allen, Co. H, 31st Wis.; age 31: was admitted Xov. 25, liSfrl, havini; lieen sick since
the 1st with scnr\ y and diarrluea. He was weak and emacrated and had pains in his legs, which were rougli and
covered with reddish spots. He was treated with citric acid, vegetable diet and, subsequently, a furlough, and was
returned to duty Feb. (i, 18t>5.
C.vSE ".—Private Henry P. Brush, Co. H, 30th Wis.; age 39; was admitted Nov. 25, 1861, with scurvy, having
had chills and fever about the 1st, followed in a few days by fever and paiu in both legs, the skin of which was dry
anil showed some yellow spots. The patient was weak and emaciated ; his gums spongy; appetite moderate. Tonics,
vegetable diet and a furlough enabled him to be returned to duty Feb. 6, 1865.
C.\8E 8.— Private Robert R. Davidson, Co. H, 30th Wis.; age 45; was admitted Xov. 25, 18l!t, with pain in the
lens and swollen gums, loss of appetite and debilitating night-sweats. Under the use of tonics and a plentiful vege-
table diet he gradually gained strength and was returned to duty Feb. 26, 1865.
C.VSE !'.— Private Chester Tuttle, Co. H, 30th Wis.; age 45; was admitted Xov. 25, 1864, with scurvy. He had
been attacked with diarrhica, soreness of the gums and pains in the legs about three mouths before admission. His
gums were spongy and the surface of his legs hot, ilry and ]iuri)lish. He was returned to duty April 1, after a course
of tonics, vegetable acids and appropriate diet.
C.\SE 10.— Private Nelson Peterson, Co. D, 30th Wis.; age 38; was admitted Nov. 26, 1804, with scurvy. II.-
had sutlered occasionally from fever and diarrha-a for six months prior to admission. His legs were painful and
spotted and his gums red and spongy. Vegetable acids and a suTiable diet were prescribed. Subsequently ho was
fnrlouglied and had an attack of pueunmnia while at home. On April 3 he was transferred to Madison, Wis.
C.vSE 11— Corp'I ,Iacob .Stotts, Co. K, 1st Mo. Eng'rs; age 39; admitted Dec. 8, 18f>l. His legs were painful,
tender and covered with purplish spots; his gums tender and swollen. He was emaciated and weak and had a
diarrhtva of three or four stools daily. Vegetable acids, chlorate of potassa, turpentine emulsion and pills of nitrate
of silver and opium were prescribed; sulphate of copper and opium were subsequently employed, but improvement
was slow and the patient was discharged April 4, 186.5.
C.S.SE 12. — Private Lewis Harry, Co. I, 147th Pa.; age 24; was admitted May 19, 1804, with scurvy. His mouth
was much inllamed. Jellies, potato salad and lemonade were jirescribed; also a teaspoonful every three liour.s of a
solution containing forty grains of chlorate of potash in an ounce of water. A gargle of chlorate of jiotash, tincture
of myrrh and water was used at lirst, and afterwards a lotion containing six grains of nitrate of silver in an ounce of
water. He was returned to duty July 10. — South Street Hospital, PhiUuMpliia, Pa.
Case 13. — Private Emmanuel Brooks, Co. A, 122d Pa., was admitted Oct. 5, 1862, having been sick for a month
in camp with scurvy. He had paiu in his back, which was habituallj- bent forward; the joints of his extremities
were painful but not tender, red nor swollen; the muscles, especially of the lower limbs, were tender, painful and
air(^cted with frequent cramps. He had no fever; his appetite was good and bowels regular. He was discharged
Feb. 12, 1863, on account of disease of the spine. — Ladies' Home Hospital, Xew I'ork. '
C.\SE 14.— Private Edwin R. Jeflries, Co. A, 122d Pa., was admitted Oct. 5, 1862. He had enlisted August 11
and served with the Army of the I'otomac, but after the latter part of this month he was taken with a fever which
lasted about eight dajs. Following this he had i)ain in the back and the extremities, particularly on both sides of
the spinous processes and in the muscles of the lower extremities. His appetite was good, liowcls reg<ilar and he had
no fever. His body was habitually bent forward. Sulphate of quinine in small doses and afterwards citrate of iron
and (piinia were administered, with dry cups to the back and stimulating linaments to the limbs. He was discharged
from service Feb. 12, 1863, because of disease of the sx)ine. — Ladies' Home Hospital, New York.
Case 15. — Sergeant David V. Whurry, Co. (J, 23d Ohio, had been confined to bed with fever for a week about
the middle of September, 1862, in Washington, D. C, prior to which he bad suftered from pain in the back, but had
been able to do duty. Subsecjuently hehad four intermittent paroxysms of the quartan type. He was admitted October
5 with nuirked tenderness over the dorsal and lumbar vertebra- and tenderness of the muscles of the extremities, but
with no cramps, swelling or tenderness of the joints and no fever; his appetite and digestion were good. He
improved somewhat under the treatment pursued in the two cases just recorded, and was discharged from service
March 21, 1863, because of anterior spinal curvature. — Ladies' Some Hospital, 2few YorJc.*
Case 16. — Corporal \Villiam A. Morris, Co. H, 29th Mo.; age 32; had a severe attack of scurvy in August, 1804,
by which he lost seventeen teeth. On admission from Baltimore, Md., Feb. 23, 1865, he was convalescent. On March
13 he was reported cured; but on Ajuil 1 he was taken with small-pox and was left much debilitated ami ana-mic.
He was mustered out of service June 14. — Satlerlce Hospital, Philadelphia, Pa.
Case 17.— Private.Elihu R. Gillet, Co. D, 37th Wis.; age 38; was admitted July 24, 1864, with debility from
miasmatic disease and scurvy. He had a cachectic appearance; i)ulse 90 and weak; skiu somewhat yellow ; tongue
furred and moist and bowels constipated. Ou the right side of his mouth was a small hard tumor, which the jiatient
said had existed there for over six mouths; his gums were livid and swollen. He was treated with rhubarb and
magnesia, tincture of iron, stimulants and fresh vegetables. In a day or two the tumor ulcerated and by sloughing
* The siDgnlar coincidence of three cases treated in tho same hospital at the same time, two of them from the same company of the same regiment,
and all presenting the »ame symptoms, which wt-re generally negative in character, suggests that probably the disease in these instances was nostalgia
manifc^tini; it*«-irarlivvly in a dcsir,- fur discharge.
Mei>. Hist., Pt. Ill— 88
69S scrBVT.
formea a sore an inch in diameter. The application of bromine cansed the surface of the nicer to assume a healthier
appearance, but the general condition of the patient did not improve: he became weak, restless and ultimately
delirious. He died August 10. In a note appended to this case Ass't Surgeon Harrisox Allex, U. S. A., says: — 1
believe this to have been a scorbutic ulcer subsequently complicated by phagedenic sloughing. Bromine did not
have the same beneticial effect observed in its application upon the phagedena of wounds. The fanees and pharynx
■were free from ulceration. The body decomposed so rapidly that no examination was made after death. — Fairfax
SemiKtirii Hospital, Va.
.\ case-books present in addition ten cases in which the patients were either rebel
prisonere or Union soldiers who had contracted the disease while in the hands of the enemy:
Case 18. — Private John S. Farthing. Co. C, 37th X. C. was admitted Jnly 21. 1S63, with scurvy. He was
weak : his gums swollen, spongy and bleeding : teeth denuded : complexion sallow : pulse slow and feeble : bowels
loose. Under the use of two lemons daily, a leaspoonfhl of lemon-juice and ten grains of iodide of potassium three
times a day and pills of opium and camphor, he was much improved by the end of two weeks, and on August 8 was
transferred to the Provost Marshars bureau. — Wmt WalHut Street Hof:pitaI. Harri^burg. Pa.
Cask 19. — ^During the invasion of Pennsylvania in 1863 private Joseph King. Co. C, 11th X. C, was in the
Winder hospital, Richmond, under treatment for scorbutic diarrhcea. When partially recovered he was ordered
with four hundred convalescents to join his regiment at Hagerstown, Md. He was transported by raU to Staunton,
Va., marched thence to Hagerstown. and was placed in hospital at Chambersburg. where he was captured. On
August 4, when he reached this hospital, he was much debilitated, having fever every evening and an exhausting
diarrhcea. The fever was controlled by tifteen grains of quinine every morning for three days and brandy, morphine,
camphor and veratrum viride at intervals. He convalesced rapiilly under tonics, anti-scorbutics and a suitable diet,
and was returned to the Provost Marshal's care Octol>er 28. — West WaJitut Street Hospital, Harrisburg, Pa.
Case 20. — Private John Haggerty, Co. A. lV3d X. T.: age 40: contracted scurvy while in a rebel prison, and
several months afterwards. June 17, 1S65, was admitted into hospital. His joints were stiff and his gums spongy
and bleeding. He was treated with vegetable diet and strong lemonade. He was discharged from service Septem-
ber 12. — SatterUe Hospital, Philadelphia, Pa.
Case 21. — Private Xathan Eaynor, Co. C, Idoth X. Y.: age 33: was admitted June 17, 1865, having suffered
more or less from scurvy since April. 1864. when he was a prisoner in Texas. His gums were swollen and painful
and he had a scorbutic ulcer on the left leg, but his health was otherwise good. He was treated with lemonade. On
the 26th he was transferred to McDougaU hospital in Xew York City. — Satterke Hospital, Philadelphia, Pa.
Case 22. — Private J. J. Snyder, Co. I, 97th X. Y.: age 37: was struck on the back with a musket at the battle
of the Bapidan, Oct. 15, 1863. This paralyzed his lower limbs and caused him to be taken prisoner. He was carried
to Richmond, where, in the course of a week, he began to be affected with incontinence of urine, hsematuria and
pain in the back and left side. At a later date he contracted scurvy. On AprU IS, 18t54, he was ailmitted to Jarvis
hospital, Baltimore, — diagnosis, quinsy: fhrloughed June 15: returned July 9: transferred to hospital, Annapolis,
ild.. on the 12th. — diagnosis, bronchitis: sent to Camp Parole hospital, near Alexandria, on the 18th. — diagnosis,
gangrenous ulcer: returned to Jarvis hospital October 12: transferred to this hospital on the 22d; furlonghed Xovem-
ber 4. returned on the 24th : transferred to Invalid Corps because of debility fit>m scurvy May 6. 18<». On Xovember
24 he was free from all trace of scurvy and able to dispense with the use of crutches. — Chester Hospital. Pa.
Cask 23. — Private Jacob Strickler. Co. H, 25th Va. (rebel), was admitted Aug. 10, 1863. On the 18lh he was
in a low condition with feeble pulse, blood oozing from the gums and a diarrhtta of twenty to thirty stools daUy.
He was treated with aromatic sulphnric acid and raw onions. At the end of two weeks the diarrhoea was checked
and the patient transferred to Point Lookout, Md., where he arrived on October 4, — diagnosis, chronic diarrhoea.
He was exchanged March 17. 1864. — Chester Hospital, Pa.
Case 24.— Private Isaac Rosa. Co. G, 89th HI.: age 35: was captured at Chickaraauga, Ga., Sept. 20, 1863,
confined two months at Richmond and five months at Danville, where he contracted scurvy. On admission to hos-
pital, June 7, 1864. he had oedema of the left foot, leg and thigh : his gums bled easily and his teeth were quite loose.
Small doses of citric acid and quinine were given frequently, with a free supply of grated raw potatoes, and afterwards
two ounces of lime-juice three times a day. He was improving when, on July 12. he was transferred to hospital at
Annapolis, Md. — AnKapolis Junction Hospital, Md.
Case 25. — Sergeant Charles Bramfels, Co. F, 16th 111. Cav.: age St': was captured at JonesviUe, Va.. Jan. 3.
1864, and carried to Belle Isle, Va. He was paroled May 2 and admitted to hospital June 7. He had been under
treatment in Richmond for ten weeks on account of scorbutic ulcers which yet remained unhealed. They persisted
notwithstanding the use of various local applications— stimulating, astringent and soothing. He was furlonghed
August 8, the ulcers still unhealed. He returned September 3 and was transferred to Quincy. 111., on the 26th.—
AHHapolis Junction Hospital, Md.
Case 26.— Private O. C. Babcoek. Co. E, 18th U. S. Inf.: age 35: was captured at Chickamanga Sept. 20, 1863,
and eonfiaed for six weeks at Richmond and for six months at Danville, where he contracted scurvy through star-
vation and exposure. It was preceded by diarrhcea. pleurisy and rheumatism. Scorbutic ulcers appeared upon the
limbs in many places. He was paroled May 2, 1864, and when admitted to hospital. June 7. was so weak as to be
unable to walk. Diarrhcea was easily controlled and his improvement was rapid. On the 28th he was employed on
light duty as a ntuse and was returned to duty July 19. — Annapolis Junction Hospital. Md.
SCURVY. 699
Case 27. — Prirate Joshna Helton. Co. D. 54ih Va.. admitted Xov. 26, 1864: returned to barracks Felj. 25, 1865.
lie stated on admission ibat lie bad Ueeu a prisoner of war at this place for six mouths, during which he never had
vegetables. Two weeks before admission he experienced acute pain on moving the right leg. which speedily Ijccanic
swollen from the knee to the heel and spotted with dark-purjjle patches: the thigh also was slightly swollen and
discolored on its inner aspect: the gums were somewhat tender and coated with accumulated tartar. The respira-
tory and digestive organs appeared to be sound. — Sock Inland Honpital, III.
Of 12.000 medical descriptive lists on file in this office only 156 refer to scorbutic
attacks. One hundred and sixteen of these were forwarded from two hospitals in Marv-
land, — 58 each from the general hospital at Annapolis and the Hammond hospital at Point
Lookout. The patients treated in the former were Union soldiers transferred from rebel
prisons by parole or exchange; 19 of these died and 39 recovered. Those treated in the
latter establishment were mostly Confederate soldiers from the neighboring prison camp; of
these 21 died and 37 recovered. The followinc: selections are submitf- ■! '^■^ illu-stratins fullv
the general character of the information furnished by these reports:
Case 28. — Private Thomas W. Travis, Co. H, 44th 111.: age 21: was admitted Dec. 17, 1864, with scurvy, direct
from Savannah. Ga. He improved rapidly on a vegetable diet, and in the course of a week was placed upon light
duty as a nurse. He was returned to duty Jan. 17, 1865.
Case 29. — Private Andrew Brown, Co. B, 77th X. Y.: age 20: was admitted Dec. 4, 1864, with scurvy contracted
while a prisoner at Andersonville. He recovered under projier diet and was furloughed Jan. 20, 186.5.
Case 30. — Corporal Ransom Dodge, Co. K, 11th N". Y. Cav.: age 30: was admitted .\pril 9, 1864, with scurvy
contracted while in prison at Belle Isle, Va.. after his capture at Edwards Ferry, Aug 28, 1863. He was much debil'
itated. his respiration labored ou account of peritoneal efiusion and the action of the heart also somewhat affected.
Id addition he had a persistent and weakening relaxation of the bowels, which were generally moved three times
daily. Citric acid, lemons, lime-juice and onions were freely used in his treatment, with full diet and porter. For
a few days bitartrate of potash was tried, but its action was considere<l too debilitating. He was improving and in
a fair way to recovery when, on August 6, he was transferred to Xew York city.
C.vSE 31 — Private John Fisher, Co. A, 74th Pa.: age 29: was admitted Nov. 18, 1863. His skin was dry and
rough, feet oedematous, legs painful, knee-joints stiff, gums tender, appetite lost. Ijowels relaxed and mind depressed.
He was sponged with vinegar and water and directed to take thirty drops of tincture of iron three times a day. with
milk-punch, lemonade for a drink and special diet. Later he was directed to have pickles, and camphor and opium
was called for on account of the diarrhceal tendency, but withal bis condition improved and ou Jan. 31. 1864. he
was considered convalescent. Jleanwhile. however, he l>egan to complain of rheumatic pains in his legs and feet,
which were still somewhat oedematous. Ten grains of iodide of potassium were given three times daily, and a lini-
ment containing chloroform and tincture of capsicum was employed. He was returned to duty February 25.
C.vSE 32. — ^Private Anderson Green, Co. H, 4th Ky. Slounted Inf.. a paroled prisoner: age 20: was admitted
Dec. 17, 1861, with scurvy and chronic diarrhoea. His lower limbs were dropsical and he was so weak as to l>e unablo
to rise from l>ed: he had a frefjuent diarrbcea, light-colored and frothy. He was treated with astringents, generous
diet and brandy, bat the diarrbtea persisted and on Jan. 19, 1865, the stools were passed involuntarily. He died on
the 21st.
Case 33.— Corporal WUliam Reed. Co. K, 162d X. Y.: age 31: was admitted Oct. 29, 1863, from Belle Isle. Va.,
where he had I^een imprisoned from the time of his capture at Springfield Landing, July 2, 1863. He was much ema-
ciated and weakened by diarrhora and had several large ulcers on difierent parts of the body: his pulse was feeble
and frequent and he had little or no appetite. Charcoal and yeast poultices were applied to the ulcers and stimulants
and tonics were administered, with a free vegetable diet, but the patient gradually failed, dying November 22.
Case 34. — Private Edward Dwyer, Co. F, 104th X. Y'.; age 35: was admitted March 11. 1865, with scurvy and
general debility. Chlorinated washes were prescribed for the mouth and throat: tonics and stimulants were adiuin-
istered with an appropriate diet: but the patient was in a hopeless condition. He died on the 17th.
Case 35. — Private M. W. White. Co. I, 25th Ul.. a paroled prisoner from Andersonville: age 24: was admitted
Dec. 4. 1864, much emaciated and weak from scnr^-y and a diarrhtea of twelve or fifteen passages daily. Astringents
and antiscorbutics were freely used, but for a week the patient's condition remained unchanged except for the devel-
opment of a chill and fever every afternoon. Quinine and stimulants were administered. On the 11th the alvine
discharges became increased in frequency, mixed with blood and associated with great thirst, increasing prostration
and much abdominal pain. The stools were passed involuntarily on the 13th, and death took place next day.
C.4SE 36. — Private A. J. Green. Co. I. 51st Ga.: age 28: was admitted Oct. 26, 1863. from the hospital at the pris-
oners' camp, complaining of weakness and soreness in the legs from scurA"y, although otherwise in fair condition. He
improved rapidly on tincttire of iron and full diet. On November 5 he was considered cured. He was transferred for
eichaii:;e >larch 17, 1864.
Case 37.— Private J. M. Gallava, Co. A, 12th S. C: age 22: was admitted Oct, 4, 1863, as a scorbutic who had
suffered more or less with diarrhcea since May. On October 20 he was reported much improved, havibg l^eeu taking
diluted sulpbtuic acid and special diet. He was returned to prisoners' camp Jan. 12, 1864.
700 SCURVY.
Case 38. — Private A. Robiuson, Co. C, 30th N. C; age 22; was admitted without a record of his previous his-
tory, Nov. 8, 1868. The jiosterior and inner aspect of the right thigli and tlie calf of the right leg were extensively
discolored witli purple spots. Tincture of iodine was applied externally and chlorate of potash prescribed for internal
use; full diet was ordered. On the 20th the spots had disappeared and the patient was nearly well, but there remained
some drojisical swelling of the foot and leg for which a mixture _pf squill, buchu and sweet spirit of nitre was admin-
istered. On March 3, 1864, he was sent to City Point for exchange.
Case 39. — Private Jacob Jenkins, Co. A, 11th N. C; age 20; was admitted Oct. 27, 1863, with an acute bron-
chitic attack, but he had been scorbutic for several mouths. He was treated with tartar emetic and opium, blue-pill
and Dover's powder, with blisters to the chest, whiskey, citrate of iron and (|uinine and special diet. By December
16 the chest aft'ectiou was entirely relieved, but there was much debility and occasional diarrluea from the scorbutic
condition. Xo decided imjirovement in this respect was manifested up to the time of his exchange, March 17, 1861.
CvSE -10.— Private D. F. Eddleman, Co. H, 52d N. C; age 33; was admitted Oct. 27, 1863, having beenaftected
for five months with scurvy and frequent attacks of diarrho?a. Under treatment and extra diet the diarrhcea was
controlled, but the gums and teeth remained in an unhealthy condition, the former swollen and disposed to bleed,
the latter decayed and loose in their sockets; one loose tooth had to be removed. He continued, however, to improve
slowly and on Jan. 12, 1864, was returned to camp.
C.\SE 41. — Private Forney Avery, Co. E, 4th N. C; age 38; was admitted Xov. 6, 1863, w-ith chronic diarrhcva.
His gums were of a deep dark -red color and spongy, but there were no scorbutic ecchymoses or ulcerations. He was
treated with vegetable diet, lemonade, potato salad and astringents. The diarrhoea persisted, causing seven or eight
stools daily, until death took place on the 21st.
Case 42. — Private W. H. Crickman, Co. C, 1st N. C; age 28; was admitted Oct. 22, 1863, with scurvy. He was
l)laced on tincture of iron and apijropriate diet, and was showing signs of improvement when, ou November 3, an
active and exhausting diarrhoea supervened. This was somewhat controlled by the 8th, but the patient was very
weak and had no appetite. Pneumonic symptoms were noted ou the 20th, and death took place ou the 23d.
C.\SE 43. — Private D. Dukes, Co. H, 61st Va.; age 22; was admitted Nov. 10, 1863, with a diarrhcea of four
months' continuance and scurvy manifested in his swollen and tender gums. He was weak and much emaciated but
had no cutaneous discolorations. Special diet was prescribed, with sulphate of iron, opium and alcoholic stimulants.
The diarrhoea became aggravated and the patient proportionately debilitated ; ten to fifteen passages from the bowels
were recorded daily, until he died ou the 21st.
C.\SE 44. — Private Thomas Logan, Co. T, 117th N. Y.; age 24; was admitted March 13, 186.5, with typhoid fever,
and died on the 24th. He had been confined in Southern prisons and fed on corn meal and sorghum molasses. He
■was very scorbutic and had sutt'ereil from chronic dysentery before the suiierventiou of the fever. Turpentine enuU-
sion, sweet spirit of nitre, morphia occasionally and persulphate of iron were prescribed. Great care was exercised
in giving suitable nourishment and in having perfect ventilation of the tent-ward in which he was treated. Act.
.\ss't Surgeon John Fee remarks on this case as follows: It was a noticeable fact that all the returned prisoners who
were scorbutic suffered from diarrhcea, and that the grave condition of the bowels was iudicatetl by the odor and
color of the stools and the presence of blood and mucus in them. Typhoid fever supervening in these cases was sure
soon to terminate fatally.
Po-ST-MOETEM OBSERVATIONS. — Few recoi'cls of post-mortem examinations in cases of
scurvy have been preserved. Scorbutic symptoms were present in twenty-one of the cases
alrea\ly submitted as illustrations of the diarrhceal diseases that prevailed among the troops;
but twelve of these, 229, 232, 234, 235, 626, 638, 640, 641, 657, 663, 667 and 681, occurred
in the persons of rebel prisoners treated in the hospitals at Point Lookout, Md., and Rock
Island, 111., and in three, 222, 223 and 251, the patients were Union soldiers recently
returned from Southern pirisons; — thus in onlv six of these cases. 111, 144, 158, 166, 187
and 798, does the diseased condition appear to have originated in men while on active service
with their commands. Two of the cases illustrating the post-mojiem appearances of the con-
tinued-fever cases were associated with scurvv, and in both of these the patients had suffered
imprisonment in the South. In addition to these the following have been gathered from
the case-books and medical descriptive lists:
Case 45. — Private Christopher Frey, 13th N. Y. Bat'y, was admitted Aug. 11, 1864, and died on the same day.
He had much aching in the bones and an exhausting diarrhiea, the stools occurring every twenty minutes. His gums
were swollen and bled on the slightest pressure, and there were large dark-colored spots on Jiis lower extremities;
his pulse was weak but not frequent; breathing quick and somewhat difflcult; tongue dry in the centre hut moist
at the edges. Post-mortem examination: Congestion of the entire body. — Second Division Hosj)ital, Twentieth Corps.
Case 46.— Private Andrew Garrett, Co. A, 16th Colored Troops; age 38; was admitted Aug. 21, 1864, from the
field with scurvv and general debiltv. He died on the 27th. rost-mortem examination: Lungs much congested;
SCURVY. 701
left lung adherent luiiversally: iitnicanlinm containing eif;lit ounces of serum; heart, weighing eijjhteeu ounces, pale
and flabby: abdominal viscera normal. — ChaltaHooijti Field Hospital, Tenii.
C.\SK 47. — Private Lsaiah Stoner. Co. H, Kith Colored Troops: age 21: was admitted Aug. 23. ISfil, from the
field with scurvy. Died September 14. rosl-mortim examination: There were pleuritic adhesions on both .sides:
the lower lobe of the right lung was gangrenous and the other lobes congested: the lefl lung w;is normal. The
remaining viscera were healthy. — Chiiltiiiwoija I'ivhl IlospituI, Tcmi.
C.\-';e 48. — Private C. II. .Smith, Co. C. 4th X. H.: age 31: was admitted .''ept. 28. 18(53, with scurvy. lie was
emaciated, greatly debilitated and had tumors and ulcers on his legs aud hips: his tongue was moist and slightly
coated: bowels regular. Tincture of iron and special diet were prescribed. On November 1 the following note was
made: The condition of the blood of this patient is improving since his ulcers have healed, but there is evidently
disease of the lungs: he has a dry teasing cough, flatness, puerile respiration and humid rales. On the 26th the
lung trouble was reported aggravated, the legs a-deniatous. the patient affected with diarrhiea and extrenu>ly jiros-
trated. He died on the 29th. Post-inorlem examination: Extensive tuberculous disease of both lungs in all stages,
bard, soft and excavated. — Act. Ans't Siiri/eon Charles 1\ Ileber, General BoHiiita} So. 14, Beaufort, S. C.
C.vSE 411. — Private Enoch Green. Co. I, 27th Miss., was admitted Xov. 1. 1864, with scurvy, ami died .laii. L'7
18G,">. r<igl-mt)rlem examination: Hoth lungs were adherent aiul filled with tubercle. The liver and spleen were
healthy but somewhat enlarged. The bowels were slightly congested and the mesenteric glands enlarged. No other
abnormal ajipearauce was observed. — Ael. Ass't Surgeon M. H. Russell, Soek Island, Til.
Case 50. — Private Philo B. Weaver. Co. K, 67th Ohio; age 20; was admitted from Richmond, Va., April 18,
18W, with scurvy and dropsy, and died May 7. rost-mortem examination: The right lung was congested; the left
tuberculous. The heart was small and flabby. The peritoneum contained three quarts of thin i)us and the intes-
tines were extensively cougested. The spleen was soft : the liver hard : the kidneys natural. — Act. Ass't Suryeon B.
B. Miles, Jarris IloxpHal, Baltimore, Md.
C.\SE 51. — Private M. H. Kindred, Co. E, 1st East Tenn.: age 28: was admitted from Richmond. \"a.. .\pril 18,
1864, with a contusion of the left lung, aud died May 11 of purpura hemorrhagica. Post-mortem examination: The
right pleural cavity contained a quart of bloody eil'usion and the lung was intensely cougested and adherent to the
parietes by shreds of soft lymph. The pericardium contained effusion; the heart was flabby. The liver ami kidneys
were somewhat enlarged and cougested: the si)leen intensely congested and hard: the mucous coat of the stoumch
was soft, thickened and ecchymosed: that of the intestine spotted with dark-colored extravasations. The blood was
thin, dark-lookiug and did not coagulate. — Act. Ass't Surgeon B. B. Miles, Jarria Hospital, Baltimore, Md.
C'.vSE 52. — Private Xoah Davis, Co. C, 8th Colored Troops, was admitted Oct. 20, 1865. He became scorbutic
two weeks after landing at Brazos, but accompanied his regiment to Ringgold Barracks, where he went into hospital
and took pulque for two weeks, but he did not get well. His gums were red and bled occasionally; his legs became
swollen aud shortly afterwards ulcerated. Later, diarrluva was develojied; and when, in October, his regiment left
to be mustered out, he was sent by steamer to this hospital for treatment. He was somewhat emaciated and so weak
as to be confined to bed. He had a diarrhu-a of eight to twelve evacuations daily. The patient failed, aud died
December 7. rost-mortem exainiuatiou: Body enuiciated and showing a few scars where the sores had been. The
thoracic viscera, liver aud pancreas were normal. The stomach contained about ten fluid ounces of greenish liquid.
The gall-bladder was empty: the spleen weighed less than two ounces aud was of a red color. The kidneys were
tough, the i>yramids contracted, infuudibula and calices enlarged aud all of a bright-red color; the bladder con-
tained twelve ounces of urine. The calibre of the last fifteen inches of the ileum was narrowed to three-fourths of
an inch: the nnicous coat was thickened and red. The caput coli was pale; the ascending colon slightly enlarged;
the transverse and descending colon, sigmoid flexure and rectum were contracted to about one inch in diameter and
were of a bluish tinge. The mucous membraue of the whole of the canal was examined without detecting ulceration
or even much congestion. The mesenteric glands were enlarged, — one-half to two inches long, one-fourth to three-
fourths of an inch thick and one-half to one and one-half inches broad, — they felt somewhat like suet to the touch. —
At»l Surgeon Ira Perry, 9th Colored Troops, Hospital, Brownsville, Texas.
Probably some of the deaths among paroled prisoners, such as the following al the
Jarvis hospital, were in a great measure due to the influence of defective alimentation.
C-VSE 53. — Corp'l William Snyder, Co. H, 13th Pa. Cav.; age 19: was admitted from Richmond, Va., April 18,
1864. with ascites and chronic diarrhtea. He died June 22. Post-mortem examination: There was much eftusion in
the i>leurai and pericardial cavities. The liver was of a bright-yellow color. The whole of the abdominal viscera
were matted together. The kidneys were small and contracted.
C.vsE .54. — Private Frederick Moore, Co. K, 14th Conu.: age 22; was admitted from Richmond, Va., April 18.
1861, with chronic diarrhoea, and died June 2. Post-mortem examination: The right lung was atrophied and bound
down by adhesions: the left pleural sac contained etfusiou and the lung was hepatized : both lungs were filled with
crude tubercle. The pericardium was distended with efl'usiou: the heart, large and flabby, was filled with fibrinous
clots. The liver aud sideen were natural : the kidneys large and congested. The intestines generally were inflamed
and the ileum ulcerated: the mesenteric glands tuberculous.
Case 55. — Private Samuel Robbius, Co. G, IGth Me.: age 22: was admitted from Richmond. \a., .Vpril 18, 1864,
with chronic diarrhoea, aud died April 27. Post-mortem examination: Both lungs were 611ed with miliary tubercle;
702 SCURVY.
the right luiig contained a yoniioa and the pleura of that side was filled with serum; the pericardium also contained
serum. The spleen was large and tuberculous; the kidneys natural.
CvSE 5o. — Private Eli Brown, Co. G, 2d East Tenn.: age 23; was admitted from Kichmond.Va., April 18, 1864,
with phthisis, and died May 17. Post-mortem examination: Both lungs were tuberculous and hepatized; the left
pleural cavity contained a gallon of efiusion. The pericardium was distended with turbid serum and the aortic
valves thickened with ossific deposits. The spleen was soft and friable ; the stomach, intestines and kidneys healthy.
Case 57. — Private John G. Aldridge, Co. H, 5th Ind. Cav.; age 27; was admitted from Richmond, Va., April
18, 1864, and died June 1. Post-mortem examination : The pleural cavities contained efi'usion and the lungs were tuber-
culous, excavated and infiltrated with pus. The heart was flabby and filled with fibrinous clots. The liver and
kidneys were natural, the spleen soft, the intestines congested and the mesenteric glands tuberculous.
Case 58. — Private John James, Co. G, 45th Ohio; age 25; was admitted from Richmond, Va., April 18, 1864,
with chronic bronchitis, and died April 28. Post-mortem examination: The lungs were extensively congested; the
heart hypertrophicd and soft. The liver was enlarged and congested ; the gall-bladder distended : the spleen enlarged
and softened; the kidneys normal. The mucous coat of the stomach and intestines was thickened and softened;
the colon small and much thickened.
Ass't Surgeon Ira Perry, 9th Colored Troops, filed a series of 41 post-mortevi observa-
tions in cases of scurvy in the 25th Army Corps at Brownsville, Texas.* A careful
examination of these records warrants the following statements:
The condition of the brain is recorded in two cases only. In both it was soft: in one there were two ounces
of serum in the membranes, in the other the ventricles were filled with a dingy liquid, a small (luautity of which
also covered the surface of the hemispheres.
The lungs were mentioned as normal in 5 and altered in 28 of the 41 cases. In 16 of the 28 both lungs were
affected, while in 8 the right and in 4 the left lung was the seat of the morbid changes. Of the 16 cases the lungs
weie pale in 6, atrophied in 2, congested in 2 and tuberculous in 6, one of which presented hepatization and another
gangrene. Of t-he 8 cases the lung was congested in 1. hepatized in 1, caruified in 3, tuberculous in 2 and in 1 so dis-
organized that only about two ounces of its tissue remained. Of the 4 cases the lung was tuberculous in 3 and
atrophied to two ounces in 1.
The pleural cavities were noted as abnormal in 14. One-half of these were characterized by adhesions and exu-
dations of coagulable layers, the other by efl'usious of more or less turbid liquid, auiuuuting in one instance on the
right side to six pints. In one case there was an empyema of the right side.
The condition of the pericardium was noted in 20 cases. In one there was adhesion, in the others effusion,
which, in one ca.se, was associated with exuded lymph and in three with tubercle. With the exception of six pints
in one instance, the largest quantity of effusion was eight ounces, present in three cases.
The condition of the heart was reported in 19 cases, in 3 of which it was normal. It was small, pale, soft or
flaccid in one-half of the remaining 16; large in 2, dilated in all its cavities in 3 and in its right auricle in 1: covered
with a red fil)rinous coating in 1 and disjjlaced to the right by a pleuritic effusion in 1. The valves of the heart
were reported thin, deficient or cribriform in 19 of the cases. Fibrinous clots were noted in 8 cases, and in 11 it is
stated that there were no clots.
The liver was noted in 28 cases, in 3 of which it was normal. It was tuberculous in 4: small in 4, in one of
which it was yellow; large in 11, in two of which it was pale and yellow, in four purple or dark, in two mottled and
in one congested and friable. Of the remaining 6 cases it was tough in 1, nutmeg-colored in 1, mottled in 1, brown
and hard in 1, dark, with tar-like bile in the gall-bladder in 1 and coated with a layer of lymph in 1.
The spleen was noted in 35 cases, in 14 of which it was normal. It was tuberculous in 10, one of which was
caruified and three enlarged; it was large in 5 cases, in two to three times the healthy size: it was small, pale and
wrinkled in 4 cases; of the remaining 2 cases the weight, two oiinces, only is given.
The pancreas was mentioned 11 times: 8 times as normal, once as large, once as small and once as tuberculous.
The condition of the kidneys was noted in 26 instances, in 5 of which they appeared normal. They were large
in 7, one of which was pale, two flaccid and one friable: pale in 3; congested in 4: fatty in 2; flaccid in 3, in two of
which they were also tough; in 1 they were small, weighing only two and a half ounces each, and in another they
are said to have exhibited a change of structure and color.
The suprarenal capsules were large in 5 cases, attaining in one instance to three times the natural size; in 1
they were large and tuberculous and in 1 small.
The condition of the urinary bladder was noted in only 3 cases. In one case it was full ; in a second it con-
tained four ounces of urine and its thickened coats were so bound by adhesions as to be incapable of further expan-
sion; in the third it was contracted into a small hard mass.
The stomach was noted 16 times: 7 times as normal, 4 times as distended with flatus or lii|uid and once as the
subject of hour-glass contracture by a band of peritoneum. Of the remaining 4 the mucous membrane was pale and
softened in two and red and congested in two.
The intestines were mentioned in whole or in part in 30 cases, in 5 of which they were normal or merely dis-
tended with air. They were recorded as j^ale in 4, in one of which the colon was congested; soft and thickened in
* Dr. Perry published one of these cases, by way of illustrating the character of the whole number, in the Boston MediccU and Siirgicitl Journal,
Vol. LXXIV, ISCO, p. 155.
SCURVY. 703
2; Muisli <ii- (lai-k-ciilored in 'J; eci'liymosoil in 1 and congosteii in U). in tuur of wliioli the colon was nlcciated. Of
the 1) irniainini; cases the colon ahine was reported as att'ected. in live witli mild congestion and in one with nlceration.
The iieritonenni was noted in 25 cases. It was tubercnlons in ,">, in lonr of which there was adhesion and in
one eti'nsion: congested in 2 and adherent in .S, in one of wliich there was a small (jnantity of reddish scrum. There
wa.x elfnsion in t>, in four of which there was also exudation, and there was exudation in 7 cases associated with moro
or less of congestion. Lastly, in 1 there was thickening and in 1 a dark-slato color of the niemltrane.
The condition of the mesenteric glands was noted in 27 cases, in all of which there was moro or less enlarge-
ment and in many softening; in 2 the glands wereof a dark color and in 7 tuberculons. The cervical and bronchial
glands were frequently associated in the morbid conditions of enlargement, softening, darkening or tubercular degen-
eration. In one case there was suppuration of the cervical, axillary and mammary glands.
In one of the 11 ca.<es no section was made; thv j'oit-moil cm record noted only the eondilion of the lymphatics
and a perforate cmpycnuitous thorax.
Chi reviewing the history of scurvy in our armies it is seen tliat, e.\eluding a few local
outbreaks, the troops were kept free from active manifestations of the cachexia. In fact it
may be said that as a whole the United States Army was as free from the scorbutic taint
as were the British troops in the Crimea during the year ending June 30, 1856, when,
although a small number of admissions were noted, they were not recorded on the table of
sick-rates, as they constituted only a fraction of a monthly rate of one case per thousand of
strength. Nevertheless scurvy, in the general opinion of the profession, occupied a prom-
inent place among army diseases. This must be attributed to the frequency of cases among
the rebel prisoners at Northern depots and the generally scorbutic condition of our own
paroled or exchanged men rather than to tlie actual presence of the disease among our troops
in the field and garrison.
A few reports on tile indicate that allhough cases of developed scurvy were rare the
scorbutic taint complicated other diseases, rendering them intractable and correspondingly
dangerous. Besides references to such complications in reports already subiniUed, as in
those of Billings and Rawson, the following have been discovered:*
SuracoH H. P. Stroxg, II//1 Wis., Des Arcs, Arkansas, June 30, 1862. — Oitr army, composed mostly of raw recruits
from rural districts, sulyected to the fatigues of long marches, unused to the bivouac or the exjiosures of a camp and
sonthern climate, and suflering more or le.ss from want of proper food supplies, has not been exempt from the disea-ses
incident to the service; yet I was a little surprised during the latter part of May to notice scorbutic symptoms in
several cases of dysentery and remittent fever. I had been of the opinion that fresh nu>at and dried vegetables are
good preventives of scurvy. We have had a fair proportion of these issued, but the men are scorbutic. There has
been no case of scurvy proper: but many cases of dysentery and remittent fever have been couii)liiated with hem-
orrhage from the mucous membranes, in a few cases to an alarming extent. Sometimes tlie bleeding appeared to come
from the entire length of the alimentary canal, while freijuently it was only observed from the nose, mouth and fauces.
In one case of continued fever epistaxis was so persistent that plugging was resorted to with the etfect of arresting
it there, while it started afresh from the mouth and fauces. When last seen this young man was recovering under the
use of large doses of niuriated tincture of iron. In a few cases I have observed slight purpuric spots on the legs and
chest. I have not noticed sponginess of the gums except in a few persons that had been taking mercury nearly to
ptyalism. A mess wliich has been kept well supplied with vinegar has not furnished me a scorbutic patient. It has
been impossible to provide the command with vinegar. Fresh vegetables cannot be obtained iu any quantity; the
enemy destroys them rather than permit them to fall into our possession. In our circumstances I believe vinegar to
rank among the best antiscorluitic remedies. The only medication of any advantage is the liberal use of mineral
acids. JIuriated tincture and proto-sulpliate of iron are particularly applicable: they seem to arrest hemorrliage
and impart tone and vitality to the capillary vessels, or, as the case may be, reinvigorate their nervous distribution.
Nitro-muriatic acid seems appropriate when there is much hepatic derangement. The scorbutic diathesis would
hardly be worth mentioning in this connection were in not that it complicates diseases of a character grave enough,
iu camp life and at this season of the year, when uucomidicated. A tendency to congestion is characteristic of all
our diseases.
•Tlip ChUaffo Meitical EjramiiHr, Vol. Ill, 1SG2, p. ;):il i't Kq., in wlmt imrports to hn remarks accompanying tbe monthly report of Surgeon H. C.
FiHTTK. 2"2<J Ohio, for An^uttt of that year, ha« tlie following: '* There have been no cases of scurvy, pure and simple, during this month, and scarce any
since the regiment has been in service, but very many of the iiatients have sufiered in a way that could not be accounted for except on the siippoHition
of some scorliutic taint. In various instances, but generally iu cases of diarrbo-a aiul dysentery, there was marked a>dema of the lower extremities and
sometimes of the face also. Partial paralysis of one or more limbs has not been uncommon, and in one or two cases, which proved fatal, there were
ecchymoses, in one case quite extensive. The treatment most successful with these cases, after subduing the active disease, was the admiuistr.ition uf
irim. Acids and nourishing diet." G. P. Hache.vkergrr, .\88't Surgeon, 2Sth Ohio, in a corresi)ondence published in the Ohio Medical ami StirtjifalJoiinml,
Vol. XIV, 1S(V2, p. ."iSS, dated Cox's Division, West Virginia, Aug. 1, 18C2, mentions some of the evils unfavorably affecting the health of the division,
and among them the ap[>earunce of a scorbutic taint on account of a deficient supply of vegetables, lie considers that the existence of this condition
added greatly to the difficulties of treating gome complaint^ particularly dysentery, ulcerations and cutaneous diseases.
704 SCURVY.
Surgeon Heni!Y C'apeiiart, 1st Vu. Cuv., Valley of Virginia. June 30, 1862. — The most prominent symptoms of
disease among tlie men of my regiment consist of general debility and an evident tendency to scorbutus. If these
are neglected they soon develop into jaundice, typhoid fever or pneumonia. But by the free and timely use of acids,
quinine aud alcoholic stimulants this condition is removed and the patient restored to duty in from two to four
days. I cannot too strongly recommend the use of tonics and stimulants in the treatment of the diseases incident
to camp life. My success has been so uniform in the treatment of acute pneumonia by this plan that I have been
forced to entertain serious doubts as to its iutlammatory character.
Althougli SLicli a complication no doubt existed in many local instances where a true
scorbutic taint had been developed, the statistics of the war do not permit the supposition
that this was at any time a general condition. Certainly the hard work, los.s of sleep, expo-
sures in all kinds of weather, and the imperfect dietary so often associated with active field
service, resulted in many instances in a debilitated condition of the system which rendered
the soldier peculiarly prone to succumb under attacks of acute disease; but it is doubtful if
in all such cases the term scorbutic could with propriety be applied to the cachexia developed.
Even the improved condition which frecpiently attended the free is.sue of vegetable food does
not establish the scorbutic nature of the deterioration ; for such issues were usually associated
with a temporary cessation of active field work, duririg which many harmful conditions
were replaced by those which were salutarv. The constitutional state resulting from the
deteriorating influences of the war was of a typhous or advuamic nature rather than simply
scorbutic.
Symptoms. — The first manifestations of the scorbutic condition were usually languor,
lassitude, fatigtie on the slightest exertion and dull aching pains in tlie legs and feet ; but other-
wise at this time the patient was in his usual condition, his appetite good and bowels regular
or perhaps inclined to be torpid. In a short time the pains increased in severity, affect-
ing chiefly the muscles of the legs and in some cases those of the back and superior extremi-
ties. The pain was often referred to the bones and in many cases to the larger joints.
Soldiers reporting at sick-call with these symptoms were at first regarded as affected with
rheumatism. The insidious character of the disease favored its unnoted invasion. Xo
doubt in many instances its pains have been regarded as rlieumatic, its debility as resulting
from malaria, and even its manifestations on the gums as a local aftection induced by irritating
chewing-tobacco, accumulations of tartar, carious stumps and other unhealthy conditions;
but in general our medical officers appear to have been from the first, and particularly after
the alarm of scurvy in the Army of the Potomac, ou the alert for the appearance of the
disease, and to have formally announced its presence if, in a. case of debility with muscular
pains, the gingival margins Avere found slightly tumid or to bleed easily when the thumb-nail
of the examiner was rasped along them, although the calves of the legs might not present
any petechial discolorations. The want of correspondence, to be noted liereafter,* between
the prevalence of scurvy and of the rheumatic aflPections shows very definitely that pains
in the muscles, bones or joints, due to the scorbutic cachexia, were not erroneously reported
as rheumatism, but met with proper recognition and treatment in the practice of our medi-
cal officers. Sometimes debility and wandering pains formed the only grounds for a diag-
nosis.f As WooDHULL has expressed it, the disease veiled itself under the guise of chronic ^
rheumatism. This view, generally accepted by our medical officers, was in one instance
officially promulgated :
George Sucklky, Surgeon, U. S. Vols., Medical Director, Ehtenth Army Corps, to Surgeon Uunkle, in charge
of the Field Hospital of the Corps, dated June 9, 1863. — I notice that there have been many cases in hospital of soldiers
* See infra, page 8.33. t See remarks of Dr. Francis R. Lyman, page GST, mpm.
SCURVY. 7"")
coiiipluiiiiii^ of painful ami " weak" backs, with painful sensations in the hips, thighs, etc. Some of these simulate
renal afl'ections, while others are looked upon as rheumatism, neuralgia ami even acute or chronic spinal meniiij;itis,
and treated accordiuijly. I wish to draw the attention of your medical officers to the fact that the data in the
Surgeon lieneral's office have pretty clearly estahlished that many of these cases are purely scorbutic and should bo
treated accordingly. Please impress also upon the minds of your officers that most of our army cases of chronic
rheumatism and chronic diarrluea are attributable to the same cause. You are respectfully requested to furnish your
nu>dical officers with a copy of this letter.
As indicated in this communication, diarrhoea also was considered a jJi'ominent symptom
of incipient scurvy. Its subsidence when tlie scorbutic taint was effaced by an appropriate
diet established in the minds of many its symptomatic character. By some the intestinal
affection was regarded as an accidental association, for where diarrhoea was so prevalent as
to occasion 711.46 cases annually in every thousand present, the chances of its occurring
in a scorbutic individual were very great. But since, as already mentioned, the vegetable
diet, which cured both the scurvy and the diarrhoea, was usually associated with the removal
of many conditions known to occasion and aggravate the latter affection, it seems probable
that the diarrluva was neither a symptom nor a purely accidental complication of the scor-
butic taint, but that its causes were intimately con-nected with the military conditions wliich
gave origin to the cachexia by preventing the issue of fresh vegetables.
When more fully developed, however, the scorbutic disease was so invariably accom-
panied by diarrhoea that the constitutional state must be conceived as having predisposed
to the local affection. According to Act. Asst Surgeon Fee of the Annapolis hospital, it
was a noticeable fact that all our returned prisoners who were scorbutic suffered from diar-
rhoea, and that the grave condition of the bowels was indicated by the color and odor of the
stools and their admixture with blood and mucus.* Indeed, in a majority of the fatal cases
an exhausting diarrhosa or dysentery, sometimes of twenty to thirty stools daily, precipitated
the issue; and in cases of recovery the intestinal disease was seldom controlled until an
improvement was manifested in the general health.
Subsec^uent to the rheumatic or diarrhoeal stage of incipiency the gums became tumid,
red, spongv and disposed to bleed, the teeth loose in their sockets and the breath exceed-
inalv offensive. The swollen gums assumed a darker color, rising to the level of the dental
crowns and obscuring the lateral view of the molars, bicuspids and canines. After this
their tissue broke down or sloughed away, leaving the necks of the teeth bare and frequently
carious; mastication became difficult or impossible and sometimes the teeth dropped out, —
in case 16, treated at the Satterlee hospital, seventeen teeth are said to have been lost. At
the same time the appearance of the patient became changed from the healthy condition.
His skin was dry and rough; his slow movements and mental despondency proclaimed his
debility, and his pale, waxy, puffy, ansemic aspect indicated the grave deterioration that
had taken place in the blood. This was further manifested by the indisposition of wounds
to heal, slight scratches becoming converted into indolent ulcers or affected with erysipe-
latous or gangrenous inflammation. Individual instances of this kind were observed by
medical officers in the field during the local outbreaks already mentioned; but, as a general
dyscrasia affecting wounds, it has been noticed only b)' Southern writers. Dr. JoxES refers
to the ulcerations induced among the prisoners at Andersonville by slight injuries, as the
•See case 44, page 700. In an article by W. B. CoBNlsu, Statistical Officer, Madias Medical Department, in the Slathaa Monthly Jour. Med. Sci.,
Vol. I, 1870, p. 177, — Oh Scftrhtttic MuladU* <is nremjilijird in Ihe Medical Wfiory of the Bcijiils in India sixiij years aijo, — in which the author attributes the
excewjlTe mortality which funn^Tly attenjvd the arrival of Driti^ih regiments in India less to climatic conditions than to scurvy developed by the confine-
ment and imp<^rfect dietar>" of the long voyape. it is b'tated thai — "In India, acconlinf^ to my own observation, the stn-ss of the scorbutic disease fi'uer-
ally falls on the large intestine. In cold countries the sponj:y gnnis. tv^lenia of the limb^ and extravasation of blood beneath the skin are the more
common symptoms; but here, often the first nuinifestation of the disease is a disordered coudilt-"* .>f t's ■ i-.u.-w, ili-i..-iiiniiL' ..n ib--rrii.tiv.- nl< i-riti,,ri of
the mucous jiurface of the ]ar,;e intestine."
Med. Hist., Pt. HI— «9
TOG SCURVY.
prick of a splinter or-tlie scratching of a mosquito bite/^" and Dr. Paul F. Eve, speaking
of scurvy in the Confederate Army, says:"}"
It certainly did complicate wounds and seriously interfered with surgical operations, and was itself aggravated
by erysipelas, syphilis, spurious vaccination. Secondary hemorrhage became much more frequent from wounds and
operations after the battle of Chiokamauga and Missionary Ridge, September and December, 1863, attributable justly
to the increased scorbutic tendency in the soldier as the war progressed. In proof of this assertion the official report
of nineteen cases of secondary hemorrhage occurring in the Gate City hospital after the battle of Chickamauga might
be presented.
Coincident witli the tumefaction of the gums petechial spots appeared on the lower
extremities, generally at first on the calves of the legs. These were followed by larger
hemorrhagic discolorations, varying in hue from a dusky-yellow to a dark-purple. The inner
aspect of the thighs was also frecjuently affected; but all parts of tlie superficial tissues were
liable to the extravasation. The spots varied in size and shape; in some instances a con-
tinuous discoloration extended alono; the trunk, thio-h and lee;. Meanwhile the affected
limbs became oedematous, pitting on pressure, and afterwards more resistant, as if some
degree of coagulation had taken place in the liquid transuded into the intercellular spaces.
Local congestions determined the formation of tumors, which subsequently became ulcers,
presenting swollen margins and dark-colored, fungoid and fetid granulations. The knee
and ankle joints in some instances became painful, stiff and contracted. Debility increased,
the pulse became slow and feeble or, in the presence of the diarrhoeal affection, rapid and
Aveak; occasionally the patient suffered from exhausting night-sweats. Eff'usions into the
peritoneum, pleura or pericardium caused oppression of the breathing and interference with
the circulation. Deatli occurred from the intestinal affection, from pulmonary oedema or
other effusions causing cardiac oppression or coma, or suddenly after muscular exertion
In the majority of cases presented during the war improvement was rajDid under appro-
priate diet and medication. In some, however, the gums remahied spongy and tender long
after the other symptoms had disappeared. Not unfrequently, also, in cases of slow improve-
ment, the patient continued weak and suffered from palpitation on exertion ; in other cases,
notwithstanding the removal of the characteristic scorbutic symptoms, a rheumatic condition
persisted, necessitating the discharge of the soldier, — in one of the cases submitted above the
patient, after five months of treatment, was discharged from service as being unable to walk
witliout crutches.
Nyctalopia as a symptom of scurvy does not appear to have been observed in the Union
armies. Sporadic cases occurred, but no general tendency to night-blindness has been
recorded as connected with the scorbutic taint. Accordino; to Suro;eon J. C. Norton, U. S.
Vols., who reported its extensive prevalence during the summer of 1864 in the 3d Division,
ith Array Cori^s, the robust and plethoric were affected rather than tlie debilitated:
As far as my personal observation extends the disease occurs more frequently in robust, plethoric persons than
in those of lax and feeble habit. The first case I saw occurred in the 19th U. S. luf., May 8, 18t)4, after a hard day's
mai-ch from Ringgold to Buzzard's Roost, Ga., in the hot sun. It came on suddenly. After this several other cases
occurred, and as the campaign advanced the disease appeared to rage as an epidemic. Some regiments had to lead
thirty or forty blind men every night. Surgeons did not understand the disease and were unable to treat it success-
fully. It is very common for medical officers, when they do not understand the disease, to accuse the soldier of
miditiijering ; so, in regard to night-blindness, mapy considered all cases feigned. I am aware that when a disease
becomes popular there are many soldiers who will take advantage of it and feign the symptoms to avoid duty. At
the same time my observation has taught me that there is not one-half as much malingering in the army as is gen-
erally supposed. That mental influences have much to do with the i)roductiou of disease there can be no doubt, as
chorea has often been caused by witnessing the convulsive movements of a patient, and it is likely that the expecta-
tion of and attention to any disease act as predisposing causes of the disease itself. Nostalgia manifests itself in a
*See eiljjra, page 37. f Xwhiille Mediai} Journal, Vol. I, X. S., 1SC6, p. 16.
SCURVY. ,07
vaiii-ty of wa.vs; Imt tluTo is no (loul>t tliat the nervous system is i)iiiuarily atleoteil, :niil it is not uiiieasouablo to
suiipose that the initaliility of the nervous centres which characterizes nostalgia is in some instances a preilisposing
cause of nyctalopia. There is no iloul)t in my mind that the exciting cause of night-blindness is excessive use of the
eyes and exposure to bright light and oppressive heat, causing local congestion first of tlio ciliary vessels supply-
ing the iris and then of the vessels of the retina. The pupil is sometimes found contracted and sonu'times dilated,
and I have seen several instances in -which there was unequal dilatation, one pupil being contracted, the otlier dilated.
lu general the only reason why the patient cannot see at night is because the pupil does not dilate sullicieutly to take
in the requisite number of rays to make vision distinct. The excitability of the iris is exhausted byccmtiuual irrita-
tion, so that it fails to respond to any hut the strongest excitant. I do noi believe that the disease is a ftum of
amaurosis, as is taught by authors generally, but it nuiy bo combined with that disease. The distinctive character
of nyctalopia, however, is congestion and partial paralysis of the muscular tissue of the iiis. It should be remem
bered that the connection of this muscle with the optic nerve or the retina is very distant, the iris being supplied
by the ciliary branches of the ophthalmic artery and the motor oculi nerve, while the retina is supplied by the arteria
centralis retina- and the optic nerve. A rational treatment consists in the removal of the exciting cause, giving nature
a chance to restore the jiroper ei|uilibrium of the circulation and nervous functions.
Dr. Robert J. Hicks of Williamsburg, N. C, affirms the prevalence of night-blindness
ill the Contederate Army of Northern Virginia, particularly at the period of the occupation
of Fredericksburg.* The soldier who had been marching all day complained at nightfall
that lie could not see, and, like a blind man, walked, holding the arm of a comrade. No
constitutional symptoms were manifested and the eyes appeared perfectly natural. Fre-
quently only one eye was affected. At first the comjDlaint was looked upon as a trick of
the malingerer; but the continued dilatation of the pupil, when exposed to the light of a
candle, demonstrated the morbid condition. It was considered to be a local innervation due
to meagre diet, tlie want of vegetables and vegetable acids and the various depressing influ-
ences that then affected the soldier's health. Medication was of little avail. Cases fre-
rjuently recovered spontaneously after treatment had been discontinued. According to Dr.
Wm. Hays of Covington, Ky.,f at one time a prisoner of war at Point Lookout, Md., the
disease was of frequent occurrence at that depot. His account does not differ from that of
Dr. Hicks. In some cases the conjunctiva was injected and sometimes the lids were u'ranu-
lar and the cornea ulcerated. Innervation iVom exposure to powerful sunlight is mentioned
as the exciting cause. Scurvy was a frequent complication. Wlien the general health was
imin'oved the sight became restored.
Perhaps the first mention of night-blindness in American medical literature, as a symp-
tom of the scorbutic dyscrasia, was made by Dr. Edwakd Coale, U. S. Navy, in his account
of the epidemic of scurvy which affected the crew of the frigate Columbia in her cruise
around the world, 1838-40. J The vessel carried 450 men, but so many became affected
with inability to see after sundown that the deck-work could not be carried on without their
assistance. During the increase of these cases scorbutic disease became distinctly manifested.
English observers, however, connected nyctalopia with scurvy at an earlier date.§ and recent
papers appear to confirm the connection. ||
Notwithstanding the intimate association with scurvy demonstrated by the history of
night-blindness, it is questionable if this constitutional state is other than one of many causes
of a debilitating character that predispose to the local affection. Night-blindness may occur
• See JfiWndOHi/ MfiticalJottriiat, Vol. Ill, I8G7, page 35. + ciuciiiuati Journal of Medicititt Vol. I, I- . ,.i- .1.^
; .l"nrri<iiB Jffiirnitl o/ the Mi^dical Scieticeif, Vol. Ill, X. S., 1S42, Jinge tiS tt sfi^.
f TliU!»GlLBP.KT Blanf., in bis Obiercaliom on the Diwnnen of S*:ittit<nt, Loudon, 179ft, p. 4So, bas the followiug panigl-aph : There is a ivuiarkaMe !^yin]t-
tom »ometinie;^ attentlaiit on tlii.s disease, which has escaped the notice of authors. This is the uyctahijna, nieutiuued in Mr. T£LI'ori/s report, ll was also
romuiou in the garrison of Gibraltar, among those affecteil with scurvy during the siege, as I was informed by Mr. C.Mlt.N'cKoss, surgeon to one of the
twltalioiis. It soniotimes takes place in that incipient state of the disease whicl; docs not show itself by any visible symptom, but betrays itself, as men-
tionetl alK,ve, by ^-xltifnimig in case of bmises or b.v scorbutic ulcery.
i Thus of tifly prison cases treated by A. Pokteb, M. D., Civil Surgeon; .\kola, India, and reported in the Mwlran Monihhj Jotinini of Medical Science^
Vol. V, IST2, p. 253, nyctalopia was present in thirty-seven cases or 74 per cent., and was the earliest symptom in thirty cases or GO per cent.
708 SCURVY.
in the absence of scurvy,* but doubtfully in the absence of all debilitating!; causes. Gen-
erallv, also, there is a notable exposure to direct or reflected suiiliglit. The following extracts
illustrate this:
Surgeon J. F. Hammond, V. S. J., Fort Jefferson^ I'la., Jan. 1, 1862. — Nyctalopia occurred in a voluuteer and was
occasioned by the glare of light reflected from the water or from the white sand. It was treated by an emetic, calo-
mel, salts, cups, blisters, bandages to the eyes excluding the light, rest and low diet. He was perfectly restored in
a few days. After the lapse of a month or two the disease recurred, caused by the reflection of light from the. water.
He has undergone the same treatment and has now recovered.
Act. Ass^t Surgeon W. R. Smith, Sioux Cifg, Xoiva, March 31, 1862. — The snow, high winds and occasionally the
reflection of a bright sun explain the cases of nyctalopia which appear in my quarterly report. Exclusion of strong
light, rest and a collyriuni composed of sulphate of zinc and morphia constituted the means eftective for the relief
and ultimate cure of aU the cases that occurred.
Dr. Tripler, in his article on scurvy, M*ritten before the war, says that nyctalopia was
of frequent occurrence among our troops in the field, particularly in Southern clLinates, and
numerous cases, totally independent of scurvy, were observed during the Florida war.f The
views of Drs. HiCKS and Hays, referring the loss of sight to a local innervation in constitu-
tions enfeebled by hardships and exposures, may, therefore, be accepted as correct.
The MORBID ANATOMY of scurvy is not clearly defined by the post-viorterii notes that
have been preserved. In one case only, 51, was the condition of the blood stated; but from
the invariable presence of subcutaneous and intermuscular extravasations, noted clinically,
or of sanguineous effusions into the lungs or serous cavities observed after death, the abnor-
mal condition of the blood may be regarded as a constant lesion. J The brain was seldom
examined or seldom presented any noteworthy changes. The lungs were usually congested
and adherent, often tuberculous. The pleural and pericardial cavities frequently contained
effused liquid. The heart was soft and flabby; fibrinous clots were sometimes found in its
* After the close of the war the writer accompanied four companies of the 14th U. S. Infantry on their march from the coast of California into the
Territory of Arizona. Tliree men became night-bliud in crossing the Carrizo Desert to Yuma, where the sun-glare on the sand was very trying. They
were not seorlmtirs. They had been wc-U fed on the short voyage to California by way of the Isthmus, and before beginning their marcli they remained
two or three montlis at San Francisco, where they had an abundance of fresh vegetables and fruits.
t Cincimiati Lancet ami Observtr, Vol. I, 185S, i)age 132.
J The earlier«2J0K^)H«Yem observations in cases of scurvy, as well as those made in recent years with the microscope and chemical processes as
accessories, give prominence to the couclition of the blood. Daring the second voyage of Cartier to Newfuundland, 153o, his crew of 110 men became
severely affected. "This malady being unknown to us, the body of one of our nieu \vas opened to see if by any means possible the occasion of it might
be discovered and the rest of us preserved. * * * The heart was found white and putrid ; its cavities were quite full of corrupted blocKl. The
lungs were blackish and putrid ; more than a quart of reddish water was found in the thorax. The liver was pretty sound ; but the spleen somewhat
corrupted and rough, as if it had boeu rubbed against a stone.'* — Hakuvt's Collection of Voyages, Vol. 3, p. 225, quoted by James Lixd in his Treatise
ou the Sciircy, Loudon, 1757, p. 29S. Lord Anson's surgeons, 1740-44, obser\"ed that when the malady was-well advanced the blood mn thin and seem-
ingly very black, "and after standing some time in the porringer turned thick, of a dark muddy color, the surface in many places of a greenish hue,
without any regular separation of its i»arts. In the thii-d degree of the disease it came out black as ink ; and though kept stirring in the vessel many
hours its fibrous jiarts had only the appearance of a (piantity of wool or hair floating in a muddy substance. In dissected bodies the blood in the veins
was so entirely broken that by cutting any considerable branch you might empty the part to which it belonged of its black and yellow liquor; and wheu
fuuud extravasated it was all of the same kind." — Ihiil, p. 255. 51. Ciealvet examined blood taken in quautities of 25 to 30 grams from the small veins
of the forearm in scorbutic cases and found it fluid, jiale and watery. The clot which formed was extremely dense and small and the serum in unusual
quantity. The fibrin of the clot was in excess of that found in normal blood ; it contained 4.5 parts per thousand, but as the case progressed the quantity
<limiiiished. A slight inci-ease of albumen was observed in the serum — 72 parts per thousand as compared with C9 parts in normal blood. The globules
were reduced to 63 parts per thousand as against 138 parts in normal blood used in a parallel experiment. — See Gazelle Hebdomadaire tie Mcdecine el de
Chintrgie^ 2« s.'ri€, t. YIII, 1871, p. 219. These observations are essentially similar to those of Bvrk, quoted from the Sydenham Society's edition of
Simon^s Chemistry^ by Surgeon Tripler in his article on scurvy. They were made in three scorbutic cases that occurred in the Dreadnaught Hospital
ship and are as folluws :
Scorbutic. Healthy
, • , lilood.
Water 849.9 8^5.9 846.2 7S8.8
Solid constituents loO.l 164.1 153.S 211.2
I'ibrin 6..» 4.5 5.9 3.3
Albumen 84.0 76.G 74.2 67.2.
Blood corpuscles _ _ 97.8 72.3 60.7 133.7
Salts 9.5 11.5 10.9 li.S
According to the Lancet, Lend., Vol. 1, 18S5, p. 1134, the blood of three cases of uncomplicated scurvy under the care of F. Stazevich, in the mili-
tary hospital at Moscow, was dark and fluid, and showed irregular red corpuscles and more or less atrophied corpuscles cohering together. After recov-
ering this irregularity disappeared. The pleura, heart and aortic valves were ecchymosed. The spleen was enlarged, light-colored and friable; the
liver enlarged ; the cortex of the kidneys thickened. The intestinal mucous membrane was soft, swollen and ecchymosed, the solitary glands enlarged
in one case ; the colon ulcerated in one case ; the peritoneal glands enlarged in all. The brain was anjemic. The middle glutei muscles had extravasa-
tions between their fasciculi. Tlie liver-cells were enlarged and cloudy, as were also those of the epithelium of the urinary passages. The alveoli of
the mesenteric glands were enlarged and filled with round colls of the size of white corpuscles. The mucous lining of the small intestine was disorgan-
ized, the coounencement of the lymphatics containing finely granular detritus and the vessels distended and surrounded by extravasations.
SCURVY. 709
chambers. Tlie aliineiitai-y canal iVom tlie stomacli downward was more or les.s conu'estcd,
occasionally ecchymosed; pseudo-membranous dysentery was a frequent comjjlication. The
mesenteric glands were generally affected, even in the absence of ulceration or much conges-
tion of the intestine. The peritoneum contained effused liquid and the viscera were some-
times matted by adhesions. No constant hepatic or splenic lesion was observed. The kidneys
were sometimes congested.
Pathology, Causation and Treatment. — These, in the case of scurvy, are so inti-
mately connected that it is impossible to speak of one without at the same time discussing
the others. When scurvv was first observed amono; the crews of the early ocean navigators
the disease was regarded as a contagious malady. The same view was taken by many of
our soldiers who saw it for the first time during their confinement at Andersonville, for
Jones informs us that they sedulously guarded their wells and springs, fearing lest some one
suffering with scurvy might use the water and thus poison them. Apparently the wonder-
ful recoveries following the use of fresh provisions when a vessel reached port, or on the
return of spring in the case of outbreaks on land, should have demonstrated that the disease
was connected with the continuance of a salt-meat dietary or the absence of greens and
fresh vegetables; but medical men continued to ascribe it to bad air, dampness, improper
diet and mental despondenc}', while prescribing infusions and syrups of scurvy-grass, water-
cresses and other herbs or the juice of oranges and lemons as medicaments. At this time
a depraved condition of the blood in scurvy was generally acknowledged, the causes assigned
being the imperfect materials from which this inqiortant fluid was elaborated and the failure
of the skin and kidneys to effect its purification. Cockburn,'^' in 1696, referred the origin
of the disease to salt provisions, and pointed out how speedy was recovery under the use of
coleworts, carrots, cabbages and turnips. He insisted that if proper care was taken with
their diet seamen would not be so liable to the disease. BACKSTROJi.f in 1734, contended
that the primary cause of the disease was an abstinence from fresh vegetable food and greens,
and that although other secondary causes might concur, recent vegetables were an effectual
preventive. Keamer,J Lind|| and Blane§ insisted on the value of lime-juice as preserva-
tive against the disease. From the experiences on wliich these opinions were basdl the
abnormal condition of the blood was of necessity referred to a lack of something contributed
to the system by fresh vegetables and fruits; and as the acid quality of many of these was
their most notable characteristic, the patholog}^ of the disease was considered unveiled.
Not until 1848 was a further advance made in our knowledge of the causes and pre-
vention of the scorbutic condition. Then Alfred B. Garrod of the University College
Hospital identified the particular element of the diet which appeared by its absence to occa-
sion the disease. II He powited out that although fruits containing organic acids are highly
antiscorbutic the acids themselves are not so; that milk, on which the infant thrives durinir
the first year of its existence, contains, when fresh, no organic acid, and that all the sub-
stances noted as antiscorbutic contained larger proportions of potash than the articles of a
scorbutic diet. His conclusions, which were advanced rather as hypothetical than as proved
by extended experiments, were very generally accepted by the profession.^
* Sw Ll.N'D's excellent suDimar>' of the literature of this subject, page 381 of liLs 'iVeafwc on tUe Scurri/, London, 1757.
t "•"/, page 394. J Ihiil, page 412. | Ibid, pjlge ICO el ieq.
? Blvnf. ri-ganktl the intnxluctiou of lime-juice into the navy su|i]ilies as an era in naval history. It wji.'* fifst issued on his rcconimendation in
1T!«, l-iit he aM-rilics thecre^Iit uf having effectetl its accejitaiice to the earnest writing of LiND. The quantity given daily to each man was at first thrce-
•luarterv of an ounce with two ounces of brown sugar. — Obttrration* on the Lueases of Seamai, by Gilbert Bla.ne, Loudon, 1799, p. 490.
I 3Iot4tlilit Journal o/ Mtdictil Scintce, Vol. VIII, 1S48, page 457.
\ They were as follows: 1st. That in all scorbutic diets polmh exists in much smaller ipiantities than in those which are capable of maintaining
health. 2d. That all siil«tances proved to act as antiscorbutics contain a large quantity of polasli. 3d. That in scurvy the blood is dcficicut in poUmli and
710 SCURVY
Meanwhile, in this country, lime-juice as a substitute for, or representative of, a fresh
vegetable diet became so intimately associated in the professional mind with the prevention
and cure of scurvv that it seems as if the operation of predisposing agencies had become
foro-otten; for when Ass't Surgeon Johx? reported some of these influences as having con-
duced to the production of scurvy at Fort Laramie, Wyoming Territory, in 1858. he was
called upon by the Surgeon General's Office for further investigation and report,"^ His state-
ment of the causes was formulated as follows:
I. That tbe pninart/ cause of scurry is the absence of material furnished to the blood by fresh vegetable matter.
II. That from the primary cause the disease is di-vdoped by — 1. Oepressiou from exposure to cold, particularly
during guard duty at night and the long-continued cold of winter; 2. Depression from fatigue; 3. Insufficient vttttila-
tioii and crowding of men in a restricted place, whether in company f|uarter3 or on shipboard: 4. Too great a pre-
ponderance of salted food.
This brief sketch of the history of our knowledge of scurvy brings us to the period of
the war. The disease had been satisfactorily connected with a deficient dietary. Its preva-
lence among bodies of men whose only constant insanitary factor was the limitation of the
the quantity of that substance tbrowD out by the kidneys less than that which occurs in health. 4th. That scorbutic patients will recover when potasli is
added to their food, tbe other constituents remaining as before, both iu quantity and quality, and without the use of succulent vegetables or milk. 5tb.
That the theoiy which ascribes scurvy to a deficiency of poUifih in the food is also cajiable of rationally explaining many symptoms of that disea.'^e.
* Tbe report of Ass't Surgeon Johns was regarded with interest as suggesting the production of scurvy at Lai-amie from local causes, some of which
might be determined by further observation. It was held in tbe first place that the garrison at Fort Laramie was probably provided with a more liberal
antiscorbutic diet than certain frontiersmen and quartermaster's employes in tbe neighborhood of the post, none of whom had suffered from scurvy.
The immunity of the mountain men having been attributed by Dr. Johns tu their living chiefly on fresh meat, Surgeon R. C. AVoop, on behalf of the
Surgeon Geuei-al's Office, inquired bow it came that, as regards scurvy, the condition of these men could be considered better than that of the troops at a
post where, as at Laramie at tbe time in quet^tion, the commissariat bad on hand, besides 520 head of beef cattle, 7,138 rations of mixed desiccated vege-
tables, S,70G rations of desiccated potatoes and large quantities of dried apples, pickles, sugar and molasses. It was further shown by a reference to tbe
abstracts of issues of a former year that fresh meat was supplied to tbe quartermaster's men in much less proportion than to tbe troops, and that while the
latter had what might be considered large quantities of desiccated potatoes and mixed vegetables the former had none ; nevertheless tbe quartermaster's
men had been but little affected by the scorbutic taint. Moreover, contrasting the condition, as regards scurvy, of the garrison of Laramie with that of
the troops on active service iu I'tah, it was found that while 42 cases were reported from tbe former command, averaging 32o officers and men, during
tlie five mouths, Nov. 1, ISoT, to March 31, ISoS, ouly 17 cases were reported from the latter, averaging 1,800 officers and men. During this period the
trooi)S in Utah were much exposed in tents, were without vegetables and did not have some of the component parts of the regular ration with which tbe
commissariat at Laramie was fully supplied. Assuming the accuracy of these data, it was claimeil that scurvy at Laramie must have been due less to a
deficient vegetable supply than to certain other conditions which affected them to a greater extent than the otber classes of men mentioned, as for
instance : 1. A want of sufficient ventilation of the quarters allotted to the trooi»s ; 2. A want of due proportion of regular exercise in the open air ;
3. An impropriety in the manner of cooking of tbe food. Ass't Suirgeon Johns was, in this connection, requested to report on : 1st. The kind of build-
ings occupied by the troops at Laramie, their occupancy, ventilation, heating, etc.; 2d. The manner of cooking tbe food ; 3d. The duties of the troop.-^,
and, 4tb. Shelter, duties and habits as to clothing, exercise, food, etc., of the quartermaster's employes. In reply to this Dr. Johns dwelt strongly on
the monotony of existence as a cause of the disease iu tbe soldiers. Api^rently the chief point of distinction between the duties performed by the quar-
termaster's men aud the soldiers consisted of tbe guard duty required of the latter at night. The quartermaster's emjiloyes performed more labor than
the soldier, but it was of a different character and exercised a different influence on tbe mental and physical condition of the men. A certain monotonous
routine and confinement hedged the soldier on all sides. His guard, drill and police duties were unvarying, and so fatiguing on this very account that
when left to himself at their conclusion be seemed to feel little inclination to do aught but vegetate in hi;? bunk, with some occasional spasmodic effort
at foot-ball. "In the topography of a sentinel's post the chief characteristic is the bet-liue. This is the straight and narrow i>ath, — from it there is
turning neither to the right hand nor the left. Longitudinally 'thus far and no farther' is the fiat ; aud thus, for two mortal hours, or any given more
or less mortal time, according to the exigencies of the service or thermometer, tbe military i»endulum vibrates his monotonous existence until the twice
blessed * relief releases him from the effort to keep bis falx cerebri in aud parallel to the same plane of direction as that of his post. Thus there is
necessarily a monotony of mental action, depressing in its character, too, from this very monotony, affording no stimulus to resist the morbific effect of
exposure. Of course I jMirticularly refer to the garrison duty of a peace establishment, when there is little to put the soldier on the qui vire of mental
aud physical vivacity,— and in ten yeai-s I have never known a sentinel to have a good excuse even to cry 'fire.* Kow, add to this hopeless mental
monotony the effects of depressing cold, particularly at night, after a day of monotonous pemlulL^lic fatigue, and it would seem that no better reagent
could be desired for either producing diseases characterized by debility or for developing such a disease from a g*rm derived from other causes. * * "
Drill is also another effort to keep the falx in the plane of certain directions and to produce jiantographic resnlts with bodies, limbs and muskets or uther
weapons. Police duty is a daily funeral procession around the garrison with twig-brushes instead of cypress boughs for the mourners." But the work
of the employes of the Quartermaster's Department afforded healthy occuimtiou for the mind as well as for tbe body. As carpenters, blacksmiths, etc.,
they preserved their individuality; even the teamsters, having the management of their animals aud a wholesome variety in their work, were unaffected
by the mental depression resulting from a monotonous existence. The inouutaiu men of the country, being their own masters, were even in better
circumstances in this respect. They hunted, fished aud were idle at their pU-asure. As to fresh meat and supplies of desiccated vegetables, Dr. Johns
Boggested that tbe quantities issued to tbe troops, not those on hand in tbe commissariat, must be used in the argument. Carefully stored in boxes and
issued homceopathically, the vegetables had no effect in raising a command from a scorbutic condition. On the other baud, tbe higher pay of the quar-
termaster's men enabled them to purchase from the sutler a variety in their diet, including fresh canned fruits, oystei-s and other luxuries, which was
beyond the reach of the soldiers; nevertheless scurvy did occasionally appear among them. The frontiersmen, as to diet, had facilities fur procuring
snch antiscorbutics as could not be obtained by the soldiers. In place of the tough and stringy beef cattle of the post they had juicy venison from the hills.
In place of the salt-junk of the soldier, which had transferred to the brine its phosphates, acids, kreatine, etc., uecessan- to the formation of blood, they
used a dried meat which had lost none of its nutritive essentials in parting with its water. Referring to the freedom of the troops in Utah from scurvy.
Dr. Johns considerwl it sufficiently explained by the mental influences. They went into winter quarters after a wholesome niaixh across the plains, and
they were in lively anticipation of something like active service to vary the monotony of the previous condition of peace. In concluding, he held to the
proposition that scurvy results primarily from imjjerfect supply or ratio of supply of the three kinds of material for the' body— azotized, non-azotized and
earthy, the point of departure being the want of fresh vegetable matter.
rvmvY. 711
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712 SCUEVY.
jiouncls aud twelve ounces of salt : four ounces of pepper; thirty pounds of potatoes, when practicable, and one quart
of molasses. The Subsistence Department, as may be most convenient or least expensive to it, and according to the
condition and amount of its supplies, shall determine whether soft bread or flour, aud what other component part of
the ration, as equivalents, shall be issued. Desiccated compressed potatoes, or desiccated compressed mixed vegeta-
bles, at the rate of one ounce and a half of the former and one ounce of the latter, to the ration, may be substituted
for beans, peas, rice, hominy or fresh potatoes.
The desiccated potatoes and mixed vegetables of the ration before the war were insuf-
ficient of themselves, in the quantities issued, to prevent the appearance of scurvy. It was
supposed, however, that the other articles of the ration were in excess of the needs of the
men, and provision was made for crediting each company with the money value of that
portion which was not drawn from the commissariat for consumption. This credit consti-
tuted the basis of a company fund, which was disbursed by the captain for the benefit of the
enlisted men of his company, pursuant to the resolves of a council consisting of all the com-
pany officers present. A company commander by exercising due supervision over the messing
of his men was enabled to save money for the purchase of vegetables. Practically the com-
pany officers in council were authorized, if they found it for the benefit of their men, to let
any part or the whole of the ration remain undrawn and purchase food supplies in open
market with its money value. Generally, however, the troops were stationed where there
were no supplies other than those retailed by the sutler at exorbitant prices. Hence the
existence of scurvy during the winter and early spring months at posts unfavorably situated.
The considerable additions made to the ration at the beo-innino; of the war would have
enabled experienced company officers to have accumulated a large fund for use in varving
the diet of the men and preventing the scorbutic taint ; but volunteer officers were in general
ignorant of their duties in relation to the domestic economy of military commands, and any
excess of food that was not wasted by improvident cooking was thrown away. Subsistence
officers also frequently discountenanced the attempt of company officers to improve the diet
of their men by means of a company fund, as it complicated their accounts when sometimes
all their energies were required to supph^ the ordinary issues. Of course there were many
notable exceptions, especially in camps of some ^^ermanence, where, through the good man-
agement of the officers, company funds were accumulated and used to advantage ; and as in
these instances the company cooking was usually of a superior order and the men well cared
for in -other respects, these commands presented a marked contrast to those less efficiently
officered.
But Congress made a liberal i^rovision for the volunteer soldiers of tlie war. The issue
of an abundance of the albuminoids, fats and starches was authorized; and to ward off the-
scorbutic taint, whether dependent on the continued use of salt j^rovisions or on an absti-
nence from vegetables, the Subsistence Department was required, if practicable, to issue fresh
meat on the order of a commanding officer of a military command and to furnish one pound
of fresh potatoes three times a week to every man. Unfortunately, the clause if practicable
defeated in a number of instances the intent of the legislators; and cases occurred, as
reported by Medical Inspector Hamilton, of regiments which for months at a time received
not a single issue of fresh potatoes and were thus, but for somewhat better facilities for pur-
chases, in no better condition as regards the prevention of scurvy than the soldiers that gar-
risoned Laramie and other Western posts before the war ; but when these cases were brought
to notice by the reports of the medical officer or medical inspector special efforts were made
and the practicability of the distribution demonstrated.
In the treatment of the developed disease a fresh vegetable diet, fresh meat, acids, salts
SCURVY. 713
of potash and tincture of iron were employed. From this the theories of causation adopted
Ijv our medical officers may be inferred. Fresh vegetables, meat and milk formed the
staples of cure as well as of prevention. Among the vegetables used were potatoes, onions,
fresh or pickled cabbage or sour-krout, lemons, oranges, limes, sweet potatoes, watermelons,
creen corn. etc. Corn-meal is highly lauded by one officer, and its use by !^^oxiean troops
is sugf^ested as the cause of their freedom from scurvy; but the scorbutic condition of the
Confederate armies on- a corn-meal ration disproves his conclusions.*
The vegetable acids — acetic, citric and tartaric — were frequently employed, and, according
to some, with advantage ; but in these cases an improvement in the diet was always coincident.
Others regarded these acids used alone as of no value. Vinegar, which has been a recog-
nized antiscorbutic since the days of the early navigators, was highly valued and much
used;f but there is no ground for assuming that a diluted acetic acid possesses any value.
Vinegar, in addition to its volatile acid, contains solid matter .of vegetable derivation. In
exceptional cases the mineral acids — diluted nitric and sulphuric — were prescribed.
Oi the potash salts the bicarbonate was preferred, given in conjunction with the vege-
table acids; sometimes the bitartrate was used; occasionally the nitrate; but as fresh vege-
tables were invariably added to the diet it is impossible to determine the amount of benefit
derived from the medication. The chlorate of potash was in general use as a local applica-
tion to the gums; several officers testify to its value when used internally in doses of twenty
to si.xtv grains daily. Weak solutions of nitrate of silver were also prescribed as topical
applications.
Iron was supplied to the patient in the form of the tinctura ferri chloridi in doses of
fifteen or twcntv drops three times a day. Sometimes this acid tincture was used locally
to promote a healthy action in the scorbutic sores.
Diarrhoea was treated by opiates and astringents, irrespective of the general antiscor-
butic cause; but special medication was not employed on behaJf of the pains unless they
persisted after the scorbutic condition was apparently removed, when colchicum, guaiacum
and iodide of potassium were tried.
Tonics, stimulants and change of air, occupatiou and mental impressions, the last often
efiected by a visit home on furlough and at other times b}- the opening of a campaign, were
the means adopted to perfect the cure.
The danger of mercurializing the scorbutic patient was occasionally noted; but few
instances have been placed on record. J
It cannot be said that the history of scurvy in our armies has added much to our knowl-
edge. It shows how readily the disease may be controlled by the adoption of appropriate
measures; but this had already been repeatedly illustrated. It shows the powerfully pre-
disposing influence of all the causes of adynamia; but this was also already well known.
It shows that although the law may provide adequate means for the prevention of the dis-
ease, the desired and anticipated results may not always follow on account of difficulty in
procuring or transporting the supplies needful for large bodies of men under the changeful
conditions of active military service. Perhaps this is its most instructive lesson. From it
• Dr. Joseph .T.ixes attributeii the existence of scurvy at Andereonville to tbe effects of salt meat and an unvarying diet of corn-meal, with but few
vegetable* and imperfect Bupjdies of vinegarand syrup ; to these he added the influence of the foul animal emanations from the crowded aud jiestilential
stockade.— Report So. 45. Fortieth Congress, M Session, Washington, 18CC", p. 110.
t Surgetin McBride, 40th Ohio, called attention to the value of vinegar in an article in the Cinciimali Lancet and Otwrrer, Vol. V, 18G2, page 39G.
I An instance of violent salivation resulting from the application of a small quantity of mercurial ointment, intended for the destruction of lice,
is meDtione<l in the Chim^ Mnlinil Jminial, Vol. XIX, 18C2, p. 474.
Mki). Hi.'iT.. Pt. Ill— 90
714 SCURVY.
may be foreseen the occasional appearance of the disease in time of war, unless the anti-
scorbutic principle be meanwhile obtained in a form in which its issue to the troops will be
more frequentlv practicable than when associated with fresh beef on the hoof and potatoes
in barrels.
Although Garrod's theory, indicating a deficiency of potash in the blood, has been
before the profession for many years, accurate quantitative determinations of the salts of
scorbutic blood have yet to be made. Shortlv after this theorv was suggested the nitrate of
potash was shown to possess no antiscorbutic virtues.* It was also generally observed that
although fresh beef and mutton contained, according to Garrod's own analyses, very notable
quantities of potash, their antiscorbutic qualities were not proportionately manifested. Dr.
Buzzard f pointed this out, and suggested in explanation that the form in which the organic
salts of potash exist in vegetable substances renders them more easily absorbed and decom-
posed by the digestive system than the jwtash salts of animal tissues. Somewhat later
Chalvet;]; suggested that the chemical combination of the potash in fresh meat and dried
leguminous vegetables prevents its assimilation by the human sj^stem. . The phosphates of
dried jDeas and beans, and the chlorides, phosphates and nitrates found in meat are too stable
to be decomjDosed in the economy and are passed from the body for the most part unchanged ;
but the potash of fresh vegetables exists in the form of easily decomposed salts of the organic
acids, as citrates, tartrates, malates, etc., which, when ingested, are traasformecl into carbon-
ate,— and this salt, when in excess, givea an alkalinity to the urine and at all times presents
the base to the tissues in an assimilable form; the acid being removed bv the circulating
current and the potash fixed in the tissues by the nutritive processes as phosphates, chlorides,
etc. This explains the want of relation between the quantity of potash in certain articles
of diet and their antiscorbutic value.
Much evidence might be adduced on behalf of the efficiency of fresh meat as an anti-
scorbutic.§ The preservation of hunters, trappers and mountain men from the disease has
been frequently ascribed to their constant use of fresh meat or meat dried with all its salts
intact. The Indians also have been frequently^ quoted in this connection. || But in all the.-e
instances the absolute exclusion of vegetable substances is not positively determined.^ Ou
* It was tried by order of tbe Director General of the British Navy on scorbutic convicts en route to New Zealaud. The nitrate at the end of two
weeks was funnd to act so injuriously and to b& taken witli s«_t much reluctancf that its use on one vessel was abanduued. In another set of cases it cau^jed
irritability of the stomach and relaxation uf the bowels to such a do^rt-e that it was necessary to combine ojiium with it. In a third set it seemed to imitair
the |iu\vers of digestion and assimilation and was therefore cousideretl injurious. Alexander Brysox — who reported the results of these experimeut^-
thought it would be worse than cruelty, under Jiny cii-cumstances, to persist in the exhibition of this salt either as a prophylactic or means of cure. — See
Mt'diciit Times, Vol. XXI, London, ISoO, p. 213.
t Keynolds' System of Mediciiiej Vol. I, London, 1866, page 749.
X *i«::e«e Htbdoniadaitt; de Mideciue et de Chtnirgie, 2« S., t. YJIl (ISTl), imge 219.
gThus, in the outbreak at Council Bluffs — see note, supra, i>age 083 — the men detailed as hunters, who resided iu the woods and subsisted ou game,
were iu no instance unhealthy; and an outlying detachment, under the command of an officer who fed his meu entirely \ipou fresh meat from the woods,
experienced no sickness of any kind. — Forry, in American Journal of the Medical i5ciences, N. S., Vol. Ill, 1S42, p. SO.
[ Ass't Surgeon Washixgtos Matthews, U. S. A., in his Elhuography and Phihlotjy of the Hydasta Indians, Washington, D. C, 1S77, p. 25, «aTS:
"Formerly they lived largely upon meat ; when out ou their hunts and war-paths they often lived exclusively on it. There were many nomadic tribes
around them who seldom tasted vegetable matter, often living for seven or eight months in the year exclusively on meat and preserving perfect health.
I have seen white meu who had lived for years among the Indians, and during such residence for six months of every year lived on nothing hut meal
(and water of course), 'buffalo straight,' as they expressed it, aud who, in the summers only, occasionally varied their diet with a mess of root> < r
berries, — not seeking such vegetable food with any larticular longing or avidity. In various books of Western travel these statements are corroboratoi .
yet there are modern physiologists who would try to persuade us that an animal diet is inadequate to the sustaining of human life iu a healthy condition."
^ Surgeon T. C. 3Iadisox, U. S. A., already cited iu note, supra, page 6S3, attributed the healthy condition of the Fur Comjmuy's men and the
Indians not solely to the fresh game or dried buffalo meat on which they subsisted, but to this and the quantities of dried plums, buffalo aud choke
berries which they put up for winter use. And even Dr. Matthews, in the paragraph sticceediug that just quoted, has the following : ''A portion of
their corn they boil when nearly ripe ; they then dry aud shell it and lay it by for winter use ; when boiled again it tastes like green corn. This is often
boiled with dried beans to make a succotash. Their beans ai-e not usually eaten uutil ripe. Squashes are cut in thin slices and dried ; the dried squash
is usually cooked by boiling. Sunflower seeds are dried, slightly scorched in pots or ^lansover the fire and then powdered. The meal is boiled or made
into cakes with grease. The sunflower cakes are often taken ou war-paths, and are said, when eaten even sparingly, to sustain the consumer against
fatigue more than any other food. They gather all manner of dried roots and berries that are eaten by the nomadic tribes of the same region ; but they
do not consume them to the extent that the wilder tribes do."
DISEASES ATTRIBUTED TO NON-MIASMATIC EXPOSURES. 715
the other haiul, maiiv instances might be cited from tlio literature of the subject where, in
the presence of more powerful predisposing factors, fresh meat, in the absence of vegetables,
has failed to protect from scurvy.'^ Such testimony indicates tliat although fresh meat
possesses an antiscorbutic value which may be preservative under favorable conditions, its
qualities in this respect are by no means equivalent to those manifested b}' a similar inges-
tion of potash salts as furnished by fresh vegetables.
Bv comparing the analysis of scorbutic and healthy urine. Dr. RALFE,f of the Seamen's
hospital. Greenwich, England, has inferred that in the diseased condition there is a dimin-
ished alkalinity of the blood; and as the home-service diet of the British soldier, which
includes potatoes and other vegetables, contains a much larger proportion of salts susceptible
of conversion into alkaline carbonates, that the diminished alkalinity must be attributed
maiulv to the withdrawal of these readily decomposable salts from the diet. The potential
alkalinity of the .soldier's ration, which is regarded as a typical antiscorbutic diet, is equiv--
alent to 10.3 grams of bicarbonate of potash, while that of the sailor is equal to only 5.9
grams. He points out that under no condition has the blood ever been observed to become
acid, and that its normal degree of alkalescence cannot be reduced without causing disturb-
ances of nutrition, citing in evidence the experiments of Leyden and Munk and F. Hoff-
mann, which show that attempts to reduce the alkalinity of the blood in animals terminate
in death with changes in the blood and tissues identical with those found in the bodies of
persons who have died of scurvy. It would seem, therefore, that the disease is due to a
chemical alteration in the quality of the blood which interferes with the processes of nutrition.
But. whether scurvv is caused by a deficiency of potash in a readily assimilable form
or by a change in the blood from a want of the alkaline salts that are best supplied by the
vegetable kingdom, it is evident that soldiers in the field may easily extract materials from
the as/ics of their camp-fires to supplement a defective diet. It must be remembered, how-
ever, that the antiscorbutic virtues of the salts in question have not been satisfactorily
demonstrated.
CHAP. IX.— OX DISEASES ATTRIBUTED TO XOX-MIASMATIC EXPOSURES.
Apart from miasmatic influences the exposures incident to active service in our armies
were credited with the development of acute diseases of the organs of respiration, tonsillitis,
diphtheria, rheumatic afi'ections, consumption, etc. The continuance of cold rainy w'eather
during a campaign was productive of an access of such cases. The active occupations of
the camp or march protected the men during the day from the injurious effects of the weather;
but at night they were fully exposed to its influence, whether standing guard in camp or on
picket, or endeavoring to gather warmth enough amid the all-pervading moisture to enable
them to pass a few hours in sleep. Fresh levies were especially prone to suffer under such
conditions. A tedious railway journey in bad weather, with a bivouac in the streets at its
conclusion or temporary quarters in some unwarmed building, was often as disastrous to a
* Frcperiok Irvino De Lisle, Medkal Tima aad Gavlle, Vol. II, London, 1ST7, {i. 301, states that the disease apiieared among the equattets in
Qut.fn9lnnd during the droughts of ISGG and 186}*. when, during the dearth uf vegetableg, they lived upon lean mutton and bi»ked flour ; also, that during
the war in Nt-w Zi'iilaud in 1869-7n a K-orliulic taint was dcveloiK'd among tlie truoi>s, whose rations consisted of lean mutton and l»iscuil. alany instances
are cited hy Bl zzard. In his artiele on Seurti/ in Itei/nMi' S;;>(mi of Mrdiriw; Vol. I, London, 1800, pp. "37 el 8e<;.
flmpiiry into the Gfnerat hUliol>t o/ScNrri/, by ClI.\BLES Henry Ralfe, Lancfly London, 1877, Vol. I, p. 870 and Vol. II, p. 81.
716 DISEASES ATTRIBUTED TO NON-MIASMATIC EXPOSURES.
new regiment, en route to the front, as some of its subsequent battles. jSTotable variations in
temperature were injurious even when the degree was not absolutely low. The specific
poison of measles rendered new troops particularly susceptible to catarrhal attacks from
trifling exposures.
Cold and dampness manifested their combined effects even in winter quarters, when the
men were supposed to have made themselves as comfortable as possible. Sometimes this
was due to insufficient supplies of clothing and blankets. Frequently the camp soil was so
retentive of moisture that no system of trenching sufficed to give the troops dry huts and
protect their feet from the dampness and discomfort of the mud of their camiD-ground.
Catarrhs, sore throats and rheumatism were endemic in these undesirable locations.
The difficulty of heating the tent or hut was, at first, a cause of much sickness. Camp-
stoves, furnished by the supply department or purchased by the men, were small and of
thin metal. A few pieces of wood, which were consumed in as many minutes, rendered the
air of the confined space oppressively hot, but if the tent had any ventilation the temperature
fell immediately until again raised by fresh supplies of fuel. Hence, to avoid excessive over-
heating and the labor of constant attention to the stove, an attempt was usually made to
prevent the escape of the warm air from the tent. Every aperture by which the foul air of
the interior might be replaced by cold streams from without was carefully chinked. But
the endeavor to retain the foul air led to greater hygienic errors: It converted the hut into
a cellar by excavation and the banking up of the excavated earth against the outer aspect
of the walls. It led also to overcrowding for the sake of warmth, and to permit of the
clubbing of blankets, overcoats, shelter-canvas, rubber blankets and other available bedding.
From crowded holes of this kind typhoid pneumonias and diphtherias were reported instead
of the catarrhs and quinsies of simple exposure to cold.
Medical officers condemned these attempts at comfort, and in subsequent winters a better
style of log and canvas hut was constructed by the troops. Men who knew nothing of this
kind of work took hints in building from the backwoodsmen of Maine and Michigan. The
new huts were trenched on the outside to secure dryness of site ; they were floored with split
logs and provided with a roomy fireplace. A more equable temperature w.as secured, espe-
cially at night; but ventilation was defective and the space overcrowded.
In the hastily-constructed pavilion barrack-rooms of permanent quarters the heating
arrangements for winter occupation were generally insufficient. Men whose bunks were
near the stove or fireplace were usually overheated, while those at a distance were exposed
to cold from the pervious character of the walls. Unequable heating was associated with
defective ventilation and overcrowding.
Although generally attributed to cold and dampness, bronchitic attacks are in some of
the reports regarded as originating in tlie inhalation of dust and irritant sandy particles.
The following extracts are submitted:
Surgeon Isaac F. Galloupe, llth Mass., Xiic Berne, X. C, April 1, 1862. — The only prevailiug disease has beeu
bronchitis, ami the cause of its j>revaleuce was long-continued exposure to moisture consequent upon leaky quarters
and insufficient protection of the feet against wet.
Surf/eon J. A. Wolf, 29*/i Pu., Frederick, J/rf., Dec. 31, 1861. — Since our return to Camp C'armel the prevailing
comjilaints have been mild catarrhal affections, yielding readily to ordinary expectorant mixtures and other mild
remedies. This is rather remarkable, since many of the men had wet feet during almost the entire march.
Surgeon Jxo. S. Jasii.sox, 86»» A\ T., Good Mope, Md., Dec. 31, 1861. — The regiment has changed its location three
times. These changes have happened in inclement weather, and before the tents of the men could be made comfort-
able at each new location many cases of catarrh were developed. Three cases of pneumonia have grown out of these
cases of catarrh.
DISEASES ATTRIBL'TED TO XON-MIASMATIC EXPOSURES. 717
Surgeon J. M. Hates, 13//i M<., Ship Island, J/i«s., Jpril 2, 18r>2. — My impressiou is that many luug diseases were
induced by overheated and inadequately ventilated tents, and suddeii exposure to cold on going out while in a state
of perspiration with insufficient clothing.
Jfif'l Surffton A. J. Dickkhiiofk, 2'ith III., London. Tenn., I'ib. 28, 1865. — The regiment was on the move daring
the greater part of the nu>nth. generally in a rolling country in the region of the Holston and French liroad rivers,
above Knoxville. The weather wa.s changeable and at times very inclement, with cold rains and one snow-fall. The
roads were muddy and as the shoes of many of the men were worn out their feet were generally wet ; the clothing of
many was inade(inate and their shelter insufiicient, but this latter was in part remedied by their energy and their
experience as old soldiers. Some of the marches were ditticult; some forced: some made by night. There was an
nnusual number of r'jeumatic cases, most of them, however, not requiring excuse from duty; many of these seemed
to be the result pf soreness or sprain from hard marching in addition to the rheumatic tendency. Ca.ses of respiratory
disease were not so numerous as might have been expected under the circumstances. The symptoms in the more
serious cases were active but not severe. Treatment was at tirst moderately antiphlogistic, including the use of
quinine if. as was usual, malarial symptoms were also present : afterwards diaphoretics and expectorants were used.
1 infer that for the prevention of this class of diseases troops in tield service should not be too warmly or closely
housed, as catarrhal attacks depend more on sudden or marked changes in temperature than on its degree or contin-
uance. The troops should be adequately clothed, including good shoes and socks, blankets, overcoats for inclement
weather, sudden changes and night duty, and rubber blankets against rain and for shelter by day and night.
Surgeon Loris 'W.vTSOX. lli(/i III.. I'ost Surgeon, St, Joseph, Mo., Dec. 31, ISGl. — Much of the bronchitis and pnen-
nionia which has prevailed may be attributed to the discomfort which the men have experienced in going to sleep in
heated quarters without suitable covering to guard against the low temperature occurring after the estinguishmeut
of their fires.
Surgeon Joseph P. CoLG.\x, 59*7i X Y., Fori Good Hope, D. C. Jan. 9, 1862. — The weather for the season of the
year has been favorable; yet the temperature has been variable and the transitions quick. This has produced per-
haps more sickness from diseases of the respiratory system than a colder and less variable season might have caused.
Catarrhal aflections Iiave prevailed to a considerable extent. Another cause of the pievalencc of such complaints is
to be found in the fact that the tents in which the men sleep are furnished with small sheet-iron stoves of poor quality,
easily and quickly heated and as quickly cooled again. I'niess these stoves are constantly supplied with fuel the
temperature quickly falls to a low range, so that the men's quarters are all the time either too hot or too cold. Just
Iwfore the break of day, when the mercury ordinarily falls many degrees lower than at any other hour, the men from
fatigue being all asleep, the stoves go quickly out, and, as the top of the tent is open to the atmosphere, dew, frost,
snow or rain, as the ca.se may be, descends on the men. who appear at surgeon's call with complaints of paiiis, coughs,
colds, fevers, etc,
Ass't Surgeon T. W. Mc-A.KTHt:R, 39th Ohio. Pahiigra, Mo., Dec. 31, 1861. — During November there were several
cases of diphtheria and pneumonia. The weather was cold, with snow, and in most of the tents some form of heating
apparatus was constructed, usually furnaces. I doubt not these furnaces had much to do in producing disease.
I may here mention an interesting incident: At midnight I was called to see a man who was said to be dying. On
arriving at the tent I found two men in slight spasms while a third was wild with delirium. In the centre of the
tent was an open vessel filled with coals. The canvas had been rendered almost impervious to air by a coating of
snow on its surface. I lost no time in dragging the smothering men into the open air. They all recovered.
Surgeon E. P. MoKOXG, 2d Md., Dec. 31, 1861. — The regiment is quartered in the common wedge or .servants'
tent. Eight of the companies were supplied with tents so worn by previous service as to be unfit for the protection
of soldiers, especially at this season of the year. Straw has been supplied, but most of the men refuse to use it,
believing it to be a fruitful source of vermin. The tents are all heated by small sheet-iron stoves or by trenches pass-
ing beneath the flooring, in one end of which a fire is built. An apartment so small is quickly overheated, and the
sudden change of temperature to which the men are exposed in passing in and out of the tent is a constant source of
catarrhal coiujdaints. Moreover, as there is no mealis of ventilation except by leaving the flap open, which no soldier
will do at this season, the atmosphere of the tent is constantly nu)re or less vitiated. The men are generally clean
and orderly in their habits. Their clothing is of poor material and they have been supplied witlvbut one blanket
each, many of which are made of two thin sheets of cotton and woolen material machine-stitched together.
.'burgeon Jxo. Letterm.^x. V. S. A., Medical Director, Armg of the Potomac, to the Adjutant General of that army,
March 9. 186:!.— I have the honor to invite the attention of the Commanding General to a practice quite prevalent in
this army, that of excavating the earth, building a hut over the hole and covering it over with brush and dirt or
canvas. This system is exceedingly pernicious and must have a deleterious effect on the health of troops occujiying
these abominable habitations. They are hot-beds for low forms of fever, and when not productive of such diseases
the health of the men is undermined, even if they are not compelled to report sick. I strongly recommend tliat all
troops that are using such huts be directed at once to discontinue their use, and that they be removed to new ground
and either build log huts above the ground or live in tents. I also recommend that in huts covered by canvas the
covering be removed at least twice a week, if the weather will permit, and that the men throughout the army be
compelled to hang their bedding in the open air every clear day. In huts not built over an excavation, but covered
with brush and dirt or other materials which cannot be removed, such apertures as the Medical Director of the corps
may deem necessary should be made to allow light and ventilation. I am convinced of the propriety of these sug-
gestions as well from my own observations as from the information which I have derived from reports of inspections
made by my orders within the past few weeks.
718 DISEASES ATTKIBUTED TO NON-MIASMATIC EXPOSURES.
Jttcmliiiij Siirinoii Hexky E. Turxeh, Fort Adams, Neifport, H. L, April 1, 18G3. — A large proportiou of the cases
have beeu coughs, sore throats and rhenniatic afl'ections. These Avere generally not severe, the men usually return-
ing to duty after two or three days. The maladies from vs'bich the garrison has suffered have been such as are inci-
dent to damp quarters and a variable climate in a remarkably open winter.
AssH Surgeon J. F. Day, Jr., IO//1 J/c, liilay Homv, Md., Dec. 31, 1861. — We were encamped in a low, damp piece
of ground, and the great increase of bronchial diseases during that time indicates that their prevalence was due to
the location; another cause was the sudden changes of weather from warm to cold and rice versa. These causes also
produced the few cases of pneumonia and pleurisy which we have bad.
Siirr/eon J. Pasc.vl S.mith, G9th N. T., near Alexandria, Va., Dec. 31, 1861. — The (juarters of our soldiers are the
common A tent, in each of which seven or eight men are crowded. As these tents are wholly unsupplied with boards
or straw and the men have but one blanket each to separate them from the damp ground and cover themselves, the
predominance of catarrhal and rheumatic at}'ectio;is is easily explaiued.
Sitrtjcon Chakles A. Dean, 89//i Corps d'Afriqiie, Port Hudson, La., Feb. 19, 18G1. — Pneumonia has been aud is
now the prevailing disease. It is caused, I think, by living in tents without lire and sleeping without suiScient bed-
ding during the recent cold weather.
Act. Ass't Surgeon Calvix G. Page, lltU U. S. Inf., Fort Independence, Mass., Oct. 5, 1861. — There has been one
other cause of bronchial trouble, which still continues. The men are furnished with woollen shirts without collars,
and there is a space, varying according to the conformation of the man, of from one to two inches between the upper
edge of the flannel shirt and the lower edge of the leather neck-stock entirely bare and unprotected by clothing.
Surgeon J. E. SanIiORN, 2~tli Iowa, .laclson, Tenn., April 30, 1863. — Most of the resj^iratory diseases have been
bronchial coughs merely, the result of exposure to spring cold and wet, together with an enfeebled condition of the
pulmonary capillaries, a sequel of measles. Our limited supply of expectorants has left us little choice in the treat-
ment of these diseases. We have used external remedies largely and internally small doses of ii^ecacuanha. Tint par-
ticularly a solution of tartar emetic with sulphate of morjihia.
Surgeon Exo.s G. Chase, 104(/! X. Y., June 30, 1862. — The regiment was at Kalorama, near Washington, during
the first half of April, when diseases of the respiratory system prevailed to a considerable extent owing, I suppose, to
sudden changes of temperature and to the fact that hundreds of men had recentlj' recovered from measles and were
therefore peculiarly susceptible to these changes.
Surgeon F. H. Peckham, 3d E. I., Fort Wells, Hilton Head, S. C, Jan. 1, 1862. — Bronchitis has been somewhat
prevalent among the officers as well as the men. This, I think, is due in a large degree to the inhalation of dust and
minute particles of sand. Owing to the absence of rain for some time past the surface of the ground has become very
dry. aud the constant movement of troops and teams has kept the atmosphere charged with dust aud fine sand.
Surgeon Pacl M. Fisher, 8tli Me., Hilton Head, S. C, Dec. 31, 1861. — Catarrhs, bronchitis aud tonsillitis have
been caused by a deficiency of straw to protect the men when sleeping on a soil which has the subsoil water-level
within three feet of the surface. But other causes have had their share in their production: The men have not had
sufficient clothing day or night; the middle of the day is very warm and the evenings and nights cold; the soil here
is sand, and when dry the least wind or motion of men or animals creates a cloud of dust, which induces and aggra-
vates all diseases of the air-passages.
Surgeon John Murphy, 92d Corps d'Afrique, Port Hudson, La., Feh. 19, 1864. — On Jan. 7, 1861, we were ordered
to Port Hudson. During a severe storm the men were jjlaced in open cars from Brashear to Algiers. Some fifty or
sixty of them had their feet frost-bitten. The regiment was quartered in a machine shop without any conveniences
for building tires, and as a result many were severely chilled. From that date- pneumonia has prevailed, assuming
at an early stage a typhoid character and attended with great mortality. We remained at Algiers from the evening
of January 7 until the 12th; we then embarked for Port Hudson, arriving on the 11th. The weather continued cold
and wet, increasing our sick report. From that time to the preseut we have lost fifteen men: Number of cases of
pneumonia treated during this period forty-nine; deaths eight.
Surgeon Robert K. Reid, 3d Cal., Salt Lu'ke City, Utah, March 31, 1863. — Bronchitis and catarrhs, [ileurisy aud
pnenmorria follow exposure and are persistent and troublesome.
Surgeon W. M. S.mith, 851h N. T., New Berne, X. C, Feh. 22, 1863. — Sickness was greatly increased within ten
days after leaving Elmira, [Dec. 3, 1861,] pneumonia, bronchitis and rheumatism being the prevailing diseases.
Many of the men had sufiered from measles at Elmira, and while in transit to Washington were nuich exposed in cars
destitute of stoves or other warming arrangements. To these causes and the exposed condition of the men for several
days after reaching Washington, beiug unable to procure straw to protect them from the ground at night, is undoubt-
edly due much of the increase of sickness. * * * A comiiarisou made at the time [shortly after Jan. 29, 1862,
when the camp was on Meridian Hill, Washington, D. C] of the prevailing diseases of regiments that occupied
barracks with those that wintered in tents convinced me that while fever was the prevailing and most serious disease
of the former, pneumonia was most frecjuent aud fatal in the latter. It appeared to me that the prevalence of pneu-
monia was greatly encouraged by the arrangements adopted for warming the Sibley tents. The sheet-iron stove in
general use for that purpose quickly heats the atmosphere of a tent to a high temperature, which falls rapidly when
the fire in the stove goes out. This fluctuation in the atmosphere cannot but greatly contribute to the development
of pneumonia. A great majority assumed a typhoid condition. An early and vigorous supporting treatment was
adopted with gratifying results. Stimulants were generally found useful and often used very freely in connection
with beef-essence.
DISE.\SES OK THE KESPIR.VTORY ORGANS.
719
Sur/jeoH M. R. G.\GE,25(/i TTis., Camj) HandaU, JTis., Dec. 31,1862. — Rheumatism has been of common occiineuce
and many of the cases serious. Lying upon the damp ground is no doulit the cliief cause, and is nearly certain to
cause a recurrence of the disease in those who have at any time previously suffered from its attacks. To these cases,
if fever lie a dominant symptom, we give first an active purgative of which calomel is an important constituent;
then follow with such doses of opium as will ijuiet the suffering, in combination with calomel as an alterative. When
the gums have shown the mercurial trace that remedy is dropped, continuing the opium as before, with small (juanti-
ties of ipecacuanha, opening the bowels at occasional intervals. When the more acute symptoms have disapj)cared
colchicum is found serviceable, in proper doses, continued with the opiate treatment already instituted. We pay
little attention to topical applications in the acute form of rheumatism, believing them to Ijc in fact of no service.
I.— DISEASES OF THE RESPIRATORY ORGANS.
From what has been submitted in the preceding paragraphs it is evident that these
diseases were due to conditions of exposure that were avoidable so long as they were
uncalled for by the military necessity. Fresh troops hail a greater susceptibility to atmos-
pheric influences than those whose experience enabled them to avoid needless dangers and
discomforts and to protect themselves more or less when the exposure was unavoidable.
As might be expected, therefore, the prevalence and fatality of these diseases were greatest
during the first year of the war, after which they became progressively diminished. This,
with the greater fatality of the cases among the colored troops, is shown by the following
series of rates :
Table LTV,
Showing 'he annual and average annual rates of Sichness and Death from Diseases of the Respiratory
Orr;ans, as also the percentage of Fatality of these diseases among the U. S. Troops for the jjeriods
stated, expressed in ratios per J, 000 of strength.
WHITE TROOPS.
Year ending June 30 —
.\verago annual
Djsea^j of tho Respiratorj-
Organs.
1862.
1803.
1864,
1865.
1860.
ratio of—
Cases.
Deaths.
Cases.
Deaths.
Cases.
Deaths.
Cases.
Deaths.
Cases.
Deaths.
Cases.
Deaths.
Catarrh*.
299.5
40.5
93.6
13.9
9.3
39.6
18.2
27.5
,02
,02
,35
,12
.12
7.45
.29
.96
92.T
99.0
15.7
0.9
34.3
17.3
40.2
1
209.5
01.4
76.8
12.3
7.9
27.8
14.5
26.1
.02
.01
.27
.22
.10
6.21
.25
.49
.00
.02
.39
1.97
1.35
24.08
1.85
2.02
.03
.31
.29
.15
7.23
.25
.53
56.1
64.4
10.2
7.4
26.0
12.7
20.9
.01
.27
,20
.08
6.00
.27
.38
51.4
02.4
10.8
6.2
20.3
12.6
17.9
."25"
.25
.06
5.54
.24
.40
22.2
53.6
8.1
4.1
9.3
9.1
14.2
.10
.05
1,75
.08
.18
Acute bnmchitis
Piii>uuioum
Pleurisy ,
Other diseases,.
Total
M2.1
9.33
308.4
8.79 '■ 197.6
7.20
181.0
6.73
120.7
2.09
265.05
7. 50
2.98
COLORED TROOPS.
88,4
185.3
20.8
16.9
181.3
56.1
47.1
.09
2.46
1.00
.35
52.90
3.40
1.02
52.7
127.7
15.2
17.9
75.0
39.5
14.1
.01
1.32
.95
.21
25.81
1.10
1.54
27.4
66.9
9.7
8.8
31.7
24.7
8.5
1
.42 i
.32
.09
8.80 '
.74
.58
53.8
123.5
14.9
14.9
88,0
39.1
20.5
.03
1.33
.78
.21
27.29
1.59
1.13
.05
1.12
5.45
1.40
32.44
4.24
5.77
.\rnte bniuchilis
("hronic bnoichitis
Larvnuitis
Other diseases
:::::::::::::::::
Total
342.1
31.01
177.7
10.95 .
354.7
32.35
9.54
Among the Confederate troops these diseases, as shown by Table XIV,t ^^''^^'^ '^^
more frequent occurrence than among the Federal soldiers, no doubt because of the com-
parative scarcity of clothing, blankets and shelter-canvas in their blockaded territory, and
of the greater susceptibility of men moved northward from a warmer climate. Pneumonia,
for instance, annually affected 103 men of every thousand, while the corresponding rate for
our white troops was but 34, and the cases reported as acute bronchitis and catarrhs num-
bered 415 yearl}^ per thousand of strength as against 192 in the Union ranks.
* Catarrh was remoTed from the list of diseases on the Jlontbl; Sick Kcports Jnno 30, 1862.
t Siipm^ page 32.
720
DISEASES OF THE RESPIRATORY ORGANS.
It appears probable, also, that generally these diseases were of as grave a character as
among the Federal troops. Joseph Jones has published many statistical tables relating to
the ratio of deaths to cases in his article on the prevalence and fatality of pneumonia in the
Confederate armies;'"' but in most of these some factor essential to accuracy is wanting.
When the calculations are made from the field reports the deaths that occurred after transfer
to the general hospitals are omitted; when made from the hospital reports the frequent
dujDlication of cases by the custom of entering every transfer as a new case is an element of
fallacy. But among his tables are two which give the needful data: The troops operating
in South Carolina, Georgia and Florida during the nineteen months, January, 1862, to July,
1863, inclusive, reported 2,220 cases, of wdiich 127 terminated fatally in the field and 370
in the hospitals, making a total of 497 deaths, equivalent to 22.4 per cent, of the whole
number of cases. During the eight months, June to December, 1862, and May, 1863, there
were reported in the Army of the West and of Tennessee 3,023 cases of pneumonia, 548
of which proved fatal in the field and 495 after their transfer to general hospitals, making
a total of 1,043 fatal cases or 34.5 per cent, of the whole number. These percentages are
higher than the actual rates, inasmuch as the cases that occurred in the floating population
of the hospitals are not included in the number of cases used in their calculation; but com-
parisons are admissible, as the Union rates are similarly affected.
The registers of the Chimborazo hospital, which have been freed from duplication of
cases, show that in the wards of this institution 37.18 per cent, of the cases of pneumonia
and ])leurisv proved fatal.f
The mortality of these diseases per thousand of the Confederate strength cannot be
obtained, except doubtfully in the instance of pneumonia. By consolidating the various
tables published by Jones the deaths caused by this disease during a period of fourteen
months in an aggregate strength of 72,617 men maybe obtained. In view of the greater
frequency of the disease among the Confederate troops and the general gravity of the cases,
a higher death-rate per thousand would be anticipated among them than among the white
troops of the United States armies.
Table LV,
Contrasting the 3IortaUty from Pneumonia in rates per thousand of strength in certain of the Confederate
armies and tlie vhile commands of the Union army.
Commands.
Strength.
i.9
R
Death-rate per
1,000 for the
period.
Annual death-
rate per 1,000.
Department of South Carolina, Georgia and Florida, January, 1862, to July,
18(.i3— 19 mouths _•
Confederate forces at Mobile, Ala., January, 1862, to July, 1S63— 19 months..
Department of Tennessee, June to December, 1862, and May, 1863 — 8 months..
Army of the Valley of Virginia, January to October, 1862 — 10 months
Average strength of the above forces for-the average period of 14 mouths
Union white troops, year ending June 30, 1863 ...^
25, 732
6, 752
30,452
15, 582
497
151
1,043
50
19.3
22.4
34.2
3.2
12 2
14'. 1
51.3
3.8
72, 617
614, 325
1,741
4,769
24.0
7.8
20.6
7.8
This table shows a Confederate death-rate of 20.6 per thousand of strength as compared
with a Union rate of 7.8; but tlie difference between the rates was actuallv greater, for the
* In the Sledical Volume, U. S. Sanitarif Commission Memoirs, Kew York, 1867.
f See Table XII, supra, page 30.
DISEASES OF THE EESPIRATORY ORGANS.
II
mortality returns from the Army of the Valley of Virginia are incomplete: Dia'ing the ten
months covered by the published statistics of this army 1,034 cases of pneumonia were
reported, with only 50 deaths or 4.8 per cent, of the cases; but to this mortality should have
been added much of that which was caused by this disease during the period in question at
the Staunton hospital, Va.. where the ordinary rates of fatality prevailed.
The statistics show also that diseases of exposure were, more prevalent and fatal among
the PRISONERS OF WAR than even among the colored troops. This was to have been expected,
in view of the many hardships and exposures which attended the capture of these men and
their transmission to the prison depots, their want of clothing and blankets and the imper-
fection of the arrangements for their well-being during confinement. The following tabular
statement summarizes the information derived from the records of the principal prison depots.
Tonsillitis and diphtheria have been embodied in this table as diseases allied to the acute
inflammatory affections of the respiratory tract :
Table LVI,
Showing the Prevalence and Mortality from certain diseases attributed to atmospheric exposures among the
Confederate prisoners held at the principal prison depots in the United States. Average period
covered by the observations two years; average strength present 40,815 men.
Diseases.
Total number
of-
Average annual
rate per 1,000
strength.
Percentage of
fatal cases.
Cases.
Deaths.
Cases. Deaths.
Catarrh, ppideniic catarrh
Chrouic bronchitis
PneiiinoDia
and acute bronchitis
17,768
1,278
12,210
,58
82
4,888
154
20
13
49
217. 6 0. 7
15.7 1.0
149.6 .59.9
0.32
6.4
40.0
7.3
2.5
0.38
10.9
Pleurisy
2,109
802
3,413
-.50
25.8
9.8
41.8
5.G
1.9
0.2
0.2
0.6
Laryngitis ..
Tonsillitis
Diphtheria ..
Total
38, 030
5,264
465.9 1 C^i 5
13.9
The average annual number of deaths from these diseases was 64.5 per thousand pris-
oners as against 32.35 among our colored troops and 7.56 among our white soldiers. Pneu-
monia was the fatal disease to which so many of these men fell victims. Its annual death-
rate per thousand men was 59.9 as compared with 27.29 among our colored and 6.21 among
our white troops. Of every hundred reported cases of pneumonia in these prisons 40.0 were
fatal as against 32.44 among the colored men and 24.03 among the white troops. The
condiUons that contributed to these results have already been explained.*
The annual death-rate from pneumonia and pleurisy per thousand prisoners at Ander-
sonville was seen by Table XVI to have been 27.4. This number is small compared with
the rates. that prevailed in Northern prisons, and may be regarded as indicating climatic
aiflferences; but the accuracy of tlie diagnosis may well be questioned at a prison where so
many died in the enclosure unknown to the medical officers.-}-
The diagram facing page 722 shows the seasonal character of the catarrhal and pneu-
monic diseases that have been ascribed to cold and moisture. Their waves of prevalence
• See «r;>ria, pacre 70.
Med. Hist., Pt. Ili— 91
t See svpra, iinge 39.
709
DISEASES OF THE EESPIEATORY ORGANS.
agree in their general outline. Their minima correspond with the warmer, their maxima
with the colder months of the year.
Tlie remarkable prominence of simple catarrh during the only year in which cases were
reported under that title was associated with an epidemic of measles. By comparing the
rise and fall of its monthly rate with those of the specific disease, as shown in the diagram
facing page 650, this catarrh will be recognized as having been a sequel of the eruptive fever;
The latter was of frequent occurrence among the new levies during the summer and autumn,
but in November its influence became largely extended, and in December it attained its
maximum; catarrh followed, reaching its maximum in January. The eruptive fever declined
to average rates in February, but these rates were not reached by catarrli until April or May.
The less extensive epidemic of measles in November and December, 1862, may be regarded
as corresponding with a prominence in the line of epidemic catarrh and the epidemic of
March, ]864, as connected with a trivial elevation of the same line.
The regularity of the seasonal waves of prevalence of acute bronchitis is broken, on the
diagram, only by a sudden elevation in July, 1862. This is evidently due to the change
then adojDted in the manner of reporting cases of catarrhal inflammation of the respiratory
mucous membrane. The rate of catarrh for June was 8.0, of acute bronchitis 2.2 — mahino-
a total of 10.2; and in July, corresponding with the exclusion of catarrh from the reports,
the rate of acute bronchitis rose from 2.2 to 8.8. The progressive decrease in the size of
the waves of pneumonia and pleuri.sy is well shown in the diagram.
The line indicating the j^revalence of tonsillitis, as seen on the diagram facing page 738,
presents seasonal elevations corresponding with those already observed in the purely respi-
ratory diseases. Diphtheria, however, had no such marked seasonal accessions. This will
be referred to hereafter.
The season of increased prevalence of the diseases mentioned extended from October
or November to March or April. Observations on their frequency in civil life in this countrv
have given similar seasonal results.*
The following tabular statement, constructed from data in Dr Jones' article, already
cited, shows the relation of season to the prevalence of pneumonia in the Confederate armies.
The disease decreased with the advent of warm weather. Th-e month of Julv, 1862, fur-
* The following tracing was made
from statistics covering tbe period frnm
January, 1880, to May, 1882, publishe.l
in the BuUetin of the National Board of
Health. The facts were derived from tht-
weekly reports of health officers. The
population represented was mostly ur-
ban and averaged about eight millions.
The monthly rates in tbe tracing are ex-
pressed in their equivalent annual rates
per thousand of population. The un-
broken line indicates tlie fluctuations in
the prevalence of all acute diseases of
the respiratory organs, the broken lino
the corresponding fluctuations of pneu-
monia, which was reported specially
only during the twelve mouths, June,
1881, to May, 1SS2. So far as these sta-
tistics go they indicate just such a jiar-
allelism, as regards prevalence, betw een
pneumonia and the other acute diseases
of the organs of respiration as has been
shown to have existed among the trooi)s
during the war.
188 0.
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DISEASES OF THE KESPIKATORY ORGANS.
123
nished an exceptionally high rate. This was noticed by JoxES, who, however, failed to give
a satisfactory explanation of the anomaly. The monthly rates in this table may be com-
pared with the lines indicating monthly prevalence in the Union Army as shown by the
diagram facing page 650.
Muutb.
streugtii.
H
•= =
253
•^ to
31oiUli.
Mean
-.tn-iiL'th,
il
I4
u
1R62: — Jiunmry
232, 138
21lt,060
lfif>,047
5S, -MA
6S.090
13fi, ZG2
7t), '.I'.ty
113,407
125,408
150, 734
3,060
2,041
1,849
801
3(50
.SSI
820
4;iO
179
384
17.05
9.31
11.20
15.28
G.13
C.4I)
10.32
3.70
1.42
2.45
18G2: — November '
270, 480
172, 800
192, 77li
215, 4o8
313, 848
100,518
li-.;i,7ii
1I'7,W3
72,390
2,282
2,085
2, U70
1,997
2,810
1,779
1, 693
21"
8.43
17.27
13. 88
9. 20
8. 97
9.33
9.73
2.49
LOG
1863 :— .Tanunry
March
April
Mav
' August
SepU'iiibcr
(Vtob'cr __.......
July
The well detined- connection between pneumonia and low temperatures leads to the
expectation that regionic intiuences would be mainly climatic; but the diversity of the cli-
matic conditions presented by the immense regions — the Atlantic, Central and Pacific — into
which the medical statistics of the war wore oritiinallv consolidated, renders the consolida-
tions valueless from the medico-topographical point of view. The table on page 724 presents
the prevalence of catarrhal and pneumonic affections in the several military departments of
the regions in figures which admit of comparison.
The average annual number of cases of catarrhal iirflammation of the respiratory mucous
membrane per thousand of strength did not differ materially in any of the regions. The
rates in the Atlantic and Central regions were very similar, and diminished progressively
year by year from 448.4 in the former and 420.6 in the latter during the year ending June
30, 1862, to 114.9 and 109.6 respectively during the year ending June 30, 1865; but the
rate in the Pacific region, although lower in the first year, owing to the comjiarative iuimu-
nity of the troops from measles, was so much higher than those of the other regions during
the remaining years as to raise its average rate to a somewhat higher figure than the average
of the regions.
Within each region the proportion of catarrhal cases depended in general terms on
latitude. In the Atlantic region during the first year the statistics were disturbed by the
great prevalence of measles in the Middle Department, which, at that time, was the camp-
ing ground of the new regiments awaiting absorption into the army; but during the remain-
ing years the departments which lay north of Washington had, as a rule, larger rates than
those which were south of it. In the Central region the Department of the Nortliwest
and the Northern Department luid generally larger rates than the Southern commands. In
the Pacific region catarrhal affections were more common in the Department of the Pacific,
which extended to the Canadian border, than in Colorado, New Mexico and Arizona, which
constituted the Department of New Mexico.
But pneumonia, although parallel with the catarrhal affections in its monthly preva-
lence, diverged from them in its regionic distribution. The rates in the Central region
greatly exceeded those that prevailed on its Pacific and Atlantic sides. Latitude was an
important factor, for in the Atlantic region the disease, like the catarrhal affections, was
more common in northern than in southern commands, and in the Central region the troops
724
diskases of the respiratory organs.
Table LYII.
Showing by ratios per thousand oj strength the relative frequency of Catarrh of the Respiratory Mucous
Membrane and Pneumonia among the white troops of the several Departments and Regions during
the four years of war service, July 1, 1861, to June SO, 1865.
Deiiartments and Regions.
Catarrh, Epidemic Catarrh and
Acute Bronchitis during the
year ending June 30 —
1862. 1863
Department of the East
Middle Department
Department of tlie Shenandoah
Middle Military Division
Department of Washington
Army of the Potomac
Department of the Rappahannock .
Department of Virginia
Department of North Carolina
Department of the South
683.2
390.1
' 476.2
I 218.7
i 399.0
! 376.8
463.0
255.9
246.9
234.5
189.2
Atlantic Region.
199.6
266.3
160.7
1864.
250.6
195. 2
204.6
96.6
133.9
141.1
170.9
1865.
210.1
132.2
81.9
123.6
90.2
162 6
117.3
135.4
448.4
205.6 142.4
114.9
Pneumonia during the years
ending June 30 —
1862.
33.9
33.2
28.0
20.5
12.7
20.2
16.1
1863.
1864. I 1865.
22.5
35.1
46.7
24.5
26.9
26.8
34.1
18.3
30.0
12.9
15.5
19.4
12.8
16.6
11.7
5.5
13.8 I 9.4
20.5 27.5
10.1 , 13.9
26.0
20.'
18.6 I 15.7
Department of the Northwest
Northern Department
Department of West Virginia
Department of Missouri
Department of the Ohio _
Department of the Cumberland
Department of the Tennessee
Military Division Mississippi, Part I..
Military Division Mississijipi, Part II-
Department of Arkansas
Department of the Gulf
Central Region .
526.6
512.2
482.2
483.0
266.6
235.5
420.6
381.
419.
208.
188.
171.
172.
159.0
148.4
176.4
172.7
306.2
111.3
220.1
119.3
80.2
73.5
125.0
311.1
166.
132.1
67.9
127.4
39.1
137.9
80.0
105.6 ' 109.6
80.6
38.6
120.7
"eo'o".
56.3
121.1
64.1
46.7
57.2
58.7
45.7
46.7
19.0
14.7
04.
17.1
39.3
111.8
16.2
69.1
37.7
19.5
25.9
40.4
14.4
34.1
69.0
'3a i
27.8
9.4
26.3
13.5
30. 4 23. 4
Department of New Mexico 109. 0
Department of the Paciec 398.3
Pacific Region 258.5
254.1
234.8
197.7
222.2
91.1
260.4
11.3
21.1
20.7
8.9
14.9
17.1
27.4
27.4
242.6
212.3
205.1
16.3
13.7
16.2
27.4
Total.. ! 433.6
191.0
120.5 I 113.8
39.6
34.3
26.0 20.3
in the Department of the Gulf enjoyed an immunity from, the disease as compared with
those in the Northern departments. Apparently the principal cause of the high rates of
the Central region was the great frequency of pneumonic cases in the Departments of the
Missouri, Oliio, Tennessee and Cumberland, particularly during the first and second years.
These cases were probably the effects of the continued exfiosure to cold and wet necessitated
by the military operations which opened up the Mississippi river. Later, as when the
armies were operating against Atlanta or crossing the country to tlie Atlantic coast, the
pneumonic rate became much reduced; but as the troops under General Sherman, in their
march across Georgia, had a rate of only 9.4 per thousand, while those left with General
Thomas continued to have a rate similar to those of the Departments of the Missouri and
Arkansas, it seems as if along the great lines of drainage of this vast central region the
causes of pneumonia had been more potent than on the ocean slopes or western prairie lands.
The Confederate statistics appear to confirm this deduction, for while the Army of the
Tennessee, which served in the States of Tennessee, Kentucky, Alabama and Mississippi,
EPIDEMIC CATARKH. 725
Iiad an average annual rate ot" 173.1 j>neiunonic cases per thousand of strength, as calculated
I'rom the statistics submitted by Dr. JoxES, the troops in South Caj-olina, Georgia and Florida
had but 54.5, those in the Valley of. Virginia 79.6 and those around Mobile, Ala., lOS.G.
I.— CATARRH.
During the fourteen months. May, 1S61, to June," 1862, inclusive, 85,677 case:< ui'
catarrh, six of which terminated fatally, were reported among the white troops. No par-
ticulars of these cases have been recorded. On the date last mentioned the terra catarrh
was dropped from the Monthly Reports of Sick and Wounded. Subsequently cases which,
according to custom, would have been reported under this title, appear, from the diagram
facing page 722, to have found place under the heading acute bronchitis.
II.— EPIDEMIC CATARRH.
A large number of cases were reported under this heading — 134,397 among the white
and 9,869 among the colored troops. Nevertheless, as these cases were distributed fairly
among the various commands and throughout the several years covered by the statistics,
giving an annual average rate of 61.4 per thousand of strength among the white and 53.8
among the colored troops, it may be doubted whether the disease thus reported was in
reality that for which the heading was provided. In fact the cases appear to have been
occasioned by local rather than epidemic influences. During the winter-quarters of the
Army of the Potomac, 1863-4, the forty-five or more regiments of the Second Army Corps
were hutted near Cole's Hill, Stevensburgh, Va. Four of these regiments reported the
existence of epidemic catarrh, while others had only occasional cases of acute bronchitis,
and a few belonging to the Second Division, which was quartered on a high and rather
exposed hill-side, were absolutely free from sickness. The four regiments affected with the
so-called epidemic catarrh were encamped on low-lying and damp ground. The principal
sufferer, the 148th Pa., reported 55 cases in January, 70 in February and 54 in March. Its
camp-ground was trampled into deep mud by the men in the routine of their daily duties.
Their feet were constantly damp and cold and their spirits depressed. The regiment^ never-
theless, labored earnestly to improve its condition. The huts were floored with split logs;
sidewalks of the same material were built on the company streets over deep trenches which
drained the building sites, and pathways were laid to keep the men dry-shod in all the
ordinary movements of the regimental domestic econom3\ In fact the command raised itself
above the mud of its camp-site. As a result of this energetic work the catarrhal epidemic
ceased; no case was reported in April. In May of the same year the 2d N. Y. Heavy
Art'y returned 150 cases of epidemic catarrh, or nearly one-half of the total of 322 cases
reported as having occurred among the 115,385 men constituting the strength of the Army
of the Potomac; and in June this regiment returned 41 of the 63 cases reported from a
strength of 98,384. The regiment was new to field service. During the previous winter
it had occupied the fortifications of Washington, D. C; but in ]May it was relieved and sent
to the front when the battles of the Wilderness, Spottsylvania and Cold Harbor were in
progress. Its raw material, under the exposures of the bivouac, became affected with catarrh
associated with great disturbance of the system and unusual prostration, which was due
rather to the unaccustomed fatigues and privations undergone by the men than to any epi-
demic influence.
726 ACUTE BEO^'CHITIS.
It seems probable, indeed, that most of the reported cases were of a character similar
to those mentioned, — endemics of simple catarrh originating in faulty camping grounds or
local epidemics due to unwonted exposures.
Surgeon Orpheus Everts, 20(AJh(Z., PoolesviUe,Md., Oci.2i, 1SG2. — Soou after camping at Fortress Monroe [Sept.
25, 1861] an epidemic of influenza appeared in the regiment, which I learned had affected the 1st Del.,* encamped
close by, before our arrival, and from -which but few escaped being more or less affected. The cough was violent and
very persistent, but attended with little constitutional disturbance. The men suffered more from loss of sleep on
account of the annoyance of the cough and muscular soreness from the violent exercise of the respiratory muscles
than from any febrile or other disturbance of the system. Eemedies administered seemed to make but little impres-
sion on the cough. All the usual formuhe were tried.
Sm-i/co)i D. Minis, 48(/i Pa., Camp CJarl-, Ta., JVoc. 30, 1861. — About the end of October, while encamped at Camp
Hamilton, near Fortress Monroe, an epidemic catarrh made its appearance amongst us. Nearly every man in the
regiment was more or less affected by it. My report exhibits but a limited number of those attacked, only those cases
of grave character coming under our official notice. The disease was characterized by severe aching, throbbing pains
in the head, back and limbs, bronchial inflammation and hepatic disorder. It yielded readily to moderately large
doses of sulphate of quinia and Dover's powder in combination; but in all its severer phases was followed by unusual
physical debility and tedious convalescence.
Sai-f/eon Ezra Read, 21st Ind., Fort Marshall, Bnllimore, Md., Jan. 14, 1862. — In December catarrh prevailed lu
an epidemic form and was attended with great irritation of the pulmonary mucous surfaces, headache and fever.
Anodynes and aijerients were the remedies relied upon and afforded as much relief as could have been expected:
depleting measures were not indicated. The disease prevailed for three weeks and had an average duration of about
eight days in each case. Loss of appetite, lassitude, debility, headache, jiain in tlie frontal sinuses and cough were
its prominent symptoms.
Surgeon S.\muel Kneeland, iotli Mass., IS'ew Berne, N. C.,Feb. 19, 1863. — A kind of influenza prevailed in Decem-
ber among the officers and men, rebellious to treatment and disappearing spontaneously.
Surgeon L. M. SlO-^naker, 19//i Iowa, Tlroiensrille, Texas, April 20, 1861. — These [cases of catarrh] were uncom-
plicated with bronchitis or pneumonia, and may all be considered dependent upon epidemic influenza. Many Avere
iiuite tedious, and two resulted in permanent partial loss of speech. The largest number occurred in March, while
the regiment was at Forsyth, Mo., on White river, — a location which is low and damp and hence favorable to catar-
rhal affections.
Ill— ACUTE BRONCHITIS.
The statistics hold this disease responsible for the occurrence of 168,715 cases of sick-
ness, of which 650 terminated fatally among the white troops. This, as has been seen in
Table LIV, is equivalent to an average annual rate of 76.8 cases and .27 deaths per thousand
of strength and to .39 fatal cases in every hundred. Among the colored troops 22,648 cases
and 255 deaths are reported, giving an average annual rate of 123.5 cases and 1.33 deaths
and a rate of fatality amounting to 1.12 per cent, of the cases. .
Only six cases of this disease appear in the case-books. Four offer no points of interest;
the two others, recorded by Act. Ass't Surgeon H. C. Newkirk, were treated at E-ock Island
hospital and, it is said, with benefit by inhalations of ether, chloroform, turpentine, etc., with
the subsequent occasional use of an expectorant mixture of squill and senega.
In addition to these cases, which recovered, there are ten deaths in the progress of or
subsequent to measles, the records of which present bronchitis as the princijjal abnormal
condition. The brain was examined in but one of these cases; the weights of the liver,
spleen and kidneys were stated, and remarks made on the condition of the intestines, while
the thoracic observations were recorded briefly as having shown the existence of bronchitis.
Possibly, in some of these instances, the influence of the specific poison destroyed life while
the lesions within the chest w'ere limited to the bronchial mucous membrane; but as nine
* D. W. M.^rll., Surgeon 1st Del., has given an account of this epidemic in the 3Iedkal and Surgical Jleporler, Philadcliihia, Vol. VII, 18G1-S2, p-
189. — ■UTiile the affection of the respiratory passages was not generally severe, although sometimes attended by uneasiness in the chest and exjiectoration
of blood, the disease was marked by a severe and almost invariable pain in the frontal region, which sometimes extended over the whole head, by pains
in the loinp, aching in the lower extremities and pain in the neck .and arms. Intestinal disorder was also prominent, evinced by severe diarrha'a with
frequent watery, bloody and mixed stools, tenesmus and tenderness of the .abdomen. There was great debility, but the febrile disturbance was not great.
Surgeon M.\ull states that thivt> -five men of his regiment reported for treatment in one day. The ejiideuiic continued more than two weeks.
ACriF. HKOXCHITIS. 727
of tliem occurred at tlio same hospital about the same tune, and were probably recorded by
the same officer, it is not unlikely that in the overpressure of work the lobular atelectasis
and coHi^estion which would have placed them among the secondary pneumonias were not
recognized. Cases 1-9 are from the records of Hospital No. 1, Nashville, Tenn.; case 10
occurred at Chattanooga hospital, Tenn.
Ca.<e 1.— Private Baker Parliani, Co. H, 2d East Tenn. Cav.; adnirtted March 2, 1864, with bronchitis consecu-
tive to measles. Died 3d. rosl-morlcm examination: The bronchial tubes were highly iullanicd and contained muco-
lins. The heart was lillcd witli unusually large light-yellow clots weighing six ounces: the heart, without the clots,
weighed fourteen ounces. The liver weighed eighty ounces; the spleen and kidneys were healthy. The mucoits
membrane of the intestines was slightly inflamed throughout.
C.KSE 2. — Private Samuel Cowan, Co. K, 17th Ohio; age IS; admitted March (!, IStil, with measles. Died lOtli,
rv.il-mortn>i examination: There was extensive bronchitis on both sides. The liver was fatty and weighed seventy-
four ounces; the spleen weighed ten ounces. The kidneys and intestines were healthy.
C.VSE 3. — Private Joseph Stacey, Co. H, 5th Iowa Cav.; ago 18; admitted March 6, 1864, with measles. .Died
20th. rost-mortem examination : There was intense bronchial inflammation on both sides. The pericardiiiui contained
three ounces of liquid. Nothing else unusual was observed in the thorax or abdomen.
C.vsE 4. — Private .Saunicl R. Davis, Co. E, 12th Tenn. Cav.; age 21; admitted March 7, 181)4, with measles.
Died 17th. rosl-morlem examination. The bronchial mucous nTpmbraue was extensively inllamcd. The heart con-
tained large light-colored clots. The liver weighed seventy-two ounces : the spleen fourteen ounces. The kidnevs
and intestines were normal.
C.\se5. — Private William Taylor, Co. F, 2d East Tenn. Cav.; age 30; admitted March 9, 18G4, with measles.
Died 9th. Post-mortem examination: There was some bronchitis, but the lungs were otherwise healthy. The liver
weighed sixty-nine ounces; the spleen seven ounces and a half. The ascending colon, ca'cuni and lower third of the
small intestine were inflamed and of a mahogany color. The kidneys appeared normal.
Case 6.— Private Sylvanus W. Davis, Co. C, 76th Ohio: age 19; admitted and died March 24, 1864. rosi-mm-tciit
examination: Large livid spots on face, neck and trunk. Seventy-two ounces of sero-bloody Ihiid in left pU'ural
cavity, two ounces in right ; lungs much congested and bronchial mucous membrane highly and extensively inllained.
Heart nine ounces; liver forty-nine ounces; spleen seven ounces; kidneys, each, four ounces — all healthy. Small
intestine slightly inflamed.
Case 7. — Private Jacob Eddleraan, Co. D, 2d Ind. Cav.; ;idmitted JIareh 21, 18t)4, with measles. Died 31st.
Post-mortem examination ; The bronchial tubes of both lungs were inflamed. The liver weiglu d seventy-seven ounces;
the spleen eleven ounces. The other organs appeared normal.
Case 8.— Private George Carder, Co. I, 31st Ohio; age 17; admitted March 2.j, 1864, with measles. Died 29th.
Poal-morlem examination: The bronchial tubes of the lower lobes of both lungs were inflamed. No other marked
lesion was observed in the thorax or abdomen.
Case 9. — Private Joseph A. Granell, Co. H, 7th Pa. Cav.; age 17 ; admitted March 27, 1864, with measles. Died
April 2. Post-mortem examination: The large bronchial tubes on both sides were greatly inflamed. There were firm
clots in the right cavities of the heart. The right kidney was of a dark coffee-color, but otherwise the abdominal
viscera were healthy.
Case 10.— Private J. F. Gensel, Co. I, 46th Ohio; age 29; was admitted March 19, 1864, with measles. On the
disappearance of the eruption, on the 24th, cough set in with muco-purulent expectoration. On the 27th the patient
had an aphthous mouth and diarrhiva, accompanied on the 29th by a good deal of fever, the tongue being dry and
fissured; mucous rales were heard on both sides of the thorax. Two days later erysipelas made its appearance on the
nose; the diarrhtea had ceased, but the patient was nervous and anxious. Delirium supervened on April 1, and death
by coma next day. Post-mortem examination : The membranes of the brain were injected. The pleura and the paren-
chyma of the lungs were normal; the mucous membrane of the bronchial tubes was red and contained a quantity of
muco-purulent secretion. The heart was normal. The mucous membrane of the stomach was mottled with bright-
red spots. The colon was injected and presented a number of ulcers, most numerous toward the rectum.
Among the post-viortem records of pneumonia are a number of instances of acute bron-
chitis fatal by the supervention of lobular inflammation.* One in.stance of plastic bronchitis
has been found:
Private Daniel Boren, Co. K, 96th Pa.; admitted Jan. 2, 1863. Diagnosis: Hemiplegia. Died February 2. /Vv(-
iiiortoii examination : Rigor mortis well marked; emaciated; veins full of blood. Brain, forty-nine ounces and a hall",
full of blood; choroid plexus pale, but its largest vessels full and tortuous; veins of pia mater injected; veins of pons
and medulla full of blood; gray matter apparently diminished in amount; striic of pons markcil. Right lung forty-
two ounces; pigment deposit on pleura in intercostal spaces; coagulable lymph on up]>er and middle lobes, which
were tirmly adherent and consolidated in the vicinity of the adhesions; remainder of the lung much congested; in
the large bronchial tube leading to the consolidated mass was a fibrinous plug one and a half inches long, filling the
* See i*i/ra, page 78.3.
728 CHKOSriC BRONCHITIS.
lumen ; surface of tube mottled white anil red. Left lung healthy. Heart, seven and a half ounces, tirm ; small clot
in each ventricle. Liver, forty-nine ounces, dark, friable; spleen, four and three-quarter ounces, much congested,
firm. Colon congested. — Lincoln Hospital, Washimjlon, 1). C.
The only paper referring to the treatment of acute bronchitis is as follows:
Surijeon M. R. Gage, 25th Wis., Columius, Ktj., March 31, 1863. — A number of cases of acute bronchitis have
occurred. It is treated in severe cases by cupping, repeated, if necessary, to relieve urgent symptoms. Counter-
irritation by mustard is found beneficial. The bowels are acted npon by podophyllin, bicarbonate of soda and calo-
mel, and this is followed by tartar emetic ad nauseam, as in pneumonia. If symptoms of debilitj' and prostration
ensue resort may be had to stimulating expectorants and to carbonate of ammonia, beef-tea, wine, etc.
But the medical descriptive lists indicate that Dover's powder, spirit of nitre, neutral
mixture and ipecacuanha were the remedies generally employed.
IV.— CHRONIC BRONCHITIS.
There were reported among the white troops 26,912 cases of chronic bronchitis, of which
529 or 1.97 per cent, had a fatal ending, giving the annual rates of 12.3 cases and .22
deaths per thousand of strength, while the number disposed of by discharge for disability
amounted to 3,729 or 13.9 per cent, of the cases. Among the colored troops 2,733 cases
and 149 deaths were reported, or 14.9 cases and .78 deaths annually per thousand of
strength, — the rate of fatality amounting to 5.45 per cent, of the cases; discharges among
the colored troops, as already explained,* were comparatively rare.
Notwithstanding the prevalence of this diseased condition, and its importance as a cause
of disability, twenty-three cases only have been discovered in the hospital case-books. The
frequency of the affection and its freedom from immediate danger to life probably account
for the want of interest displayed in the preservation of its records. From the meagre data
at command little can be said by way of generalization. The symptoms noted are more or
less cough with an expectoration scanty and glairy, whitish, frothy and mucous, sometimes
streaked with blood, or, more profuse, yellow and muco-purulent; pain in the chest, but
generally only on coughing; palpitation, shortness of breath and paroxysmal cough on exer-
tion. Tlie tongue was usually coated, although the bowels might be regular. The pulse
was frequent and weak. The body was sometimes fairly nourished and the appetite good,
but more frequently there was some emaciation and in advanced cases hectic fever. The
chest resonance was normal or increased ; the respiratory murmur was sometimes obscure,
but generally harsh and prolonged in expiration; mucous, sonorous and sibilant rales were
frequently noted. From these observations the condition of the bronchial mucous membrane
maybe appreciated as congested and swollen, with more or less hypersecretion and increased
corpuscular development, occasional obstruction of the tubes and emphysematous dilatation
of the air-cells.
Usually these cases had lasted for months before their appearance on the record. Med-
ication for a time was followed by no marked benefit. Expectorants were given, compound
liquorice mixture, squill, senega, ipecacuanha, etc.; chloride of ammonium was also employed;
wild-cherry was largely used as a tonic and to allay bronchial irritation, for which it was
given with morphine and chloroform. In addition the chest was blistered, or counter-irri-
tation was kept up by emplastrum picis cum cantharide, crotoa oil or iodine. Extra diet,
quinine and iron, cod-liver oil, porter or whiskey were also generally prescribed, with aro-
matic sulphuric acid in the presence of hectic. In progress of time an improvement was
manifested, the patient gaining in flesh and strength, but prone to dyspnoea and cough on
exertion and to a recurrence of his trouble on slight exposure. Furloughs enter into the
* See supra, page 28.
ASTHMA. 729
medical history of many of these cases, while others were placed on light duty in the wards
or kitchens of hospitals. Many recovered and returned to duty, and their names do not
reappear on the sick-reports from this cause. Others were ultimately transferred to the
Invalid Corps or discharged as untit for service. Although the statistics show that a notable
percentage of these bronchitic cases died, in but two instances do the case-books record tlie
progress to a fatal issue, — in one death appears to have resulted from the sudden develop-
ment of pulmonary congestion, and in the other from the supervention of laryngitis.
Case 1.— Private Joseph Hawkins, Co. K, 19tli Colored Troops ; age 24 ; was admitted Sept. 29, 1864, witli chionic
broiieliitis. Cod-liver oil, iron, stinuilant.s, expectorants and dry cupping were used in the treatment, witU iodide of
pota.ssiuni and volatile liniment when complaint was made at times of rheumatic pains, lie seemed to bo ini|>roving
steadily when, on ,Ian. 18, 18ti,">. he was taken with a pain in the left side of the chest and symptomatic pyrexia;
a blister was applied. Xext day he said he felt better; he got up and dressed; lie died within an hour afterward.
Post-mortem examination: The left lung was decidedly congested. — Summit Mouse IIo!<i»laI, Philadcljihia, Pa.
Case 2.— Private Christopher Wagner, Co. E, 61st N. V.; admitted Ang. 9, 1862. Bronchitis. Died Sept. 7th,
with symptoms of acute laryngitis. Post-mortem examination : Body vigorous; ageabout35. Adhesions of the right
lungthrougliout, also at middle portion of upper lobe of left lung; both lungs somewhat congested with black blood.
Mucous membrane of the air-passages, larynx included, indamed a;id the cricoid cartilage ossified and carious. The
heart was rather large, fatty and llabby; left ventricle dilated, walls about half an inch thick: one of the aortic
valves thickened by an opaijne yellowish-white deposit. Spleen large and .softened: the renuiiuing abdominal organs
healtliy. — Act. Ass't Surijton ,J. Lkidv, Suttirlee Hosintal, riiihi<hlpliln, I'u.
v.— ASTHMA.
This was, comparatively, an infrequent disease. During the tivo and one-sixth vears
covered by the statistics there were reported 9,365 cases among the wliite troops, or about
four cases annually in every thousand men; but as only 1,220, or about one-eighth of the
number, were discharged from the service as unfit for duty, it maybe inferred that in general
the bronchial spasm was amenable to treatment. The records, however, throw little light
on this subject. They are few and meagre, consisting of but six imperfect cases: In two of
these the origin of the disease is ascribed to exposure in cold and rainy weather. A slight
attack of bronchitis was associated with the onset in two cases, while in one every paroxysm
was preceded by a chill. In one case the patient was aflfected with tape-worm, but its expul-
sion, l)y means of turpentine, produced no beneficial effect on the asthmatic trouble. \n
another case the patient had been subject to the disease from childhood. Treatment was
continued in four of the cases for the respective j^eriods of four, seven, nine and nineteen
months, but without notable or permanent benefit to the patients. Tonics, as quinine and
iron, sedative expectorants and counter-irritants were employed. Chloroform entered fre-
quently into the prescriptions given to prevent or cut short the attacks,— three to five drops
in mucilage or with extract of wild-cherry or expectorants. During an attack small and
repeated doses of wine of ipecacuanha were sometimes administered. Mustard was used to
produce counter-irritation. In one instance iodide of potassium and extract of hyoscyatnus
appeared to exercise a marked influence on the conditions that occasioned the bronchial spasm :
Frederick Wilkesson, Co. C, 84th 111.; age 24; was admitted Dec. 2, 1863, with a gunshot wound of the left hand
and asthma. The wound was received at Chickamauga Sept. 20, 1863, and was healed at the date of admission; but
the patient had frequent attacks or paroxysms of asthma. Ordered iodide of potash and extract of hyoscyamus,
with fluid extract of cinchona, three times a day, and light diet. He had no paroxysm after he commenced taking
this preparation and was sent to his regiment March 22, \9&i.—Ho»inlal, Quincy, III.
In one of the four cases that were continued so long under treatment a mixture con-
taining iodide of potassium, hyoscvamus and lobelia appeared to have a good eff"ect for six
or seven days, but the patient at the end of this period went on a drunken frolic and the
asthma became thereafter much aggravated. One case was relieved by stramonium :
Med. Hist., Pt. Ill— 92
730 INFLAMMATION OF THE LARYNX.
Private Thomas L. Rea, Co. I, 2(1 lU. Cav.; age 29; was admitted .Sept. 23, 18G3, with asthma, with which he
had been afi'ected since the winter of 1861. His rest at night was much disturbed and his mind depressed by frequent
paroxysms of urgent dyspncea; his appetite was fair. He had a cough but no expectoration. Gave stramonium to
smoke; full diet. Oct. 29: Patient rested at night without sitting up in bed: he feels better generally. Not. 25:
Transferred to Veteran Reserve Corps. — Hospital, Qitiiicij, III.
VI,— INFLAMMATION OF THE LARYNX.
Altliough the records make frequent mention of laryngeal inflammation as a compli-
cation of other diseases, there are but eleven cases of death specially attributed to this cause,
concerning which some details have been preserved. The 17,318 cases reported as having
occurred among the white troops consisted, no doubt, largely of mild catarrhal attacks, of
chronic thickening marked by hoarseness or aphonia, and of some which might with pro-
priety have been referred to syphilis or tuberculosis; but the 234 fatal cases — a mortality
of only 1.4 per cent.— may be considered as fairly represented by these eleven cases. The
attack was generally sudden and induced by exposure to cold and dampness, especially if
the individual was in low condition, as during convalescence from some serious malat"h-.
The throat became sore, the voice hoarse and the larynx, trachea and cervical glands swollen
and tender. There was much pain and difficulty in swallowing and a rapidly increasing
dyspnoea, with inspiration more difficult than expiration. The patient sat up in bed with his
head thrown back, and in his struggle for breath his respiration and pulse became acceler-
ated. Sometimes a chill, followed by active febrile manifestations, preceded or accompanied
the local inflammation. In the progress of the case the imperfect asration of the blood became
indicated by the dusky complexion and blueness of the lips and finger-nails; the anxious
expression disappeared and insensibility deepened into coma and death, or the fatal termina-
tion was suddenly reached by an occlusion of the glottis.
The rapidly fatal result of laryngeal stenosis is seen in case 2, in which the interference
with respiration was due to the presence of plastic lymph, wdiether in or on the mucous
membrane is uncertain. The conditions in 5 and 6 a.re equally uncertain, — the fibrinous
exudation is said to have been under the folds of the glottis. In 1 oedema is assumed as the
cause, but free incisions failed to collapse the swollen membrane; in 8-11 the closure was
due to oedema; in 7 the larynx appears to have been implicated by an extension of the dis-
eased action from the pharynx.
So long as the dyspncea depended mainly on narrowing of the laryngeal passage an
artificial opening gave an assurance of safety, — case 1 illustrates the rapid improvement
effected by the entrance of air into the lungs; but, when the pulmonary stasis ended in an
oedematous permeation of the tissues, laryngotomy was obviously of no avail. Even when
the lungs were free from effused or exuded matters the operation was sometimes unsuccessful
if delayed until the nervous centres had become affected by the depraved quality of the blood,
as in cases 2 and 9. In case 3, in which tracheotomy failed to save life, although the lungs
were found in normal condition after death, we are probably not in possession of all the cir-
cumstances bearing on the result.
Treatment, aside from opening the tube below the constriction, was of doubtful value
in these dangerous cases. Scarification gave temporary relief but failed to cure. Warm
moist inhalations and g?rgles were emploved, with hot fomentations externally or counter-
irritation, as by iodine or cantharidal collodion. Active cathartics and free doses of iodide
of potassium were unavailing in case 4. Chlorate of potash was administered in 5, proba-
bly in the hope of supplying oxygen to the blood.
INFLAMMATION OF TUK LAKYNX. 731
Cask 1.— Private Saimu'l Frosli. Co. F, 1st Pa. Hoavy Ait'y: af;i« 21 : a well-formpd, liealtliy-IookiiiK youiip; man.
was ailiiiittfd March 21, IMil. uiulor Ur. John II. Kakthoi.k, with iiliuro-piunuiKniia of tlie left .side. During hi.s
convaks-iii-ncc from this attack he \va.s ahsent without leave on Ai)ril !1. a cliilly rainy day. On the lOlh he had sore
throat with much dyspno'a and occasional strangling in attempting to swallow; the larynx and trachea were tender
and there was slight redness in the throat. A gargle and hot fomentations were ordered. 12lh: He slept but little
during the uight ; the front of the neck was swollen and tender and swallowing caused much pain; there was no
cough, hut the voice was whispering, the respiration difficult, the countenauco anxious and the liead thrown hack.
The fauces were reddened and the epiglottis cushiony, yellowish-red and shining as if from effused serum. The
mucous niemhraue was incised, the vapor of warm water inhaled and tincture of iodine api)lied externally. The
incisions gave so much relief that the patient asked to have them repeated. 13th: At midnight he had a severe par-
oxysm of dyspno-a, inspiration being more dirticult than expiration: ho sat up in bed sucking in the air, with an
anxious face and dull-colored lips and linger nails. The apex of the epiglottis was in better condition than on the
preceding <lay, but the remainder of the organ was unchanged. At 3 A. M. incisions were made in the swollen mem-
brane and repeated many times until daylight, but they did not give satisfactory relief. The ))ulse was 120. Can-
tharidal collodion was ajiidied to the front of the neck and thirty drops of laudanum given; warm-water vapor
and warm-water gargles were usi'd. At 9 A. M. the pulse was 128 and the patient weak. At 11 a. m. he was worse. A
consultation was held: a strong solution of nitrate of silver was applied to the larynx. At noon he was much worse;
his pulse 13t>, resjiiration 3.'), countenance dusky, nails bluish and his muscular power so affected that ho slipped
down in bed. Dr. K. F. Weir, surgeon in charge, unide an incision through the crico-tliyroid"niembrane, the cricoid
cartilage and one or two rings of the trachea; a double tracheal tube was inserted and a warm moist sponge with a
folded piece of mosquito netting placed over the opening. Two toaspoonfuls of blood, mostly venous, were lost.
The dyspnoja was inuuediately relieved and the livid color lessened. In half an hour the pulso fell to 120, the respi-
ration to 34, and soon after the patient dropped into a doze which lasted the entire afternoon. In the evening he
asked for food ; beef-tea was given. At G p. M. the pulse was 112. Ho passed a good night, llth: The pulse was il2.
Liquid food was given. He was directed to use the larynx as much as possible in respiration by putting his finger
on the mouth of the tube. 1.5th ; He passed a good night but had a red flush on his cheeks and a stitch in each side,
with slight cough; pulse 100. He breathed much through the larynx without closing the tube. IGth : The thoracic
symptoms have disappeared; pulse 90; appetite good. 18th: The tube was removed. li)th: The orifice was nearly
closed, no air escaping. May 3: He was still somewhat hoarse: the granulating snrfaco at the site of the incision
was nearly cicatrized. He was returned to his comjiany to receive a re-enlistment furlough. June 9: He called at
the hospital. His voice was still rough: in hallooing the note was not clear: in slioiitiug there was a higli-pitihed
squeaking noise; he was otherwise perfectly healthy. — Hospital, FrederkU, Md.
Case 2.— Samuel Mitchell, Co. C, 12tli U. S. Inf., was affected with sore throat during his cmivalescence, from
typhoid fever. On Oct. I, 18G2, at 3 r. M. respiration became embarrassed and he grew rapidly worse; at 1 r. Ji. the
neck was swollen, especially on the right side; there was dyspncpa, coldness of extremities and insensibility. Laryn-
gotomy was performed and resjiiration through the artificial opening was free, but in about fifteen minutes ho died.
rosl-iiioilim examination: Tonsils deejily eroded: epiglottis firm from effusion of plastic lymph, which etl'usion was
also marked about the vocal chords, especially on the right side. Lungs congested. — UoKpilal, Frederick, Md.
Case 3. — David R. Zimmerman, Co. C, 7th S. C; age 30; was admitted at noon April 9, 1864, with cronpy
breathing, dusky countenance and blue lips. Sonorous and subcrepitant rales were heard over both lungs; the epi-
glottis, tonsils and surrounding parts were much swollen. Tracheotomy was performed one hour after admission
and a quill tube was inserted, through which he breathed freely and with marked improvement until 2 o'clock of the
succeeding night, when he had a severe chill and rapidly sank, dying at 8 a. jr. April 10. Pont-morlem examination:
Thickening and enlargement of the epiglottis and tonsils; fibrinous exudation under the folds of the glottis, pro-
ducing almost complete closure. Lungs normal. — Jet. Ass't Siirr/eoii M. K. Glcaxoii, llock- Ixlainl Ho^pitul, III.
Case 4. — Marion Evans, Co. 0, 2d Ark. Cav.; age 26; temperate and free from constitutional taint; was taken
suddenly with a violent chill while attending roll-call on the evening of Sept. 25, 1864. High febrile excitement fol-
lowed, with intense headache and pain in the back and limbs ; next day he had soro throat, enlarged glands, aphonia
and difficult deglutition. On admission on the 27th his countenance was suffused and anxious, breathing loud and
distressingly labored, respiration 30; he preferred the sitting posture and kept his head thrown back. His cough
was dry and croupy ; pulse 120, hard and full : tongue coated ; skin ilry and hot ; throat swollen and tender. Croton
oil was given internally and applied externally to free i>ustulation. The pharynx was swabbed with nitrate of silver
solntiou. After catharsis ten grains of iodide of potash were given every four hours. He died suddenly, September
28, after an attempt to rise from bed. rost-mortem examination: Parotid and submaxillary glands greatly enlarged:
epiglottis swollen and exuding pus on puncture; three drachms of sero-puruleiit liquid in the larynx, the chink firmly
closed. [Spei-imen 652, Army Medical Museum.]— Jc<. Jss't Surgeon M. E. Gleason, Hock fsUmd Hospital, III.
Case .').— James B. Lloyd, Co. C, 9th Fla.; a plethoric man; age 35; was admitted April 3, 1864, with fever,
cronpy breathing and pain over the larynx; the fauces were inflamed and the submaxillary region swollen and
tender. He became very rt'stless and delirious. He was treated with cathartics, chlorate of potash internally and
iodine externally. He died April 5. Post-mortem examination; Swollen condition of glottis from fibrinous exuda-
tion.—.Jc/. Aas't Surgeon M. K. Gleason, Hock Island Hospital, III.
Case 6.— Joshua Watson, Co. C, 7th Fla.; age 40; was admitted March 22, 1864, in a very debilitated condition,
haviug been sick for some time with typhoid fever; his tongue was dry, teeth covered with sordes, eounteiiance dull
and expression vacant. On March 25 he was suddenly attacked with acute laryngitis and died on the same day.
732 I^^FLAMMATIO^■ OF THE LAKYXX.
Post-mortem esamiiiation: Fever's patches congested, thickened and ulcerated. Glottis and surrounding parts con-
gested and swollen, with fibrinous esudation.-^Jct. Ass't Surgeon 21. K. Gleason, Soci Island Hospital, III.
Case 7.— Private Asa C. Wentworth. Co. H, 19th Me.: admitted >'ov. 26, 1863: died Jan. 12, 1864. Post-mortem
examination: The velum palati was hard, stiff and white; the tonsils in normal condition. Pharyngitis was present,
especially ou the right side. Opposite the right arytenoid cartilage a large abscess, with hard, yellowish-white walls,
was observed, and the cartilage itself was the seat of a large protuberance, probably a collection of pus. This
swelling and the abscess of the pharynx explained the difficulty of deglutition observed during life. A small col-
lection of pus was seen on the opposite side of this region immediately above the greater horn of the hyoid bone.
The epiglottis and vocal chords were cedematous and yellowish-white. The heart was soft and the liver bronzed
and mottled with hard lardaceous spots. [The condition of the lungs is not stated.] — Ass't Surgeon H. Allen, V. S. A.,
Lincoln Hospital. Washington, D. C.
Case 8.— Corporal Samuel Dillingham, Co. H, 24th V. R. C: age 22: was admitted March 29, 1864. He had
been taken with fever and sore throat on the previous day. He died on the 31st, after a suddenly-developed paroxysm
of dyspnoea which lasted thirty minutes. Post-mortem examination: Inflammation of the larynx and a?dema of the
glottis. — Second Dirision Hospital. Alexandria, Va.
Case 9. — Private William H. Schlosser, Co. F, 140th Ind.: age 43: was admitted Feb. 3, 1865, having been
affected for a week or two with cough. He had an abundant expectoration and well-marked symptoms of bronchitis.
On the 12th his throat became slightly sore, the fauces somewhat reddened, tonsils enlarged and cervical glands
swollen. A gargle was prescribed. Two days later he had a little diarrhoea but the throat was better. About uooa
of the 17th he was suddenly seized with great dyspntea, his lips becoming quite blue. when, ou examiu.ttion, the
uvula, epiglottis and glottis were found to be (Edematous. Scarification gave some relief, but an emetic, which was
administered, was without effect. At 5 r. M. the patient again became threatened with suftbcation, which scarifica-
tion and inhalation of hot vapor and of acetic acid and ether failed to relieve. Laryngotomy was performed at 7
r. M. by Ass't Surgeon William Xorkis, U. S. A., the incision passing in the mesial line through the crico-thyroid
membrane and cricoid cartilage. After the operation the patient took two or three inspirations, coughed up a few drops
of blood, and died. Post-mortem examination : The chink of the glottis was completely closed by oedema of the sur-
rounding tissue. {^Specimen 519. Med. Sec. Army Medical Museum.] The epiglottis was cedematous and much thick-
ened. The trachea aud bronchial tubes were inllamed. their mucous membrane thickened and reddened to their
minute subdivisions : no false membrane was found in any part of the air-passages. A small patch of pneumonia
was discovered in the lower part of the left lung. The otherorgans were healthy. — Act. Ass't Surgion Darid L. Haight,
Douglas Hospital, Washington, D. C.
Case 10. — Private K. B. Curtis, Co. C, 24th Mich., was admitted Xov. 1, 1862, with laryngitis. He died on the
8th. Post-mortem examination: Throat swollen and bloodvessels of neck engorged: larynx inllamed and so swollen
from serous eftnsion in the submucous tissue as to occlude the air-passage. There was no exudation on any part of
the respiratory mucous membrane. — Hareicood Hospital, Washington, D. C.
Case 11. — Kecruit Henry F. White died of acute laryngitis Feb. 13, 1864. Xo history recorded. ISpecimen
570, Med. Sec. Army Sledical Museum, shows the larynx and epiglottis of this case, with the mucous membrane around
the orifice of the glottis thickened from oedema.] — Surgeon John Xeill, V. S. V., Hospital Broad and Cherry streets,
Philadelphia, Pa.
Gangrene of the larynx was noted by two medical officers, who have already published
their observations.*
Vn.— INFLAMMATION OF THE TONSILS.
Inflammation of the tonsils was reported as the cause of 59,911 cases of sickness and
97 deaths among the white troops, equaling an average annual rate of 26.9 cases per thousand
of strength, .16 per cent, of the cases ending fatally; and of 6,754 cases and 12 deaths among
* W. H. Sttdixt. Act. Ass't Snr^ieon — Amerktat Mtd. Timf&, ToL V, 1S62, p. 215 — gives the history of a case of disease of the throat which occurred
at Fort Hamilton. N. T.. in August, 1S62; The patient, a soldier, convalescing from a i>?niittent fever which had developed the characteristics of gen-
uine typhus, became affected with sore throat considered due to expceure to cold aud damp air. Fever supervened with considerable debility, aud after
three days his breathing became laborious and attended with an inspiratory whoop. There was a semitransparent tumor below and anterior to the left
tonsil, which was a little swollen ; the epiglottis and glottis were very o?dematous. Incisions into the tumor and the diseased parts in the vicinity of the
larynx gave temporary relief. Death occurred in the night, hut whether from esdiaustion or suffocation could not be determined from the imperfect
accotmt given by the attendant. Rw-morfcm examination revealed no morbid appearances except such as were found in the larynx. The mucous mem-
brane was swollen and of a dark -green color on the right side, the tissues being affected to the depth of one-fourth to one-third of an inch : the morbid
condition extended over the ventricle to the epiglottis and by a narrow tract to the left tonsil. Rrrrs King Brows, Surgeon U. S. Vols,, has described
— .4»ierK>3»» Mtit Ium«w, Vol. T, IS62. p. 243 — a gangrene of the throat that appearvd in the general hospital of the Department of the Gulf in the fall of
IStS ; The disease involved the root of the tongue, the ventricles and cartilages of the larynx. Its existence during life was not at first known. Out
of fourteen cases in which the disease was discovered after death only thrve presented symptoms that might have directetl attention to the seat of the
affection : in one there was marked dyspnoea shortly before death and in the others some fetor of the breath. It attacked the sick and debilitated;
nearly all affected had been greatly reduced by the miasmatic fever of the Mississippi, and many had suffered long from chronic diarrhoea. Death wae
sudden and apparently from sheer debility. Evidences of the disease were first observed while making autopsies to find some lesion or morbid state of
the internal organs that might account for the fatal result in these cases. The diseased parts had the color of gangrene of pulmonary tissue, although
free from the strong fetor of the latter. In a few cases there was oedema of the glottis and serous infiltration in the vicinity of the larynx. The heart
was flabby and the blood waterv. This condition of the throat was not associated with scurvy.
INFLAMMATION OF THE TONSILS. 733
tbe colored troops, equaling an average annual rate of 36.8 per tliousaiiJ and a fatality of
.18 per cent, of the cases.
These numbers probably include all the cases of quinsy that came under observation
excepting only rare instances of mistaken diagnosis. Thus the 2d Cal. Cav. appears to have
suffered at one time from inflammation of the tonsils, which, owing to the violence of the
symptoms, and particularly the suffocative feelings experienced by those afflicted, was regarded
and reported as an epidemic of complicated laryngitis.'-' It seems equally probable that
the reported cases included most of those in which the tonsils were involved in a catarrhal
inflammation of the pharynx, not a few of those in which the inflammation was diphtheritic,
and perhaps some in which the tonsillitis was a local manifestation of a constitutional affec-
tion. It may be assumed that the percentage of unfavorable results was in part due to
diphtheritic inflammation, although the following cases indicate that some at least were fatal
from oedema or inflammatory tumefaction of the lining membrane of the larynx:
C.\SK 1. — Sergeant John R. Kurtz, Co. C, 147tli Pa., was admitted Oct. 2.?, 186.3, with secondary Kj-philis.
Shortly after admission he coiitnuteil scabies, which prevaihul to^ome extent in the ward in which lie was placed,
but it soon yielded to treatment. On the morning of December 7 his throat was sore and slightly swollen, but there
was little or no constitutional disturbance. A stimulating liniment was applied, the throat was wrai)ped in tlanncl,
and the bowels being costive were moved by Epsom salt. Next day the right tonsil was much enlarged and the pulse
a little i|uickened. Chlorate of potassa was used internally and, with capsicum, as a gargle; stimulants were given,
together with such nutritious articles of food as the patient could swallow. On the 9th he felt easy; the right tonsil
was discharging freely and the left but little swollen; there was no difficulty in breathing. His condition remained
unaltered until midnight of the 11th, when he began to be restless and complained of inability to sleep, for which
an anodyne was prescribed. The symptoms did not appear alarming at this time: but in half an hour the patient
expired. Poat-morttni examination: Both tonsils were much enlarged and. suppurating freely. The epiglottis and
larynx were irdcmatous. The viscera of the thorax and abdomen appeared healthy. — Act. Aaa't Surgeon R.M.OiRVix,
Satlerlee Ilosjiittil, I'liilndclphia, Pa.
C.vSE 2.— Private H. Nelson Young, 2d Me. Bafy: age 23; was admitted Oct. Ifi. 18G2, with a slight gunshot
wound received at .Vntietam. On October 2it the right tonsil became inflamed and suppurated. Chlorate of ])otash
was used as a gargle and tincture of iron andguaiacum given internally. On the 31st the patient was so much relieved
by the escape of the matter that in the afternoon he was walking about; but at 9 P. M. he was seized with dyspnnea;
the veins of the head and neck became turgid and the pulse feeble and too rapid to be counted. On pulling out the
tongue by a pair of artery forceps respiratiou was temporarily relieved: but as it grew more urgent an iucision
was made through the skin and the crico-thyroid ligament. A little froth issued from the opening, through which
the patient breathed freely; his pulse fell immediately to about 96 and his lips appeared almost natural in appear-
ance. Finding respiration thus easy no tube was u.sed. At 11 P. M., the urgent symptoms having reappeared and no
tube being at hand, a triangular portion of the cricoid cartilage was removed, but the respirations diminished in fre-
quency and the patient died in half an hour, ront-mortan examination: The lungs were filled with serum. The heart
was normal. The right tonsil was deeply ulcerated and contained some pus; the left was also ulcerated. The uvula
was thickened by effusion of lymph and ulcerated on its right side. The epiglottis was erect, hard and thickened by
effusion of lymph beneath the mucous membrane; the aryteno-epiglottideau folds were much thickeueil, especially
on the right side; the chink of the glottis was almost entirely closed by the eftusion; several small i)atches of false
membrane were found above the vocal cords, especially on the right side, but there was none below. The mucous
membrane of the trachea and bronchial tubes was deeply congested, but without ulceration, eftusion or deposit. —
Act. Jfs'l Surgeon W. W. Keex, Jr., Central Hospital, Frederick, Md.
Case 3. — Colonel J. M.; age 36; of sallow complexion and having the appearance of one broken down by malarial
disease, was attacked Dec. 13, 1865, with inflammation of the left tonsil, followed by considerable external swelling.
Ho had fever; the pulse was 96, full and hard. Cathartics and antimonials were administered, counter-irritants
applied to the throat and vapor of hot water directed to bo inhaled. The symptoms were relieved for a time under
this treatment : but on the fourth day the jiatient grew hoarse and suffered from dyspnoea, although the tonsillitis had
subsided and the external swelling had almost disappeared. The dyspnoea rapidly increasing, a solution of nitrate
of silver containing sixty grains to an ounce of water was applied to the root of the tongue and fauces. This had
little effect, and in an hour and a half respiration had become so difficult that suftbcation was imminent. Relief was
immediately obtained by an incision through the crico-thyroid membrane. A tracheotomy tube was inserted and in
a few minutes the patient was able to lie down. Forty-eight hours after the operation respiration could readily be
performed through the natural passage. The tube was therefore removed and the wound closed with adhesive plaster.
• S« San Francitfo ifrdiral Prfxr^ Vol. lY, 18G3, p. 14. AcconJing to the report of Charles C. Fabley, the surgeon of the regiment, the di!^>ase
WMB sudden in ita attack and of grt* at soTcrity, being characterized by high fever and gn-iil dy-jpn«;a and drs]diagia. Tbe latter 5yniptonis were present
from the fiTht and soon incrt-aseJ to an alarming degree. In two or three days the disease usually readied a crisis. It affected almost exclusively tbos«
who bad b**en exposed to cold at night. No ca«e terminated fatally.
734 INFLAMMATION OF THE TONSILS.
Next tlay the plaster was changed for a thick coating of collodion. The wound healed in a few days. An erj'sipe-
latous rash appeared at the seat of the operation and spread over the right side of the neck, scalp and forehead. It
soon disappeared under the application of iodine and the use of internal remedies.
Surgeon Wilson, IStli Ohio, who reported the tliird case,'-'' considered it one of ery-
sipelatous inflammation which, beginning at the tonsils, invaded the larynx, and finally
appeared externally at the wound and spread over the surface.
A few extracts relating to inflammation of the tonsils are submitted along with the
records that afford any information in addition to diagnosis and dates of attack and recovery:
Surgeon Louis Watsox, Wth III., St. Joseph, Mo., Dec. 31, 1861. — Inllanmiation of the isthnnis fauciuni, with
tonsillitis, prevailed epidemically. The tonsils rarely suppurated.
Surgeon H. W. Kendall, rMh III., St. Joseph, Mo., Dec. 31, 1801. — The second epidemic, one of tonsillitis, fol-
lowed closely npon the decline of the measles. Consequently most of the debilitated subjectsof rubeola were attacked
Tiy the new epidemic. This, with the want of sufficient hospital acconnnodatious, reijuiring a hasty return of conva-
lescents to quarters, brought many of the :nen back again and again with relapses and complications which would
not otherwise have occurred.
Surgeon J. M. Allen, 5ith Fa., Sir John's Ilun, Hi., Sejtt. 1, 1862. — Malarial fevers and tonsillitis prevailed as
epidemics during August. The latter was confined solely to one company; the cause could not be ascertained. This
company was almost exempt from fever during the past month. The disease although violent was in no instance
fatal. It was accomiianied with more or less constitutional disturbance, and invariably yielded to the free use of
nitrate of silver. Neither tonsillitis nor dijihtheria, to my knowledge, prevailed in the surrounding neighborhood at
the time.
Surgeon Eurus King Brown, C. S. Vols., Shi2> Island, Miss., Februarij, 1864. — There were many cases of inllanima-
tion of the fauces. The seat of this was circumscribed and not attended with exudation or destruction of any part
of the membrane involved.
Act. Ass't Surgeon Joel Seavens, Fort TVcirrcn, Boston, Mass., April 1, 1863. — Tonsillitis has been quite prevalent,
most of those having catarrh or bronchitis having at some time during its course been affected also with an intlamma-
tion of the throat. This inflammation has in many cases assumed a diphtheritic aspect, presenting exuded lymph
and at times the constitutional symptoms of diphtheria; but it has always yielded readily to appropriate treatment.
Case 1. — Private Augustus Bevens, Co. B, 20th Me., was admitted Dec. 18, 1862, with incontinence of urine.
* * * Jan. 17, 1863: Throatsore; tonsils enlarged. Gave a gargle of capsicum. 18th: Throat better. 21st: Gave
ten drops of tincture of iron three times a day in water. 29th: Omittediron. FebruaryB: Sore throat; greatpainin
last tooth of left side of lower jaw, which on examination was found overgrown by the gum, preventing the patient
from closing his mouth. Gave capsicum gargle. 10th: Tonsils much swollen and painful; dysi^hagia. Gave a gargle
of chlorate of potash. 11th: Less fever and headache; bowels regular. 12th: Throat still swollen; dysphagia.
Removed redundancy of gum. 13th: Continued gargle ; gave milk diet. 17th: Applied dried alum to gnin. March
23: Returned to duty. — Satterlee Hospital, I'liiladclphia, Fa.
Case 2.— Private Bradbury P. Doe, Co. I, 1st Me. Cav.; age 19; was admitted Dec. 23, 1862, with debility.
* * * April 16, 1863: Tonsils very large; deglutition painful. Scarified tonsils. Gave extra diet. 17th: Applied
two blisters over tonsils. 18th: Full diet. May 14: Applied tincture of iodine over tonsils. 16th: Tonsils much
swollen. 18th: Gave cod-liver oil three times a day. 27th: On guard duty. — Satterlee Hospital , Fhiladelphia, Pa.
Case 3. — Private Jerome McLain, Co. K, 12th N. J.; age 25; was admitted Dec. 12, 1862, from duty as a mem-
ber of the hospital guard. He had a mild attack of tonsillitis. A solution of nitrate of silver, ten grains to one ounce
of water, was applied to the throat and a dose of Epsom salt administered. 22d: Throat better. Repeat the
local application. 23d: Discovered an excavated ulcer on each tonsil, that on the right being iiarticularly large.
Throat to be swabbed twice with the caustic solution and a chlorate of potash gargle to be used in addition. 24th:
Continued the application to the throat. Ulcers covered with a grayish slough. 26th: Throat decidedly better.
Treatment continued. oOth: Patient is sitting up. Continue gargle; disuse nitrate of silver. Jan. 12, 1803: Returned
to guard duty. — Satterlee Hospital, Philadelphia, Fa.
Case 4. — Private John D. Sargent, Co. K,4th N. J.; age 21; was admitted from guard Feb. 19, 1863, with some
fever and sore throat. The right tonsil presented an ulcerated patch about the size of a three-cent piece and covered
with a grayish pultaceons slough; the left had a smaller but similar ulcer. They were directed to be swabbed morn-
ing and evening with a solution of nitrate of silver, fifteen grains to an ounce of water; a chlorate of potash and
muriatic acid gargle was also prescribed. The ulcers continued to increase in size until the 22d notwithstanding
treatment. After this the general and local symptoms improved, and the record leaves the patient on the 27th doing
well and taking full diet with eggs for breakfast and a pint of milk three times a day. [In connection with this case
the previous history should be recorded: Admitted Nov. 7, 1862, with two soft chancres, one on the left side of the
glans, the other on the fnenum. These were cauterized with nitrate of silver. A superficial gland in the left groin
became inflamed and was opened December 11. The jiatient was cured and transferred to the guard for duty on the
30th. No symptoms of constitutional syphilis were manifested.] — Satterlee Hospital, Philadelphix, Pa.
* In the ArnerUan Jount'tl o/ the Medavl Si-inic€s, Vol. LII, ISGG, page 275.
DIPHTHERITIC INFLAMMATION OK THE FAUCES, ETC. 735
Case 5. — Hospital Steward Jolm J. Malian, 28th Mass., was perfectly well until about 3 a. m. of ,Iau. 28, 1862,
when, having got up to put coal on the tire, ho found he had headache, fever and sore throat. lie had been for some
days Iiaek wa'ting upon a patient suft'ering froui sore throat aud suhmaxiUavy swelling. At the morning visit his
pulse was 96, full: skin warm and moist : throat aud uvula very red and inllamed, with purulent appearances upon
the tonsils; pain on swallowing; bowels regular. A doso of Epsom salt was administered aud blisters applied over
the tonsils. 29th: Spent the day yesterday quietly; rested well during the night; the lilister rose well; feels better;
pulse slightly accelerated and full; throat red aud inllamed, particularly the right tonsil, which is coated with a
purulent deposit. Treatment continued. 30th: Skin hot aud moist; pulseoverSO; feels pretty well; throatstill red,
particularly on right tonsil. An alum garglo was prescribed. 31st: Attended to duty yesterday; rested well during
the night and now feels very well, but throat still iulianu-d. — Hospital, '26tk Mhhk., Hilton Ucad, S. C.
Case 6. — Private Samuel G. Williams, Co. G, l'M\\ 111. Cav.: age 45; was admitted April 3, 18(il, from lienlon
Barracks with dysphagia; tonsils swollen and touching each other: uvula elongated and swollen; soft palate
iutlaiued: cervical glaiuls and cellular tissue also swollen: stittuess of Jaw: fever: full pulse; headache: anorexia;
furred tongue and constipation. Gave a cathartic aud applied a solution of nitrate of silver. -Vpril 2Ulh: Returned
to duty. — Lawson Ilogpital, St. Louis, Mo,
Vm.— DIPHTHERITIC INf LAMIiIATION OF THE FAUCES, ETC.
Prevalence, etc. — During tbe first fourteen months of the war no special provision
was made on the blank forms of the Report of Sick -and Wounded for the numerical record
of diphtheritic cases. A form issued in July, 1862, gave diphtheria a place in the miasmatic
order of zymotic diseases; but some time elapsed before cases were reported on this form.
None appeared during the months of July, August and September; in October 125 cases
were reported; in November 217; in December 338, aud in January, 1863, 435. This did
not signify a rapid increase in the prevalence of diphtheritic disease, but simply that month
by month so many medical officers recognized that the new form differed in some respects
from the old, and reported as diphtheria cases which had formerly been otherwise returned
as, for instance, in the waste-basket of other diseases of the miasmatic class.
During the forty-five months, September, 1862, to June, 1866, there were reported
among the white troops 7,277 cases, equivalent to an average annual rate of 3.92 per thou-
sand of strength, and 716 deaths, a mortality of 9.84 per cent, of the cases.
Among the colored troops, during the three years of their service, 776 cases and 61
deaths were recorded, a mortality of 7.86 per cent., the average annual rate of cases per
thousand of strength being 4.25, or slightly in excess of the rate among the whites. Diph-
theria appears to have affected the white men almost as extensively and with a greater
fatality than the negroes. Generally the latter sufi'ered more from camp diseases and suc-
cumbed to morbific influences more readily than the whites, — cases were in the proportion
of 136 among the colored men to 100 among the white men, and deaths as 269 to 100; but
diphtheria was so far below this average in its influence on the colored troops that the operation
of some saving cause tnust be assumed, perhaps a racial idiosyncracy, as suggested b3'some
observers.* Lines indicating the monthly rate of prevalence among the white and colored
troops may be found on the diagram facing page 738.
It is doubtful if the diphtheria of our camps and hospitals was in every instance, or
even generally, a constitutional disease occasioned by a specific poison and manifested by a
specific local lesion. In cases 1 and 2, given below, the disease was apparently a sloughing
• In ninuuariziiig tlio mortality statUtics of Wilmington, Del., for tlic year 1882, L. P. Bisil, |iresi(lcnt of the board of health, comments upon thj
flict that although thirtei-u deaths from diphtheria occurred among the white people no fatal case was reported among the colored population. "Thi*
stiti further confirms the opinion of the frt-edom of the hlack race from diphtheria. This resit-tance of that class of people to the cause of this disca.«e has
bwn oh^frved and recorded in the sttti^tics of Wilmington since the disease made its first api>carance among us in 18C0." The Mettirnl Xetrf, Vol. XLII,
PhiMelphia, p. 57r., referring to Dr. BeSH's opinion, gives the statistics from some of our Southern cities, hy which it is shown that 211 deaths from diph-
theria were re[«..rted from a population of 3.31,70*: whites and 73 deaths from the disease among 170,022 colore<l people. If the latter had sufl'^.Ted efjually
with the white race there should hare been lOU deaths instead of 73. These numbers show that in civil life, .ts in the army during the war, the colored
■wn manifested a relative insnsceptibility to tlie causes of pseudomembranous inflammation of the throat.
736 DIPHTHERITIC INFLAMMATION OF THE FAUCES, ETC.
pharyngitis, and in case 3 death probably resulted from pneumonia consecutive to a catarrhal
inflammation of the fauces.
Case 1. — Private William Cainiibell, Co. H, 18tli Conn.; age 17; was admitted Sept. 6, 1863, -witli fever and fre-
quent pulse, swollen tonsils and difficulty of breathing. A solution of nitrate of silver was applied locally and chlo-
rate of potash, in ten-grain doses, given every three hours. There was no improvement next day; the tonsils were
covered with purulent matter; a thick tenacious expectoration was brought up; respiration was difficult and pros-
tration increasing. An emetic of ii)ecacuanha and tartar emetic was prescribed, to be followed by quinine, whiskey
and beef-tea. On the 8th, after the removal of membranous matter, the tonsils were found to have sloughed consid-
erably. On the 9th the patient was greatly prostrated ; he had not slept since his admission ; he had much difficulty
in swallowing and urgent dysjino-a. He became unconscious at 5 P. M. and died two hours later. Post-mortem exam-
ination: The tonsils were in a sloughing condition and the fauces much inflamed, but no false membrane was discov-
ered. The lower lobe of the left lung was hepatized and the upper lobe contained tubercular deposits; the right luug
was normal. — Act. AusH Siit-yeon J. M. Matlack, Hospital Ko. 1, Annapolis, Md.
Case 2. — Private Wilson Weir, Co. K, 4th Me.; age 22; was admitted May 7, 1864, convalescing from typhoid
fever. On June 7 while on light duty he was taken with diphtheria, and on the 10th was reported as improving,
chlorate of potash, chlorinated soda and solution of nitrate of silver having been used locally and neutral mixture
with antimony and spirit of nitre internally. After this the throat was swabbed with tincture of iodine and lauda-
num, ammonia and olive oil, and gargled with iodine and sulphate of zinc solutions, while whiskey-punch and tinc-
ture of iron were employed internally. On the 16th the throat was reported as being too painful to admit of swab-
bing, and, as the ingesta returned through the nostrils, beef-tea was ordered by the rectum. On the 17th medication
by the mouth was resumed, and on the 20th a Seidlitz powder was given in the morning and Dover's powder at night,
alum gargle being used as a local astringent. On the 23d tincture of iron was prescribed in doses of fifteen drops
three times daily. Next day the patient was much debilitated ; he was unable to open his mouth to permit of inspec-
tion of the fauces; he drank two pints of milk, and at 6 p. m., having had some milk-punch, he felt better; but death
occurred suddenly two hours later. Po8(-)HOi'(f»t examination: Considerable mucus in trachea; sloughing of fauces. —
Mower Hospital, Philadelphia, Pa.
Case 3. — Private Cyrus G. Chatterton, Co. C, 24th N. Y. Cav.; age 17; was admitted July 24, 1864, scorbutic
and much emaciated from long-continued diarrhcea. On August 3 the patient experienced difficulty in opening his
mouth and complained of sore throat. The fauces were found inflamed and the tonsils covered with matter. Iron
and stimulants were administered, with chlorate of potash as a gargle and counter-irritation externally. On the 5th
mucous rales were heard over the chest. An emetic was given but without effect. He died asphyxiated on the 6th.
"The constitution of the patient being scorbutic and his condition very low there was not a chance for tracheotomy." —
Fairfax Seminar;/ Hospital, Va.
But outside of these exceptional instances it is of interest to inquire whether some of
the recorded cases of diphtheria were not in reality inflammations of the fauces due to ordi-
nary and non-specific causes, such as exposure to cold and dampness. Some medical officers
have alluded to the difficulty of determining with accuracy the true nature of cases that were
called diphtheritic.''' In the autumn of 1863 diphtheria was reported from certain regiments
near Norfolk, Va. The principal sufferers were the 10th and 13th N. H., the latter having
had 60 cases and 10 deaths, the former 20 severe cases, one of which was fatal, and about
40 or 50 cases of sore throat, in six of which the tonsils suppurated. Surgeon N. P. Rice,
U. S. Vols., who investigated these cases Sept. 8, 1863, regarded them as specific inflam-
mations of the throat in men broken down by excessive fatigue, a deficient dietary and pre-
vious sickness.
From careful inquiries in these and all the other regiments of the division I should say that there was some
doubt whether the disease was idiopathic diphtheritis. Enough material could not be shown to define this with a
sufficient degree of positiveness, I saw but one patient, a man in the 4th R. I., who exhibited any serious trouble in
the throat. There was here a distinct membrane on a raw bleeding surface, but as the throat had just been freely
cauterized with nitrate of silver and the man was using tincture of iron, the particular character of the exudation was
much obscured. In a Connecticut regiment three cases were observed which showed great congestion and tumefac-
tion of the tonsils, with small patches of jius immediately beneath the mucous membrane. It was stated by one of
the medical officers that he had seen the exudation covering the fauces, the roof of the mouth and the nasal passages.
The description of the disease, with the manner of death, answers as well for a great dejiression of the vital powers
due to exhaustion from the inflammatory action of the throat and the inability to take food as for a true diphtheria.
It is the universal testimony of all the medical and regimental officers that the disease appeared shortly after the
* Thus, A. C Haulin, Ass't Surgeon 2d Mo., remarking on the blended and masked character of disease as often observed in our armies, alludes to
diphtheria as having phases and complications that render its recognition by no means easy. — See American Med. Times, Vol. IV, 1802, p. 107. The cases
which he saw were those reported by Surgeon S. B. Muhrison, 2d Me. — See infra, page 738.
DIPHTHERITIC IXFI.AMMATIOX OK THF. FAUCES, ETC. loi
return of the regiments from the expedition up the Peninsuhi, where the men sntTereil greatly fvom fatigue and exhaus-
tion. On their return tliey reoeenpied tlieir ohl (|iiarters, which had been K'ft standing. They went into eamp after-
Avard in a liea . y cohl rain upon ground wliich is naturally of a col 1 character, with the subsoil water hut a few feet
below the surface. The cases occurred in men of a dejjraveil and broken down constitution, and especially in those
who had sufl'ered from fatigue on the Peninsula or w ho had been atVcclcd with sickness or sunstroke. A peculiar fact,
discovered in all the regiments, was the existence in uuiuy of the men of indolent ulcerations of greater or less size,
occurring singly, in patches or diftused on the legs and ankles. They are said to have coiumenccd as slight pustules
with no i)urpuric blotches: they are dittieult to treat, stimulation seeming to increase their size. These cases aver-
age 20 to 10 to a regiment. Other scorbutic symptoms do not show themselves. The ulcerations lirst appeared on
the return from the expedition, about the .same time as the alleged diphtheritic trouble. Most of the medical officers
asserted that the two manifestations of disease never existed in the same per.sou. Nothing could be discovered in
the neighborhood to account for these ulcerations, nor was there anytliing peculiar in the living or habits of the men
except the slight general use made of vegetables and the occurrence of the disease upon their return from the Penin-
sular expeilition, during wliich it is probable that they were almost wholly deprived of antiscorbutic diet. The ulcer-
ations have, indeed, the ajipearance and character of those seen during the severe scorbutic attack aumng the troops
of the Army of the Potomac al Harrison's Landing in Jul}', 1862. The trouble iu the throat may have been of the same
character, exhibiting itself in this more acute intlammatory uuinner because occurring in persons of broken-down
constitutions at a time when the vital force was much lowered by previous fatigue and |)rivation. The immediate
cause was probably the cold and dampness of their camp-sites. The disease is subsiding in both the regiments
because they have gone into dryer and more open camping-grounds, — because they are rested and iu better physical
con<lition, and because the use of vegetables is now more general. The ulcerations have ceased to break out afresh
and in most cases are improving. The discrepancy in the number of cases reported by the two regiments I consider
due to the ditferent character of ground upon which each was camped at the time the disease appeared, the l.Sth being
on a damp, cold, thickly shaded site, tlie 10th close by but on more open ground. Tlio dilfeieut physical character-
istics of the men of the two regiments may have also had au intiueuce, the om< least affected being of much better
material than the other.
Act. A.SS t Surgeon Joel Seavens i-eported that iiuiuy of his cases ot' iuiiauunation of
the throat assumed a diphtheritic aspect,* and a similar phraseology is occasionally encoun-
tered in .-^orac of the recorded cases.
C.vSE 4. — T. T. Royal, prisoner of war: age 14: was admitted May 9, 1864, with inllanunation of the tonsils. A
chlorate of potash gargle was used and tincture of iron given every three hours. After a time the throat assumed a
dii)btheritic appearance, when cauterization was employed and stimulants administered. He died on the 2.">tli.
Poslmortcm examination : The diphtheritic exudation extended as far as the glottis.which was ulcerated ; the trachea
was full of pus. The pericardium contained a <iuautity of serum. — Third Dirision Hospital, Alexandria, T'«.
Cask 5. — Private EliC. Mattson, Co. H,9th N. Y. Cav.; age 22; was admitted from Augur hospital, Alexandria,
Va., Feb. 11, 1865, sulfering from acute pharyngitis and tonsillitis, with exudation and sthenic pyrexia. The disease
at first ajipeared to yield partially to treatment, but later it developed a distinct diphtheritic character: the local
ati'ection increased iu severity, the false membrane appearing on the walls of the pharynx and gradually cxtcudin"'.
Abcnit a week after admission the patient's stomach became irritable, and for the last two days before death nothin"
was retained except a little water from ice melting iu the mouth. The fever continued sthenic iu character until
two days before death, when the system began to suffer from imperfect a?ration of the blood. From that time the
purple hue of the skin became increasingly marked. Latterly very little urine was voided, but no ura'mic effects
were observable, the mind being perfectly clear until d(^atli, which occurred on the 24th. The case was treated at
first with saline laxatives aud Dover's powder, with tincture of iron internally in doses of fifteen drops repeated
every four hours, — api)lied locally by sponge aud used diluted as a gargle. Nitrate of silver aud alum solutious were
also employed as topical ap]>lications. Afterwards lime-water was given with milk; sinapisms and a blister were
applied to the epigastrium and nutrient enemata administered. Post-mortem examination: The tonsils aud larynx
were much intlamed; the trachea lined throughout with a firm false membrane, which, on the left side, extended
into the ramifications of the bronchus: the bronchial tubes of the right Inng were greatly iuflamed but not lined
with membrane; the lungs were healthy. The heart contained a firm washed clot in each ventricle, the right clot
being larger and more firmly attached than the other. The stomach, liver, spleen and intestines were normal.
[■"^piciiiiiii .")1.">, Med. Sec, Army Medical Museum, from this ease, shows the epiglottis umch thickened and the larynx
lined by a thick pscndomembrane which extends to the tonsils and over the sides of the tongue.] — .Is*'/ Surgeon-
Harrison Allen, U. S. A., Mount Pleasant Hospital, Washington. D. C.
Sometimes, after the tonsils became injected and swollen, many days elapsed bel'ore the
diphtheritic character of the inflammation was evident. In cases 6 and 7 an ordinary or
non-specific inflammation was present for ten days before the diphtheritic appearances were
observed: and in the latter case the attack was apparently the result of exposure to cold
while the individual lay asleep on the hospital grounds,
* Supra, page 734. •
Mki>. Hist., Pt. HI— 93
738 DIPHTHERITIC I:NFLAMMATI0N OF THE FAUCE?, ETC.
Case 6.— Private James Van<ler\vorker, Co. E, 46th N. Y.; age 19: was admitted Oct. .5, 1864, -svitU a gunshot
wouud of the fingers. On the 12th he was attacked -nith tonsillitis and ou the L'2d diphtheria was developed. He
died on the 26th. Fost-mortem examination: A false membrane lined the larynx, trachea and bronchial tnbes, form-
ing on the left side a complete cast of the whole of the air-passages to the minutest ramifications, but not extending
into the air-vesicles. The right lung was not involved. A small portion of the membrane had been detached from
the surface of the larynx and hung loosely in the cavity. Large portions of it were also detached from the trachea
and lost. In the left bronchus was found a perfect tube. When the false membrane had been detached the mucous
membrane was found to be highly congested and to have lost the more superficial parts of its epithelium. ISjieciincn
411, Med. Sec, Army Medical Museum, shows the left bronchial tube and its principal ramifications occupied by a
tubular cast of pseudomembrane.] — Ass't Siiygeon C. A. McCall, U. S. A., Mount rUasant Hospital, Washington, D. C.
C.vSE 7. — Private Charles A. Greenman, Co. C, 32d N. Y., was admitted Sept. 2, 1861, with typhoid fever.
During convalescence he took cold, on the 20th. while sleeping in the hospital garden, bis throat at once swelling
and becoming sore. Ou October 1 a diphtheritic membrane was observed in the upper part of the pharynx, Imt
there was little constitutional disturbance. A solution of nitrate of silver, forty grains to an ounce of water, was
used locally, with chlorate of potash and tincture of iron for internal use. On the 4th the membrane appeared in
irregular patches about the palate and tonsils, interfering but little with swallowing, although the parts were very
tender; the patient was an.'emic. On the 5th a fly-blister was applied to each side of the neck. On the loth the
false membranes were disappearing. — Hospital, Alexandria, Vit.
Exposure to cold and danipness, especially at night, was frequently regarded as the
cause of diphtheritic attacks as well as of the quinsies and sore throats that were invariabl}'
associated with them in a command. AVhen diphtheria prevailed tonsillitis was common,
and the latter was generally referred to the milder operation of the epidemic cause.
Surgeon S. B. Morrison, 2d Me., Hall's Hill, Fa., Oct. 31, 1861. — There have lieen many cases of sore throat in
this regiment during the last two months. Most of them appeared immediately after a storm, especially among those
who had been on guard at night or on picket duty and exposed to the combined influence of cold and moisture,
though some occurred without any such exposure. At first there would be a slight difdcnlty of swallowing, with a
general tumidity and redness of the fauces. Soon the uvula became elongated and enlarged and the tonsils highly
inflamed, with aphthous patches upon them the size of half a dime. These patches often spread so rapidly that, in
the coTirse of twenty-four hours from their first appearance, they would cover both tonsils and nearly the whole inter-
vening space, and the surrounding parts would be so much swollen as to cause great difliculty in swallowing. Soon
afterwards the membrane became detached, either wholly ot partly, leaving the parts underneath of a deep-red or
almost purple color. The cervical glands were liable to swell and the neck in front to become full and oedematous,
though this did not usually occur until the disease had lasted two or three days. Typhoid symptoms appeared
only in severe or prolonged cases. There have been in the regiment eight cases which I have no hesitation in pro-
nouncing genuine diphtheria and a large number showing premonitory indications of this disease, which have been
speedily subdued by local applications of nitrate of silver, tannic acid, chlorate of potassa and persulphate of iron,
The same local applications have been made in more advanced stages of the disease, and tonics and stimulants have
been given freely when typhoid symptoms called for them. Xo fatal case has occurred in camp, though one patient
died at the general hospital a day or two after being sent there. In that case there was severe ejiistaxis and a large
abscess in the fauces; neither of these symptoms was present in any other case.
Surgeon B. B. Bkasheak, IGth Ohio, Cumherland Ford, Eij., April 10, 1862.^-Diphtheria made its appearance
among the sick in quarters as well as among those in hospital, but only to a limited extent. It attacked some of the
convalescents from continued fever, two of whom died. There was a great deal of sore throat, which was no doubt
referable to the diphtheritic influence and which might have been called diphtheria; but no case was so recorded
unless the characteristic membrane was observed. Fifty per cent, of the cases of this kind terminated fatally.
SurgeonT. Hildketh,3(Z J/6., White's Ford, Md., Xoremhr, 1S61. — Inflammation of the throat prevailed, and we had
eight cases of well-marked diphtheria, one of which proved fatal. All of these cases occurred in company G, although
there was nothing in its location to account for the di.sea.se prevailing in it more than in the other companies. The
treatment in nearly all the cases was tonic and sustaiuing ; there was great depression of the vital powers, the patient
in the fatal case apparently dying from exhaustion. Local applications to the throat were used freely, but with
little or no apparent advantage. The causes of this disease appeared to be exposure during cold damp weather.
The tents at this time were old and leaked badly, and .the dimimition of all inflammatory aflections of the throat after
the men got into new and comfortable tents was very apparent.
But the statistics fail to show that coincidence between the prevalence of tonsillitis and
diphtheria which should be observed had the former been, even in part, a mild expression
of the epidemicity of the more dangerous disease. Tonsillitis appeared among the white
troops in waves of prevalence distributed over the winter and spring months, December ta
March, inclusive. These are illustrated in the diagram facing this page. Had diphtheria
been connected with their causation the line indicating its prevalence would pi'obably have
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DIPHTflERITIC INFLAMMATION OF THE FAUCES, ETC. 739
given some evidence of the connection. But no such distinct seasonal inHuence is exhibited
by the record of diplitheria. SHght elevations may be observed in the rate for some of the
cold months, but these rarely coincide with the greatest prevalence of tonsillitis. In fact
the increased prevalence of diphtheria does not appear to have exercised any eflfect in ele-
vating the line of tonsillitis. It may be said that the waves of prevalence of the non-spe-
cific inflammation of the throat were too high to be materially aflPected by those due to a
diphtheritic tendency. This may be granted; but when the periods of infrequency of ton-
sillitis, for instance the month of August of each year, are found to coincide with high rates
as well as with low rates for diphtheria, the latter disease cannot have exerted.much influ-
ence on the prevalence of the former. In August, 1863, when the diphtheria-rate was high,
only 2.4 cases of tonsillitis occurred for each reported case of diphtheria, while in August,
1S65, when the diphtheria-rate was low, the ratio was 15.9 to 1. The same want of relation
is observed in the statistics of the colored troops, if the month of October, 1863, be excluded.
During that month both diseases were of frequent occurrence ; but as no other analogous coin-
cidence appears tiiis must be regarded as accidental.
There is another method of viewing the association of diphtheria and tonsilHtis which
is not inconsistent with a want of relation between their lines of prevalence. The records
already submitted indicate that ordinary influences, such as exposure to cold wliile sleeping
on the ground or in the open air, produced a disease which was as much a true diphtheria
as if it had been propagated by specific infection. It had the same local lesions which from
peculiarity of site were prone to occasion sudden death, and was attended with the same
constitutional disturbances and general prostratiun. Practically it was the same disease as
that which is usually considered a specific diplitheria. If the cases hereafter presented be
examined, most of the patients will be found to have been in a low condition from the effects
of some antecedent disease or injury. Thus many were suffering or convalescing from
typhoid fever, some from malarial fever, pneumonia or diarrhoea. These were cases that
oceurred in the general hospitals, the inmates of which had usuallv a liietory of previous
sickness. Taken alone they would therefore have no weight in the argument; but when
it is remembered that in the field the men attacked were those that had just been exposed
to the depressing yet actively injurious influences of guard and picket duty at nio-ht, or, as
in the experience of Surgeon Brashear, the sick in quarters and the convalescents from
fever in the regimental hospital, a condition of lowered vitafity may be readily allowed as
one predisposing to the diphtheritic attack. But it is not found that tonsillitis selected its
subjects from among the convalescents. Whence it may be inferred that while the frequent
and sometimes inevitable exposures of military life induced tonsillitis or catharrhal pharyn-
gitis in the robust and healthy, their effect on tlie weakly or prostrated was a pseudo-
membranous inflammation; and that in our camps the conversion of the milder into the
more dangerous disease, by the presence of unwholesome conditions in the system of the
individual, was the true explanation of the association of sore throat with epidemics of diph-
theria, although that usually accepted regarded the diphtheria as the primary disease and
the milder cases as an extended expression of its endemicity. This explanation does not
involve a tendency to parallelism in the prevalence of the two diseases. Exposure to c«ld
and dampness produced tonsillitis; hence the prominences in the line expressing its preva-
lence during the winter and spring months, — but something more was required for the pro-
duction of diphtheria, apparently a broken down condition of the system. During the war
740 DIPHTHERITIC INFLAMMATION OF THE FAUCES, ETC.
tlie winter was for a large p:irt of the army a season of rest, recuperation and ample sup-
plies, which would oljviously have tended to counteract a disposition to pseudomembranous
inflammation. The somewhat greater prevalence of diphtheria among the Confederate
prisoners, 5.6 cases annually per thousand of strength, as compared with 3.9 cases among
our white troops, is of interest in view of the generally deteriorated condition of those men.
This view finds material support in the fact that the fever of diphtheria is a symptomatic
fever winch keeps pace with the local inflammation and subsides on its cessation.*
Moreover, the inflammation of the fauces associated with and dependent on the specific
poisons of the eruptive fevers sometimes assumed a diphtheritic character. In erysipelas
of the head and face there was at the outset an inflammation of the mouth and throat in so
many instances that its dependence on the erysipelatous poison is strongly suggested. f In
some it was merely erythematous, but in others the tissues became largely infiltrated;
sloughs were occasionally cast off" and at times a pseudomembrane was developed. These
diphtheritic cases can be separated from their erysipelatous connections and attributed to a
specific diphtheritic poison only by faith in a doctrine and not by the authorization of facts.
The records of diphtheritic dysentery must not be forgotten in this connection. In the
majority of these there was nothing to suggest a specific infectious disease with its jDrimary
disorder of the blood and its subsequent local lesions. J On the contrary, the disease was
generally not only a local but a simple inflammatory aftectioii at the outset. Diphtheritic
dysentery began with a simple inflammatory stage either developed independently or super-
vening on an acute diarrhoea. In other instances it appeared in the progress of a chronic
flux, when the vitality of the patient had been much reduced, and, indeed, it was a common
mode of fatal termination in disorders of that class. Only occasionally was its attack so abrupt
and intense as to countenance the assumption of Heubner that it may occur without any
preliminary catarrhal stage. An* acute diarrhoea or dysentery lasted days or weeks before
it assumed the diphtheritic character. The prevalence of diphtheritic inflammation can only
be approximated. It was present in 12.7 per cent, of 905 post-mortem observations in cases
of diarrhoea and dysentery. Applying this rate to the total number of deaths from these
diseases, no less than 4,800 deaths among white troops must be attributed to diphtheritic
inflammation of the intestinal lining, although only 716 deaths are reported as due to the
same pathological process affecting the mucous membrane of the throat. §
Either there was no specific diphtheria in our camps or the specific cause was subordi-
* 111 tho latest authoritative publication on tho subject of diphtheria Gerhardt of Wurtzburg i<j reports as speaking of the ferer in the following
terms: — "Diphtheria may be said to be always accompanied by fever, or at least those cases in which no fever is present are cxceedinglj- rare. This fever
diftei-5 in many respects from that accompanying other infections diseases. Thus wo find that in many infectious diseases, as in variola, measles, etc.,
the original fever is caused by a peculiar process of infection which takes place in the blood and which is the characteristic of these diseases ; and that,
ou the contrary, certain periods of fever which supervene later on, as for instance the fever of suppuration, the fever of decrustation in variola, thcs-'
forms of high fever occurring in parotitis wheu the testicles become implicated, are independent of the original fever. It is very different with diph-
theria. Hero the fever is directly dependent upon the local affection, and the rule may as well be stated here, that as long as the local affection keeps on
increasing the fever will also increase, and that so soon as this ceases the fever will also cease." — Dr. Beyer's tran.slation of Hei-bxer's Prize Essay —
Erperimeiilal Diphllteria, Detroit, 1S85, p. 50,
f See sKjjfd, page Gl35. J See Part IT of this work, page 3.M'.
^ The tmusmission of diphtheritic inflammation from the throat to the intestiue and vice fcrm is suggested l»y an editorial in the Medical Tinier,
Phi-lndelphia, Pa., Vol. XII, 1S81-S2, p. -P.I7. In referring to the experimental researches of Drs. Wool) and FonMAli on pseudomembrancs from a diph-
.theritic epidemic at Lakeview, Mich., the following statement is made ; — " A very important and curious observation was made by Dr. FoRilAD at the
spot of the epidemic. The pigs of a family living iu an isolated position in the forest were fed with slojis from a room where three or four children were
sick with the disease. Several of the pigs sickened and one died. At the autopsy, made by Dr. FoltsiAD, the hiryux and respiratory passages were found
entirely free from disease, whilst the lower end of the cesophagus, the stomach and the upj)er duodenum were coated with a very thick false membrane
loaded with micrococci and containing the other anatomical elements of true diphtheritic membraue. Underneath this false membrane tho mucous mem-
brane was inflamed aud in numerous places ulcerated. In the blood of the pig, as well as in the spleeu and the bone-marrow, the micrococci were exceed-
ingly numerous. They were seen attacking the leucocytes and in other particulars conforming with the action of the plant in malignant human diph-
theria. Inoculation of rabbits with the membrane from the stomach of the pig produced sickness and death, with symptoms and local and genenil lesions
similar to those caused by the human mt'mbrane. This observation is very important as showing the local natuR* of diphtheria in its first onset, and
especially as raising the suspicion that the swine-plague of the West has close relations with human diphtheria."
0
DIPHTHERITIC INFLAMMATION OF THK FAUCES, ETC. 741
nate to ami obscured by other influences. The reported cases derived their origin iVoni the
ordinary causes of inflammation of tlie fauces in individuals predisposed to pseudomem-
branous developments, or tliey were tlie product of a specific cause which was controlled by
the vitality of the individual exposed to its influence. On the latter supposition, with the
system in a normal or healthy state, the specific germ, poison, agency or influence had no
more power than an ordinary irritant and its results were local, — a subsiding or suppurative
tonsillitis or a catarrhal pharyngitis controlled by the vitality of the suffbrer; but with the
system in a condition of depression the inflammatory products passed beyond tlie control of
the vitality of the individual and were given U]i to putrefactive agencies bv whicli tlio system
became exposed to septic infection.
Since Oertel called attention to the presence of micrococci in diphtheritic pseudo-
niembrane'=" many observers have urged the germ theory of this disease; but this theory has
not been established, and indeed the latest observations do not subvert the conclusion reached
by Dr. "Woodward in his investigation of this subject in connection witli diphtheritic dys-
entery,— that the micrococci naturally j^resent in the locality found favorable conditions for
their development in the necrosed tissues, and that their multiplication is not a cause but a
result of the diseased action.f
In the healthy buccal cavity are many species of micro-organisms which varj'in difier-
nt individuals, and in the same individual at difterent times, as well in shape as in mode of
action. These bacteria have a septic influence when introduced into the circulation of certain
animals, as the rabbit, but so far as the ordinary state of the human organization is concerned
they have no pathological significance. When, however, the vitality of a tissue ceases, its
organic elements are given up to the fermentative or putrefactive action of just such micro-
organisms as are found at all times in the mouth. When vitality is impaired, as in the
pseudomembrane of a diphtheritic inflammation, it may reasonably be assumed that the
diseased tissues aftbrd a more congenial nidus for bacterial development than the healthy
epithelial surface. The micrococci are therefore to be regarded, in the absence of atfirma-
tive testimony to the contrary, rather as a result than a cause of the disease. The inanifest
inefficiency of all attempts to disinfect the throat, and the aggravation of the disease which
follows such attempts when of an irritant character, seem also to indicate that the inflannna-
tion is not due to the micrococci, wliich must therefore be considered as accidental. But
although unconnected with the causation of the primary inflammation, they may be plausibly
regarded as productive of septic results in the individual by absorption of the necrotic pro-
ducts associated with their growtli and multiplication, and if these products bo considered
possessed of infectious cjualities the pathology of the disease is complete until a stronger
light is thrown on this subject by the progress of investigation.
Drs. Wood and Formad of Philadelphia have pre.sented results of much interest. J
According to these observers the micrococci of dijjhtheria do not differ from those ordinarily
found in the mouth except in their tendency to grow in culture-fluids. The rapidity of growth
of the micrococci is in direct proportion to the malignancy of the diphtheritic case which
furnished them. Every grade of case may be found in man, from an ordinary sore throat,.
* Aeruliihcn IiiUUi'jnK-Dlnf, XV, Muuich, 1SG8, page 407 el seq.
t According to IIevbneie, if these micrococci were the cause of the disease the hloodvessels of the diseased mucous membrane and the cai)illarios of
the kidneys, liver, etc., ought to he filled witli )»acteria, but "entire sections of the uvuln. of the throat, kidneys, Ac, of patients dead uf di]>I)1hentic
in'ection have been treated with gentian-violet, fuchsin in Itismark brown (also in aniline dyes) without succeeding in discovering a Hiiigle bacterium,
which in the diseased surface of the mucous menihnuieare so easily made out." He therefore concludes that the disease-poison is as yet unknown. — Page
44 of Dr. Bevf.r's translation, alrea<ly cited.
I Utportoa hiphlhertay in the Annuid Ileport tyf Ote Xaf;/>tm/ Hoard of ffeaWi, ISSl, page 21 tts^q.
742 DIPHTHERITIC INFLAMMATION OF THE FAUCES. ETC.
throuo;li simple pseudomembranous angina and tracheitis up to malignant diphtheria. The
micrococci, although jjrimarily accidental, become, by growth under favorable conditions,
invested Avith specific properties. The theory of the disease, deduced from these observa-
tions, is that certain circumstances outside of the human body are capable of throwing this
common micrococcus into its condition of active growth and engendering an epidemic of
diphtheria. Later observations by the same authors lead to the conclusion that the septic
and diphtheritic micrococci are specifically one, and that diphtheria is a septic sore throat,
or "is simply what it was called a century ago, putrid sore throat with or rvithout a secondary
eonstitvtioncd septiccemia."*
Experience of diphtheria in civil life indicates the existence of an infectious qualitv con-
nected probably Avith the products of bacterial growth in necrosed tissues, or, according to
the views of Wood and Formad, with the increased vital activities of an ordinary septic
micrococcus. The disease may thus be propagated in favorable circumstances independent
of the constitutional state; but there is little evidence of its spread in this way during the
war. Surgeon Thayer speaks of its prevalence in his regimental hospital; the statement
in the case of Sergeant George W. Hough, that the patient was taken with the ward sore
throat, indicates a local prevalence in one of the wards of the Satterlee hospital, Philadelpiliia;
and Brigade Surgeon McRuEE reported some cases that were suggestive of contagion.
Surgeon Wm. H. Thayeh, 14;7i X H., CurroUton. La.. 2Jatji. 18(54. — Diphtheria was first seen in June, 1863. and
the regimental hospital was not without it afterwards for six mouths: but it did not extend in the hospital to any
other patients until November, when three inmates were suddenly attacked. All other patients except those with
diphtheria were at once removed to general hospital and there was no further extension.
Serg't George W. Hough, Co. E, 14th Mich.; age 20: was admitted Dec. 12. 1862. This patient had been sent
to hospital at Washington, D. C, September, 1862, on account of great debility, the result of constant exposure and fre-
quent attacks of rheumatism. He has at present a slight cough with pain in the left breast and rheumatic pains in
the ankle-joints and the muscles of his legs and lumbar region; he sleeps well, has a good appetite, and for the last
two weeks has had no diarrhoea. He has been taking cod-liver oil and liquorice mixture. On December 28 the cod-
liver oil was omitted and wine of colchicnm substituted. At this time he was taken with "ward" sore throat, for
which an alum gargle was used. On Jan. 7, 1863, acetate of potassa was added to the colchicum, and a drachm of
iodine tincture in an ounce of camphorated oil was used as an external application. He was discharged February
14. — Satterlee Hospital, rhiladeljihia, Pa.
Surgeon D. McRuER, Sechjiricl's Brigade, Army of the rotiimac, December, 1861. — During the last tuo months diph-
theria has prevailed in the 3d and 4th Me., and from the manner of its introduction as well as its mode of jirogress
through the camps it might be inferred to be contagious. It was first observed in the families of three civilians who
lived in the vicinity of the 4th Me.; five children died of the disease. The soldiers of the 4th, who had free inter-
course witli these families, were first attacked; fourteen cases occurred, three fatal. The troops of the 3d, having
free communication with the 4th, were next seized : seven cases, two fatal. The other regiments, the 38th and 40th
N. Y., have not suffered, although only separated from the Me. regiments by a public highway: and as this immunity
might be attributed to the fact that the N. Y. and Me. troops have but little intimacy it atibrds another point of
suspicion in favor of contagion.
Clinical Records. — The general character of the clinical records of diphtheria may
be gathered from the following examples: 8-17 from the records of the hospitals at Alex-
andria, Va.; 18 and 19 from the Satterlee and 20-22 from the Mower hospitals of Phila-
deljahia, Pa., and 23 from the Field hospital of the Fifth Army Corps.
C.\SE 8. — Private L. W. Doloft", Co. I, 5th Me., was admitted Sept. 2, 1861, with typhoid fever. He was conva-
lescent when, on October 25, he was taken with sore throat: pulse 88; skin hot; slight exudation with swelling of left
tonsil: no external swelling. Applied nitrate of sUver solution, ten grains to an ounce of water, morning and even-
ing; prescribed tincture of iron in water as a gargle and five grains of chlorate of potash every four hours for
internal use. On the 27th the pulse was 78; skin cool; bowels constipated, and the exudation spreading over the
tonsils. By November 2 the exudation had disappeared. The patient was returned to duty Deceml>er 14. He occu-
pied a bed in a large, well-lighted and ventilated ward. His was the third case of diphtheria in this ward.
C.iSE S).— Private Jacob Cunningham, Co. A, 4th Me., was admitted Sept. 1, 1861, with typhoid fever,from which
he recovered. On November 3 his skin became hot and dry; pulse 90 and full; tonsils much swollen and covered
* Manoirou Die Kalure of DipUhen-ia, Ammal Report of the Kaiimial Board of Health, 18^2, page 133.
DIPHTHERITIC INFLAMMATIOX OF THF: FAUCES, ETC. 743
\. lih exudation. Asiiliuioii uf nitrate of silver was apjilieil: tiuctiiie of iron. ilihUi-il. was useil as a iiarglc auJ five
Sraii'.s of chlorate of potash given every three hours. Itli: Pulse 90; skin hot: swelling stationary: exudation
Jimiuished. olh: Pulse 80; skin cool; bowels open: swelling diminished: but little exudation and conlined to tho
••eft tonsil, (ith; Sitting np all day; appetite good. 13th: Returned to duty.
C.vsK 10.— Private Lyman Howard, Ifith X. Y.; admitted Sept. 3, 1801, with typhoid fever. He convalesced,
but on November ti had a slight inllamniation of tho tonsils and soft palate, .\liiui was used as a gargle and a sin-
apism was applied. 7th. flight deposits of white exudation on the iutlamed parts. Applied solid nitrate of silver:
gave twenty drops of tincture of iron, one drachm of a saturated solution of chlorate of jiotash and one grain of
sulphate of ([uinia three times daily. 8lh; White exudation covering inllamed surface of left tonsil, edge of soft
Valate and left siile of uvula. Keapi)lied nitrate of silver; repeated sinapism: u.sed tincture of iron and solution of
'.'hlorate of ]iotasli as a gargle. iUh: Exudation stationary; pulse 90; bowels regular. Kci)eated nitrate of silver;
towards e\ening exudation lieeanu" detached. 11th: Patient in\proving. Applied a solution often giains of nitrate
of silver in one ounce of water. 12th: Exudation thinner and less extensive. 21th: Returued to duty.
C.VSK 11. — Corporal Charles AVickwiro, Co. (i, 16th N. Y.; age 21; was admitted Sept. 22, 18G1, w ith intermit-
tent fever, for which Kowler's solution was administered. On October 6 he was returned to duty, but w-as readmitted
on the llth with a recurrence of the disease. On the afternoon of the 24th he had fever not preceded by a rigor;
pulse 90; skin hot; throat sore and right tonsil covered with an exudation. On the evening of the following day
the left tonsil also became coated. The throat was swabbed with a solution of nitrate of silver; tincture of iron,
dilnlcd. was used as a gargle, and live grains of chlorate of potash were given every four hours; castor oil was
employeil to move the bowels. The exudation did not entirely disappear until Xovember '>. Sugar was found in
the patient's urine some time afterwards. He was placed on duty as uurse on the 21st. This was the fust ease of
diphtheria which occurred in the Fairfax street ward, — one of the best wards of the hospital. Proper |ireeautions
were taken to prevent contact with the other patients.
Case 12. — Private Moses Packard, Co. K, 5th Me., while convalescing from typhoid fever was taken, Oct. 24,
l.MJl. with sore throat; pulse 95; skin hot; tonsils much swollen; exudation on right tonsil. ITsed nitrate of silver
solution and iron gargle: chlorate of potash internally. 25th: Pnlse 90; skin hot; bowels costive: tonsils swollen;
exudation extending towards the right ; submaxillary glands swollen. Ciave an ounce of castor oil. 2fitli : Pul.se 90;
skin hot: swelling and exudation unchanged: bowels nu)ved. 27th: Pulse 85; skin hot ; exudation extended to the
left tonsil: l)Owelsopen. 29th: Pulse70: skin cool; swelling much diminished and exudation les.sened. Novembers:
Steadily improving; but little swelling; slight exudation on left tonsil. 13th: Returned to duty.
C.VS1-; 13. — John Adams, Co. G, 40th N. Y.; age 25: was admitted Nov. 8, 1861, having suffered for two weeks
with headache, much lassitude and pain in the back and bones. Flis pulse was 90 and full, skin hot, tongue dry and
brown in the centre, right iliac region tender but the bowels quiet. He became dcliriouson the 10th and for some days
had more or less diarrhoea. On the 18th he felt chilly and afterwards feverish ; his throat became sore in the evening,
and next day a patch of exudation about tho size of a three-cent piece was found on the left tonsil. This extended
rapidly, covering the fauces and interfering with respiration. He died on the 22d.
C'a.<e 14. — Private . I. 'SV. Johnson, Co. B,32d Pa., was admitted Nov. 9, 1861, with typhoid fiver. He iminoved,
and on the lOth all medicine was stopped except turpentine emulsion, and he was placed on milk diet. On the 20th
oyster soup was permitted. On the 24th he became feverish, had pain in the throat and an exudation on the left
tonsil, which continued to extend until the 26th, and thereafter gradually disappeared. Nitrate of silver, tincture
of iron, chlorate of potash and whiskcy-puuch were used in the treatment. Fie was returned to duty Jan. 22. 1802.
Case 15. — Private Lewis Lamon, Co. D, 32d Pa., was admitted Nov. 14, 1861, having been sick for two weeks
with chills and fever, which had assumed latterly a typhoid type. His tongue was dry and fissured and he had
great abdominal tenderness, diarrhoea and much cough. Delirium supervened on the 19th ; sordes appeared on the teeth
on the 20th and there was meteorism with much epigastric tenderness. Diphtheritic exudation was found in the
throat on the 21st, when the breathing became labored and the feet and hands purple. He died at noon of the 22d.
Case lO.^Recruit James McGowan, 30th Me.; age 26; was admitted Jan. 5, 1865, from Washington street pri.son,
Alexandria. Va., with pneiiiuonia. He convalesced; but suddenly the tongue and sublingual glands became much
swollen and the tonsils and jiharynx covered with an ashy-Avhite membrane easily removed by means of nitrate of
silver; it came away in flakes half au inch s(]uare. but it formed anew very rapidly. Chlorinated soda solution was
used as a gargle and stimulants, tonics and nutrients wen' administered. The patient died on tlie 2Ntli.
Case 17. — Private Adam Huff, llth N. J.; age 24; was admitted March 22, 18(!4, with diplitlieria: Tonsils
enlarged: speech indistinct ; skin hot and dry; pulse fre(|uent ; severe i>ain in the head and upper part of chest. Used
a saturated solution of chlorate of potash in hot water as a gargle; Dover's powder. 23d: Pulse lOO.hard; skin hot
anil dry: tonsils much swollen, covered thickly with exudation; breath very offensive, (iave twenty drops of tinc-
ture of iron every three hours. 24th: Pulse 80, full. April 26: Returned to duty.
Case 18. — Corporal John O. Tuell, Co. V, 6th Me., was admitted Aug. 10, 1862, with chronic diarrluea, hyi)er-
trophy of the heart and general debility. In a few weeks he was able to move about the ward with other convales-
cents. On the morning of C)ctober 10 he was found in bed suffering from .severe headache, with furred tongue, quick
pulse and hot skin. In the afternoon he took three compound cathartic pills, which moved his bowels freely and to
some extent checked the fever. In the evening he complaimd of sore throat, and next day the fauces and part of
the tongue were covered with a diphtheritic membrane. The throat was touched four times a ilay with hydrochloric
aeiil and water, the internal treatment consisting of twenty drops of muriated tincture of iron every tliiee Innirs.
744 DIPHTHERITIC INFLAMMATION OF THE FAUCES, ETC.
On tbe llitU tho patient seemed somewliat better, his skiu moist aud pulse Jess frequent. In tlie afternoon chlorate
of potash was prescril)eil along with the iron in doses of ten grains every three hours. On the 13th the fever and
swelling had somewhat diminished and deglutition was less difficult. Treatment was continued, and on the 17th the
throat was nearly free from diphtheritic dejiosits and the patient recovering rapidly. He had during the attack as
much beef-tea and other nutritious articles as he could take.
Cask 19. — Private Timothy Donovan, 1st N. Y. Cav.: age 33; was seized with sore throat Oct. 8, 1862. At this
time he had just begun to recover from a severe attack of jaundice, with obstinate constipation and fainting tits. He
had thus been for some time in feeble health. The sore throat was accompanied with extreme prostration, dysphagia
and severe pain in the ear and right side of the face; his pulse was upwards of 100 and feeble. On the right side of
the fauces and posterior wall of the pharynx were thin grayish-white exudations; the voice was somewhat husky;
there was slight cough, and sometimes, in swallowing, fluids returned through the nose. Tinctur-e of chloride of iron
was given every fourth hour, and a stroug solution of sulphate of copper was applied on and around the exudation
every four or five hours. The membranes did not spread after this and by the 19th they had disappeared. By
November 1 the jiatient was well, though still very weak.
Case 20. — Private James M. Greer, Co. D, oth Mich, Cav.; age 35; was admitted May 6, 1864, as a convalescent
from typhoid fever. He was weak and much emaciated. Iron, quinine and extra diet were prescribed. 17th: Sore
throat ; diphtheritic patches on fauces. Gave tincture of nuiriate of irou and chlorate of potash. 18th : Very weak.
19th: Dark-colored offensive stools. Gave beef-tea and milk-punch every hour. 20th: Beef-tea and punch every half
hour; five grains of carl>ouate of ammonia every two hours. Failing rapidly. 21st: Died at 1 .\. .M.
Case 21. — Private Truman B. Richardson, Co. E, 2d N. Y. Cav.; age 19; was admitted from City Point, Va.,
July 16, 1864, nmch prostrated by severe diarrhoMl attacks. 22d : Inllanunation of throat. Gave astringent gargle;
applied tincture of iodine. 24th: Throat and fauces much worse; no diarrlKea. Used nitrate of silver solution; gave
tonics. 26th: Uvula, tonsils and palatine arch covered with diphtheritic membranes. Cauterized with strong solu-
tion of nitrate of silver; applied saturated solution of chlorate of potash and tincture of iron to throat every half
hour. 28th: Profuse expectoration; throat gangrenous. Cauterized every six hours with eighty grains of nitrate
of silver in one ounce of water; gave a gargle of alum and chlorate of potash; ice freely; beef-essence and milk-
punch every half hour; applied tincture of iodine externally three times a day. 29th: Complete aphonia: tongue
swollen; diphtheritic membrane extending below posterior arch; dysphagia extreme. 30th: Died at 4 p. M.
Case 22. — Private John Parmenter, Co. K, 2d Pa. Provisional Art'y: age 20; was admitted July 26, 1864, with
diphtheria. Applied volatile liniment and flax.seed poultices to throat; gave ten grains of chlorate of potash, fifteen
drops of tincture of iron, two grains of sulphate of quiuia and one-fourth of a grain of extract of belladonna every
four hours; extra diet. 27th: Tonsils, uvula and soft palate covered with a dark ashy deposit. Sponged with tinc-
ture of muriate of irou morning and evening; gave twelve drops of tincture of opium in half an ounce of spirit of
Mindererus every four hours ; used a gargle of muriatic acid in sweetened water ; applied powdered alum ; gave milk-
punch, whiskey and porter. 28th: High fever; pulse 98. 29th: Tonsils cleaning; ato a little toast and ice-cream.
30th: Died at 9.45 P. M.
C.iSE 23. — Private A. C. Wentz, Co. F, 83d Pa., was admitted June 7, 1864, suffering with sore throat. The
patient came on foot to the hospital and seemed in fair condition ; but a membrane was observed covering tho fauces.
Quinine in whiskey was given every two hours and tincture of iron applied every half hour to the fauces. On the
9th, after a hard spell of coughing, the membraue was ejected [see Sjjecimi'n 391, Med. Sec, Army Medical Mu.seum],
and for thirty hours the patient appeared in good condition and likely to do well; but at the end of that time dysp-
ncea came on, and he died in three hours. 'So pont-iiwytiiii examination was held.
Ill case 24, reported by Sufgeon John A. Lidell, U. S. Vols., an opening through tlie
crico-thyroid membrane gave relief but failed to save the patient. Failure also attended
the only other recorded efforts to save the patient by surgical interference.'^'
Case 24. — Private D. M. Brimmer, Co. H, 169th N. Y., a young soldier of good constitution, was admitted Feb.
26, 1863, with typhoid fever. He was treated by the tonic and expectant method, and did so well that on March 15
he was out of bed most of the time, though still pale, thin and weak. On the 16th he was attacked with sore throat.
Next day, his case having assumed an unfavorable appearance, my attention was called to him by the attending sur-
geon. Dr. C. H. OsiiOi'.XE. His throat was swollen externally a good deal; countenance anxious aud dusky; respira-
tion hurried aud rather difficult; pulse weak aud about 120, and he complained of great deliility. On depressing his
tongue to examine the fauces a very ofi'eusive odor was exhaled. The tonsils, palatine arches and posterior fauces
were covered with diphtheritic membrane of moderate thickness and dirty-gray color. Dr. OsisofiNE had already
cauterized the throat with a strong solution of nitrate of silver, and was administering quinine aud iron, whiskey
freely, along with beef-tea aud any other nutrient that the patient could swallow. I ordered this treatment to bo
continued. Next morning he was decidedly worse; his neck was more swollen; he had greater difficulty in swal-
lowiug and the respiration was croupy to a marked degree; his pulse was weaker and more frequent aud other evi-
dences of debility were increased. As the morning wore away he lost the power of deglutition; he became more
stupid; his countenance grew darker in hue and death by suffocation seemed to be close at hand. Under these cir-
cumstances, and as a remedy of last resort, I performed laryngotoniy at noon. His neck was swelled so much that
I was unwilling to attempt tracheotomy. As it was, the swelling embarrassed me a good deal by obliterating the.
* See cases 1 aud 1 G of tlio pofl-nwrltut records. •
DIPHTHERITIC INFLAMMATION OF THE FAUCE8, ETC. 74-5
laiulniaiks by changed color of tissjie, liy iucreasotl thickness of soft parts to lie cut through and li_v llie constant
oozing of a liloody liquid from the surface of the necessary incision, thus obscuring and at times hiding the jiarts
from view; no artery required to be tied. On cutting through the crico-thyroid meuibrane I was enabled to with-
draw from the larynx a considerable quantity of false membrane stained with blood. The patient breathed easily
through the ariifuial opening and directly afterwards was able to swallow again : and an assistant, whose lingers
were on the radial pulse, told me that the circulation rallied decidedly at the same moment. Not nmre than an ounce
of lilood was lost by the operation. The jiatient apjieared to lie nearly if not (jiiite insensible to pain by reason of
the increasing coma of suffocation. His breathing seemed to continue free and easy, but ho died, apparently from
exhaustion, four hours after the operation.
Po?;t-mortem Records. — Observations \ww maJi' ami ivcoi-iUhI in twenty-five cases,
wliicli are herewith submitted. In 1-3 tlie mucous membrane ot" the larvnx was swollen
and (Tedematous, but not covered with pseudomembrane, the diphtlierilic infiltration being
confined to the tonsils or to the fauces and epiglottis. In 4-7 pseudomembrane extended
from the fauces and pharynx into the laryngeal passage; the last-mentioned case was com-
plicated with swelling of the parotid glands and an absce.ss in the neck on the left side of the
larynx. ' In 8-18 the larynx was affected and the trachea invaded; swelling of the parotids
was noted also in the last of these cases. In ll)-25 the exudation extended into the bron-
chial tubes, plugging in some instances their smaller ramifications. In 26 the condition of
the pharynx and air-passages was not stated.
C'.v.<K 1.— Private David Late, Co. K, 1st Vt. Cav.; age 19: was admitted Dec. 23, IStil, complaining of lassitude,
chilliness, jiaiu in the limbs, anorexia and jaundice. On the 28th his throat became sore, both tonsils and palatine
arches, the soft and part of the hard palate jiarticipating in the intlauuuatory process: dysjintea was apparent next
day, Ou Jan, 1, 186,5, a nienibrauous exudation of some cousistcnco hung from the uvula and on being detached left
.1 clean, red, highly inflamed surface. The expectorated matters were very olleusive, consisting of glairy mucus,
blood and particles of membrane. The patient became asphyxiated on the 2d duringa sudden paroxysm of dysimcea.
Tracheotoniy was performed but failed to resuscitate him. I'o8l-mortem examination: The Specimen [.")28, Med. Sec,
Army Medical Museum], consisting of the tongue, palate, pharynx, larynx and one inch and a half of the trachea,
was renmved oh mas«e. The velum palati was covered with a partially detached nu'mbrauous exudation of some
consistence, blackened externally by the pr<>parations of iron which had Ijeen used medicinally and liaviu" beneath
it some eftusiou of blood: the tonsils were covered with a grayish-white deposit, firmly adherent and extending into
the follicles; the glottis, epiglottis and aryteno-cpiglottidcau folds were (edematous and there was some extrava-
sation of blood in the larynx. — Axs't Surgeon I!. F. Weir, U. S. A., Hospital, Frederick, Md.
C.\SE 2.— Private .Jos. Oldham, Co. (i, 52d N. V.; age 20; admitted Nov. 23, 18(1;!. l)i<-d December V.i. I'ost-
mortem examination: The posterior portion of the eiiiglottis and pharynx was covered by a diphtheritic membrane;
the cellular tissue of the larynx was edematous and indurated; the upper portion of the first and the whole of the
third lobe of the riglit lung were hepatized; other thoracic and abdominal organs normal. — Aas't Surgeon H. Allen, V.
S. A., Lincoln Iloxpital, Washington, D.C.
C.v.SE 3.— Private Thomas Shea, Co. F, 4th Minn.; age 2."): was admitted Feb. Hi. 180."), with pneumonia. He
progressed satisfactorily until the 21st, when white deposits appeared upon tlie throat. He died on the 25th, Post-
mortem examination: Membranes of brain fully injected. Pharynx dark-purple; tonsils with patches of thick white
dejKisit. Eight lung crepitant but coated with yellow lymph; upper lobe of left lung solidified and lironchial tubes
dark-colored. Heart adherent and some yellow serum in pericardium. Liver small, aua-mic, with old adhesions;
■spleen soft, pale, granular; kidneys fatty, — Third Virision Hospital, Alexandria, Vn.
C'A.-iF. 1, — Private James Evans, Co. F, 48th Pa.; age 25; was admitted Feb. 27, 1803, having been sick for four
weeks. His tonsils were ragged and ulcerated and there were small patches of exudation in the throat; he swal-
lowed with ditBculty. He had an oppression in the right lung, mucous rales over both sides of the chest and an
otfcusive, purulent expectoration. Ou March 1 the dyspna-a increased and he became delirious and died next day.
I'ont-murlem examination: Ueueral hypostasis. Brain reddish, firm, much congested; pia mater extremely injected.
liase of tongue, half arches, tonsils, epiglottis, glottis, more than half the larynx and pharynx swollen and covered
with white, stringy, semi-granular, firmly-adherent material, believed to be diphtheritic. Lungs congested, — ri<'ht
twenty-eight ounces; left twenty-oue ounces; bronchial tubes dark-colored. Heart containing white clots in both
ventricles. Liver irregularly congested; spleen twelve ounces and a half, bright red and very soft. — Lincoln Bospital,
Washington, I). C.
C.vSE 5.— Private Eli Jacobs, Co. B, 109th N. Y.; age 22; was admitted Jan. 22, 1864, with pneumonia. Warm
fomentations, cups and blisters w«re applied to the chest, and tartar emetic, opium, senega and carbonate of ammonia
prescribed, with tnilk-puiich and nourishing diet. On February 9 a diphtheritic appearance was recognized in the
throat. He died on the 11th. Post-mortem examination : A membranous formation was found in the fauces and larvns.
The lungs were adherent thronghout and hepati7,ed in their lower lobes; the apex of the right lung was cicatrized.
The kidneys were enlarged and fatty. [Specimen 46. Med. Sec. Army Medical Museum.] The other organs were
healthy.— .^iirj/coii F.dicin Bentleij, V. S. Vols., Third Dirision Uospital, Alexandria, To,
Med. Hist., Pt. Ill— 94
74:6 DIPHTHEPJTIC INFLAMMATION OF THE FAUCES, ETC.
Case 6. Private Charles E. Bates, Co. G, 39tli Mass.: age 26: was admitted May 15, 1864, with a gunshot womid
of the left ana. He died November 2 of diph thelitis. Post-mortem examination: The mucous membrane of the larynx
was swollen, almost completely closing the glottis: the diphtheritic membrane had in a great measure separated,
only traces of it remaining. — Jiirrw Hospitiil, liuUimore, Md.
C.vSE 7. — Private Harrison Tibbetts, Co. A, 12th Mass.; age 24: was admitted June 1, 1862, with chronic diar-
rliira. Ho recovered and was acting as wardmaster when, on October 11, be was attacked with diphtheria, which
proved fatal on the 19th. rost-mortem examination: The pharynx, tonsils and velum palati were covered with false
membrane and the larynx was lined throughout with the characteristic exudation. On the left side of the lower part
of the larynx was an abscess containing about three ounces of oftensive pus. The parotid glands were much enlarged
and the surrounding cellular tissue oedematous. — Eospitcil, Alexandria, Va.
Case 8. — Private Caros O. Gibson, Co. H, 4th Vt.; ageSl; was admitted Oct. 25, 1864, his right leg having been
amputated for a gunshot wound received at Cedar Creek, Va. , on the 19th. On admission the stump was healing
kindly and the patient in good condition, but a tendency to sloughing, with some diarrhita and homesickness, subse-
quently retarded his recovery. On November 22 he complained that for a day or two his throat had been somewhat
sore; a slight diphtheritic deposit was observed on one of the tonsils. Quinine and whiskey were given, with tincture
of iron internally and as a local application. The patient felt certain that his attack would end fatally. On the 24th
the exudation was not very extensive on the palate but appeared to have extended into the left nostril. He died on
the 26th, but not from asphyxia. Post-mortem examination : The false membrane extended about two inches into the
trachea ; the glottis was only slightly involved and there was but little exudation except on the tonsils and soft palate.
[Specimen 446, Med. Sec, Army Medical Museum, shows the nasal mucous membrane coated with pseudoiaembrane.]
— Act. Ass't Surgeon Geo. TV. Fay, Patterson Parle Hospital, Baltimore, Md.
Case 9. — Private' Thomas Bromeling, Co. C, 106th N. Y.; age 24; was admitted July 10, 1864, with a gunshot
wound of the knee-joint, received on the previous day, for which amputation was performed in the lower third of the
thigh. Eight days later about half of the stumji had healed, but about August 1 the appetite failed and profuse per-
spiration occurred. As pus from the posterior part of the stump was burrowing in the thigh a counter opening was
made. On the 8th the patient complained of sore throat. Tincture of iodine was applied to the fauces and the
cutaneous surface of the throat and a gargle of chlorate of potash and alum was prescribed. Next day a large diph-
theritic deposit was formed on the palate and fauces, to which lunar caitstic in sulistance was ai^iilied. Stimulants
were given, but the p:itieut died on the 11th. Post-mortem examination: The soft palate was coated with pseudo-
membrane, which lined the pharynx, larynx and trachea. [See Specimen 529, Med. Sec, Army Medical Museum.] —
Act. Ass't Surgeon George M. PaulVm, Hospital, Frederick, Md.
Case 10. — Private John B. Smith, Co. I, 13th N. H., was admitted Feb. 7, 1863, with debility and diarrhoea
consequent on typhoid fever and measles. He improved under treatment and was able to be out of bed most of the
day when, on March 11, he complained of sore tliroat and in the evening diphtheritic exudation had already occurred,
although difficulty in swallowing and the return of liquids through the nosowere not manifested until the following
day. On the 13th respiration was quite laborious, the tonsils much swolleu and the surrounding parts covered with
false membrane which nearly closed the fauces. Some of this was removed by forceps with temporary relief; but
towards evening suffocation again threatened and a second attempt was made, without success, to clear the throat.
The feeble coudition of the patient did not warrant the administration of nauseants. He was treated with quinine
and tinctureof iron, whichlatter was also applied to the fauces. He diedon the 14thof apna>a. Post-mortem examina-
tion : The fauces were covered and the glottis and trachea lined throughout with diphtheritic membrane. lS2)ecimeii
13, Med. Sec, Army Medical Museum.] Pulmonary congestion was manifest. — Ass't Surgeon II. B. Bucl, U. S. Vols.,
Columbian Hospital, Tfashington, I). C.
Case 11. — Private Michael Messner, Co. H, 8th N. Y., was admitted Jan. 22, 1863, with chronic rheumatism.
He had. moreover, just recovered from a severe attack of pleuro-pneumonia and was pale and somewhat emaciated.
On the 24th he complained of sore throat and his cough assumed a rough, hoarse character, and was brought on by
every effort at sjieech. After a time dyspnoea set in, his countenance became anxious, pulse frequent and feeble, skin
cold and bathed in clammy sweat. He died on the 27th. Post-mortem examination: The mucous membrane of the
larynx and trachea was red and jiresented a few patches of adherent pseudomembrane; the submucous tissue was
oedematous. There were pleuritic adhesions on the left side. The heart was fatty. — Hospital, Alexandria, Va.
Case 12.— Private E. Griffith, Co. D, 10th N. Y.; age 26; was admitted with typhoid fever Aug. 3, 1864. He
convalesced sufficiently by the 15th to sit up a part of each day. He then became atfected with sore throat, and on
the 18th white patches were discovered on the tonsils. He was seized with a paroxysm of dyspnoea on the night of the
20th, and died asphyxiated before surgical assistance could be summoned. Post-mortem examination showed false
membrane upon the sides of the fauces and larynx and extending a short distance into the trachea; the remainder of
the trachea was congested; the lungs were tilled with serum. — Hospital, Frederic!;, Md.
Case 13.— Private Charles Winslow, Co. A, 44th N. Y.; age 19; admitted from the lield Oct. 21, 1864, with
chronic diarrhoea and syphilis. Died November 6 of diphtheria. Pos(-)»or<em examination: Brain normal; spinal cord
not examined. Two spots, half an inch in diameter, on each side of the uvula were covered with false membrane : the
epiglottis was erect from oedema and its under surface covered with false membrane, which extendeol through the
larynx about two inches into the trachea. [Specimen 440, Med. Sec, Army Medical Museum.] The heart and left
lung were normal; the right pleural sac contained three ounces of serum and a small shred of loose floating lymph,
but there was no adhesion : the lower part of the upjier lobe was carnified posteriorly, but the remainder was healthy.
DIPHTHERITIC INKLAMMATIOX OF THE FAUCES, ETC. 747
The liver, pancreas, spleen, kidneys, stomach, small intestine and colon were normal; the mesenteric glands were
a little darker than nsual. — Act. Ans't Surgeon Thomas Bouin, Second Division Hospital, Alexandria, )'u.
Case II. — I'rivato H. H. Goodwin, Co. (J, 1st Mass. Cav., was admitted Fel>. 1. IHlM, from the Army of the
Potomac with dii)htheria. Hediedon the 3d. /'osZ-woi-Mii examination: The mncous mcmliranc of the pharynx was
covered with diphtheritic menihrane. The epiglottis was mnch congested and ulcerated; the larynx and tirst two
rings of the trachea were congested and covered with false memhrane; the cavity of the larynx contained a largo
fibrinous plug- — Act. Ass't Suryeon L. Dorseij, Uareteood Uoxpitul, Washington, D. C.
Case 15. — Sergeant George AV. Baldwin, Co. 1, 11th Conn., was ;Mlniitted July lij, 1863, in a weak and exhausted
condition, surt'ering from chronic diarrluea and a gunshot wound of the hip, received at Gettysburg, Pa. The wouud
was in an unhealthy stateand did not improve under treatment. On August 12 the throat became sore and the uvula
and fauces uuich congested. Solution of nitrate of silver was applied and chlorate of potash with muriatic acid
administered. Diphtheritic patches appeared on the 14th, large Hakes of which were removed by the ajiplication of
a solution of one drachm of ioiliile of zinc in one ounce of water; but the membrane extended downwards, and the
patient died on the loth. i'»»7-H(iir((m examination ; The larynx and trachea were lined with false membrane. [■Sjjcc-
inien 11, Jied. Sec, Army Medical Museum.] — Act. Ass't burgeon John Dickson, Jarvis llospilut, BtiUimore, Mil.
Case 16. — Sergeant James W. Sutherland, Co. D, 1st Me.; age 24; was admitted Oct. 24, 1864, with a gunshot
fracture of the femur, which in progress of time united and the patient improved in flesh and strength, although some
sinuses continued to discharge. On the morning of May 24, 180.5, his throat became sore, but no patches of a diph-
theritic character were visible. At 10 i>. M. the nurse was awakened by the groaus and efforts of the patient to get
breatli. The tonsils were much swollen and the throat covered with diphtheritic patches. Other measures having
failed, tracheotomy was performed at midnight with considerable relief: but dyspntea returned, and death took place
at 4 A. M. of the 2.")th. Post-mortem examination: The tonsils were greatly enlarged and the laryix and posterior
nares covered with diphtheritic membrane which extended a considerable distance into the trachea. ISjyeciinen 591,
Med. Sec, .Vrmy Medical Museum.] — Jurris Hospital, Baltimore, Md.
Cask 17. — Corporal William 11. Vosberg, Co. H, 13th \. Y. Cav.; age 21; was admitted .Vug. 16, 1862, with chronic
diarrluea. He improved under treatment, but on September 4 his throat became sore and his tonsils, uvula and soft
palate red and swollen, the pulse being natural but feeble. Chlorate of potassa with muriatic acid was giveu inter-
nally and as a gargle. By the 6th a diphtheritic membrane covered the uvula, tonsils audei)iglottis. Quinine, tincture
of iron, beef-essence and stimulants were added to the treatment. At 8 P. M. the patient seemed moribund, — great
dyspn(va, with rapid, thready pulse and coldness of surface; but a few hours later ho rallied and slept well during
the night. The urgent symptoms returned ou the night of the 7tb, and he died next morning. About fifteen minutes
before death he vomited a large quantity of greenish liquid containing whitish shreddy matter. I'ost-mortem exam-
ination; The larynx and trachea were highly inllanied. but as no false membrane was found it was assumed to have
been dislodged by the emesis. — Act. Ass't Surgeon Pierre It. Holly, Douglas Hospital, Washington, D. C.
Ca.se 18. — Private Sylvester Green, Co. D, 186th N.Y.; age 19; was admitted May 2. 1865, with fever and swelling
of the parotid glands. On the 5th there was much swelling of the neck with increased dyspniea and dysphagia, thready
pnlse, anxious countenance and profuse perspiration. He died asphyxiated ou that day. Post-mortem examination:
A ]ierfectly-formed false membrane extended from the glottis to the bronchi ; the lungs were emphysematous. — Slough
Hos2>ital, Alcrandria, ('«.
Case 19. — J. T. St. John, .\ct. Ass't Surgeon, was admitted March 3, 1865, with diplitlieria. He had been sick
for eleven days prior to admission, and while en route to hospital was treated by Dr. W. P. Paku, who administered iron
anil stimulants and cauterized the throat with fused silver nitrate, thereby disengaging large masses of f;ilse mem-
brane and enabling the patient to breathe and swallow with less dilliculty; but the men)brane was renewed and the
subseiinent use of the silver salt was not followed l)y benefit. Ou his arrival by steamer from City Point, Va., he
was uiuch prostrated; he had to be propped up in bed, and what ho said could not be understood unless the ear
was closely inclined to him; his countenance was anxious and slightly venous; partial paralysis of the left arm was
observed and he complaiued of tenderuess over the wrist; a grayish-white exudation covered the tonsils and soft
palate. The iron, brandy aud beef-tea which he had been taking were continued, and au emetic often grains of cap-
sicum and a teaspoonful of mustard having failed to produce vomiting, sulphate of zinc was administered, but although
some membranous shreds were dislodged the patient was not much benefited. A concentrated solution of capsicum
was applied w ith a probaug every third hour and was also used e.xternally. 4th: Some shreds of the expectorated
membrane are of firm consistence, being even somewhat cartilaginous; delirium during the night: deglutition imjios-
sible; continued but unsuccessful eft'orts to rid the air-passages of the obstruction. 5th: Respiratory murmur feeble
over right lung; counter-irritation by mustard aud turpentine on chest and a blister to each deltoid; persul))hate of
iron solution to the tonsils and larynx. 6th: Intellect unaft'ected; death impending; face aud hands dusky. He died
at noon. Post-mortem examination: From the soft palate, half arches, tonsils, pharynx, epiglottis and root of tongue
a white or ash-colored substance, closely adherent to the originating tissue, extended downward, forming au interior
tubf ir. the trachea and bronchi. This membranous lining varied from one-fourth of a line to two lines in thickness
aud in parts it appeared as if laminated. In the upper part of the aftected region the exudation was ragged — in the
lower part smooth. The surface of the lower part of the main tubes covered by the membrane was scarlet, and in
spots of a deeper scarlet fine granulation was considered to be present. The lungs were in parts crepitant, in others
carnified and a-deumtous: the left lung, in addition, contaiued some small apoplectic clots and ecchymoses. In the
bronchial tubes of the left lungashred-likefibrinoussubstance was continuous with the abnormal lining of the trachea.
In the right lung the bronchial tubes to those of the third magnitude, aud even further, were occupied by hollow
748 DIPHTHERITIC INFLAMMATION OF THE FAUCES, ETC.
fibrinous casts, aud tubes of lesser magnitude not seen to be so occupied presented an abnonually white ajineaiano.
The right lung weiglicd tliirty-two, the left twenty-eight ounces. The heart contained mixed clots in all Us cavitiet.
The brain was tirm; the pia mater congested, two ounces of serum having escaped when the arachnoidal sac wao
opened; an arborescent spot of congestion was found on the floor of the fourth ventricle on the right side, above the
origin of the auditory nerve ; the right lateral ventricle contained a small quantity of liquid. [Specimens 585 aud 586,
Army Medical Museum, show the larynx and trachea with their abnormal lining and a portion of the Inug with fibrin-
ous casts in the smaller bronchial tubes.] — Ass't Surgeon Geo. M. McGiU, U. S. A., Xationul Hoiij)ita}, Bitltimore, Aid.
Case 20.— Private David G. Hatch, Co. H, 13th N. H.; age 23 ; was admitted Dec. 30, 1862, with typhoid fever.
On Feb. 23, 1863, ho had high fever, pulse 144, and a dry hacking cough; his throat, lips and tongue were much
swollen and his mouth and fauces dry and inflamed. He continued to take food till March 1, when he complained
that he could not swallow. At this time the chest was dull on percussion and bronchial breathing was heard ; respi-
ration was painful and diflicult, the pulse low, breath offensive and the extremities cold; acrid discharges came from
the nose, sordes accumulated on the teeth and the expectoration was mixed with putrid masses. He died on the 3d.
rost-mortein examination: The brain was pale and firm. The trachea, larynx, posterior half of the left side of the
fauces, the pharynx on the line of the nares and the posterior part of the floor of the nares were covered with a fibrin-
ous mass, grayish-white in the larynx and red in the trachea. [Specimen 7, Med. Sec, Army Medical Museum, shows
a diphtheritic layer coating the posterior surface of the soft jialate and the under surface of the epiglottis; it is
notably present at the rima glottidis.] The right lung weighed thirty-nine ounces ; its bronchial tubes were occluded
■with plugs of white fibrinous lymph, which, when detached with difficulty, revealed longitudinally striated mucous
membrane, roughened and in places granulated; on section the tubes appeared as yellowish-white spots; the lower
lobe was almost entirely consolidated; the middle lobe, shrivelled and partially carnified, had its main bronchus
totally occluded by a large plug; the upper lobe was generally consolidated, but the bronchial plugs were less adhe-
rent aud there were neither striaj nor granulations in the bronchi. Some of the bronchial glands were in a state of
cheesy and calcareous degeneration. The heart was pale and contained fibrinous clots in both sides; nineteen
drachms of brownish serum were found in the jiericardivim. The duodenum was stained ; Peyer's patches were much
congested and spotted; the valvuhe were thin and irregularly congested and the mucous membrane of a livid flesh-
color. The large intestine was normal. The liver, fifty-nine ounces, was mottled, pale and softened; the spleen,
seven ounces and a quarter, was mottled of a light-purple color, its trabecuhe distinct and firm aud its substance
pulpy; the pancreas firm and purple; the kidneys reddish flesh-colored and firm; the suprarenal capsules enlarged,
straw-colored and of natural consistence. — Ass't Surgeon Geo. M. McGiU, V. S. A., Lincoln Hospital, Washington, D. C.
C.\SE 21.— Corporal J. L. Blake, Co. I, 7th Me.; age 30; admitted Aug. 10, 1862, with diarrhtea. Died September
23. Post-mortem examination: The fauces and pharynx to the commencement of the o?sophagus, the larynx, trachea
aud bronchi were inflamed and lined with pseudomembrane. The tissue of the lungs was healthy, but the bronchial
tubes were filled with mucus, and some blood was eft'used into the interlobular connective. The heart, liver, spleen,
pancreas and kidneys were healthy. The stomach was more or less inflamed throughout. The mucous membrane of
the duodenum, jejunum and ileum Mere slightly reddened and 6t.ained with bile. The large intestine was exceed-
ingly contracted and nearly uniformly pink. — Act. Ass't Surgeon J. Leidij, Satterlee Hospital, ritihiclelphia. Pa.
Case 22. — Private Henry B. Kern, Co. F, 52d Pa.; age 18; was admitted July 3, 1863, with a contusion which
required no special treatment. He was taken with sore throat August 10, aud died on the 15th. Post-mortem exami-
nation: The fauces, pharynx, trachea and bronchi were inflamed, their mucous membrane dark-red aud covered
everywhere with an ash-colored pseudomembrane; the inflammation extended to the bronchial tubes and even to
isolated lobules of the lungs, the lobules aft'ected being filled with a bloody fluid to the entire exclusion of air. The
anterior inferior angle of the ujiper lobe of the left lung and the corresponding portion of the middle lobe of the right
lung were congested for about two inches in extent. The remaining organs appeared to l)e healthy. — Act. Ass't Sur-
geon J. Leidij, Satterlee Hos2>ital, Pkiladcljtltia, Pa.
Case 23.— Private Milo Bray, 4th N. Y. Batfy; age 25: admitted Aug. 28, 1863. Died October 8. Post-mortem
examination : The brain was firm and its vessels, esi)ecially those of the pia mater, injected. The larynx and trachea
were lined throughout by false membrane, which covered both surfaces of the epiglottis; the underlying mucous
membrane was of an intense purplish-red color. [Specimeti 10, Med. Sec, Army Medical Museum.] The tt-sophagns
was very pale. The right lung, twenty-three ounces, was well filled with air except in its third lobe, which was
intensely congested, and in the lower part of its first lobe, which was carnified ; the left lung, nineteen ounces, showed
carnified portions here and there among healthy tissue and the bronchial tubes of its lower lobe contained a false
membrane similar to that found in the trachea. The pleura? enclosed twenty-six ounces of dark-red serum, con-
tained chiefly in the right cavity. Mixed clots were found in the right cavities of the heart and venous clots in the
left cavities, aorta, veme cavic and pulmonary artery: the pericardium contained eight ounces of straw-colored .serum.
The liver and intestines were healthy, the kidneys congested, and the spleen, which weighed twelve ounces and a half,
was dark-colored and pultaceons. — Ass't Surgeon H. Allen, U. S. A., Lincoln Hospital, Wash'tngton, D. C.
Case 24. — Private Marcus L. Myers, Co. G, 10th Iowa; age 24; was admitted May 16, 1864, with the cervical
glands much swollen and indurated, dysphagia and dyspnoea; pulse 110, small and quick. He died next morning.
Post-»iO)-/fni examination : Pseudomembrane lining the fauces and all the air-passages; one piece of an arborescent
appearance ; mucous membrane much congested. Heart normal ; fibrinous clots in both ventricles (conceived to have
been the immediate cause of death). Spleen twice the normal size and friable. — Hospital, Madison, Ind.
Case 25.— Private John Feastcr, Co. C, 7th N. Y., was admitted Aug. 17, 1864, on account of a gunshot wound;
but he had indications of diphtheria, which became fully developeil seven days later. His throat became swollen
DIPHTHERITIC INFLAMMATION OK THE FAUCES, ETC. 749
ami a liliii of white substance foriiu-il almiit the tonsils; food leliiriR'tl thiouj;h ihf nostrils when attempts weie made
to swallow ; respiration was diliiiult. Imt there was no cough. A gargle of tannin solution lirouglit away a consid-
eralile anu>unt of the film. Chlorate of potassa, muriate of ammonia and tincture of iron were prescrilied. The patient
died of surtocation on the 30tli. ront-morlim examination: Tlie trachea contained a tnhular ]>seudomemluaue which
extended into the bronchial tubes. ISpvcimtii 110. Med. Sec, .\rmy Medical Museum.] — .Id. Ass'l Surgeon Snmnil
Grahtim, Emory Hospital, Washiiigloii, 1). C.
Cask 26.-T-Private Joseph Lester, Co. ¥, 15lh \'t., was admitted May 2, 18G3, with intermittent fever. On the
.">th diphtheritic iutlammation of the fauces was apparent, accompanied with aphonia, great depression, rapid pulse,
130 per minute, and semi-unconsciousness. Under alteratives, stinnililnts and beef-tea, with astringents locally, he
improved until the 9th, when his ))ulse became weak and thready and his lungs congested. He died on the lltli.
Vutl-morliiii examination : I'leura' healthy: right lnnghei>atized posteriorly; left lung difi'u.sely congested : right side of
heart llabby, empty: left siile tilled with blood: abdominal viscera healthy. — Second I)iri!<ion Ilospilul, Ahxandriii, Tu.'
SequeliT? of diphtheria are alluded to only in the following papers:
Act. Aas'l Surgeon Is.v.\c G. PoHTKii, Fort TrumhuU, Conn., JuneSO, 1862. — Among a few cases of diphtheria there
was one, now on furlongli, which, while not inordinately severe, left the patient with partial paralysis of the soft
palate and (esophagus, which has given a decided nasal tone to his voice and caiises frei|uent strangulation while
swallowing his food. He is also highly aujcmic and all his motions are tottering and uncertain.
C.vSK 27. — Musician Robert D. Shook, Co. G, .5th Mich.: age 18: was admitted Aug. 30, 18G3, having been attacked
three days before with heada<he, fever, pain in the thioat and stitfuess and swelling of the neck. He had consider-
able fever of a continued type; pulse 100 and feeble: tongue coated with white fur; fauces completely covered with
a yellow exudation, the surrounding mucous membrane being of a bright-red color; tonsils markedly tumefied; glands
enlarged and neck swollen. The patient had no appetite and his bowels were constipated. Cathartics and a gargle
of chlorate of potassa were prescribed; two days later quinine and iron were used. On the 7th the membrane had
nearly separated; the appetite was good and the patient felt well but weak. On the 9th, when treatment was dis-
continued, there was a slight patch of membrane on the left tonsil. A difficulty of swallowing, from paralysis of the
pharynx , was observed ou October 1 ; there was also loss of power in the npjier and lower ext romities. Tonics, stim-
ulants and moderate exercise were prescribed. He was discharged from service November 22, on account of paralysis,
which necessitated the use of crutches. — Central I'ark Hospital, Xew York Citij.
Treatment. — The treatment adopted in these diphtheritic inflammutionsdoes not appear
to have been satisfactory. When the disease, at its inception, was attended with acute febrile
symptoms a purgative, usuallv a mercurial on account of the foul condition of the tongue,
was administered, with neutral mixture, counter-irritation externally b}'' sinapisms or lini-
ment of ammonia, and a solution of chlorate of potash as a gargle; but when the pscudo-
raembrane was observed this mild method of treatment was superceded. The application
of the most powerful agents was considered justified in the endeavor to change the character
of the inflammatory process, to destroy the infiltrated membrane or to remove it from its
underlying connections. Naturally, when suffocation threatened the patient, the sight of a
semi-detached pseudomembrane on the tonsils or epiglottis suggested that its removal might
*A few cases of diphtheria with poi^-niorlnn notes have been piiblishal in the Medical Jonrnals, as for instance: — P. R. Garvin, A.<w't Surgeon, 40tli
MiL'«.. reixirtitl tlie cjise of Private \V. K., Co. K, of liis regiment, who was ailniitlol I)i r. :il, ISW, with liifh fever, filid lireatli au.l great swelling of
the tonsils, vvliicli were covoreii with an ash-coloreil exiulatioil. Local and general treatment was atteudeit !»>■ app:irent liein'fit for fonr days, when the
fever Itecame associated vvitli stupor and low delirium ; tlie pulse ranged from 120 to 1.30 ; the throat had a du.slcy hue aud the countenance became livid.
Doatli ocenrntl tive days after admission. Posi-mortem examination found the trachea inflamed aud a large part of its surface covered bj' a false uieni-
hranc wliich extended into tho brunclii. Tlie exudation became thicker below and completely filled the right bronchus, where it wjis miugled with a
stringy niuco-puruleut matter. The right lung presented bhack patches at its base and anterior edge of the middle lobe. Recent adhesions were found
on the left lung with gray hepatization in its lower lobe. — See Ania-ican Mat. J'trwes, Vol. YIII, 1SG4, p. iH. Li;wis II. Konjl.vx, Medical Cadet, U. S.
.\nny. reportcl the ni.<e of Private Drai>er, aged IG, who, while convalescing from typhoid fever in August, ISCt, began to suffer from small uicei-s of the
nioutb aud inlhtnimation of the tbrojlt. Three days later false membrane appeared on tho palate ; the pulse became (juick and feeble ; the skin hot and
dry. I»istri-»ing cough and dytipua>a followed the extension of the di..iease into the larynx. Treatment was of no avail. Death occurred suddenly seven
d.-iys after theapiM\araneeof the tirst symjitom.i. Po^-morfem examination : An ash-colored membrane extended from the tonsils and sides of the posterior
nares through the larynx and traelu-a to the bronchi. The lungs presented hyiwstatic cougi-stion aud commencing iutlammation. Peyor's glands had
tiegliu to cicatrize prior to the diphtheritic atUick.— See American .Ved. Tiiii«, Vol. IV, 1SC2, p. C7. A. B. MoTT, .\ttending Surgeon Soldiers' Home Hos-
pital. New York City, reportcil the case of .Mden F. Page, Co. E, 2d >Ie., « ho was admitted June 25, 18C2, with chronic rliennmtism. Four days later he
complained of sore thro;it aud pain in swallo^ving. Kext day a membranous exudation w;ui observed on tho tonsils and palate. Tonic and stimulant
treatment wxs at once adoptetl, with the use of chlorate of potash internally and locally. The pulse was ]<Mt, deglutition ]iainful and the countenance
anxious. Notwithstanding treatment the exudation spread over the tonsils and palate aud seemed to extend into the air-piis.sages. Dyspn<ea wasextrenn-
anil tile sutfering intense. The case terminated by asphyxia five days after the onset. At the examination a membrane was found lining the air-passngrs
to the third ramifications of the bronchi.— .InrcnV.oi Jlfed. Timei*^ Vol. V, 1862, p. IXJ. .1. II. Thompson, Surgeon 39th N. Y. — Medicni mid Snrgirnl Itrjiorhv,
PhiliL, ^ ol. X, ISiiS, p. 2.11 — gives a short account of a pseudomembranous disease that prevailed among army horses at Williamsliurg, Va. The uiiimals
aftect^'dapiieared to he well in the morning; but later in theilay they refused to eat, and by evening they were unable to swallow and died in a few hours
after. Pb»/-ntnrlau examination found the mouth, larynx and trachea covered by false membrane in appearance like that of diphtheria in the human
sutijiH't. but much thicker and more tenacious.
750 DIPHTHERITIC INFLAMMATION OF TliK FAUCKS, ETC.
afford relief. Sometimes the forceps was successfully employed to effect this. Cauterization
with nitrate of silver occasional!}'- disengaged large masses and enabled the patient to breathe
and swallow with less difficulty. Emetics of mustard and sulphate of zinc, ipeeacuanlia and
tartar emetic failed to bring relief, although sometimes, perhaps, dislodging shreds of the
pscudomembrane. Among the direct applications to the site of the inflammation, so far as
it could be reached, may be mentioned strong solutions of nitrate of silver, sulj^hate of cop-
per, iodide of zinc, persulphate of iron, tincture of the muriate of iron, hydrochloric acid,
ammonia and olive oil, tinctures of ojDium and iodine, strong infusions of cayenne pepjDer,
powdered alum, etc. These swabbings were supplemented by gargling with dilutions of the
same potent substances. There is abundant testimony to the inefficacy of these local appli-
cations. When a membrane became detached under their influence, or pending their use,
the diphtheritic process was immediately re-established on the vacated site. Moreover, as
they reached only a limited portion of the affected membrane, that lying superior to the
laryngeal passage, they could obviate no danger save that from occlusion of the rima glot-
tidis. Perhaps this danger, when imminent, might have been more effectually combatted
by an opening into the trachea than by persistent swabbing with corrosives and irritants.
Of coarse tracheotomy would have been attended with no benefit when the disease had
extended into the bronchi and their ramifications; but in these cases no impression on the
mucous membrane of the fauces and upper aspect of the larynx by caustics or other powerful
.agents would have affected the invaded bronchioles. Tracheotomy would have protected
the patient, if needful, from suffocation by pseudomembranes in the larynx, and this is all
that their effectual removal by corrosives would have accomplished.
Meanwhile, besides this active local treatment, counter-irritants were applied to the
cervical region, although in some instances emollient cataplasms were used with inhalations
of steam. Internally tincture of iron, quinine and chlorate of potash were administered
freelv, with as much beef-essence and milk-punch or other stimulants as the patient could
be prevailed upon to swallow. But in most of the recorded cases the fatal ending was not
averted. Unfortunately there is no record of the many cases that recovered. It would be
of interest to know whether the active local treatment above mentioned was instituted, or
whether, as in some of the recoveries at the Alexandria, Va., hospitals, the local applications
were restricted to a solution of nitrate of silver containing ten grains in an ounce of water
and a gargle of diluted tincture of iron. In this connection the uniform success claimed by
Surgeon Egbert, U. S. Vols., for his plan of treatment, submitted below, is of jDarticular
interest, as it involved no more irritant application to the inflamed parts than a solution of
chlorate of potash in an infusion of hydrastis. The successful use of ice, reported by Sur-
geon Hammer, U. S. Vols., and of the slightly alkaline vapors from slaking lime, by Act.
Ass't Surgeon McElderry, also involved the disuse of irritant local applications.* The
records are meagre, but they do not favor a local treatment that would be productive of a
dangerous laryngitis in a healthy subject. The following papers are all that have been dis-
covered relating in general terms to the treatment of diphtheria:
» Uexey HcEldeerv, Act. .iss't Surgeon,— .Iffrfical and Sur.jicnl Eeporler, Philadelphia, Vol. XIV, 186G, p. 344,— gives a favorable report of the use
of the vapor arisiDg from hot water poured upon lime. The case, that of a child six years old, at Fort SIcHenry, 3Id., in April, 186G, was severe in its
general and local symptoms and had advanced to a state marked by difficult and labored respiration. Local applications to the diseased parte had given
no good results. A large handful of lime was then put into a pitcher into which half a pint of boiling water was afterwards poured. The child's face
was held over this that the fumes might be inhaled. Meanwhile a dessertspoonful was given every two hours of a mixture containing two drachms of
chlorate of potash, two fluid drachms of tincture of iron, half a drachm of aromatic spirit of ammonia and six fluid ounces of lime-water. Immediate
relief followed the inhalation, and after this had been used twice, at intervals of two hours, the breathing became easier and the swelling of the throat
considerably reduced. This improvement ended in recovery five days after the onset of the disease. Dr. McEldeeky's attention was called to this
remedial measure by a communication from A. Geiger, of Dayton, Ohio, published in a previous issue of the journal cited.
PNEUMONIA. 751
Surgeon M. li. U.vGE, 25//i U'i!i.,V<iiiip HaiHlull, (I'lx., Die. 31, 18G2.— Diiilithoria wo treat mililly or ciu-igctioally,
according to the form iuwhichtlio attack shows itself. If the .symptoms aroof an inllammatory grade, as shown hy
headache, pain in tbo loins and slight rigors, wo give a mild cathartic and nse as a gargle sohition of chlorate of
potash, also conn tor-irritation liy sinapisms, solution of ammonia or oil of tnrpentinc, to the region of the throat exter-
nally. Hut if the case be nnilignant in its type and the powers of life rapi<lly depressed hy the cirenlating poison,
stimulantsand tonics are promptly resorted to — brandy, tincture of muriate of iron, (|uinine,cte. — together with local
stimulating applications to tlie internal parts affected so far as they can be rcacho<l. Wo use for the latter purpose
nitrate of silver, tincture of iron, tincture of iodine and ereasote, and have but little choice among them. Some of
these cases of malignant diphtheria irilldiv whatever may be done. The .system is at onco overwhelnu'd.
Surgeon J. >[. Uatks. VMIi Mc. Ship Talanil, Mm.. .Sepl. 27, 1802.— During the months of May and .luiic we had
twenty-live or thirty cases of diphtheria of a malignant form, which in a majority of cases proved fatal in spite of
tonic and stimulant treatment with iiuinine, tincture of iron, chlorate of potash, brandy, whiskey, etc.
Surgeon AUGUSTUS R. Eguekt, U. S. Vols., Fort llmnhoUU, CaJ., July 3, 1863.— The only violent disease for (ln^
last three ir.onths in this country has been a comhiuation of diphtheria and typhoid fever; but none of the cases have
occurred at this post. I will mention in brief the treatment which I find invariably successful: A wet bandage is
applied to the throat and the following gargle prescribed for use every two or three hours. I'onr a pint of boiling
water on a drachm of the root of Hydrastis Canadensis; when cold strain and dissolve in the infusion two drachms
of chlorate of potash. When the tongue is dry a pill consisting of one grain of Iduo-pill and one of i]iecacuanlia is
administered every three hours until it becomes moist. After the third, sometimes .second day. milk-)iuneli or egg-
nog is given freely. I have been invariably successful, as well as those who have followed this |il:in. vvhilo those
who did otherwise lost more than half their cases.
Surgeon A. Hammer, U. S. Vols., St. Louis, Mo., Sept. 11, 1863. — I take the liberty of bringing to notice a case of
considerable importance that occurred in my hospital, in which there was used a new remedy. On .September 1 I was
called by Dr. LEi'tiXGWELL to see a patient sutfering from diphtheria. The patient had complained the evening before
of great dyspno-a and painful sensations about the throat which had been relieved by the application of a solution
of nitrate of silver. I found the ca.seoneof well-marked and extensive diphtheria; the tonsils, soft ))alate and uvula
on both surfaces being covered with thick grayish- white, continuous, croupous exudations. Knowing the uncertainty
of our present treatment Of this insidious disease, I concluded to prescribe the swallowing of small bits of ice con-
tinuously, as I had seen it recommended in a journal article by a French surgeon. Next day the diphtheritic exuda-
tions were more marked and the case aggravated; but to give the treatment a fair trial 1 ordered its continuance,
and in addition ire compresses around the neck. Ou the 3d the progress of the disease had been arrested and parts
of the membranes thrown oil' by coughing. The ice was continued for two days more, during which time the exuda-
tions became steadily thinner, and ou the 8th recovery was perfect. The patient. Private .James A. Mitchell, of Co.
I, 2d Wis. Cav., at the time of this attack had just recovered from a severe remittent fever. Should the ice jirove as
beneficial in other cases as in this it would he a great blessing to mankind. I have no reason to doubt that the
exudative processes are checked by the action of cold upon the capillaries. From the result of this treatment, if
there be a doubt left in any professional mind, it will be now apparent that diphtheria is not a constitutional but a
local disease. In similar croupous exudative processes on other parts of the body the ice will no doubt produce simi-
lar ettects, and in future I shall not hesitate to apply it externally and internally in croup, there being no dilicreuce
between the morbid processes of both diseases excepting in the seat of the affection.
IX.— PNEUMONIA.
The statistical facts relating to inflammation of tlie lungs as an army disease have
already been submitted in treating generally of diseases of the organs of respiration. The
61,202 cases that occurred among the white troops during the war period have their distribu-
tion throughout tl>e months and years indicated in the diagram facing page 722. The 14,738
deaths are similarly distributed in the diagram facing page 20. Regionic prevalence is shown
in Table LVIL* The rates of prevalence and mortality derived from these cases have been
stated and compared with corresponding rates among the colored troops, the Confederate
armies and the Union and Confederate prisoncrs.f Many diseases were of more frequent
occurrence than pneumonia, but only diarrhcea and dysentery and the continued fevers fur-
nished a larger death-list.J It has been shown, however, in discussing the points of interest
connected with these grave camp diseases, that pneumonia was present and caused or has-
tened the fatal issue in 21.6 per cent, of the deaths from diarrhosa and dyseiitery§ and in
68.3 per cent, of those attributed to the continued fevers; || the mortality from measles also
•Page 724, TOjji-n. f Supra, p. ^l9 d Kq. J See Tabic II, page 11, «ii;ini.
'iSte Part H of thi.s Work, page 635. I S«e «"J"". P^B" ''"''•
752 PNEUMONIA.
resulted largelv from inflammatory processes in the lungs. In fact, the importance of pneu-
monia as a destroyer of life in our camps and hospitals can hardly be overestimated.
Clinical Records. — The records of pneumonitic cases are usually incomplete. A
more or less satisfactory view of the patient is afforded on his admission into liospital, and
an occasional entry subsequently enables the reader to fill up the gaps in the history. In
manv cases the reporter was satisfied with entering the diagnosis without referring to the
symjitoms on which it was based. The records are especially deficient as regards the history
of relapses, recurrences and aggravations of the diseased conditions when perfect recovery
did not follow the subsidence of the primary attack. On this account it has been deemed
advisable to summarize the reports and give in full only a few cases as illustrative specimens.
Thus, 1 and 2 have been selected as acute uncomplicated ca.ses endinj; favorably; 3-5 have pleuritic complica-
tions; 6 and 7 present typhoid symptoms, but recover; 8 and 9 illustrate the progress of adynamic cases to a fatal
termination; 10 and 11 end in pulmonary gangrene and 12 in empyema; in 13 the diseased action persisted aud led
to a diagnosis of consumption; 14 was characterized by the sudden access of ■nild delirium; 15, a catarrhal ca.se in
•which venesection gave slight but passing relief; 16-18, catarrhal cases following measles.
Case 1. — Private R. S. Hopkins, Co. D, 73d 111.; admitted Sept. 12, 1862; skin hot aud dry; pulse 138; tongue
much coated; intense pain in right lung; rusty sputa; crepitant rales; exaggerated respiration in left lung. Gave
of tartar emetic four grains, acetate of morphia three grains, sweet spirit of nitre half an ounce, syrup of lemon one
ounce, distilled water three ounces ; a tablespoonful every hour. Applied blister over right lung, loth : Doubled
the dose of the antimonial. 16th: Pulse 120; tongire coated; fever high. Gave two grains each of calomel and
Dover's jjowder every three hours. 17th: Better: pulse 103; skin cooler; sputa loose but bloody. 18th: Pulse 92;
appetite improved. Gave two doses of nitrate of potash and Dover's powder during the day and in the evening
whiskey toddies. 19th: Pulse 73, full and soft; slept well by the aid of morphia; skin and extremities cool. Gave
citrate of iron and quinine in Catawba wine. 20th: Pulse and skin nearly natural. 24th: Tongue clean and moist;
no cough. He recovered aud was returned to duty November 12. — Wtst End Hospital, Cincinnati, Ohio.
C.VSE 2. — .Sergeant Hiram J. Bond, Co. A, 4th 111. Cav.; age 29 ; admitted April 20, 1864, with pneumonia of the
right side; cough; paiu in chest; scanty, viscid expectoration mixed with blood; quickened respiration; fever;
accelerated pulse ; some dulness on percussion ; crepitant rales and absence of vesicular murmur. Gave a cathartic,
nitrate of potash, digitalis and tartar emetic; bled the patient; in the declining stage gave expectorants. He fully
recovered aud was furloughed May 16. — Lawson Hospital, St. Louis, Mo.
Ca.se 3. — There was but one case of pneumonia during the past quarter,— a violent case in a dissipated subject.
The patient stated that the day before ho had a chill w hich was followed by fever and cough, with much pain in the
side, so severe that he could scarcely breathe aud did not sleep any during the night. He had violent cough with the
characteristic rusty sputa; severe pain in the left side: great dyspntva; high fever; intense headache; jiulse full,
strong and frequent; skin hot aud dry; face livid and anxious; respiration hurried; bowels constipated aud urine
scanty. 1st day: Gave four compound cathartic pills and applied a blister over the seat of pain. 2d: Bowels well
opened; the blister relieved the severe pain in the side; other symptoms unaltered. Gave brandy, eight ounces,
morning, noon aud night, with good nourishment. 3d: Very restless and sleepless during the night; symptoms
unchanged. Gave twenty grains of sulphate of quiuia, with half a grain of tartar emetic, morning and evening;
continued brandy and beef-tea. 4th: All the symptoms much improved; fever subsiding; pulse soft; skin moist;
breathing easier; sputa mingled with less blood; secretion of urine copious. Diminished the quinia and tartar
emetic by one-half; continued brandy and beef-tea. From this day complete convalescence was established aud tlie
patient soon recovered his strength — Surgeon AUni F. Peck, 1st X. M., Ft. Stanton, \. J/., Dec. 31, 1862.
Case 4. — John Dalton, Co.C, 28th Mass.; admitted April 10, 1863, complaining of chilliness and pain in every
part of body; headache ; bowels moved by a cathartic yesterday: tongue coated. Half a drachm each of solution of
acetate of ammonia and sweet spirit of nitre four times a day; low diet. 11th : Restless ; pulse 90 ; tongue coated
white; skin hot; no appetite; much thirst; pain in right lung; dulness over left nipple; crepitant rales distinct.
Tincture of veratrum viride, three drops four times a day aud Dover's powder at night. 12th : Rested badly; pulse
110. Solution of acetate of ammonia two drachms and sweet spirit of nitre half a drachm three times. 13tU: Rest-
less; headache; pulse quick, 120 ; continued treatment. 14th: Pulse quick; headache; delirious during the night ;
rubbing sound heard over upper part of left thorax, rales below and dnlness over all ; sputa -a little tinged ;' tongue
dry. Treatment continued, with tiftecu drops of turpentine three times a day. loth: Less delirium last night; pulse
104; two stools ; tongue less furred aud dry. Coutinue turpentine aud give ipecacuanha one grain, sweet spirit of
nitre half a drachm, three times. 16th : Appears better; pulse feeble, 80 ; skq)t a little: bowels regular ; skin cool
and moist. Solution of acetate of ammonia one drachm, sweet spirit of nitre half a drachm, fluid extract of ipecac-
uanha four drops, three times a day. 17th: Slept pretty well: pulse regular; no rubbing sound and dulness less
marked. Continue treatment and give half an ounce of whiskey three times a day. 19th: Blisters applied yester-
day afternoon over front and back of left side. Sulphate of quinine one grain, whiskey three ounces, every three
hours. 26th: Pulse 60; tongue clean: appetite good: a little dulness at apex of left lung. Rub croton oil above
and below clavicle. Sent to general hospital to-day. — Hegimental Register, 2StJi Mass.
PNEUMONIA. 753
Case 5. — Private Eli J. Keeler, Co. ti, ITtli Conn.: .ige 33; while recovering fidni Wdiinds received at (iottys-
IrniS, Pa., July 1, 1863. auil on light duty a.s nurse, liecainc siok March 9. 1.SG4: Sharp pain in right side over nipple;
high fever: cough: no hereditary phthisis: father, 08 years old, had fourteen out oftifleen sons in active service; mother
71 years old. 11th: Pulse TJO, small and conipressilde: skin hot and dry; facetlushed: respiration 80; sputa copious,
frothy, somewhat tenacious and bloody: tongue moist and coated; bowels open (had taken sulphate of magnesia);
urine scanty and high-colored: decubitus, mostly on right side: sharp pain in right side in breathing or coughing;
dulness and tubular respiration over upper part of lung anteriorly in axillary region and posteriorly; largo moist
niles anteriorly above and friction anteriorly below right nipple, with slight moist rales and absence of vesicular
breathing posteriorly. Applied six wet cups over root of right lung; milk diet. Gave small doses of nitrate of potash,
calonu-1 and ipecacuanha every three hours. 12th: Pulse 112, stronger, but compressible; skin less dry; respiration
18: sputa scanty and not so bloody, tenacious; tongue coated, moist ; urine augmented; livestools; sharp pain under
right nipple: right lateral decubitus; dulness and tubular breathing in right subclavian region; friction below;
severe pain in liver, especially in upper part of right lobe ; dulness in right axilla less marked ; friction and prolonged
expiration over lower axillary region ; well-marked dulness and tuhular breathing over upper and posterior part of
lung: friction over lower part posteriorly. Gave repeated doses of nitrate of potash and Dover's powder. 13th:
Pulse 104, very small and compressible; skin moist and cool; respiration 60; sputa scanty, tenacious; tongue white
and moist: urine augmented and depositing lithates; pain in mammary region continues, relieved by bending for-
ward: dulness and tubular breathing in upper jiart of lung less marked; friction well marked anteriorly and pos-
teriorly in axillary region. Extra diet. 11th : Pulse 80, full, stronger: skin moist and warm : respi:ation 32; sputa only
slightly tinged: four to five stools: timgue cleaning, moisi : pain in mammary region much relieved: appetite return-
ing: tubular breathing replaced by large and small moist rales. 16th: Moist sounds diminishing in extent: .sputa
copious but tenacious. Applied blister. 17th: Much better; hlister renuiined on eight hours and ;i half. 18tl!:
Physical signs of pleuritic effusion: vesicular breathing returning in apex of lung. 21st: Keturn of pain over right
lung. Transferred to Knight hospital, New Haven, Conn, [arriving on the 30th. Furlonghed on the 31st. Returned
to hospital April 12. Keturned to duty May 7]. — Satterlce Hoxitital, Philaddphia , Pa.
Cask 6. — Private M. McDonall, Co. C, 5th N. J., was taken Feb. 23, 1862, with typhoid pneuimmla involving
a large portion of the lower part of the right lung, with some implication of the left lung ; crepitus was clearly audible
and fever, pain, bloody sputa, etc., were present. Ordered blue mass ten grains :ind half-ounce doses of liii. potassiB
citratis. 24th: Pulse 144, feeble; nuittering delirium; sputa streaked with blood : passages very dark, bilious : sys-
tem much prostrated. Mustard cataplasm to chest; beef-tea and brandy punch every alternate hour. 25th: Improv-
ing: pulse 1(X): respiration easier: nodelirium. A stimulant every four hours and beef-tea at similar intervals. 26th:
Pulse Wi; tongue cleaning: pain in lower part of right lung. Pitch and cantharides plaster: treatment continued.
27th: Pulse 86. Senega and wild cherry administered and stimulants decreased. March 24th: Gaining strength
slowly. — Satterlee Hospital, riiihnUlphia, Pa.
Cask 7. — Private Joseph Burns, Co. I, 43d N. Y., was admitted Aug. 10, 1862, almost moribund with typhoid
pneumonia. Gave milk-punch, beef-essence, cough syrup; extra diet. After much suffering from bedsores he began
to improve, but when well advanced toward recovery was attacked with erysipelas, which prostrated him again.
Applied lead-water and laudanum and gave quinine and wine whey. November 25: Convalescent. Jan. 1. 1863:
Fat. but unfit for field service. September 4 : Transferred to Invalid Corps. — Satterlce Hospital, Philaclclphia, Pa.
Case 8. — Private James Wilson. 14th N. H., was admitted Sept. 25, 1864, with typhoid pneumonia: Much
pain in head, back and limbs; skin hot and dry: pulse (luick : tongue furred and dryish. Gave Dover's powder at
once: repeated in six hours. 26tli: Gave turpentine. 27th: Some cough ; pain and dulness on right side; low mut-
tering delirium. Gave antimony (juartcr of a grain, sulphate of magnesia one drachm, every two hours; a]iplied
fomentations to chest. 29th: Involuntary stools. Added whiskey and opiates. He lay in a deei) stupor and was
aroused with difficulty. 30th: Died. — Third Division Hospital, Alexandria, Va.
Case 9.— Private Nathaniel Davenport, Co. I, 2Glh Mich.: admitted Jan. 27, 1863, having been ill two weeks:
Delirium: headache; face livid: skin hot and dry: i)ulse 100 and feeble; tongue dry; bowels loose; abdomen tumid
and tender: thoracic symptoms trilling at first but afterwards aggravated; cough frequent and )>ainful, with slight
viscid, bloody expectoration, subsecjuently becoming mixed with pus : diminished resonance over right side anteriorly,
with subcrepitant ronchus below and puerile respiration above. Gave iron, senega, carbonate of ammonia and mor-
phia every four hours, with dry cui)s and turpentine stupes, followed by a blister. The sputa became copious and
fetid and the patient emaciated by night-sweats and exhausting diarrluca. Gave tonics, stimulants and nutritious
diet. He died April 30. — Third Division Hospital, Alexandria, Va.
Case 10. — Private Michael Dowd, Co. B, 12th N. Y.; admitted March 14, 1863. For six weeks prior to admis-
sion, during most of which time he was in Ncav York city on furlough, he suli'ered from cough and pain in the
left chest : Sputa copious, dark-colored and fetid ; dulness posteriorly over the upper portion of the lower lobe of the
left lung, with feeble respiratory murmur and moist bronchial rales. Gave chlorate of potash and morphia, porter,
whiskey and good diet. The cough and expectoration gradually diminished, the fetor continuing. The jiatient
gained 8trei\gth gradually and on July 22 was transferred to Lovell hospital, Portsmouth Grove, K. I. [whence, on
Jan. 29. I.s61, he was returned to duty]. — Ladies' Home Hospital, Xew yorkCiti/.
Case 11. — Private Benjamin McKean, 2d Cal. Cav.; age 35; of good habits and constitution, was admitted March
28, 1865, with acute pneumonia, which was accompanied with gangrene from the very first. The disease was mainly
confined to the right lung, but during its jirogress the left lung became involved. Treatment consisted of a cathartic
followed by acetate of lead, Dover's powder and chlorate of potash. At the end of ten days stimulants and tonics
JlED. Hist., Pt. Ill— 95
754 PNEUMONIA.
became imperatively necessary, owing to the large quantity of excessively offensive matter expectorated. His diet
from the first consisted of beef tea, with eggs, etc. At this period he commenced taking milk-punch every three
hours. The jiatient's breath was so oft'eusive as to taint the whole ward. At the end of a month hectic was devel-
oped, with diarrhoea, night-sweats, tedema of the feet and legs and more or less anasarca. His emaciation was very
great, although he took large quantities of food after the first four or five weeks. About May 1 he began to improve,
the gangrenous expectoration progressively diminishing, and on July i was returned to duty sound and well. — Sur
(jeou C. S. Wood, U. S. Vols., Saeramenio, Cal.
C'.iSE 12. — Private Thomas E. Faun, Co. M, 15th Ivans. Cav., was admitted July IS, 1864, from the post hos-
pital, where he had been under treatment for pneumonia since February 29. In April an abscess opened midway of
the seventh rib on the right side and discharged about four ounces of purulent matter daily, spurting quite freely
during coughing: the right side of the chest was much atrophied. Quinine, whiskey and cod-liver oil were ordered.
October 30: Somewhat improved. November 30: Discharge decreasing. December 31: Imi^roved in flesh; able to
dress himself. He continued to improve slightly under ferruginous tonics and good diet until he was discharged
July 14, 1865. — Kansas City IIospiM, ilo.
Case 13. — Private Nathan C. Barlow, 93d 111., was admitted March 24, 1864, with an acute attack of pneumonia
of the right side. He was blistered and treated satisfactorily with veratrum viride every two hours for five or six
day«. Tonics and expectorants were given during April, with cod-liver oil and beer; hut he continued feeble and
affected with cough and pain in the side. He was discharged from service Oct. 1, 1864, on account of consumption. —
Hospital, Quincij, III.
Case 14. — James Fisher, Co. H, 2Gth Mich.; admitted Dec. 16, 1862. Respiration quiet; slight mucous sounds
iu right lung, diminishing from below upwards. A l)lister was applied ; cough-syrup was given every two hours and
powders of ipecacuanha, calomel and opium every four hours. He continued in the same quiet state, expectorating
high-colored sputa from time to time, and taking crackers and tea, until 2 a., m. of the 17th, when he suddenly
awakened from sleep, swearing and making desperate efforts to leave hia bed. Force was required to hold him. His
profanity continued without interruption until he died. In the forenoon his face was pinched and his hands and feet
cold and livid; his respiration was quick and there was rattling in the larger air-tubes; the pulse was quick and
feeble, and sordes had accumulated thickly on his lips and tongue. He shut his teeth against medicine and food.
Morphine quieted his delirium and he ceased his struggles to get up, though he continued to talk. In au attempt to
give him driuk he indented the spoon with his teeth. He died at 6 A. .M. of the lSi\\.— Hospital, Elmira, X. T.
Case 15. — Private George Kellers, Co. B, 5th Mich., was admitted Nov. 7, 1861, having had acute bronchitis
with high fever for twelve days prior to admission: Pulse 106; face flushed; respiration 32; tongue dry and brown
in centre; cough frequent; uneasiness in lower part of the chest, amounting to dull jiain on full insjiiratiou; viscid
and bloody sputa. Applied blister and gave Dover's powder eight grains, calomel one grain. 8th: Pulse 120, quick ;
respiration 32; tongue dry and brown; skin hot; countenance anxious; expectoration scanty, viscid and slightly
tinged with blood; lips blue and nostrils dilated on inspiration. Gave small doses of quinine, calomel, turpentine
and chlorate of potash, whiskey occasionally and milk as desired; applied dry cups to back. In the evening gave
veratrum viride and ipecacuanha. 9th: Pulse 106, feeble; respiration 44, labored; lips dark-purple; countenance
anxious; nostrils widelj' distended on inspiration; thick mucous expectoration. Applied dry cups to back; gave
brandy; half a grain of calomel every hour; dressed blister with mercurial ointment. 10th: Pnlse 84, full and soft;
respiration 43, short; no respiratory murmur in right lung; dulness with but little expansion. Continued calomel
and stimulants. 11th : Pulse 84 ; dyspntca urgent, somewhat relieved by the removal of ten ounces of blood by vene-
section. 12th: Dyspna'a increased. Gave quinine eight grains daily; brandy punch. Eemoved a few ounces of
blood by venesection. Kith; Some expectoration; respiration 30; countenance less anxious; tongue cleaning; pulse
120, soft. 17th: Pulse 120; respiration 32; tongue clean; free purulent expectoration. 2 p. m.: Mucli pain in right
side; great dyspnea and much anxiety of countenance; profuse sweating. 18th: Died. — Hospital, Ahxamlria, Va.
Case 16. — Private Henry K. Eastman, Co. I, 31st Me.; age 18; contracted measles about Ajiril 5, 1864, while at
Soldiers' Kest, Alexandria. A'a.; admitted to Third Division hospital April 23, and transferred to this hospital May 7.
Health much iuipaired; jiain in left side; tongue coated; fever; slight dyspna'a; quick pulse; dulness on percus-
sion and absence of respiratory murmur in posterior and inferior parts of left lung. Gave milk-punch, two ounces,
every two hours. 12th: Dulness; crepitation in right lung posteriorly and inferiorly. Gave of sulphate of quinia
two grains every three hours; continued milk-imnch. 19th; Severecough; sleeplessness. Added anodynes. 25th:
Less dulness posteriorly, increasing anteriorly in left side ; muco-purulent sjiuta. Continued treatment; gave brandy,
half an ounce every three hours, instead of milk-punch. June 25th: Physical signs of disease persist. Gave tonics
and astringents. July 1: Furloughed. 18th: Transferred to hospital at Augusta, Me. September 28: Eeturned to
duty. — Turner's Lane Hospital, Philadelphia, Pa.
Case 17. — Private Richard P. Lundy, Co. G, 120th 111.; age 28; was received from St. Louis without medical
history Aug. 26, 1863. He states that he had measles eight months ago, and has since suft'ered from pain in the chest
and lumbar region: Body emaciated; tongue clean, pointed; bowels regular; urine red; appetite poor. Elixir of
calisaya given with each meal. September 14: No improvemeut. Calisaya continued and belladonna applied to
lumbar region. October 13; Pain in left side of chest; pain and sense of fulness in frontal region. 30th: Conditiou
unaltered. Gave iodide of iron and syrup of tolu in addition to calisaya. November 5 : Pulse 90, small ; extremities
cold: palpitation and feeling of weakness in cardiac region. Treatruent continued, with moxa on lumbar region.
25th; Neuralgic pain in right side of head. December 24th: Impulse of heart increased, second sound not clear;
pulse 108; pain iu left side of chest; cough and iirogressive emaciation. 29th; Varioloid. Sent to pest-house. He
PNEUMONIA. 755
was given tonics, cod-lirer oil anil wine, but the cou~l' and expectoration eontinind and his emaciation and debility
increased. He was discharged June 25, 1864, for phthisis pulnionalis. —i7osj)i(«?, QuiHci/, III.
Case 18.— Private 'Williani llymucs, Co. M, 22d Pa. Cav.; age 21: Avas admitted April 9, 1864, with measles.
He caught cold, after which the measles retroceded and pleuro-pueunumia of a typhoid type was developed: I'ulse
120 and thready: skin hot and dry; tongue coated white, with centre brownish and nungins red; respiration short
and hurried: countenance pinched and anxious: pain lancinating in left hypuehondriuni, extending to nipple: ten-
derness over bowels: dulness on percussion, especially over left chest; dry rales; vocal resonance nuirked beneath
davieles; expectoration scanty and thin. The typhoid coiulition disappeared ((uickly under the use of oil of tuvjien-
tine, with stimulants and light nutritious diet. Klfusion into the pleural cavity took place, absorption, resolution
and probably adhesion, with sonu' consolidation of the left lung. Gave lla.x-seed tea with lemon-juice and cough
■Mixture. A large bedsore formed on the lumbar region four or live inches in extent, eating in deep ragged fissures
to the bone, undermining the snperlicial tissues with deep gangrenous pockets and exuding abundantly a thin fetid
ichor. It was dressed with chlorinated poultices and balsam of lir. A strong natural effort was uuuXv to recuperate,
assisted by iron and wine, but colli(|uative diarrhtea set in w itb bectie tVvir ami night-sweats. Hi> died June 3. —
Ciiiiihtrlaiid Ilofpitiil, Md.
Of one huiulred and thirty cases in wliich the symptoms were noted with some precision,
eiglity were acute pneumonias and fifty recurrences or sequences of the acute attack.
The cause, when any is assigned, is said to have been exposure to cokl and dampness.
ReU^pses during convalescence are in several instances attributed to cold from throwing off
the bedclothes at night, exposure while washing in the bath-room or dampness from recent
scrubbing of the floor of the ward.
In six of the acute cases the disease was reported as having been ushered in by chills
or rigors, and in three by febrile action and vomiting before the development of chest symp-
toms: but as the pneumonia was usually well established when the patient came under the
observation of the recorder, its early symptoms were seldom noted except in regimental prac-
tice or when an inmate of a general hospital was seized, as in cases 4 and 5 of the above selec-
tion. The febrile movement preceding or accompanying the chest svmptoms was generally
well marked. Of fifty-six cases in which the pulse-rate is specified thirty-four i^resented a
maximum of 100 to 120 per minute; in others, in which the number of beats is not stated,
the pulse is characterized as frequent, rapid, accelerated, quick, full, strong or corded. In
an exceptional instance, with distinct pneumonitic symptoms, the maximum rate recorded
was 65. Occasionally a morning remission was noted. Epistaxis occurred in two of the
cases: In one a full, corded pulse, with much oppression of the breathing, was relieved by
the bleeding sujiplemented by cupping; in the other the hemorrhage took place on the fifth
day, continued at intervals for thirty-six hours, and although ultimately suppressed, con-
tributed largely to the fatal termination. The hot sJdn, flushed cheeks, headache, furred
tongue, anorexia, thirst and scanty urine which accompanied the accelerated pulse appear
frequently in the reports. In one case the flush on the cheeks and neck was characterized
as bright and erysipelatous. Headache, restlessness and inability to sleep culminated in
sthenic delirium in but four of the acute cases, — for one of which see case 4, submitted above.
The locality of the thoracic pain is generally stated, but its character seldom. In some
instances it is recorded as dull, and in a few as sharp or severe; in the latter the friction
sounds of pleurisy are frequently, but not always, concomitant. The cough is usually
described in the reports as slight, dry, supjyressed, considerable, severe, and sometimes as
kara.ssing, painhd or distressing; the sputa as adhesive, glairy, viscid, tenacious, occasion-
ally mixed or streaked icith blood, but more frequently tinged with blood, rusty, pneumonic,
orange-colored, like prune-juice, and in an instance of concurrent jaundice tinged with bile.
The interference with the function of the lungs occasioned the conditions expressed as
respiration hurried, short and hurried, short and quick, frequent, quickened or labored.
7o6
PNEUiMONIA.
IS'uniLTioal statements are usually 30 to 40 jier minute, but 80 res]3irations are reconl.xl in
case 5, submitted above, in wliicli the pleural membrane was involved. Sometimes the inter-
ference was also manifested by duskiness of the countenance or livklity of the lips, and occa-
<?ionallv dyspnoea is seen to liave been urgent by such statements as expression anxious,
nostrils dilated, obliged to sit up in bed, etc.
AVith dulness on ]:iercussion over the afiected part there was usually some obscuration
or absence of the vesicular murmur, with rude bronchial or tubular breathing, and, perhaps,
exao-gerated respiration in the unaffected parts. Fine crepitant r.'iles are frequently reported.
Pleurisy was indicated in eight cases by friction sounds and in four by effusion, in one of
Avhich the thoracic wall was distended.
After lasting from three to eight days the febrile symptoms suddenly aljated, pain
becoming relieved and tlie breathing easy, with free or increased renal secretion, in which
the return of the chlorides is sometimes noted. In favorable cases the patient, within a
month of the onset, was returned to duty with vesicular respiration re-establislied in the
recently affected part of the lung. But a relapse from indiscreet exposure occasionally
•delayed the return to duty for ten days longer.
The so-called tijjohoid symptoms appeared in the progress of twenty-four of the eighty
ficute cases. In some, these, consisting of a xveak and rapid peAmps flidferinff pulse, black-
ening of the tongue ^\\A great prostration, were speedily removed b)' appropriate treatment;
but in others, notwithstanding the most liberal use of stimulants and concentrated nourish-
ment, a steady and more or less rapid progress to a fatal issue is recorded. Death occurred
from asthenia in some cases, with cold sweats, involuntary stools and muttering delirium,
unaccompanied by marked symptoms of the disorder of the lungs; 1:)ut in most instances the
pneumonic condition was manifested by hurried hrecdhing and indications of imp^erfect a?ra-
tion such as duskiness of countenance, drowsiness, semi-unconsciousness and, tinally, coma.
The following extracts will indicate the manner in which this adynamic tendency was
usually brought to the notice of the Surgeon General's Office:
Surgeon A. W. McClure, Wi Iowa Car., near Helena, Ark., Dec. 31, 1802. — Within the last two weeks pneumonia
lias prevailed to a considerable extent. The disease is of au adynamic type and difficult of management, attacking
usually those somewhat broken down by malarious disease. Tliree have died from this cause. I have treated them
■with quinine, Dover's powder, carbonate of ammonia and milk-punch, with mustard over the affected lung.
Ass't Surgeon W. L. Tolman, 10//( Mo. Car., near riclcshnrg, Miss., March 31, 1863. — The greatest fatality has
attended cases of pneumonia. Typhoid symptoms and nervous jirostration were jjresent in nearly every case, so that
an expectant and supporting plan of treatment was found to be necessary.
Surgeon R. W. Pease, lOlh N. T. Car., Havre de Grace, Md., March 31, 1862. — During the month of January pneu-
monia prevailed quite extensively. It arose from colds contracted on the passage from Elmira to Gettysburg and
fr'om the unventilated and crowded quarters in which the men were placed. The fatal case assumed a typhoid
character, as did many others in which the termination was more fortunate. It is pertinent to remark here that
company B, which suttered greatly from typhoid pneumonia, arising out of poorly ventilated quarters, was made
the most healthy company in the regiment by introducing Mackinuell's ventilators into its quarters. These consist
of two hollow shafts, the inner one extending below the outer one in the room and ahore the outer one outside the
roof. Two of these were placed in the carriage factory occupied as a barrack by this company, after which sickness
rapidly diminished among the men until scarcely a case was reported. These ventilators were afterwards iilaced in
the barracks erected for the regiment, and this, together with careful policing of the camp, gave us unusual exemp-
tion from diseases of a serious character.
Surgeon H. W. Brovvx, 4(/i Corjjs d'Jfrique, Port Hudson, La., April 5, 1804. — Pulmonic disorders are very preva-
lent and have a tendency in tliis latitude, and jiarticularly in the negro, to assume ab initio a severe typhoid type.
C'onse(|Hently the results of this chiss of diseases, typhoid pneumonia for instance, are unfavorable; I should say the
fatal cases form about thirty per cent, of the whole. I have found pneumonia very common among colored soldiers.
Many of the cases, however, resulted neither in a satisfactory recovery nor in death
iy asthenia and apnoea as the immediate consequence of the acute attack. Instead of the
PXF.fMONIA. 757
re-establishment of healthy ooiulitions in the king there remained in some of these an
impaction of the air-cells or consolidation of the pulmonary tissues, giving continuance to
slight constitutional disturbance, dulness on percussion and abnormal auscultatory sounds,
with some pain, cough, shortness of breath and liability to an extension and aggravation of
the diseased condition, — in fact, to the establishment of a lobular or secondary pneumonia.
In others the inflammatory processes that persisted on the subsidence of the primarv attack
may be assumed to have been chronic or curative, involving the separation of sound fi-om
diseased parts by interstitial growth or by the walling in of softened tissues and meta-
morphic products. In either event the case was of a serious character and the patient
exposed to many dangers before a return to comparative health, if the injury to the lung
was fortunately of a nature to permit of this favorable result. Tvphoid symptoms mi"ht
occur during any temporary febrile accession. Emaciation and long confinement led to the
formation of bedsores. Diarrhceal attacks were specially dangerous in these cases; but
the congestion of the enteric mucous membrane, mentioned so frequently, as will be seen
hereafter in the post-mortem records, does not appear to have been intimately connected
with the pneumonic processes. Diarrhoea is mentioned in the progress of but forty of the
one hundred and thirty cases at present under consideration; and tjie medical treatment
was occasionally responsible for the flux. Hsemoptysis was recorded in but one of the chronic
or secondary cases, and, although there was no hereditary tendency to tuberculosis, the
physical signs of tubercle are said to have been well marked. Many patients with persisting
lung trouble characterized by cough and purulent or muco-purulent sputa sometimes mixed
with blood, and attended with debility and tendency to hectic, were discharged from the
service as consumptives. Similar cases in the Confederate hospitals were retained in service
by the surgeons, as the policy of their government ^vas to hold every man for such duty as
lie could perform, and many of these were eventually restored to apparently vigorous health.*
The physical signs of these chronic pneumonias included dulness on percussion and
various sounds expressed on the records as rude respiration, tubular breathing, sibilant rales,
inucous rules, crc^ntatioji and gurgling. The last-mentioned sound was present in two cases :
In one death took place with symptoms similar to those of 139 of the post-mortem records,
in which the lung was said to have been destroyed by suppuration ; in the other it was prob-
ably due to the formation of a cavity by the rapid liquefaction of a mass of the lung tissue, —
this case terminated in recovery after a prolonged convalescence, during which the patient
was entered as a consumptive at one of the hospitals.
Surgeon J. E. Saxborx, 27th Iowa, in a report from Jackson, Tenu., dated April 30,
1863, makes note of a case of chronic pneumonia in which the patient declined to be con-
sidered sick.
One singular case consisted of what ought to he called chronic hepatization of almo.st the entire left lung anil
of the lower portion of the right. The young man, of good hahits and aged ahout 20, came from picket duty and
reported himself as merely ailing slightly, hut hardly worse than he had hecn for two or three weeks before. Phys-
ical examination revealed at once the above condition fully developed. Percussion was as dull as over the liver, and
respiration entirely out of the question. The history showed he must have been in that condition for some length
of time, but how long is quite conjectural. Though feeble and short-winded he refused to bo confined to bed .a single
day. He has been carefully examined by a number of surgeons, who agree as to the pathology. Tlie engorged con-
* J.is. L. Cap.eli.— 0;i Chronic Pnemnotiia ami ila relnlioii (o TiihtTcnloiis—Itkhmonil mul Ixmirrillc 3le<l. Jour., Oct. 18l"<8, IV.;. T7, p. 352 :—" During the Into
w;»r it was excoediiigly common to see patients:, some of whom had suffered an attack of acute pneumonia while others had never been coufiued to ImmI,
walking about the wards aud grounds of the hospitals and exhibiting evidences of chronic solidification of a portion of a lung, with considerable emacia-
liou and debility. They were generally regarded as consumptives, and would have been discharged from service had not the policy of the Confederate
government at the time preferred long furloughs, to be renewed when necessary, to absolute discharge from service. Tlie return to duty of many of
these parties, in apparently vigorous health, led to a diflerent interpretation of the symptoms. We are now convinced that most of these cases were
examples of chronic interstitial pueiununia.**
758 PNEUMONIA.
ditioii continued iiliout two months, yielding gradually to blisters and croton oil externally, with the internal use of
■whiskey, carbonate of ammonia and quinine.
Erysipelas occurred in the progress of three of the one liundreil and thirty cases, mumps
in one, variola in two, tonsiUitis in one, mppurafive parotitis in one — a case of prolonged
duration, tubercle in one, dysentery in one, jaundice in one and aphonia in four. One
instance of aphonia, occurring suddenly and from an unknown cause, was treated by blister-
ino- the back of the neck, with what success is not stated, as the man was shortly afterwards
discharo-ed. In the three other cases the loss of voice was probably due to laryngeal inflam-
mation, as reference is made to hoarseness and a stridulous cough. Aphonia, sometimes
mentioned in the typhoid cases, is referable to prostration and dyspnoea, — in some instances
instead of aphonia the record has it that the patient could not speak above a whisper.
In none of these cases is there an indication of the intercurrence of pericarditis. Friction
sounds were heard in three of the cases characterized by delirium, but in one they were o/i
tJiG riqld side from the axilla downward, in the second over the vpper part oj tlie left thorax
and in the last over the base of the left lung.
Under unhygienic conditions pneumonia, like catarrh, assumed sucli a prominence in
certain regiments as to be considered due to an epidemic influence. Surgeon D. Poete
Smyth£, 19th Texas, has recorded with jn'ccision an instance of this kind, in which the
commaml, reduced by previous attacks of measles, mump^s and remittent fever, and by the
fatigues of an exhausting march of three hundred miles in a hot season, became suddenly
exposed to cold and affected, apparently in consequence, with a pneumonitic tendency.
This officer's regiment, and others of Walker's division ■which ■were associated ■witii it in its experience of pneu-
monia, ■were composed chiefly of young men from the non-malarious sections of Western Texas. Measles with pul-
monary comjilications and a subsequent epidemic of mum])S preluded a march of three hundred miles at the close
of a hot, exhausting summer, into a malarious couatry at the height of its sickly season. About two hundred men,
or 18 per cent, of the regiment, were seized with remittent fever and left at various points on the route. While in
bivouac at Little Rock a sudden snow-storm came on during the night, after a warm day, and occasioned numerous
cases of severe catarrh, wiiieh passed rapi<lly into obstinate pneumonias. During November the regiment had five
hundred cases of sickness in a strength of nine hundred officers and men. Two hundred of these were cases of pneu-
monia, of -which 50 per cent, were catarrhal, 40 per cent, croupous and the remaining 10 per cent, of cerebral and
erysipelatous types, which were very deadly. The cerebral, ■which was at first mistaken for meningitis, as it was
characterized by rigors, headache and but little pulmonary disturbance, proTcd fatal with convulsions and delirium
in from twelve to twenty-four hours. In some of the erysipelatous cases the inflammation seized upon the jjharynx
and air-passages and suffocated the patient without giving time for the recognition of the pulmonary complaint;
but in others the erysipelas was developed subsequent to the pulmonary symptoms and appeared more as an acci-
dental complication. In the robust cases tartar emetic was chiefly used, and alterative doses of mercury in those
which were not decidedly asthenic. Free cujiping relieved the lung symptoms, but early and extensive blistering
■was productive of the best results. Bleeding was practiced at first in the cerebral cases, in the belief that a menin-
gitis was nnder treatment ; but neither this nor the cupping and blistering of the chest and sinapisms to the extremi-
ties, ■which followed a recognition of the nature of the disease, were of any avail.
Similar causes induced similar effects among the colored troops. Surgeon Ira RtjSSELL,
U. S. Vols., has placed on record some valuable observations on jineumonia as it appeared
among them'-' at Benton Barracks, ^lo., in the early part of 1S64-. Six regiments in pro-
cess of formation were quartered at the post.
From January 1 to May 1, 784 cases of pneumonia were treated in the hos]iital, and of these 156 were fatal.
There were also 075 cases of measles, with 130 deaths resulting mainly from jiulnionary complications. Surgeon Rus-
sell attributed these pneumonias chiefly to cold. The frequency and fatalitj- of the disease varied with the char-
acter of the weather. A few warm days moderated the violence of the epidemic, and finally, with the advent of warm
weather in Jlay, it suddenly subsided. Among the predisposing factors he enumerates malaria, overcrowding, an
epidemic influence and measles. The epidemic influence is considered to have been manifested by the illness of phy-
sicians and nurses who had not been greatly exposed to the vicissitudes of the weather and the other causes men-
tioned. Some intelligent surgeons formed the opinion that the disease was actually contagious. In barracks men
occupying the same bunks with those affected -were more liable to be attacked than those more remote.
^See bis paper in the V. S. iSutnlarit Commission 3Iemoirs, Nyw York, 18G7, p. 310 ct seq.
PXEU.MONIA. 759
Surgeon IJrssKi.l. divided the imeiimonic cases into three classes : Coiigestiic jineumoniasjlyplioid jiiieumonidn ami
jileiiropiiiiimonia^. In the conijcstUi- form the patient sulVered for several days with catarrhal symptoms attended with
mental dnlness. This was followed by a severe chill, like that of pernicious fever, accompanied l)y great prostration
and pain in the head, hack and limbs. The state of depression continued for twelve to forty-eight hours, when, if
death did not close the scene, an asthenic fever ensued, attended with cough, expectoration which soon became
copious and mueo-purulent. more or less stupor and occasionally boisterous delirium. Death speedily occurred, and
was as a rule preceded by coma. The liiphoid variety was usually ushered in without a severe chill. Its adynamic
character was manifest from the first. Chest symptoms were so slightly marked that but for tin- physical signs i)neu-
niouia would hardly have been suspected. With the dry, brown and cracked tongue and feeble and frequent pulse
there was dulness over the aftected parts of the lungs with mucous or subcrepitant riles; but fine crepitation was
seldom heard. Cough was generally neither severe nor frequent. Expectoration was sometimes scanty and at other
times copious; at first it consisted of viscid mucus, but it soon became muco- or sero-purulent with a fetid and dis-
agreeable odor. I'ltKio-iiiiniiiionic cases were frequently remarkable for the absence of pain in the pleura during the
stage of active inllammation : but sometimes the pain was severe. Relapses,consequent on slight exposures, improper
indulgence or change of weather were frequent and fatal. Pleurisy with copious etl'iision often complicated ciisi^s of
the typhoid variety. — 04 of 1."jO such cases had pleurisy.
Pericarditis is not noted as having lieen observed clinically in any of these varieties, and what is more singular,
uo jwst-moitiin mention is made of the pericardium, although the condition of the lungs and pleura in a hundred fatal
cases was carefully noted. This appears to have been an oversight, for Surgeon G. S. Palmer, L'. S. Vols., superin-
tendent of hospitals at Benton barracks, in a report dated March 14, 1864, gives a tabular statement of the jwni-
moilim appearances in 200 fatal cases of disease among the colored men. In many of these the diagnosis is not stated,
si. that it is impossible to determine from the record whether the patient died of pneumonia or measles, and although
pneumonia is given as the fatal disease in 73 cases the consolidations may have been in many the result of catarrhal
processes. The condition of the pericardium was noted in most of these cases. Generally it contained an excess of
liquid. — quantities varying from five to eight ounces are frequently mentioned, and in one case sixteen ounces are said
to have been found. The sac is recorded as having been engorged in one case and adherent in another; it contained
bloody serum in four cases in quantity from one to six and a half ounces; and in two cases the inllammatory action
was nuinifested by the presence of, in one. four ounces of serum and lymph, and in the other nine ounces of exuded
lymph and purulent matter. Pericarditis was therefore probably as frequent a complication of pneumonia among the
colored troops as among the white soldiers."
The posT-iiOKTEM KECOEDS of cases reported as pneumonia show that death in tlie
majoritv of instances resulted not alone from hyperseraic or inflammatory processes in the
pulmonary tissues, but from these in conjunction uith similar processes affecting particularly
the pleural membranes, bronchial tubes or pericardium. With the production of these con-
gestive or inflammatory results the malarial, typhous and tuberculous cachexias and the
specific cause of measles were apparently often connected. The recorded lesions differ much
in individual cases. This variety in itself renders difficult a systematic presentation of the
cases; but the difficulty is occasionally enhanced by doubts concerning the actual condition
of the affected organs, referable to a want of precision in the recorded statements.
The hospital case-books and medical descriptive lists contain 435 cases recorded after
post-mortem observation as having terminated fatally by pneumonia; of these 300 were
probably cases of lobar pneumonia and 135 of secondary or catarrhal inflammation.
LoB.\R Pneumonias. — Among the 300 cases of apparently acute lobar pneumonia are
213 in which, with or without concurrent pleurisy, the lungs were more or less congested,
hepatized or infiltrated with a pus-like liquid when not, as in a few instances, collapsed or
compressed by excessive pleuritic effusion. It has been deemed unnecessary to present the
whole of these cases in detail, as the condition of the lungs and other organs in them will
be embraced in a summary of the lesions of the acute lobar cases, and their general character
may be fully appreciated by selections including all those that possess points of interest
irrespective- of the lobe or lobes implicated in the pneumonic processes. The pneumonia
was unilateral in 59 of the 213 cases; both luns;s were affected in 154. Pleuritic inflam-
raation complicated more than one-half of the cases. The selections submitted in illustra-
tion of these 213 cases are G9 in number, as follow:
• See infra, page 781 .
760 p^'EUMO^'IA.
I'u-fiitij-firo ciista in u-JiicIi ilic post-mortem record is jtrefuced hi/ mite-mortem notes, iiidicalinfj the gciurnl course of the disease.
Case 1. — Piivate Moyordis TIerraiul, Co. A, 1st Jlicli. Eug'is: age 22; admitted April 11, 1864, in low condition.
Pulse 150, soft and irregular; tougue dry; surface covered with in-ofuse cold sweat; dulness over right lung and
lower portion of left lung: mucous rales iu right lung; diarrhcea. He improved under stimulant and supporting
treatment until the liHli, when he became restless, with frequent pulse and great anxiety, which increased until
death on the 26th. Post-mortem examination: Hepatization of the posterior and lower portion of the right lung and
recent firm pleuritic adhesions. Hepatization of the posterior jiortion of tlie left lung; congestion anteriorly; slight
recent pleuritic adhesions. Heart healthy. Liver nutmeg; spleen very large. — Hospital So. 8, Xashville, Teiin.
Case 2. — Private John Hehn, Co. F, 114th Colored Troops, was admitted Aug. 18, 1865, having been affected for
five days with slight pain and cough with blood-tinged exjiectoration. Consolidation of the right lung and pleuritic
efi'usion were determined by the physical signs. Tlie expectoration assumed the color and consistency of coagulated
blood. Death occurred on the 28th, after a profuse expectoration of blood and nnicus. rost-mortcm exanunation:
The right pleural cavity was distended with bloody serum which pushed the lung upward and compressed it into
half its usual size; the lung was of the consistency and color of coagulated blood, its tissues breaking down and
escaping from the fingers in the attempt to remove it. The heart was normal; the liver and kidneys larger than
usual and fatty. — Act. Ass't Snrgeoii H. liuphael, Hospital, BrownsriUe, Texas.
Case 3. — Private Hilman Tuttle, Co. K, 14th W. Va.; age 24; a large robust man: admitted March 25, 1865,
with syphilis; was about to bo returned to duty when, on the night of April 30, he awoke, .sprang suddenly from
bed complaining of choking, and coughed violently as if about to strangle. He became comatose in a few minutes,
lying on his right side with his limbs flexed, breathing laboriously and a sero-bloody fluid Lssuing from his mouth
and nostrils at each resjiiration; face swollen and livid; pulse full and strong. He died May 1. I'ost-mortem exami-
nation: Lungs thoroughly saturated with a mucous and serous bloody fluid. Liver and spleen slightly enlarged and
congested. — Cumlerland HospiiiiJ, Md.
C.vsE 4. — Private William Vaughan, Co. H, 10th Mich.; age 18; was admitted from Belle Isle, Va., per flag-of-
truce boat "New York," March 24, 1864. He had been captured at Knoxville, Teun., Jan. 22, 1864, and was sick with
diarrhoea during all the time of his imprisonment. On admission he was very feeble and much emaciated — in fact a
mere skeleton brought into the ward on a stretcher. He had a distressing cough but was too weak to expectorate ;
pain in the right side, over which there was dulness with bronchial respiration ; thin offensive jiassage from his
bowels every fifteen minutes; his mind was flighty, pulse small and quick and tongue furred. The I'^itient was
sponged with warm vinegar and water and supplied with clean clothing. Beef-essence and brandy toddy were given
at short intervals ; a sinapism was applied to the right side and a cough mixture prescribed consisting of ipecacuanha,
muriate of ammonia, syrup of wild-cherry bark, morphia and mucilage. Tlie cough and diarrhn?a became lessened
and flie mental condition improved; but the pulse gradually failed, and he died on the 27th. I'ost-mortem examina-
tion : The chest only was examined. The right lung was coated with recent lymph and adherent iu part to the costal
jileura; its substance was non-crepitant, solid and heavier than water; blood flowed from its upper part on section;
a small quantity of liquid wa.s found in the pleural sac. — Act. Ass't Sure/eon- ,S. J. Iladcliffe, Hosjiital, Annapolis, Md.
C.VSE 5. — Private James Dodge, Harris's Mo. Batt'y; age 28; was admitted Dec. 21, 1864, with a lung disease,
caused by exposure during his service iu the Southern Army since 1861. Two weeks before admission he became
sick with fever and pain in the chest and his legs began to swell: Tongue coated and brown; bowels loose; pulse
100; respiration hurried; severe cough with expectoration; appetite small; pain iu right side; legs badly swollen.
He grew worse raijidly, aud died on tlio2oth. Jf'o.5/-Hioc(('m examination: Emaciation; o'dema of feet and legs. Hep-
atization of right lung; eflusion iu right iileural cavity. Blood liroken down and thin. Slight congestion of liowels. —
Act. Ass't Surycon H. C. Xewldrk, Bock Island Hospital, III.
Case 6. — Private Michael Peters, Co. D,56th Pa.; age 51; admitted Oct. 30, 1863, with pleuro-pneumoiiia. He
breathed with difficulty and was much depressed. Tubular respiration with large moist rales was heard over the
left lung, which was dull on percussion; there were also signs of pleuritic ett'usiou on the right side. Quinine, car-
bonate of ammonia and nitrate of potash were given, with whiskey, nourishing diet and Dover's powder at night.
The expectoration was scanty, tenacious and blood-tinged. A blister was applied,on November 1. On the 4th the
patient's face was mottled and his pulse feeble; he complained of no pain and coughed but little; he Avas disposed
to get out of bed and desired to have his clothes. He died on the 5th. rost-mortcm examination: The right pleural
cavity contained by estimate half a gallon of serum mixed with i]us and lymph flakes which comjiressed tlie lung
backwards; the lung was collapsed, darker in color than natural and its bronclii contained a frothy reddish mucus.
The anterior surface of the left lung was covered by a thick padding of lemon-colored lymph six inches long, three
broad and one-half inch thick ; the left pleural cavity contained a pint of pale-yellow serum ; the lung was much
congested and softened throughout its jiosterior and lower portions. Both lungs were adherent to the walls of the
chest at various points posteriorly. The other organs were not examined. — Act. Ass't Surgeon Edmond G. Waters,
Xational HospitaX, Baltimore, Md.
Case 7.— Recruit Joseph Peters, 29th Colored Troops; age 20; was admitted Feb. 20, 1805, having been sick
for several days with pneumonia of the right side. He had a full strong pulse and severe cough, with rusty viscid
sputa. A poultice was applied and expectorants administered. He became restless on the 25th and complained of
much pain. Dover's powder was given. On March 5 there was dulness over the lower part of the left lung and some
crepitation was heard; the breathing became labored. On the 8th the patient was weak and restless; his pulse
feeble; skin cold and freely perspiring. StimuUints and beef-extract were given every hour; a blister was applied
PNEUMONIA. 761
to the left side, and two grains of calomel with opium weie adminislereil liouily I'oi- six lioms. Xext day his skin
was warm and he IVlt easier; Ijut the pulse heeanio snuill, the lireathini; irregular and laliored. llediedon the 1:2th.
rost-iiKiittm examination: The right pleural sac contained twenty-eight ounces of serum mixed with pus and the
greater part of the lung was infiltrated with pus; the lower portion of the left lung was hepatized. — .let. Ass't Siir-
ffeoii S. I). Tniniiiff, L'Oinirliire Uusjiilal, Jlrrandrin, I'd.
C.\SK 8. — Private David Hamp, Co. 1>, 26th Mich., was admitted Feb. 19, 18G3, with pneumonia of an asthenic
type. Cough was frequent and painful, expectoration ditlicult, the skin hot and dry, the tongue darkly coated, the
liowels constipated and the pulse frequent and compressible. Diminished resonance was observed over the lower
portion of the right lung and moist rales were heanl anteriorly over the light side of the chest. .V mercurial cathar-
tic followed by an emetic of ipecacuanha and subseiiuently by small doses of calomel, opium and ipecacuanha, were
employed, with dry cups and turpentine stupes locally. The patient grow steadily worse and died on the 28th, not-
withstanding the administration of stimulants. Posl-mortcm examination: The niiddh> ami lowerlobes of the right
lung were engorged; the lower lobe of the left lung was hepatized. There was a copious elfusion into both pleural
sacs and some plastic exudat ion on the right costal pleura ; there was also some serous eflusion into the pericardium.
—Tltinl Dhhiun Ilotinliil, Jhxaiiilrki, 7'ti.
Case 9.— Private Marion Hague, Co. D, 14th Ind.; age 25; was admitted Oct. 2.">, 18()t, with pneumonia. The
patient was very feeble and restless; he had a severe cough, pain in the right side and hurried respiration; his
voice was extremely weak. Dover's powder was given every three hours and mustard applied to the chest. He died
on the 29tli, after attempting to rise from bed. J'oal-morliiii examination: Both lungs were adherent and in largo
part engorged, some portions of the right being hepatized. Four bird-shot were found encysted in the lower part of
the costal pleura, but no cicatrix indicated their point of entrance. The heart was normal: a fibrinous clot extended
from its right ventricle into the pulmonary artery. The liver was enlarged and contained some encysted bird-shot:
the spleen also was much enlarged. The mucous membrane of the stomach was inllamed. Peritoneal adhesions
bound all the abdominal organs together. ISpecimeii Hi, Med. Sec, Army Medical Museum, shows a section of the
hepatized right lung from which the adherent pleura has been partly reflected.]— .*»)v/coh A'. BcnIUij, V. S. Voh., Third
Hh-igioii nonpital, AUrundria, Vu.
C.\SK 10. — Private lienjamin F. Urahani, Co. I, lltli Vt.; age 38 ; w:is admitted Feb. 8, 180."), having been affected
with pleuro-pneuuionia for some weeks. He was very weak and enuiciated ; his countenance sallow and eyes sunken ;
pulse 100 and feeble; ho had been blistered for pain in the left side of the chest. He had a cough with slight expec-
toration : dulness over the left side anteriorly and posteriorly and over the right side posteriorly; slight subcrepitant
rales on the left side, with a rough friction murmur which, posteriorly, was somewhat indistinct; on the right
side, posteriorly, absence of murmur. On the 10th, at 3 p. M., the patient got up and walked across the ward and
back again to his bed, a distance often yards. He died suddenly half an hour afterwards. I'ost-morUm examination:
Patches of lymph were found on the left lung which was attached to the walls of the thorax by old adhesions; the
upper lobe was consolidated, the lower congested. The apex of the right lung was slightly indurated, the remain-
der of the upper lobe, together with the middle lobe, was healthy, whilst the lower lobe was abnormally large, con-
densed and apparently entering into a state of suppuration. — Act. Ass't Surycon A. \\ ahh Emory, I'atUrsun furk Hos-
jiildl, Baltimore, Md.
Ca.sk 11. — Private 'William A. Martin, Co. H, 75th Ohio, was admitted Aug. 30, 1863, with pneumonia. Ho
had been taken prisoner at Gettysburg, Pa., July 2, 1863, and had suffered much from cold, wet and want of food
on his journey thcnco to Richmond. On admission he had a short hoarse cough, rusty sputa, pain mostly in the
right lung, a rapid pulse, 112, hot and dry skin, dry and brown tongue and two or three thin stools daily: there was
dulness with bronchial respiration over the greater part of the right lung. He was treated with acetate of ammonia,
wild-cherry, ipecacuanha and morphia, with sinapisms to the chest and nourishment; but his condition remained
unchanged. About 5 1". M. of September 1 he said he felt better and desired to be shaved and have his h;iir cut. The
nurse acceded to his request ; but streams of frothy mucus came gushing from his nose and continued for more than
half an hour; dyspnoea increased and rapid prostration ended in death about 8 r. M. I'ost-mortan examination: The
right lung was hepatized, the left engorged, and both adhered strongly to the walls of the chest: the pleural sacs
contained a small ijuantity of serum. The liver was very large. The other organs were healthy. — Act. Ass't Sitrijeon
S. ./. Biidcliffc, Sosjiiial, Annapolis, Md.
Case 12.— Private Peter St. George, 2d Vt. liatt'y; age 22; was admitted Oct. 29, 1863, with double pneumonia,
contracted about the 2od whilst exposed on Helle Isle, Va. The onset was by chill. On admission the pulse was
small. 130: respiration 60; lips, ears, nose and fingers blue; dulness over the chest was not great, but bubbling sounds
daring respiration could be heard in all parts of the room. Tartar emetic in small doses every two hours, with squill,
ipecacuanha and sinapisms were employed, but he died October 31. Post-mortem examination: The left lung was
purple, — the lower lobe darker than the upper, — crejjitant all over except a strip two and a half inches wide at the
base of the upper lobe, a section of which sank in water; there was no adhesion. The right lung adhered by recent
lymph and was very large and dark-purple in color, the lower and middle lobes hepatized, the upper crepitant bnt
congested. The pericardium was normal; the left side of the heart and the cardiac veins were gorged with black
blood. The abdominal organs were normal except the spleen, which was much enlarged. — Act. Ass'i Sunjcon E. C.
Mattocl; Hospital, Annapolis, Md.
Case 13.— Private (iarret Huff. Co. G, 10th Ind. Cav.; age 10 ; admitted March 1, 1864, the sixth day of an attack
of pneumonia. Slight delirium : high fever: irritability of stomach: rusty sputa: extreme pain in and dulness over
lower lobe of right lung, with bronchial respiration and mucous rales; crepitation in middle lobe. He died on the
Mei>. Hlst., Pt. 111—96
762 PNEUMONIA.
7th. Fost-mortem examination: Heart normal, filiiiuous clots in Ijoth sides. Riijlit pleura extensively adherent;
lower lobe of light lung hepatized, middle lobe engorged; lower lobe of left lung engorged. Stomach and email
intestine somewhat congested. — Act.Aas't Surgeon M. G.Eogers, HospitaJ, Madison, Inil.
Case 14. — Private Robert Black, Co. G, 8th Me.; age 41; -was admitted Feb. 13, 1864, with headache, dyspnoea
and pain in the chest; skin hot and somewhat jaundiced; pulse 100, soft and rather small; tongne coated white;
bowels ijiiiet; eyes injected and yellowish ; bronchial respiration heard over the upper lobe of the right lung; mucous
rales in the lower lobe and imerile respiration with roughness in the left lung. A blister was applied to the chest
and repeated doses of l)lue-pill, opium and ipecacuanha prescribed. Brandy aud quinine, one grain every hour, were
given on the loth, and subsequently carbonate of ammonia: but the dyspncea became extreme, the expectoration
bloody, the pulse frequent, small aud feeble and the circulation in the extremities imperfect. He died ou the 19th.
rost-mortcm examination: The right lung was largely adherent by recent iirm adhesions; it was in a state of gray
hepatization and its apex and base were disintegrated : the pleural cavity contained sis ounces of serum. The left
lung was hepatized in its upper aud congested in its lower lobe. The bronchial tubes were Inflamed. There were
firm coagula in both ventricles of the heart. — Act.AssH Surgeon Charles T. Beher, Sospitcd, Beaufort, S. C.
Case 15. — Private Alfred McCabe, 63d! 111., was admitted March 5, 1864, with headache, pain in the liack aud
limbs and slight fever, which had been ushered in on the j)revious day by a chill. On the 8tli the fever increased,
with cough and pain, crepitation and dulness in the right side. He died on the 14th. Post-mortem examination:
Right lung much congested: left congested; effusion iu both pleural cavities. Heart flabby, clot in right auricle:
two ounces of fluid iu pericardium. — Hospital So. 8, Sashrille, Tenn.
Case 1G.— Private Henry C. Chase, Co. G, 79th Ohio, left Nashville Feb. 27, 1864, iu good health,— weather
rainy and cold; the troops slept in the rain. Admitted March 1. Pulse 145; tongue dry aud red; lungs congested,
right impervious to air except in apex and larger tubes, upper lobe of left lung iu similar conditiou. Died March
5. Post-mortem examination: Body well nourished. Right lung hepatized and universally adherent : upper portion
of left lung congested, lower normal; no adhesions; some liquid in cavity. — TuUahoma Hospital, Tenn.
Case 17. — Private Reulien AV. Fernner, Co. B, 54th Pa., bad been sick three weeks and was quite anai-mic ou
admission, July 25, 1864. Pulse 90, feeble; cough dry and frequent; respiration difficult and hurried; pain iu left
side; soreness in intercostal spaces; dulness on percussion; tongue clean : appetite poor; able to walkabout. Gave
tonics and expectorants. August 3, while ascending the steps to the dining-room, be became exhausted and fell ; he
was removed to bed and died shortly afterwards. Post-mortem examination: Lungs adherent and much congested:
middle lobe of right luug hepatized. Heart pale, thin, soft and containing dark clots. — Cumherland Hospital, J/rf.
Case 18. — Silas Hibler, a farmer of Gasconade County, Mo.; age 25: had an attack of imeumonia in June, 1864,
and has suftered from its effects siuce then. He was conscripted and made his way from Missouri to give himself
up to the Uniou authorities. Exposure during the journey caused an aggravation of his lung trouble. On admis-
sion, December 4, his tongue was red and corrugated: bowels loose: pulse 120, not very full: respiration hurried;
cough severe and attended with expectoration ; left lung consolidated. The looseness of the bowels continued and
the lung symptoms became aggravated. He died on the 15th. Post-mortem examination : Hepatization of left lung
and of base of right lung; effusion in left pleural cavity. Clots in both auricles. Bowels distended with gas; meseu-
teric aud solitary glands diseased. Blood impoverished. — Act. Ass't Surgeon H. C. Xeivkirk, Bock Island Hospital, HI.
Case 19. — Moses Lockard, a farmer of Van Bnren County, Ark.; age 31; was admitted Dec. 6, 1864, with
typhoid pneumonia. He had been afflicted for several years with chronic inflammation of the liver and spleen. He
deserted iu October from the 10th Ark. Cav., and attributes his present sickness to exposure while en route from
Missouri. Tongue coated aud brown; bowels normal; pulse 120, full; respiration hurried ; expectoration rusty: pain
in right side; dulness; creiiitaut rales. He died ou the 11th. Post-mortem examination: Hepatization of right luug
and of posterior jiortion of left luug; effusion in the right jileural cavity. Liver normal; spleen three times its
natural size. Bowels somewhat congested, solitary glands disorganized and rectum inflamed. — Act. Ass't Surgeon H.
C. XewJdrh, Boole Island Hospital, III.
Case 20. — Private Thomas McGee, Co. F, 1st Ala. (refugee); age 28; admitted Feb. 23, 1805, with pneumonia of
lower lobe of right lung. Incessant vomiting of bilious matters, amounting to six or eight pints daily; tougue moist
aud clean; pulse feeble and rapid; some cough ; slight expectoration. Gave ojiiates aud diaphoretics; applied oiled-
silk jacket. 24th: Pulse weaker; still vomiting; hiccough. 25th: Pulse feeble, very rapid; no cough or expectora-
tion. Gave whiskey, beef-tea and carbonate of ammonia. 26th: Tougue moist. Gave tincture of iron. 28th: Pulse
almost imperceptible; still vomiting. March 1: Pulse stronger. 3d: Pulse96, of fair strength; tongue clean; entire
right lung aftected. 6th: Pulse 110. 7th: Pulse 130 and feeble; no pain ; pneumonia iu lower part of left lung. 8th:
Died at noon. Post-mortem examination: Right lung hepatized throughout; lower edge of left solidified; two pints
of serum and much recent lymph in pleune. Other organs healthy.— Z)om(/Z«s Hospital, Washington, D. C.
Case 21.— Priv.ate Samuel E. Oakes, Co. E, 13th Mich.; age 36; admitted May 23, 1865, much oppressed; pulse
strong, Ijoundiug ; severe dyspniea; sputa tough, tenacious. Died 28th. Pos^-wioc/chi exauiiuation: Pleurie adherent,
containing twelve ounces of serum; lungs hepatized. — Slough Hospital, Alexandria, Va.
Case 22.— Private Thomas H. Mitchell, Co. G, 16th N. Y. Cav.; age 45; admitted Nov. 20, 1864, with scurvy,
which yielded to the usual treatment. On March 28, 1865, he had chills followed by paiu in the chest with cough
Died April 6. Post-mortem examination: Upper aud middle lobes of right lung largely adherent, solid, gray, grauulai
and friable; lower lobe ci-epitaut, slightly injected. Lower lobe of left lung brownish-red, its bronchial tubes dark
aud thickened. Liver cirrhosed; spleen soft, full of blood; kidneys pale.— T/ii/rf Dit-ision Hospital, Alexandria, Va.
PNEUMONIA. 763
Five coses of laryngeaJ conijAications.
Case 23. — Private William Joues, Co. K, 6th X. Y. Cav : age 19; admitted April '2o, 1865; very feeble: pulse
110: tongue coated with whitish fur: little appetite; breathing hurried and difficult: sore throat; aphonia. 2!lth:
Decidedly typhoid condition : tongue dry and swollen : teeth covered w iih sordes. Died May 11. rost-moitcm exam-
ination: Body much emaciated. J.arynx inllanied and thickened: vocal chords destroyed; mucous menihrane of
tracliea inllanied. roughened and thickened: lungs hepatized and infiltrated with pus except lower lobe of left lung,
which was healthy. — CiimbtrhuHl Iloxjjitul, Md.
C.^sK 21.— Serg't John Bruuskill, Co. I, 99th Pa.: age 50; admiued Xov. 23. 1803. Died 27tli. Post-moi-lim
examination: The brain was healthy. The pharynx was dark-purple: tlie lesophagns of a white color above, stone-
blue mixed with ochre color below. The epiglottis was not thickened but highly injected, especially at its free edge;
at the central basil portion was a darkened spot about the size of a pea. The vocal chords were ulcerated posteriorly,
the ulcers linear, with high, roundish, pale walls and the mucous membrano around of a dark-purplisli color. The
sides of the larynx, below this point, were of a stoue-blue color and considerably injected. The trachea was intensely
purple but not thickened. The bronchial glands were large and blackened. The first and second lobes of the right
lung were slightly engorged, the third lobe splenified: weight of lung thirty-fi%e ounces. The left lung wa.s hepa-
tized gray: its central portion was of a darker line than the rest of the tissue and appeared to be in the last stage of
red hepatization; weight seventy-five ounces. The heart eontaiued venous clots on both sides. The liver was healthy
but weighed ninety-five ounces; the gall-bladder was empty; the spleen, dark and pultaceous, weighed ten ounces;
the pancreas, firm and whitish, four ounces; the kidneys were intensely congested. — Ass'l ^'iiirycoii Hanixoii Allen, U.
S. A., Lincoln General IIos2>ilul, IVaahinyton, D. C.
C.\SE 25. — Private James Simonds, Co. A, 3d X. H.: age 39: admitted Feb. 2, ISfJo, with pneumonia of lift lung.
Laryngeal inllamuuitiou set in with a>dema, necessitating laryugotomy. Died 7th. rost-morlem examination : Heart-
clots in all the cavities. Left lung hepatized, fifty-eight ounces; pleural sac iuflanied throughout. (.Jlottis occluded,
larynx and trachea reddened. — Ass't Surgeon Geo. M. ^fcGiU, U. S. A., Xational Hospital, Baltimore, Md.
C.isK 2ii.— Private William E. Abels. Co. G, 9th X. Y. Art.; age 21; admitted July 10, 1861, very weak. Died
suddenly by asphyxia next day. rost-mortim examination: Vessels of brain injected. Epiglottis and its folds much
swollen: mucous memlirane of larynx and trachea brig"it-red: no ulcers or false membrane. Kiglit lung nineteen
ounces: upper lobe and jiosterior portion of lower lobe much congested, dark-purple, on section like blackberry jelly:
left lung, eighteen ounces, much congested. Heart nine ounces and a half; semilunar valvi^s and lining of aorta and
pulmonary artery bright pink. Liver, fifty-four ounces, very soft, acini sc&rcely j)erceptible, external surface quite
dark, capsule of Glissou easily separated. — Lincoln Hospital, Washington, D. C.
Ca.se 27. — Piyvato John Waldron, 29th Mass. Uatfy; admitted and died Feb. 21, 1865. On the preceding day
this man had become intoxicated, and was foun<l at night lying in the rain near Fort Bennett, rosl-morlem exam-
ination : Glottis and larynx inflamed. Right lung adherent and hepatized : left adherent, lower lobe hepatized and
present ing a tuljcrcular deposit three-rjuarters of au inch in diameter, with the tissue around it indurated and slightly
intlamed. Heart normal. Liver adlierent to diaphragm, substance normal: spleen normal: right kiilney congested.
h>tomach in its pyloric half covered with brownish patches; duodenum similarly atiected ; jejunum, ileum and large
intestine normal. — Hospilnl, I'ort t'Ironij, Va.
Tiro coses til patients affected with delirium tremens.
Case 28. — Private John Maquilla, Co. C, 11th Md., reported to have died of delirium tremens. I'd-^t-mdrleni
examination: Serum iu arachnoidal sac and below visceral layer, also in lateral ventricles ; softening of ijrnix, con-
gestion of corpora striata. Communicating channel between auricles large enough to admit little finger: fibrinous
clots extending into vessels. Posterior portion of left lung dark-colored and containing solidified nodulations, weight
forty-four ounces; adhesions on right side and eight ounces of serum in sac; lung hepatized, seventy-seven ounces.
Spleen pulpy; kidneys congested. — Ass't Surgeon Geo. M. McGill, V. S. A., Xationul Hospital, Baltimore, Aid.
Case 29. — Private Patrick Hennessy, Co. E, 1st Md. Inf.; age 25: admitted Sept. 11, 1865; died next day. He
had been on a debauch for eight or ten days, during which time he had not taken food. I'ost-mortem examination:
Congestion of pia mater: opacity of arachnoid: two ounces of liquid iu sac and as much in lateral ventricles. Eight
lung dark-purple, but ciepitant, except under iileuritic bands on sides and summit, weight thirty-two ounces; left
lung engorged, dark-red. weight thirty-one ounces. Fil>rinous clots in heart. Spleen enlarged, dark-red and puljiy.
Stomach diffused red iu fundus, with marbling of a darker hue: duodenum and jejunum liyperaMui^. — Ass't Surgeon
Geo. M. McGill, U. S. A., Hicls Hospital, Baltimore, Md.
One case in ichich cerebral lesions iccrenot associated with recognised cerebral symptoms.
Case .30.— Private Alfred E. French, Co. K, 5th Vt.; age 21: admitted Aug. 10, 18G2. suffering from chr-nic
diarrlupa contracted on the Chickahominy. By October 1 the diarrlnca was in a measure checked, recurring only at
intervals, when some imprudence had been eommitteil, and even then it was not excessive and w:is easily checked by
astringents. There was at all times a great deal of gastric irritability and tendency to dyspepsia, which was bene-
fited and at times wholly relieved by subnitrate of bismuth iu five-grain doses three times daily, but the stomach
would at no time retain large quantities of strong food. The patient appeared to gain strength and was, as soon as
able, required to take exercise every day in the open air. This state of things continued until Feb. 8, l!<63, when he
complained of pain over the middle poition of the right lung, which iu a short time developed into well-marked pneu-
monia, for which stimulants were administered and warm fomentations applied to the chest; diaphoretics, also, were
764 PNEUMONIA.
freely employed but all to no effect, the patient contiuuiug to grow worse until death on the 18tb. Fost-morterj
examination confirmed the diagnosis and brought to light other things which had not been indicated by the sym;.
toms: There was great effusion into the substance of the brain; the arachnoid was opaque, and other phenomena
present, such as purulent patches over the surface of the brain, gave evidence of the existence of a violent arachnitis
No symptom during illness indicated cerebral trouble unless the irritability of the stomach could be attributed to
pneumogastric disturbance. The patient never complained of headache or dizziness; wa.; perfectly natural up to
the time of his death, which was about ten days from the date of the pneumonic attack. The whole intestinal sur-
face showed signs of inflammation and there was a deposit of black pigment in the solitary and agmiuated glands.
The liver, spleen and pancreas were health}-. The thoracic viscera were mostly healthy except the right lung, which
was the seat of the pneumonia; there were also pleuritic adhesions on both sides. — Satterlee Honpiiid, PhiUuhlphia , Fa,
Three cases unmarked hy characteristic pneumonic si/mptoms.
Case 31. — Private George Biown, Co. E, 1st Me. Cav.; age 24; was admitted from the Army of the Potomar,
Aug. 9, 1864. The patient was scarcely able to raise himself in bed. His skin was covered with perspiration and
sudamina, which in some places were on inflamed bases. He had diarrhcea, cough and pain in the chest, but the
chest symptoms were not of much severity. He lay upon either side without inconvenience, breathed regularly
though rather slowly, and complained of distress only in the bowels. Astringents, opiates and stimulants, with
counter-irritation, were employed. He rallied for a day or two, but again grew worse, and died on the 2.5th. Post-
mortem examination : The left lung was hepatized, a portion of it being in the gray stage ; the right lung was nearly
healthy. The small intestine was inflamed but not ulcerated.— TAi'rd Division Hospital, Alexandria, Va.
Case 32. — Corporal Milan Drake, Co. B, 22d Mich.; age 33; was admitted April 16, 1864. A severe chill on the
morning of admission was followed by high fever and delirium ; the pulse was 100, strong and full, the tongue covered
with a yellowish coat and the eyes injected. The bowels were moved freely by cathartic pills after which the tongue
became less coated, but otherwise the patient's condition remained unchanged until the morning of the 19th, when,
having rested well during the i)revious night, his skin was found to be moist, pulse 104, tongue moist aud brown,
bowels regular and appetite returning; there was a purulent discharge from the eyes. On the 20th pneumonia was
recognized on the right side aud a blister was apjilied. Next day the breathing became more hurried, the tongue dry
and brown, the pulse small aud weak aud the eyes continued inflamed. Turpentine emulsion and wine were jire-
seribed; but he died on this day. rost-mortem examination: There was some serous effusion beneath the arachnoid,
but the brain-substance was normal. The right lung was adherent; its upper lobe was hepatized gray, its middle
lobe red, its lower lobe congested; the mucous membrane of the bronchial tubes was much injected and thickened.
The other viscera were normal. — Act.Ass't Surgeon L, C. Cool', Hospital, Chattanooga, Tenn.
Case 33. — James Sutton, substitute, unassigned; age 20; was admitted April 9, 1865. The prominent symptom
was headache, for the relief of which ten grains of blue-pill, with castor oil to follow, were prescribed. During the
night the bowels were freely opened and next day the headache was relieved ; but the patient complained of uneasiness
or slight pain in the right side, where was some duluess on percussion, with coarse crepitation over the lower and
posterior part of the right lung. There was but little cough and no expectoration ; pulse 100, rather small and com-
pressible. Quinine, stimulants and nuti'ients were freely administered, but without effect ; the jiatient died towards
evening. Post-mortem examination : The lower lobe of the right lung and the lower part of its upper lobe were hepa-
tized; the left lung was congested throughout. The spleen was congested and softened. The other organs were
normal. — Act. Ass't Surgeon Leu-is Heard, L'Ouverture Hospital, Alexandria, Va.
Ten cases of relapse or recurrence.
C.\SE 34. — Private Milas Houp, Co. K, 3d Ark. Cav.: age 37; had an attack of pneumonia in February, 1864,
from which he never entirely recovered. He was taken with chill and severe pain in the head and breast Dec. 9,
1864, and was admitted next day. Tongue coated and red: bowels loose; pulse 120: respiration difficult and hur-
ried ; cough with expectoration ; pain in breast : dulness over upper lobes of both lungs : sibilant rales on left side.
He died on the 22d. Post-mortem examination : Great emaciation. Gray hepatization of the left lung: lymph on the
pleura and pus and serum in the cavity. Fibrinous clots in the heart. Bowels congested; rectum inflamed and
softened; glands disorganized. — Act. Ass't Surgeon H. C. Xewkirl', Pock Island Hospital, HI.
Case 35.— Private L. Ireland, Co. I, 121st Ohio; age 31; admitted March 3, 1863. This patient had sufterett
from pneumonia in December, 1862, and was on admission feeble, emaciated, sallow aud affected with diarrhcea. Oa
the 17th he was seized with pain in the lower part of the right lung, accompanied with fever, cough and rusty expec-
toration. He died on the 24th. Post-mortem examination: Upper and middle lobes of right lung hepatized gray, lower
lobe- engorged. Fibriuoirs clots in right auricle. — Hospital, Quinctj, III.
Case 36. — Jeremiah M. C'lubb; age 50; a farmer of Madison Co.. Mo.: was admitted Nov. 28, 1864, with typhoid
pneumonia. He had been conscripted in Sej)tember. but escaped from the rebel army and reported to the United
.States forces at Kock Island, III., November 24. He had not fully recovered from a previous attack of pneumonia,
and the unaccustomed exposure attending his escape caused a return of the cough and paiu in the breast, which grew
worse aud seemed to shift from side to side. Dover's powder, camphor, quinine, turpentine emulsion, whiskey and
milk diet were used in his treatment, but be continued to grow weaker. On December 13 his countenance assumed
a dark-leaden hue and he became very drowsy, falling into a semi-unconscious state on the 15th and dying next day.
Post-mortem examination: Great emaciation. Hepatization of the lower lobes of both lungs. Mesenter}- highly
PiNEUMONIA. 765
inflamed and glands disorganized, lilood iliiii ;in(l watiiy— ai>i)Uient lack of led cuipuscles. — Jet. Ami't Simjion II.
C. Xeukirk, Hock IsIoihI Ho^jiilal, III.
Case 37. — rrivate Henry H. Maxson, Co. C. 9lh Jlicli.: age 28: was admitted Fell. 2G. 1864, with imeumonia. —
prognosis favorahlo. l>nt on Mareli ." he died, alter heing suddenly seized with severe jiain in the chest, hurried res-
piration aud Creiiuent juilse. The relajise was apparently occasioned hy throwing otVthe bedclothes at night. Post-
iiioittm examination: Kight Inng frialile, hepatized red alternated with gray except a narrow liorder at base, which
was healthy: lower lobe of left lung hepatized red. The spleen weighed twenty-eight ounces : the other viscera were
healthy. — //os^ji/aJ JN'o. 8, yashville, Ttiin.
Case 38.— Private Nathaniel T. Reek, Co. G, 8tli Tenn. Cav.: admitted Jan. 7, 186.5. This patient bad two
attacks of pneumonia aud one of typhoid fever since his enlistment in 1861. A third attack of pneumonia was treated
in this hospital Oct. 18 to Dec. 29, 1864. He caught cold after his return to barracks, and died from a recurrence of
the inllaunnatory process. Ponl-iiiortein examination : Great emaciation. Kight pleural cavity tilled with pus. Liver
jiale: bowels congested : rectum intlamcd. — Act. Ans'l Surgeon B. C. Xeiekiik, lioek Island UospituJ, III.
C.KSE 39. — Private George Trite, Co. H, 28th Mich.: ago 18: admitted Jan. 30, 1865: General febrile excitement;
jiain and crepitant rales in the right side: respiration hurried, labored; some cough; sputa scanty, white and
tenacious. February 4: Fever abated; much cough; sputa copious and less tenacious. 8th: Worse, probably from
exposure to draft of cold air; quite delirious; high fever; much cough; rusty sputa; dulness over lower lobe, absence
of vocal resonance. Died 12th. rost-mortem examination : Right lower lobe hepatized; pleura contained more than
a pint of serum. Other viscera normal. — Third Divinion Hoxpital, Alexandria, Va.
C.\SE 40.— Private Z. T. Buckingham, Co. K, 10th E. Tenn. Cav., was admittcu Jan. 24, 1864, with diarrhwa.
He contracted pneumonia February .">. and on the 17th, while convalescing, a relapse took place from exposure; be
died on the 20lli. I'lKl-morlem examination: 15ody well nourished. The meraliraues of the brain were injected.
There were pleuritic adhesions on the right side: the lower lobe of the right lung was hepatized, the upper lobe
engorged: the lower lobe of the left lung was slightly engorged; the Ijronchial tubes also were inflamed; the lungs
weighed flfty-ono ounces. The heart, peritoneum and stomach were healthy; the lower portion of the small intestine
was slightly inflamed; the large intestine inflamed and thickened but not ulcerated. The liver weighed seventy-
six ounces aud was softer than natural; the spleen ten ounces. Only one kidney was found; it was on the left side
and weighed ten ounces and a half. — Act. Asi't SurtjeoH J. E. Marsh , Hospital Xo. 19, Nashville, Tenn.
C.KST. 41. — Private George P. Wade, Co. A, 48th la.; age 25; admitted March 25, 1864, convalescent from pneu-
niouia. April 6: Severe vomiting of bilious matter, which recurred at intervals; little pain in chest, but at times
a paroxysm of coughing of ten minutes' duration. Died 16th. rosl-mortein examination: Kight lung hepatized
throughout; flrni but recent pleuritic adhesions; left lung, upper lobe hepatized, lower somewhat emphysematous. —
Hospital Xo. 8, Xashrille, Teini.
C'.vSE 42. — Thomas Watkins, Co. K, Sth Iowa Cav.; age 20; admitted Feb. 17, 1864. In November, 1863, after
exposure, he had a chill, followed by fever aud cough with bloody expectoration. On admission his symptoms were
pain ill the chest, dulness, especially on the axillary line and posteriorly on the left side and anteriorly below the
nipple on the right: fine rales in the left lung, more natural sounds in the right lung; expectoration tenacious,
scanty aud streaked with blood; respiration frequent and short ; appetite poor; pulse small, rapid and weak. Died
March 11. rost-morlem examination: Lower lobe of right lung hepatized red and covered with old and strong adhe-
sions; left lung hepatized red with spots of gray: jileural cavity contained eight ounces of purulent liiiuid. Heart
normal. — Uospilal Xo. 8, Xashi-illc, Tenn.
Case 43. — Private E. A. Chaiuberlain, 3d Vt.: age 27; admitted Feb. 28, 1864, with pneumonia. He was
improviTig under treatment when, on March 15, he was seized with vomiting, fever and cough, with blood-tinged
sputa. He died on the 23d. Postmortem examination: Left lung hepatized throughout except anterior margin of
upper lobe ; lower part of right ower lobe impervious, nnich of the remainder congested ; but little pleuritic ettusion ;
pleura in several places much inflamed, especially near the pericardium. Several ounces of limpid serum in the
pericardial sac. Liver cirrhosed, atrophied, dense, mammillated, puckered. — Third Division Hospital, Alexandria, Va.
Six cases suggestire of malarial complications.
Case 44. — John P.. Crofton, rebel prisoner; admitted Oct. 13, 1864. Died 20th. /'os(-HioWem exaniiuatiim: The
left lung was hepatized and infiltrated with pus. The heart contained a thrombus. The liver was congested to twice
its normal size, the spleen to five times its normal size; the pancreas was enlarged: the kidneys healthy: the small
intestine was congested.— Jc/. Ass't Surgeon H. H. liussell, Hock Island Hospital, III.
Case 45. — Jno. W. Whigham, Government employf', age 34: admitted March 26, 1864, with pneumonia. Died
30th. Post-mortem examination: Left bronchial tubes much inflamed; right lung, upper lobes hepatized gray, lower
lobe mnch inflamed. Heart filled with firm black clots. Liver ninety-three ounces; spleen twenty-one ounces, dark;
right kidney tea ounces, left eleven ounces. Intestines normal. — Hospital Xo. 1, Xashrille, Tenn.
Case 46.— Private John W. Tipton, Co. E, 15th Ohio; age 18: admitted Fel). 27, 1864; had been sick for some
days but could not tell how long. Sordes on teeth and gums; tongue dry and black; pulse 1.30. DiedMarch5. Post-
mortem examination: Kight lung thoroughly congested, upper lobe hepatized red: left lung congested throughout.
Spleen weighed twenty-four ounces; other viscera nornuil. — Hospital Xo. 8. Xashrille, Tenn.
Case 47. — Private Samuel Crawford, Co. G, 2d La. Cav.; age 20; was admitted Jan. 7, 1864, with severe cutting
pains in the right side, difficulty in breathing and violent cough attended with a brown mucous expectoration; his
66 PNEUMONIA.
foco was fluslied niul pulse 120. Calomel and opium, and afterwards chloride of ammonium, were used, with sinapisms
and belladonna externally. The patient died on the 14tb. Prior to this fatal .seizure he had suffered from sevoio
attacks of intermittent fever. Fosi-mortem examination: The rig-ht lung was hepatized red and partly adherent tc
the costal and diaphragmatic pleurie; the left lung was normal. The liver weighed four pounds and a half, the spleen
two and a half pounds. — Act. Ass't Siir/icon H. Urban, Universit i/ Hospital, Xew Orleans, La.
Case 48. — John Fowler; age 20; citizen of Carter Co. Mo., subject to ague for several years; admitted Jan.
26, 1865, with pneumonia and jaundice which dated from the 12th. Skin very yellow ; urine highly colored ; bowels
normal: tongue coated; pulse 120, quick and sharp; respiration somewhat hurried and labored; cough, with expec-
toration of mucus tinged with bile. Died 31st. Pest-mortcm examination: Skin jaundiced. Gray hepatization of
the posterior portion of both lungs, involving two-thirds of their extent; etfusion into pleural cavities. Large
thrombi in right side of heart, extending into and tilling the pulmonary arteries. Liver rather paler than usual;
gall-bladder distended with transparent gelatinous liquid ; spleen about three times the normal size ; bowels normal. —
Act. Ass't Surgeon H, C. Xeu-larl, Bock Island Hospital, III.
Case 49. — Private William Taylor, E. Tenn. Cav., unassigned ; age 23; admitted Feb. 1, 1864, from the field.
Died 6th, Fost-mortem examination : Extensive recent pleuritic adhesions on left side with heavy deposits of lymph;
left lung throughout entering gray hepatization. Extensive firm ifleuritic adhesions of right side ; lower lobe of lung
hepatized red, middle and upper lobes much congested. Heart contained large recent butf clots. Liver, ninety-eight
ounces, congested, fatty and adhering to diaphragm; spleen, twenty ounces, pulpy; kidneys, eight ounces each,
healthy. Stomach and intestines healthy. — Hospital Xo. 1, Xashville, Tenn.
Six cases suggestive of the poison of tijphoid ferer.*
Case .50. — Serg't C. W. Breese, Co. C, 141st N. Y.; age 30; was admitted July 29, 1863, having been taken sick
about three weeks before with pneumonia of both lungs and diarrhoea. He was treated with stimulants and beef-
essence, turpentine stupes, opium, catechu and opiate enemata. He died August 2. Post-mortem examination : The
lower lobe of each lung was hepatized and the glands of Peyer ulcerated. The other organs were healthy. — Stanton
Hosjiital, JVasliington, D. C.
Case 51.— Private John B. Pope, Co. A, 2d N. J. Cav.: aduiitted Jan. 2, 1S63, witli pneumonia. Died 27th.
Post-mortem examination: Emaciation. Kight lung, twenty-three ounces, caruitied posteriorly and interiorly in lower
lobe, reddish-purple and containing melauic matter; pus in bronchial tubes. Left lung twenty-one ounces, lower
lobe caruified and containing melauic matter; jms issued on section from what appeared to be dilatations of the
bronchial tubes ; bronchial glands black. Heart i)ale, flabby and with iibrinous clots in all its cavities. Liver, sixty-
five ounces, full of blood; siileen, nine ounces, pulpy. Heum thinned, congested and with some ulceration of Peyer's
patches; large intestine thinned and congested. Kidneys pale and showing lines of congestion in the cortical sub-
stance.— Lincoln Hospital, Washington, D. C.
Case 52. — Private Nelson Cochran, Co. F, 44th Colored Troops: age 17; was admitted July 26, 1864. and died
September 10. Post-mortem examination: Lower lobe of each lung hepatized; upper lolie of right lung hepatized
gray. Heart pale and flabby. Liver, spleen and kidneys normal; mucous membrane of intestines congested and
softened, and ulcerated in the ileum and large intestine. — Chattanooga Field Hospital, Tenn.
Case 53. — Private Samuel Gordon, Co. H, 13th W, Va.; age 37; was admitted March 8, 1865, with pneumonia.
His pulse was 104, tongue dry and fissured, skin hot and dry, face flushed; he complained of a dull pain in the chest
and had a cough with scanty sputa tinged with blood. He was treated with au expectorant mixture containing one-
fourth of a grain of tartar emetic in each dose, given every four hours. He died on the 15th. Post-mortem examina-
tion: The upper lobe of the right lung was hepatized and bound to the thoracic parietes by slight recent adhesions;
the upper lobe of the left lung was also adherent, the lower lobe partially hepatized. The liver was pale, large and
soft; the spleen much enlarged; the small intestine inflamed and in portions almost gangrenous. — Act. Ass't Surgeon
Tliomas II. Clement, Cumberland Hospital, Aid.
Case 54. — Private George J. Warren, Co. G, 123d Ohio; age 20: admitted Oct. 14, 1863. Auscultation indicated
abscess of lung; expectoration muco-purulent; tongue red, dry and smooth; anorexia; prostration, lie gradually
failed, and died Jan. 4, 1864. Post-mortem examination: Extensive pleuritic adhesions; lungs filled with purulent
fluid; a portion of upper and middle lobes of right lung pervious to air. Intestines showing signs of former inflam-
mation, with occasional small ulcers in the lower ileum. — Cumhcrlund Hospital, Md.
Case 55. — William H. Jones, unassigned substitute ; admitted Oct. 6, 1863, with typhoid j)neumonia. He had
some looseness of the bowels, great dyspna>a and cough with rusty sputa; tongue brown and parched, skin hot and
dry; he was much prostrated, had slight subsultus and at night delirium. He died comatose on the 8th. Post-mortem
examination: Kight lung and lower lobe of left in a state of complete splenization; pleuritic adhesions on the right
side; no ertusion. Eight ounces of serum in iiericardium ; heart flabby and atrophied. Spleen and lower portion of
gastro-colic omentum congested; lower part of ileum and descending colon ulcerated and containing pus: kidneys
and bladder normal.— Jc?. Ass't Surgeon TF. Leon Hammond, 1st Division Hospital, Alexandria, Va
Five cases of enlargement of the solitary follicles.
Case 56. — James Hunter, Missouri guerilla; age 25; admitted Nov. 24, 1864, with typhoid pneumonia which
lasted ten days. Pulse 120: respiration hurried; pain in side; expectoration scanty and tinged with blood; counte-
* S<?c also the post-inorlem records of the continued fevers, snjmt, page 412.
p^"EUMO^•IA. ibi
nance anxious: dulness on percussion ami crepitant sonmls over right lung; bowels tympanitic and tender. Died
Deoeiiilier 1. rost-moiltiii exaniinaiion : Uray hepatization of rijjht lun<; and lower loho of left. Distention of Uowels
with gas and enlargement and disorganization of solitary glands. Other viscera noinial. — Hod,' UUinil Euxiiilal, III.
C.\SE r>7. — Private Henry S. Rikard.Co. U. SHth .Via. Typhoid iineunionia. Admitted Nov. 22, 1864; died 21!! Ii.
roet-mortim examination: Gray hepatization of the right lung and of the lower lobe of the left. The heart contained
c large tlirombu.-;, which extended into the pulmonary artery and was the probable cause of death. The intestines
were congested and ulcerated, the solitary glands enlarged and resembling polypi. The blood presented a disorgan-
ized and broken-down appearance. — Jet. .Iss't Surgeon II. C. Xcickirk, Hock Island Hosjiilal, III.
C.vSE 58. — Private Daniel Bivins, Co. C, 133d N. Y.; ago 25; adiiiitted April 11. 18G5. Restless; irrational;
pulse rapid and feeble: tongue dry and brown: breathing dillicult; dulness, crepitus and friction over lower lobe
of right lung: diarrlia'a ; involuntary passages. He died on the l.'jth. rost-mortim examination: Pia mater con-
gested, lining of ventricles injected, fornix softened. Old costal and interlobar adhesions on right, side: congestion
and solidilieation in spots in both lungs, especially posteriorly. Fibrinous clots in heart. Nutmeg liver. Mucous
niembraneof ileum thinned and -softened and solitary glands enlarged. — Jss't Surgeon Geo. M. MeGill, C S. A., Xutional
Hospital, ISullimore, Mil.
Case 59. — Francis Robinson, of Asheville, X. C: rebel deserter; admitted Feb. 11, 18ii3. Pulse 120, thready;
tongue <Uirk and cracked; pungent odor of typhoid condition; left lung solidified: signs of pleural implication.
Died 18th, after being unconscious for nearly two days. Fost-mortem examination : Liquid in arachnoid and a little
in lateral ventricles. Eighteen ounces of serum in left pleural sac; lung fifteen ounces, its lower lobe adherent,
solid, mottled red and gray, granular and yielding a bloody scrum on pressure; right lung normal but some serous
liquid in pleural sac. Mixed clots in cavities of heart. Some spots of congestion ; enlarged solitary glands and local
thinning of intestinal mucous membrane. Spleen pulpy. — Ass't Surgeon Geo. M. ilcGill, V. S. A., Xalionol Jlonpiliil,
Batliiiiore, JJtl.
C.vsE CO. — John L. Bridges; age 30; Missouri guerilla: admitted Dee. 4, 18(54. with typhoid pneumonia which
had lasted a week. Tongue dry, brown and narrow, with red margins ; bowels rather loose ; pulse 120, full ; respira-
tion hurried: cough with copious expectoration ; pain in side; dulness over base of right lung and crepitant rales
generally difiused. He became delirious on the 13th, and died next morning. Post-mortem examination: Great ema-
ciation. Serum and pus in right jileural cavity, with collapse, softening and imiiermeability of the lung. Thrombi
in botli auricles. Congestion of the liver and bowels with enlargement of the mesenteric glands and disorganization
of the solitary follicles. — Act. Asa'i Surgeon H. C. Xewkirk, Hock Island Hospital, III.
Seren cases of marked typhoid symptoms unconnected with an enteric lesion.
C\SE tU. — Private Griftiu Canterberry, Co. G, 3d \V. Va.: age ."i5 : was admitted April 1, 18(i5, with typhoid fever.
The patient was emaciateil and delirious : he had considerable congh and crepitant rales were audible over the lower
third of the right lung: his tongue was moist. Tonics and stimulants were freely administered. He died on the
0th. I'ost-morlem examination: The lower lobe of the right lung was hepatized. The liver was slightly congested;
the gall-bladder distended with healthy-looking bile; the spleen large and soft; the kidneys congested and softened
and one of the pyramids of the left kidney converted into a cyst. The bowels were much distended with gas. — Ass't
Surgeon David Shanor, Glh !V. 1'a. Vols., Cumberland Hospital, Md.
C.\SE 62. — Private John Shay, Co. G, 16th X. Y. Cav.; age 35; while in hospital under treatment for chronic
rheumatism was attacked, May 2, 1865, with pneumonia. Typhoid symptoms appeared on the 11th, and death took
place on the 14th. Post-mortem examination: Left lung, except a s-iiall portion at the base, solidified, of a dirty-gray
color, firm and fatty: right lung congested. Other viscera normal. — Augur Hospital, Alexandria, T'a.
C.\sE G3. — Tobias Gibbons: paroled rebel prisoner; age 45; admitted May 6, 1865, in a state of great prostra-
tion; pulse 100, feeble ; respiration normal: no pain or cough ; eyes heavy and expressionless: tenderness over abdo-
men, more intense in right iliac fossa ; dulness over greater portion of both lungs; bronchial respiration and crepitus.
I'ied lOtli. without having been thoroughly conscious from the time of his admission. Post-mortem examination:
Brain normal. Right lung, fifty-six ounces, congested iu upper and puruloid in lower parts; left lung, twenty-nine
ounces, intensely congested posteriorly. Fibrinous clots iu heart. Liver congested. No lesion observed iu small
intestine.— J8s'< Surgeon Geo. J/. MeGill, V. S. A., Xational Hospital, Baltimore, Md.
Case 64.— Hospital Steward Benjamin Y. Stone, 28th Mich.; age 28; was admitted Feb. 14, 1865, with i)neii-
monia. The patient, of a nervous temperament, was considerably depressed and seemed to be laboring under mental
anxiety. He said he had been subject to tertian intermittent fever and diarrhoea, for which he had taken opium and
quinine in large quantities. He was not much emaciated, but his i)ulse was weak and he had no appetite; a slight
crepitus was detected iu the lower lobes of the lungs; he had headache and some deafness on both sides. He con-
tinuril to grow weaker and more depressed in mind, so that by the 20th he could not leave his bed. The diarrho;!*
yielded readily, but the deafness increased; the pulse became thready and rose to 140; restlessness was followed by
'lelirium, during which the patient wanted to sit up or kept picking at the bedclothes. He became drowsy on the
-'8th, but continued picking at the bedclothes until the coma deepened. He died March 3. Post-mortem examination :
rhe cerebral membranes were opaijue and serum was eftused beneath them; the brain was quite hard and rather
pale: the choroid plexus pale, almost white near the foramen of Monro; the spinal cord was pale. The pericardium
contained clear serum. The npper lobe of the right lung was soft, hepatized gray behind and crepitant only in its
anterior edge ; its bronchial tubes were full of pus: the lower lobe was brown iu color and sank in water; its tubes
768 PKEUMOXIA.
■were daik-pnrple aud thickened. A patch of strong adhesion was found on the external surface of the left lung, the
upiier lolie of -nhich was crepitant but softened and presented a little cicatrix at the posterior part of its apex; the
lower lobe was softened and spotted with blackish or brownish-red patches in a gray or pinkish-gray crepitant tissue ;
the bronchial tuV)es, dark-purple in color, were filled with pus. The liver was soft, pale-yellow and of good size:
the spleen soft and small. The ileum was full of air and slightly injected, but otherwise normal. The kidneys w-ere
fatty and injected with dark blood. — Third Division Moxxnial, Jlej-aiidria, J'ti.
Cask 05. — Private George E. Blackmer, Co. C, 3d Mass.; age 20; taken sick Feb. 1(3, 1862. with diarrhiea. and
admitted March 2. Diagnosis: Typhoid fever. 4th: Drowsy: cheeks tlushed : pulse full, weak and rapid: skin hot
and dry; some deafness; tongue coated; much thirst; two watery stools daily; much cough with mucous expectora-
tion. Gave stimulants, iron and turpentine emulsion. 6th: Tongue moist; no abdominal tenderness; cough less-
ened: appetite returning: bowels regular. He continued thus until the 10th, when the record shows some delirium
at ni"Ut, epistaxis and dry tongue. In answering cjuestions he confused his dreams with realities, and for some days
afterward had curious hallucinations. His appetite continued good and his bowels regular, but the pulse remained
quick and weak. On the 16th his cheeks became much flushed; he had severe pain in the right breast and was
unable to breathe deei>ly, to cough or to lie down. 17th: Eeplies rationally, but at once relapses into delirium: pulse
rapid, soft; skin natural; tongue moist, slightly coated; appetite poor; bowels regular; some deafness; much epi-
gastric tenderness and severe pain in chest. Applied fly-blister over summit of right lung. He gradually failed, and
died on the 25th. Fost-mortem examination: Extensive pleuritic adhesions on left side; slight adhesions on right
side, with thin layers of coagulable lymph and thirty ounces of eft'usion; hepatization aud purulent infiltration of
ri"ht lung and a portion of the lower lobe, two inches square, choked with coagulated blood; bronchial tubes oi
both lungs filled with frothy mucus. — Seminary Hospital. Giort/ctoun, D. C.
C.\SE 66. — Private Thomas Warner, Co. K, 15th Ya.; age 28; admitted Nov. 20, 1864, with typhoid fever. Died
26th. rost-mortem examination: The posterior two-thirds of both lungs were hepatized and the remaining parts con-
gested. The left pleura and the pericardium contained efl'used liquid. The heart was flabby, the liver large, the spleen
hypertrophied and soft. The other organs were normal. — Act. Ass'i Surg. B. B. Miles, Jarvis Mospita}, Baltimore, Md.
Case 67. — Private Jackson Freeman, 1st Mich. Colored troops; age 19; was admitted March 17, 1865, with
pneumonia. His pulse was 100, skin hot, tongue furred; he had severe cough with viscid sputa, crepitus on the
right side of the chest and bronchial respiration on both sides. Stimulants, expectorants, Dover's powder aud poul-
tices were prescribed. On the 19th crepitation was heard ou both sides. The tongue on the 24th became dry and
brown in the centre, red and moist on the edges; sordes appeared on the teeth and there was considerable abdominal
tenderness. He died April 17. Post-mortem examination: The greater part of the right lung was adherent and in a
state of red hepatization — in places commencing to soften; the right pleural sac contained sixteen ounces of serum
mixed with pus ; the left lung was congested. The pericardium contained four ounces of serum. A number of him-
bricoid worms were fonud in the ileum. The kidneys were congested and soft. — Act. Ass't Surgeon S. D. Twinimj,
L'Ourerture Hospitul, Alexandria. Va.
Two cases shouinij the maximum ueiyht of the consolidated lung in the series of tuo hundred and thirteen cases.
Case 68. — Private William Barker, Co. 1, 123d Ind.; age 43; admitted Feb. 4, 1805: Distressing dyspnoea; large
crepitation on right side of chest superiorly and but little sound at all inferiorly, with dulness over all; puerile
respiration, with slight resonance on left side. Died 10th. rost-mortcm examination : Universal adhesion of lungs;
right lung seventy-three ounces, its upper and lower lobes completely hepatized, middle lobe unaftected; left lung
congested; bronchial glands enlarged. Other organs healthy. — Douglas Hospital, Washington, D. C.
Cask 69. — Tolland Ephraim Couso, rebel soldier; age 26; admitted Jan. 27. 1864, with pneumonia. Died 31st.
Post-mortem examination : Much emaciation; left leg and thigh largely (edematous: left femoral vein distended with
clotted blood and left common iliac vein obstructed by a strong fibrinous clot three inches long. Firm adhesions
posteriorly and at the base of left lung, with a pint of serum in the sac; lung completely hepatized gray; weight
ninety-two and a quarter ounces. Firm adhesions posteriorly and at the base of right lung, middle and lower lobes
posteriorly hepatized red; weight twenty-seven ounces. Heart contained large dark clots in each side. Liver,
seventy-three ounces, fatty; spleen, ten ounces, light-colored, mottled with several dark sjiots; kidneys healthy. —
Hospital Xo. 1, Sashville, Tenn.
Besides the 213 cases illustrated liy the selections just submitted, the records furnish
87 cases of pneumonia characterized by peculiarities in their complications or results.
Tifcntij-seren of these iverc associated tvith 2>ericarditis.
Case 70.— Private Charles Chadburne, Co. A, 11th U. S. Inf.; age 22; admitted Aug. 10, 1862, with debility.
Died Feb. 4, 1863. Post-mortem examination: Body emaciated. The surface of the heart was roughened with recent
pseudomembrane and the inner surface of the pericardial sac was injected and partially roughened, but there was
no adhesion; the sac contained about half a gill of serum. The right lung was collapsed to about the size of two
fists and was in a condition of complete pneumonic hepatization ; the pleural cavity was lined with a thick and
roughened pyogenic membrane and contained about a gallon and a half of pus. The left lung, with the exception
of bronchial inflammation aud slight congestion, was healthy. The liver was flattened above from the purulent
accumulation in the thorax, aud jmrplish-red and darkly-spotted from engorgement of the central vessels of the
PNEUMONIA. 769
loliiili; ilif s]ili'i>n \v.i> latliei- soft .-iihI Iiidiaii-icd on srction. The .stoiiiaoli and intestines {jcniMally wnu hraltliy
(•xcc|>tinj; some iiunleratidy and locontl.v inllanu-d patches anil streaks in thu ileum and eoh)n: the intestinal glands
were healthy. The kidneys, though seeming somewhat fatty to the naked eye, appeareil nonnal on mii-roscoiiical
examination. — Act. Ass't Sunjcon J. Lciili/, SiiIIitIcc ITonjiilul, I'hiladtlphia, I'd.
CvsK 71.— Private James D. Pettis, Co. E, 114th X. Y.: ago 22; was admitted Aug. 27, ISlil, with typhoid i)ncu-
monia. This man was taken sick on the 8th with a chill, followed by fever and vomiting which continued twenty-
f.iur hours. On the 12th he began to suffer from pain in the bowels and in the left side of the cliest. On admission
I hero was dulncss with crepitant rales over the whole of the left lung except its ai)ex ; tho cheeks were Unshed, tlio
r.-spiiation ;J0, the pulse 120 and soft and the tongue red at the tip and covered with a white fur; ho had diarrhu-a,
and pain in the left side and shoulder. A blister was applie<l to the side, and catechu, i)aregoric and wine were prc-
scribeil. He improved under treatnuMit, the bowels becoming ([uiet, the skin cool, the pain diminished and tho res-
piration lessene<t in frequency: but the tongue continued red at the tip, and on September '> a sore began to form on
his back. On the lltli the jiatient was much better: his appetite and spirits excellent, — but when about to take
supper he was suddenly seized with violent pain in the right side, retching, oi>pressed respiration and feeble pulse.
Next day his extremities liecamecold and his skin assumed an icteric hue. He died on the morning of the 13th.
roKl-miirlvin examination: The left lung was solidified except at its apex and the pleural sac contjiiiKtd two quarts of
pus; the right lung was congested and coated with lymph and the sac contained ten ounces of serum. The peri-
cardium was distended with serum containing a slight admixture of pus and was lined with a thick coating of lyuijih ;
a simihir coating covered the heart, which was enlarged. [S2)ecimen -Ul, Med. Sec., Army Medical Museum.] Tho
liver also was considerably enlarged.— J«s'< Surgeon C. Bacon, jr., U. S. A., Annapolis Junction, Mel
Cask 72.— Serg't P. T. Bentley, Co. M, 1st Mich. Cav.; age 23; was admitted Oct. 29, 1801, with f.ver. cough,
pain in theehest, hurried res|)iration aiul rusty sputa. A cathartic was administered, followed by small doses of tartar
emetic and afterwards by calomel, oi)iuin and ipeeaciuinha; a blister was applied to the chest. He appeared to
improve until November !1. when he had a chill followed by a renewal of all the symptoms. He again improved
apparently until the 20th, when extreme dyspniea set in and he .sank rapidly, dying on the 22d. roKl-mortvm exami-
nation : I'he right lung was connected with the thoracic parietes by thick layers of lymph in which serum was sac-
culated : tho left was coated with reticulated lymph and compressed against the mediastinum by an accumulation of
pale seriun. Tho heart adhered to tho pericardium, the apex only being free. [Sjuicimen 4,51, Med. Sec, Army Jledi-
cal Museum.] The liver presented the nutmeg appearance; the spleen was large and its trabeouhe distinct: the
mesenteric glands enlarged. The remaining viscera were normal.— Jc(. Ass't Surrjcon W. C. Minor, Third Dirision IIos-
piliil, Ahxtmilriu, To.
Case 7,S, — Private Acjuilla Merrifield, Co, F, 27th JIass., was admitted Dec. 7, 181)2. His history and condi-
tion are not stated; but his treatment consisted in tiie administration of veratrum viride and afterwards chalk and
mercury, with Dover's powder, quinine and the application of a blister. He died on the 15th. J'ost-mortrm exami-
nation: The brain was healthy. The lungs were more or less hepatized and covered with recent lym])h. The ]>eri-
cardinm contained four ounces of yellow serum, and the heart was completely enveloped in a thick deposit of lymph
one-sixteenlh of an inch in thickness; both surfaces of the membrane were much injected. There were old hepatic
adhesions and recent lymph on the intestinal convolutions. — Suryeon B. Darrach, U. -S. Volx., Binton Barracks, Mo.
Ca.sk 74. — Isaac Thacker, Government employi?, was admitted Feb. 20, 1804, and died tho same evening.
PobZ-ihoi-^™ examination: Body well nourished. Brain healthy. There were extensive old pleuritic adhesions: the
lungs weighed eighty-four ounces; the right lung was hepatized throughout, the left congested, the bronchi iLllamed.
The pericardium was distended with ten ounces of turbid serum; the parietal lining of the sac was coated with
fibrinous exudate and masses of lymph three and four lines in thickness adhered to its visceral portion. — Act. Ass'l
Surijcnn .S. J/. Olden, ffn.ijntal Xo. lit, yashrillc, Tenn.
Case 75.— Private George A. Chedel, Co. G, 16th Vt.; age 3S; was admitted April 14, 1863, having been ill two
■weeks. Pulse 130, very feeble; respiration 28; pain in chest; cough hard and frequent; expectoration of bloody
mucus; dulness and absence of auscultatory sounds over right side of chest, front and back, extending as high as the
third rib. ami puerile respiration in upper part; diminished resonance and crepitation over lower half of left lung.
He died on the 17th. I'usl-mortcm examination: Right pleura contained three pints, left pleura half a iiiut, of liquid,
with lloating lymph-tiakes; extensive recent adhesions on both sides; middle and lower lobes of right lung hepa-
tized, upper lobe congested ; lower lobe of left lung in first stage of inflammation, upper lobe normal. Pericardium
contained half a pint of serum: heart covered with lyniidi. Stomach congested; mucous membrane of lower ileum
injected and softened; spleen enlarged and softened.- r/iin/ Dirision Uospitnl, Alexandria, Va.
Case 76.— Private William Morse, Co. I, IGth Vt. : age 30 ; admitted April 14, 1863, with pain in left side ; cough ;
urgent dyspnoea; pulse 120 and feeble: respiration 30; dulness over entire right lung and tubular respiration along
the posterior border of the scapula; dulness over lower half of left lung, mucous rales over upper half, 23d: Pain in
both lungs increased ; dyspnoa urgent ; diarrhcca with pain in abdomen ; copious sanguineo-i)urulent expectoration ;
free diaphoresis. Died 26th, I'ost-morinn examination: Right pleura, much thickened with lymph, contained three
pints sero-purulent liquid; lung solid, exuding a little pus on inessure. Left pleura containeil two pints of sero-
purulcnt liquid ; lung in second stage of intlammatiou. Six ounces of serum, with lloating particles of lymph, in
pericardium; villous-shaped lymph coating the heart. Liver and spleen somewhat enlarged. Mucous coat of stom-
ach injected, of small intestine reddened and softened,— 27ii/rf Division Eospital, Alexandria, Va.
Case 77.— Serg't Wm. P. Cahoon, Co. E, 19th Ala., a large fleshy man; age 2.5: was admitted Nov. 28, 1864,
Med, Hist,, Pt. Ill— 97
770 p:neumonia.
with acute pneumouia. Pulse 130: tongue ccf-ted and dark; surfiice of body bluish ; couutenance anxious; respira-
tiou 32; bauds raised above head for ease in breathing; paiu in both sides of chest : duluess and suppressed resjiiratory
breathing on right side from apex to base; intercostal spaces full but no bulging; dulness very general on left side
also; cough troublesome; expectoration streaked with blood. Died December 4. Posf-morfcm examination: Right lung
collapsed and disorganized and pleural cavity filled with serum; left cavity contained about twelve ounces of effu-
sion : lower lobe of lung hepatized, upper highly congested. Pericardium contained eight ounces of serum and was
much thickened and roughened; surface of heart roughened and corrugated; endocardium apparently unchanged.
Abdominal viscera normal. — Act. Jss't Sunjeon M. Hale, Eock Island Hospital, III.
Case 78.— Private Gain O. Robinson, Co. H, 28th llich.; age 38; admitted Feb. 6, 1865, with much pain: fever of
remittent character; excessive dyspna'a: vomiting of bilious matters; face livid; delirious most of the time. Died
14th. Post-mortem examination: Sudamina; capillary congestion on neck and breast. Lungs much congested and
exuding a bloody liquid on section. Pericardium thickened, containing four drachms and a half of serum: heart of
medium size, fatty. — Third Division Hospital, Alexandria, Va.
Case 79. — Private William Simpson, Co. F. 4th Fla.; age 20; admitted Jan. 4, 1864, with pneumonia. Died
21st. Po.s(-Hii)r/rm examination : Moderate emaciation. Strong pleuritic adhesions on botli sides; left pleural cavity
contained four pints of serum, right two pints of pus. Left lung hepatized red and covered with a thin layer of lymph;
lower half of right lung hepatized gray and presenting a vomica lined with a thin layer of disorganized lymph.
Pericardium somewhat inflamed and containing about two ounces of serum; heart with large buff clots entangled
in the chordie. Liver, seventy-four ounces, infiltrated with fat; spleen, eighteen ounces, light-colored and pulpy;
kidneys healthy, eight ounces each. Mesenteric glands somewhat enlarged; small intestine much inflamed. — Hospital
Xo. 1, Xashville, Tenn.
Case 80. — Private John (inyman, Co. I, 10th 111.; age 22; admitted March 2, 1864, with pneumonia. Died Oth.
rost-morteiii examination: Recent firm and universal pleuritic adhesions on both sides; lungs coated thickly with
lymph ; ten ounces of serum in right pleural cavity; upper lobes of both lungs hepatized red, lower lobes deejily con-
gested. Heart contained large clots : pericardium coated interually with recent heavy deposits of lymph. Liver, one
hundred and two ounces, fatty; spleen thirty-three ounces; right kidney nine ounces, left ten ounces, fatty. I'eyer's
patches somewhat thickened. — Hospital Xo. 1, Xashville, Tenn.
Case 81.-- -Private George W.Lute, Co. H, 2."itli Iowa; age 24; admitted Feb. 29, 1864. Died March 26. Post-
mortem examination: Pleuritic adhesions slight on the left side, firm on right; upper two-thirds of right lung hepa-
tized gray lower third red: left lung intensely congested. Heart weighed ten ounces, slight pericarditis. Liver,
seventy ounces, normal; spleen, sixteen ounces, unusually firm. Intestines and kidneys healthy. — Hospiiai Xo. 1,
Xashville, Tenn.
Case 82. — Edward Lucan, teamster; age 40; admitted March 23, 1864, with pneumonia. Died April 2. Post-
mortem, examination: The right lung, sixty-one ounces, was adherent and hepatized; the left, twenty-four ounces,
was collapsed. The heart was covered with a firm layer of lymph an eighth of an inch thick; the endocardium on
the right side was inflamed. Tlie liver weighed eighty-five ounces; the spleen nineteen ounces and a half; the kid-
neys were fatty; the intestines healthy. — Hospital Xo. 1, Xashville, Tenn.
Case 83. — Thomas Rihl, Government employe ; age 40; was admitted April 11, 1864, complaining of pain in his
arms, shoulders and legs; his ankles were slightly swollen. A half drachm of nitrate of potassa was given in water
every three hours, under which treatment he seemed to improve; but on the evening of the loth he had a slight chill
with pain in the chest and some cough; slight crepitation was heard over the lower part of the right lung. Wet cups
were applied and five-grain doses of blue-pill given every four hours. Afterwards a blister was applied and carbonate
of ammonia administered. He died on the 23d. Post-mortem examination: The posterior part of the upper lobe and
the greater part of the lower lobe of the left lung were hepatized, partly red, partly graj'. The heart was rather flabby
and the pericardium contained a large quantity of serum. The liver was enlarged and had the nutmeg appearance;
the spleen was healthy; the right kidney congested. — Act. Ass't Surgeon L. A. Walton, Hospital Xo. 8, Xashville, Tenn.
Case 84.— Private Franklin Fisk, Co. I, 19th Me.; admitted July 10, 1863. Died 16th. Post-mortem examina-
tion : The lungs were adherent and hepatized in their lower lobes ; the upper lobe of the left lung was in the stage of
aoftening and the apex of the right filled with miliary tubercle. The pericardium was thickened and contained eight
ounces of serum; the heart was normal. — Act. Ass't Surgeon John Dickson, Jarvis Hospital, Baltimore, Md.
Case 85. — Private William King, Co. C, 15th Pa. Cav., was admitted March 25, 1864, much exhansted. He said
he had been sick some time with consumption. Died 26th. Post-mortem examination: Body somewhat emaciated.
Pericardium inflamed, containing serum and lymph. Adhesions with eft'usion of lymph and serum in left pleural
cavity and lower two-thirds of lung hepatized red; right lung healthy except some old iileuritic adhesions. Liver
and spleen enlarged; kidneys congested. Extensive peritonitis with effusion of serum and lymph degenerating into
pus. — Turner's Lane Hospital, Philadelphia, Pa.
Case 86.— Private Robert Close, Co. B, 8th 111. Cav.; age 33; admitted March 6, 1864, with pneumonia. Died
14tli. Post-niorlrm examination: Brain fifty-six ounces, much congested. Trachea and bronchi congested and lined
with tenacious reddish-brown mucus. Right lung, thirty ounces, congested, especially at the base; left, fifty-seven
ounces, solidified, adherent throughout by recent lymph and with seven ounces of serum in the i>leural sac. Peri-
cardium contained four ounces of dark liquid like mulberrj- -juice; heart flabby, reddish-brown in color and filled
with fibrinous clots. Intestines normal but Peyer's patches prominent. Liver seventy-one ounces; spleen twelve
PNEUMONIA. 771
ounces ami a lialt": pancreas iliroe ounces; iij;lit kidney live ounces anu a uali, left seven ounces — all api)aicntly
liealtliy. — Linvolii UospUul. Il'ushiiirjtoii. D. C.
Case 87. — Private John McLaujiUlan. Co. 15,23(1 111.; a^e II ; was admitted Nov. 2, 18(!l, witli chionic synovitis.
The knee-joint became much swollen, and on December H dianhu-a set iu and the patient became sleepless at night.
The bowels were regular on the 7th, but cough with purulent sputa had meanwhile developed. Astringents were
discontinued and whiskey ordered to the amount of four ounces daily. On the lltli fine crepitation was detected
over the lower ])ortion of both lungs ; skin hot and dry; pulse 120 and feeble. Tartar emetic was given in small doses.
Delirium came on, and the patient died on the 15th. /'i)»/-m»c/cm examination: lioth lungs were slightly adlu'rent
and hepali/ed red, bordering on gray interiorly. There were small patches of lymph in the pericardium. The knee-
joinl contained an ounce of sanious synovia; its cartilages were ulcerated. — Act. .Isn't Siirijeoii E. 1!. Uiihl, IIo«iiilal,
FnikricU, Mil.
C.\SK 88. — Private Asa Iveynolds, '>i\\ \. Y. Art'y; age 19; was ;idmitt(d March 22, IXlil. He was feverish and
complained of cough, acute pain in the right side and dyspniea. Small doses of tartar emetic and sulphate of nuig-
nesia were prescribed. Next day the force and rapidity of the pulse were reduced, the pain and cough diminished
and the bowels freely opened; but in the evening he became worse, the pulse rising to IGO, the skiu becoming dry,
the sputa rusty and the pain in the side .severe. He was very weak on the 21th, the alidonu'u tympanitic and tendin-
and the stomach irrit.able. Medicine was omitted and beef-tea, wine and morphia directed to bo used; turpentine
stupes were applied to the abdomen. He died on the 27th. Post-mortem examination : Nearly the whole of the right
lung was s(didilied and lirmly adherent to the thoracic parietes; the left lung was considerably congested. The inner
surface of the pericardium was roughene<l with lymph and the Site eont.ijned a little lliiiil. The stomach and intes-
tines were healthy: the liver and kidneys congested. — UospUul. .ll<x<iiHlriii, /'<(.
C.vsK 8il. — Simeon Snyder, recruit, 10th Ohio Cav.: age 18: was admitted Feb. 25, 18(11, complaining of pain in
the left side of the chest. His skin was hot and dry, tongue furred, pulse frequent and moderately full Ijut irrital)le,
respiration huriied. There was nuirked dulness on percussion, with some crepitation on the left side, sibilant and
flight mucous rales on the right, heard best toward the apex of the lung. Five grains each of Dover's powder and
bicarbonate of soda were given every three hours. On the 28th the jiatient became delirious, with lividitj' of face,
rapidity of pulse and great difficulty of breathing; dulness was comitlete over the left side. A blister was applied.
He died next morning. Post-mortem examination: There were firm pleuritic adhesions on the right side, with red
hepatization and intense congestion of the upper lobe of the lung, about one-half of which .sank in water. The left
lung was hepatizcd red except at the lower edge of the upper lolie, where a strip about an inch wide remained crep-
itant, and at the apex, where were some spots of gray hepatization; the lower lobe, though .apparently hei>atized,
floated in water, while the upper lobe, after the crepitant strip was cut oft', sank promptly. The apex of the heart
adhered to the pericardium by a narrow band of recent lymph which, at its cardiac extremity, was attached to a
patch of lymph about half an inch in diameter; the right auricle contained a large fibrinous clot coated with black
coagulnm extending into the ventricle on one side and for nuiny inches into the vena' cava' on the other : the left cav-
ities of the heart also contained a fibrinous clot which was prolonged into the aorta. The liver and kidneys were
healthy. The other organs were not examined. — Act. Ass't Surgeon T. J. Karher, Ilospital A'o. 8, Xashville, Teiin.
Case 90. — R. Ostis, a colored soldier under treatment for pleurisy, died suddenly while eating his breakfast iu
bed, Feb. 10, 18G4. Post-mortem examination : Brain normal. The pericardium contained about one ounce of yellow
liquid ; numerous white, stringy deposits connected its vi.sceral and parietal layers ; a white fibrinous clot oceui)ied
the right auricle, interdigitating with the musculi jiectinati and connecting with a smaller clot in the ventricle : the
heart was a little to the right of its normal position. The left pleural sac was distended with a serous liquid wliieli
compressed the lung into a thin gray mass. The right lung was slightly adherent; its upper lobe was emphysema-
tous and crepitant although injected; the middle lobe was less emphysematous; the lower lobe was hepatizcd and
purulent posteriorly. — Act. Ass't Surr/eon (C. C. Minor, Kniyht IIospUul, Sew Haven, Conn.
Case 91. — Post-mortem examination of Reuben W. Baker, a white soldier, April 17, 18(54: Arachnoid firmly
adherent to dura mater at vertex; considerable fluid under the membranes at this part, the gyri being-well sepa-
rated and the pia mater coming out very readily; substance of brain but little altered. Pericardium contained six
ounces of lluid, in which were some flocculent tufts; heart with clots in both sides and mitral valve thickened.
Lower lobe of left lung red and injected; this lobe was bronchially crepitant throughout (i. c, small bubbles came
from the minute bronchi, but not from the pulmonary vesicles) ; there were faint spots of pus in the bronchial tubes,
which were intlamed but not hardened or prominent: upper lobe crepitant, hut with a tract that was hard, .solid,
indurated and nodulated. From one of the arteries near the root of the right lung was drawn out a long, hard,
white clot; the lower lobe was adherent, solidified and grayish-red: the upper and middle lobes o'dematous. The
liver was large, soft and pale: the spleen pnltaceous; the kidneys soft. — Act. Ass't Siirijrun JV.C. Mimir, Kiiiijhf ffospital,
Xeie Ilmcn, Conn.
C.\se 92.— Private James Fletcher, Co. A, IGGth N. Y.; admitted April 24, 1865. Died 27th. Post-morlem exam-
ination: The right lung was hepatizcd; the left normal. The heart was healthy, but the pericardium contained six
ounces of bloody serum. The intestines were healthy. — Dcjiot Field Hospital, 6lh A. C, City Point, Va.
Case 93.— Private Peter Breunan, Co. K, 5th N. II.; admitted Dec. 24, 1862, with a gunshot wound of the
right thigh. Died April 22, 1865. Post-mortem examination : Carbuncle on right side posteriorly. CEsopliagus jiale,
larynx slightly and trachea and larger bronchi intensely congested, with many dark-purple s]>ots the size of mustard-
seed. Right lung, twenty-six ounces, solidified at apex and with a, thick layer of lymph on the pleura : middle lobe
somewhat congested; lower lobe blui.sh-slate color, much congested, heavier than water but not hejiatized. Lel'li
7/2 PNEUMONIA.
lung, nineteen ounces, adherent and showing recent exudation and much venous congestion. Heart enlarged, with
thickening of valves, clots in all the cavities, white elevated points on the endocardium, firm old adhesions on the
left side, dark-iiurple spots on the pericardium and nine drachms of fluid in the serous sac. Liver dark-purple, lighter
on section, soft, acini well marked; spleen soft, lirokea down. Stomach showing dark-purple spots; duodenum
slightly congested; jejunum generally pale and valvulse absent; much congestion near ileocecal valve. Mucous
membrane of large intestine pale, solitary follicles enlarged and numerous. Left kidney congested in cortical sub-
stance, pyramids pale, pelvis congested. — Lincoln Uosjiital, Washington, D. C.
C'.iSK 94. — Private Theodore Somers, Co. D, 55th Mass.; age 19; admitted Jan. 29, l«6o. Dulness on percussion
over the upper lobe of tlie left lung; severe cough; free expectoration; anorexia; excessive nostalgia; })ul.se 120,
full and soft. 31st: EoUing about, looking anxious; wanting to die; refusing food and medicine. Died February 7.
rost-moriein examination: Dark straw-colored liquid and lymph in pericardium. Apes of left lung solid, lower
anterior part cre2)itant but sloughy; lower lobe dark brownish-red and doughy; miliary tubercle in right lower lobe.
Liver jialo and fatty: spleen small ; kiduej-s granular. — Third Dicision Hospital, Alexandria, Va.
Case 9."). — Private James Blackburn, Co. G, 18th Ky.; age 29; admitted Jan. 1, 18G1. Died 5th. Post-niDrlim
examination: Some enurciation. Firm pleuritic adhesions ou both sides except anteriorly; apices of lungs filled with
large hard tubercles, lower lobes hepatized gray. Pericardium and heart firmly adherent; valves tliickeued and
much indurated; ascending aorta and arch containing ossific deposits. Liver, fifty-one ounces, healthy: spleen three
ounces and a half, very soft ; kidneys, six ounces each, healthy. — Hospital No. 1, Xashvillc, Teiin.
Case 9ti. — Private John Henry, Co. E, 1st Vt., an Indian; age 29; died April 21, 1865. Post-mortem examina-
tion : Some serum was found in the sac of the arachnoid and in the ventricles of the brain. The lungs were adherent
and the left pleural sac contained eight ounces of serum; the left lung, weighing thirty ounces, was engorged and
presented spots of ecchymosis on its anterior surface and collections of softened tubercle, about the size of peas, near
tho middle of the upper lobe; the right lung, thirty-three ounces, was in a similar condition as to engorgement and
ecchymoses, but presented only a few isolated tubercles. Finely granulated patches on the pericardium were sup-
posed to be of a tubercular character. It was thought that the ileum presented isolated tubercles beneath the mucous
membrane, but the distinction between these and the solitary glands was not clearly established. Other organs nor-
mal.— Ass't Snrgeon Geo. 21. McGill, V. S. A., National Hospital, Baltimore, ltd.
Three teith jieritoiiitis.
Ca.se 97. — Private Clark D. Dexter, Co. L, 10th N. Y. Cav.; age 21; was admitted Feb. 19, 1863, as a conva.
lescent from typhoid fever. He improved and in a short time had entirely recovered. On March 21 he complained
of pain in the upjier part of the chest on both sides and of some cough, but no dyspncea ; sonorous ronchus was heard,
but both sides were resonant. Two days later, having been treated in the meantime with dry cups, blue-pili and
ipecacuanha, the pain and cough had increased, the expectoration was slightly tinged with blood, and there was dul-
ness with subcrcpitant rales over the upper part of the left side. He suffered nmch from pain during the night of the
21th and did not sleep; next morning the expectoration was decidedly pneumouitic. Calomel, muriate of .ammonia
and Dover's powder were given every three hours; a blister was ajiplied over the left lung and the whole chest was
covered with an oil-silk jacket. On the 2l)th the abdomen was so painful and tender that complaint was made of the
weight of the bedclothes. On the 28th there was bronchial respiration with dulness on percussion over the entire
left lung. Carbonate of ammonia, syrup of squill and camphorated tincture of opium were given, with beef-tea and
milk-punch. Next day the upper part of the right lung became involved; resjiiration was hurried and laborious.
He died on the 31st. Post-nwrtcm examination: Body somewhat emaciated. The brain was healthy. The right lung,
twenty-five ounces, was partly adherent; the posterior part of its upper lobe was consolidated and grayish-purple;
the remaining lobes were healthy. The left pleural sac contained nine ounces of serum ; the lung, twenty-five ounces,
was adherent to the parietes by thick, tough, recent lymph ; its ujiper lobe was hepatized red, the lower lobe highly
congested but not solidified. The right cavities of the heart were filled with fibrinous and mixed clots which extended
into the ]>uImonary artery, and there were some patches of atheroma in the aorta. The omentum was contracted
and drawn to the right side; the knuckles of intestine were united by a soft exudation. The liver, seventy-three
ounces, was rather soft and adherent to adjoining organs in several places. The si)lecn, seven ounces and a half,
was soft; the pancreas nonual; the kidneys pale; the suprarenal cajisules dark-colored; the mucous membrane of
the bladder was injected and presented a number of black-bordered brown spots about a quarter of an inch in diam-
eter. The mucous membrane of the stomach and duodenum was gray and not injected : in the rest of the small intes-
tine the mucous membrane was of a light red-lead color; Peyer's patches were healthy to within four feet of the
ileocascal valve, below this point they were dark-colored but not elevated; the solitary glands were not visible, and
there was no softening of the mucous membrane ; the small intestine was distended with gas. The mucous membrane
of the cipcum was gray and the solitary follicles numerous and prominent ; the transverse colon was contracted; the
rest of the large intestine uonnal. — Ass't Surgeon Harrison Allen, U. S. A., Lincoln Hospital, Washington, D. C.
C.vSE 98. — Private Lawrence D. Gamble, Co. D, 1st Ark.; age 32; admitted Jan. 16, 1865, — tongue brown, pulse
120, bowels loose, severe pain in left side of chest, dulness and crepitant rales. Died 25th. Post-mortem examination :
Left lung hepatized and sero-pus effused into left pleural cavity. Stomach distended with bilious liquid. Perito-
neum over the liver and intestines inflamed and softened; abdominal cavity containing a considerable quantity of
pus. Mucous coat of intestines healthy. — Act. Ass't Surgeon H. C. Xewkirk, Hock Island Hospital, III.
Case 99.— Private Wm. E. Hamilton, Co. A, 2d Batt., 12th Tenu.; age 23; admitted Nov. 23, 1861,— tongue coated
brown, corrugated and dry with red margins; pulse 120, sharp and full; respiration hurried; pain inchest; dulness
PXEUMONIA. 773
and siliilant nilcs over lower lobes of both luii^s; slight couyh with little expeetoration ; Uowel.s teiuKr on jnessuro
ami tympanitic. Pied Decenilier 4. PoKl-mortem examination: Blood imjioverished. Softening of left Innj:; and
ell'usion of serum and pus in the left pleura ; hepatizat ion of tho lower lobe of the right lung. Heart normal. General
adhesion of i)eritoneal surfaces; gall-bladder distended with a transparent albuminous lluid; spleen enlarged and
softened; solitary follicles enlarged but not ulcerated. — Jet. Jss'l Siiryeoii II. C. Xiukirk, Rod; Inland Ilonpital, III.
Eleven tilth eri/sijyetas.
C.v.'iK 100. — Private James T. Piper, Co. K, 7:Sd Ind.; admitted Feb, 15, 1863, with erysipelas, the fourth succcs-
sivo attack from which he had sulfered. Ho recovered under tho use of tincture of iron and the local application of
iodine, but on March 3 double pneumonia of a typhoid character sot in ; pulso 95; louguo dry; dysputt'a ; rusty sputa.
Notwithstanding active supporting treatment ho failed gradually, drowsiness and subsultus appeared, and he died
on the 17th. I'oat-uiortem examination : Kight lung,oxccpt a small portion anteriorly, adherent, hepatized and exuding
a pnro-sanguiuolent fluid ; left lung adherent by bands of false membrane, congested and with foci of extravasated
blood. Heart, kidneys and small intestine normal ; liver paler than natural, much enlarged, somewhat indurated ;
spleen snuill; mucous membrane of largo intestine softened but not ulcerated. — Honpital, Kvansvillc, Ind.
Cask 101. — Private Samuel Estcs, 2d JIass. Cav.; age 37. On admission, April 6, 18G5, with pneumonia, this
patient was convalescing from an attack of erysipelas of the fitce. Ho was delirious, but in a few days his intel-
lect became clearer. He gradually improved under tonics and stimulants till tho 20th, when ho again became
delirious, with pain in the right side and bowels, freriuent pulse and dry red tongue. He passed into a typhoid con-
dition and died May 5. Post-mortem examination : Right lung adherent posteriorly and with a purulent deposit over
its apex, congested generally and its lower lobe infiltrated with pus. Four ounces of serum in pericardium ; heart
enlarged and softened. Liver pale; spleen and left kidney enlarged and softened. — Cumberland Hospital, Md.
C.^SE 102. — Private Thonuis E. Boyles, Co. B, 5th Ark. Cav.; admitted Dec. 25, 1861, with pneumonia and ery-
sipelas. He was weak and very deaf in consciiuenco of the extension of the swelling into the meatus auditorius,
from which, on tho .29th, pus was discharged. He died Jan. 7, 1865. J'ost-morlcm examination: Pus and coaguhi
lodged under the scalp in patches; external aural meatus much inflamed; tympanic membrane eroded and perforated.
Right lung hepati/.ed throughout ; left hepatized in part; pleural adherent. Liver contained an abscess which had
discharged into tho peritoneal cavity. — Act. Ass't Surgeon If. Mallltvira, Hock Island Hospital, III.
C.VSE 103. — William Dorey, Government employe?; admitted March 25, 1864, with erysipelas. Pneumonia set
in two days later, and on the 30th ho became comatose and died. I'ost-mortem examinatiou: Left lung congested;
lower lobe of right hepatized red, upper congested. Heart and liver normal; spleen somewhat enlarged: kidneys
slightly inflamed. — IIos2>ilal Xo. 8, Xashiille, Tenn.
Case 101.— Private Henry B. Welker, Co. I, 87th Pa.; age 40; admitted March 30, 1805, from the Army of the
Potomac, with erysipelas of tho face. On April 6 he was suddenly attacked with gasping respiration and died in a
few minutes, rost-mortcm examination: Body somewhat enuiciated. Heart healthy; pericardium thickened and
containing a small quantity of scrum; largo fibrinous clots in the pulmonary artery and aortic arch. Right lung
healthy; left firmly adherent and purulent throughout, with an abscess containing eight to ten ounces of pus which
had burst into the trachea and filled the bronchial tubes; two pints of serum in the left pleural cavity. Liver some-
what enlarged; spleen infiltrated with pus; intestines normal. — Stanton Hospital, Washington, D. C.
Case 105. — Private George Andrews, Co. F, 3d Wis.; age 40; admitted May 15, 1865, with pneumonia of the
right lower lobe. 17th: Stage of hepatization; erysipelas of face. 21st: Died. Po«(-)noi-fc»i examination: Lower lobe
of right lung hepatized, verging on gray; lower lobe of left lung congested. Heart soft and flabby; liver large,
fatty; spleen small; intestines normal; kidneys somewhat fatty. — Augur Hospital, Alexandria, Va.
Case 106.— Private Daniel Bancroft, Co. G, 28th Mich.; age 38; admitted Jan. 28, 1865. I'aiu in chest ante-
riorly; much cough; sputa white, tenacious, abundant; pulse frequent, not hard; much fever at night, with
remission in morning. 31st: Pain in. left side; dysjiua'a; dry cough; hot skin; frequent imlse; physical signs of
pleuro-pnenmonia. February 3: Pleuritic efl'usion in left chest, extending to fifth rib in front while sitting. 8th :
Erysipelas of face; much dyspnoea; efl'usion unaltered; delirium. 12th: Failing; left pleura filling up. 14th: Died.
Post-mortem examination: Left lower lobe hepatized throughout; a pint of serum and lymi^h in the pleural cavity
and both pleural surfaces covered with coagulable lymph. — Third Division Hospital, Alexandria, Va.
Case 107. — Private AVilliamUiison, 12th Co., 1st Mich. Eug'rs; age 18; admitted Fcl). 17, 18G4, with iineumonia,
which progressed favorably until the head and face became enormously swollen from erysipelas. 2yth : Tongue very
dry and black; sordes on teeth and gums; dyspnoea; eyes closed; delirium. IMed March 4. Post-mortem examina-
tion: Left lung congested and in its lower part hepatized red and covered with recent exudation; right lung somewhat
congested and adherent. Other viscera normal. — Hospital Xo. 8, Xashrillc, Tenn.
C.VSE 108. — Private Jeremiah Brooke, Co. C, loth Ark.; admitted Dee. 23, 1864, with pneumonia and erysipelas.
Qnite delirious; pulse weak, almost imperceptible; tongue inflamed, indeed, a general (somewhat erysipelatous)
stomatitis; loss of appetite; emaciation; dyspncca; great dulness on percussion except near eternal region, where,
for a small space on each side, there was resonance; bronchial rales distinct and bronchophony in some places; slight
facial erysipelas. Ho died Jan. 12, 1S65, I'o«t-mortem examination: Both lungs extensively hepatized: large white
clots in the heart, Xo other morbid appearances, — Act. Ass't Surgeon TT, Mattheus, Hock Island Hospital, III.
Case 109, — Private Harrison Blake, Co, D, 71st Ohio; admitted March 14, 1864, much reduced, feeble and some-
what delirious. He improved a little under stimulant and supporting treatment, but on April 7 became letliargic
774 PNEUMONIA.
as erysipelas of the face made its appearance. He liad been lying near an erysipelatous case. Died 20tb. I'ost-
mortem exaniiuation : Much emaciated. Meningitis: coagulated fibrin in longitudinal sinus. Both lungs hepatized
red and the left pleural cavity containing a large quantity of serum and partially organized lymph. Three ounces
of liquid in pericardium; heart pale and flabby: small firm clot in right auricle. Liver and kidneys healthy: spleen
enlarged. Ileum much inflamed, showing patches of ulceration. — Hospital Xo. 8, XiishriUe, Teini.
C.-iSE 110. — Private Enos Campbell, Co. E, 30th Ga.; admitted Jan. 5, 1865, -nitli pneumonia and erysipelas.
Died comato.se on the 7th. The patient was very weak and unable to speak; he had lieen expectorating blood and
purulent matter for six weeks, but the erysipelas was recent and slight, atfecting the face only, rosf-mortcm exami-
nation: Left lung hepatized; rightuot so much involved: both containing large deposits of tubercle and having old
and recent adhesions. One pint of cftusiou in iiericardium. Liver closely adherent to diaphragm.— Jc(. Ass'1 Surgeou
jr. Matlheu-s, Jiock Inland EospitcO, 111.
Three leith 'nithniimatiini i\f lite pitroltd fjleinda.
C'.iSE 111. — C'orp'l William F. Harris, Co. D, 2d Ark. Cav.: age 48: had several attacks of broncliitis from
exjiosure, and was admitted Dec. 10, 18G4, with acute pneumonia. Tongue coated but margins red; bowels loose:
pulse 90: some cough with expectoration; pain in right side; dulness over right lung: mucous riles. He continued
thus until .Tan. 10, 1865, when an enlargement of tlie right parotid gland was developed and typhoid symptoms came
on. February 2: Tongue swollen enormously, filling the mouth and protruiUng. Died. i'osNmocfcw examination:
Great emaciation. Impoverished condition of the blood: hepatization of the right lung; pleuritic inflanniiation and
effusion: congestion of the bowels. — Act. Ass't Surgeon H. C. Xewlirk, iiocA' Island Hospital, 111.
C.\SE 112. — Private ,Tohn Ryan, Co. B, 7th N. Y. Heavy Art'y; age 20; admitted March 11, 1865, in a comatose"
condition. Both iiarotids were swollen. Died 17th. Post-mortem examination: Left parotid infiltrated with pus.
Brain softened; serum in lateral ventricles; congestion of fourth ventricle; jjosterior and lower part of left lung solidi-
fied, fleshy and not granulated, the upper lobe in its posterior part containing small masses of coagulated blood,
apparently due to apoplexy; right lung ecchymosed and the po-^terior iiart of its lower lobe mottled and heavier
than water. Filirinous masses on the surface of the liver, extending into the hepatic tissue; congestion of kidneys
and mucous membrane of bowels. — Ass't Surgeon Geo. M. McGill, U. S. A., Xational Hospital, Baltimore, ild.
C'.\SE 113. — Private Wallace Wilder, Co. H, 124th 111.; age 24; admitted March 11, 1865. unconscious. Died 17th.
Post-mortem examination : Congestion of the pia mater, brain-substance and walls of the ventricles : serum in the sac
of the arachnoid. Engorgement of both lungs, with portions atelectatic ; bronchial tubes reddened internally.
Fibrinous clots in heart. Liver congested: spleen enlarged; kidneys, pancreas and bowels congested; right parotid
infiltrated with pus; larynx normal. — Ass't Surgeon Geo. M. McGill, U. S. A., Xational Hospital, Baltimore, Md.
Two cases fatal h;/ liemorrhage iutc the pleural caritij.
C.\.sE 114. — Private Andrew Magee, Co. K, 93d N. Y.; age 47: was taken with pneumonia of the left side May 2,
1864, and admitted on the 6th. Severe pain and dyspncea. 13th: Urgent dyspuiea ; fainting; unconsciousness for an
hour. 15th: Very weak; dyspnoea; left side of chest much enlarged: no soreness and but little pain. 16th: Died.
Post-mortem examination : Left lung consolidated throughout and but a fourth its normal size ; five quarts of blood in
its pleural sac. — Mower Hospital, Philadelphia, Pa.
C.A..SE 115. — Private Charles Leary, 22d Pa.; age 26; was seized, Scjit. 20, 1861, with fever and jiain in the chest.
27th: Admitted with pleuro-pneumouia. Pulse 98, strong; skin cool and moist: tongue red at tip, coated grayish-
white in centre ; stools thin and involuntary; acute right iliac tenderness: slight borborygmus ; no tympanites: dry,
hacking cough; slight expectoration; submucous and sibilant rales in upi)er part of lungs, crepitation in axillary
regions and a creaking leathery sound posteriorly. 28th : Sleep much interrupted by cough ; towards morning rai.sed
blood: skin warm, dry; two stools, voluntary; dysj)noea; voice low; some delirium. Evening: Chest very sore; voice
whispering; raised.much blood; pulse 100, weak; some dysimtea. While attempting to reach the chair, about twelve
feet away, he threw up his arms and fell but was caught and put in bed by an attendant. He breathed a few times
with a gurgling sound and died. Post-mortem examination: Thorax filled with blood, left lung in some places nearly
gangrenous. — Seminary Hospital, Georgetown, 1). C.
Twenty cases terminated in abscess or circumscrihed disintegration of the pulmonary tissue.
Case 116. — Private Henry Henning, Co. I, 54th Pa.; age 44, but apparently over 60; German, and unalde to
speak English ; admitted April 16,1804, with pneumonia. Breathing rapid and laborious; pulse small, occasionally
fluttering, about 120: tongue large, pale, edges indented and moist, dorsum coated white with a central brown stripe:
sharp pain in cardiac region: anorexia: great pro.stration: dnlness of left side. 17th: Friction sounds, moist rales
and ab.sence of vesicular breathing on left side; dulness on percussion over lungs; action of heart lal)orious, pulsa-
tion visible; he has no appetite and lies most of the time, without delirium but comatose. 19th: No improvement.
20th: Gradually failing. 21st: Seized afresh with paroxysmal pain. 22d: While raising him in bed lie fell back and
died. Post-mortem examination : Left pleura adherent and containing two pints of liquid: lungs dark-blue, mottled,
mehinotic externally and on section showing abscesses and hepatized tissue, with crepitus limited to the apices. Peri-
cardium embedded in fatty deposits. Heart enlarged and fittty, liver-brow-, in color and friable. Liver normal;
stomach and intestines distended with Qatus.— Cumberland Hos2)ital, Md.
C'.\SE 117.— Private Albert Ladd, Co. D. 1.5th N. Y. Cav.: age 20: admitted May 18, 1864, with pneumonia. Died
PNF.rMONTA. 775
24tb. Post-mortem exaiiiiiiatiuii: I eft lung and iiiitliUc ami lowi-r lobes of right liepatizoil ami piinilcnt : plriua on
both sides tiiiiily adherent. No other organs examined. — Ciimhirliniit nonpiial, Md.
t'.vSK 118. — .Joseph Waldeu, Mi.ssouri guerrilla. Typhoid pneumonia. [Xo dates given. J rovt-morlim exam-
ination: Itody greatly emaeiated. Tliero was ert'usion in the right pleural cavity; the lower lobe of tlie right lung
contained a large abscess and its pleura was covered with jius. The right auricle contained large white clots. The
spieeu was enlarged. — Act. Ass't Siirinoii H. C. Xiii-kirk, Hock Inland IJospildl, III.
C.\SE 11!).— "Wni. E. AVatkins, Co. I?. 19th S. C; age 18; admitted Nov. 3, ISliJ. On this day he liad a chill fol-
lowed by fever, with pain in the right side and dry cough: pulse 110; respiration 50. His condition remained com-
paratively unchanged until the 7th. when licjuid gathered in the right pleural cavity. The pulso increased to 150
and the resjiiration to (iO shortly before death on the 10th. I'ost-morteiii examination: A large al>scess in the lower
lobe of the right lung had discharged into the pleural cavity. — Act. J.vs'/ Surgeon II. II. Ilussell, Itock Islnud IIoKpital. III.
C.\SK 120. — Private Otto C. Murray, Co. H, 1st Md.. was admitted May 19, 1863. The patient's comrades stated
that he had been sntfering for about two months with |)neunmnia. He was delirious and had a Hushed, anxious
face, rapid and rather feeble pulse, dry tongue and great thirst: respiration was hurried, with violent cough and
free expectoration of thick viscid matter; the stools were fre(iuent, thin and yellow. There was dulness with crepi-
tation over the right lung, and dulness below with a harsh respiratory murmur over the left lung. He constantly
carried his left hand to the right side of the head, but his right arm seemed useless. On the 28th he vomited bilious
nuitter freely and had a discharge from the right ear. He died next day. rost-morlem examination: Two ounces of
serum were found at the base of the brain and half an ounce of pus in the right ventricle; the brain-substance was
much brcdvcn down and softened, weight forty-four ounces. The right tonsil was much ulcerated, the ulceration
extending into the Eustachian tube. The right lung was hepatized and contained an abscess in the lower lobe com-
municating with the upper edge of the liver: the lower lobe of the left lung was hepatized. The heart was normal.
The liver, seventy-six ounces, was congested in regions, disintegrated and fatty; four distinct abscesses, containing
about a pint and a half of pus, were found in the riglit lobe. The intestines were healthy. The kidneys were normal
in size but somewhat fatty. — Hospital, Frederick, Md.
t ASE 121. — Pri\ ate William Boulton, Co. X), 21st N. Y. Cav.; age 46; was admitted May 17, 18G1, with pneumonia
ami a trifling congli and expectoration. He was cheerful and hopeful, had a good appetite, and was able to sit up,
read, write and conver.se; sputa sometimes tinged with blood. He became steadily emaciated, and was found dead
in bed on the morning of July 16. Pont-mortem examination : Universal congestion of lungs and infiltration with dark
grumous blood, small abscesses developing here and there. Heart pale, flabby, friable and fatty, containing fibrin-
ous clots in right ventricle. Liver and intestines normal. — Cnmlicrland Ho-ijiHal, Md.
C\»F. 122. — Pri vate Charles W. Moore. Co. I),6(ith Ohio; age 22; admitted May 7, 1801, with typhoid pneumonia.
Hulness and creiiitani rales over both lungs; sputa scanty, rusty and very viscid. 8th : Pulse 85 to 90, compressible.
loth: Delirious: occasional vomiting, much dyspntea: respiratory murmur faint in upper part of lungs, alisent at
base, llth; Delirium furious; pulse rapid and small: less dyspnoea: slight expectoration. 12tli : Sinking rajiidly:
mattering delirium; pulse scarcely perceptible; face purplish: mucous obstruction in air-tubes: he occasionally
clasped his head. Died at 3.30 p.m. Post-mortem examination: Euugs hepatized tlnougliout : a small aliscess in
middle lobe of right. — IIo.92>ital 2lth and South streets, Philadelphia, Pa.
C.vSE 123.— Private Ira Woodcock, Co. E, 28th Mich.; age 29; admitted .Ian. 26. IStio. from regimental hospital
with pneumonia. Died February 12. Poft-morlem examination : No emaciation ; much suggillation posteriorly. Kight
jdenra adherent and containing three pints of serum with large flakes of unorganized lymph ; upper and lower lobes
of lung hepatized and two snutll abscesses in lower lobe. Left jileura normal but lung congested. Pericardium and
heart normal. Liver slightly enlarged and engorged. Other abdominal viscera normal. — .Second Dirision Ilusitital,
Alexandria, J'a.
C.vsE 121.— Private J. F. Dean, Co. I, 43d N. C; admitted Dec. 11, 1803. Died Jan. 1, 1864. Post-mortem exam-
ination The larynx and trachea were of a pale greenish-blue color but otherwise normal. Both lungs were inflamed ;
the first lobe of the right lung was hepatized red and gray and had at its base, posteriorly, a large abscess the size of
a teacup filled with oftensive pus and broken-down pulmonary tissue; the second lobe was splenified; the third in
the last stage of red hepatization. The liver was very large and presented whitish lardaeeous spots; the spleen was
Cabliy: the kidneys congested. — Ass't Surgeon Harrison Allen, U. S. J., Lincoln Hospital, Washington, D. C.
C.vSE 125. — Post-mortem examination of Richard Roster, a colored soldier, Feb. 2, 1864; The pericardium was
full of fluid; the right auricle contained a large white clot and the ventricle a smaller clot. The left lung, with the
exception of its anterior edge, was adherent to the thorax and its lobes were united : its substance had traits of a
pale, solid structure, with here and there a well-defined pus-cavity; a few spots of a dull-red colordistinctly resembled
hepatization. The right lung w.as free from parietal adhesions but its lobes were partly iuteradhereut ; it was more
decidedly tubercular but less congested, admitting air more freely than the other. The liver was unusually purplish;
the spleen and kidneys natural. — Act. Ass't Surgeon JC. C. Minor, Knight Hospital, Xew Haven, Conn.
C.xsK 126. — Private George Dewley, Co. E, Alexander's Va. IJatt'y: admitted Nov. 4, 1864. Pneumonia. Died 6th.
Po(i(-iiio)/(m examination: The right greater pectoral muscle had a gelatinous appearance. Both i)lcural sacs were
full of lii|uid. There was an abscess in the right lung. The heart was one-third larger than usual and contained a
clot. The spleen was softened. — Act. Ass't Surgeon H. H. Ilussell, Pock Island Hospital, III.
C.iSE 127. — Private Bradford Lewis, Co. H, 13th .S. C, died of typhoid pneumonia Jan. 17, 1864. Post-mortem
examination: There was a good deal of serum in the cerebral membranes; the brain-substance was hardened, its veu-
776 PNEUMONIA.
tricles Tveie enlarged but contained little fluid; the clioroid vessels were pale. The pericardium was full of serum.
The left lung was adherent behind and had several abscesses in its substance: the right was adherent except aute-
riorly. and on section jiresented many cartilaginous indurations. The liver was normal ; the transverse colon con-
tracted.—Jc<. Ass't SunjeOH IT. C. Minor, Eiiiijlil Honpiial , Xiw Ruren, Conn.
Case 128.— Captain D.W. Parks, Co. E, 54th N.C.; age 33; admitted May 10, 1863. Died June 12. Post-mortem
examination : The brain was healthy. The mucous membrane of the trachea was softened, pale in its upper portion
and purplish towards the bifurcation. The right lung weighed twenty-two ounces and a half; the whole of its lower
lobe and the posterior portions of the other lobes were solidified and contained circumscribed collections of pus; the
middle and lower lobes were interadherent and coated with yellowish lymph. The left lung weighed eighteen ounces;
its lower lobe was aft'ected like that on the opposite side, but it was less iirmly solidified ami contained fewer pus
deposits ; the left i^leural sac contained sixteen ounces of pus. Two ounces of liquid were found in the pericardium ;
venous clots and uucoagulated blood in the right cavities of the heart, and a small clot in the left side. The liver
weighed fifty-eight ounces ; the spleen, niueteen ounces, was extremely soft; the pancreas and kidneys normal. Some
regions of hyper.tmia were observed in the small intestine, but the large intestine was healthy. — Jun't l<i(rgeon Har-
rison Allen, TJ. S. A., Lincoln Hospital, TTashinyton, D. C.
C.\SE 129. — Private William Schroeder, Co. G, 1st Conn. Cav.; age 28; was admitted Dec. 27. 1864, with an ulcer
on the leg. He died Feb, 9, 1865, Post-mortem examination : The upper half of each pleural cavity was obliterated
by adhesions; the lower half on the right was filled with pus, on the left with turbid serum; both lungs contained
many abscesses. The heart was normal and contained fibrinous clots. The liver was much congested; the spleen
natural; the kidnejs were degenerated, presenting many abscesses which seemed of recent formation. — Act. Ass't
Surgeon B. B. Miles, Jurvis Hospital, Baltimore, Mil.
C.-i.SE 1.30. — Private John Lower, Co. C, 178th Ohio, was admitted Feb. 6, 1865. with pain in the right side and
cough of several weeks duration. He improved under treatment until March 1, when, having imprudently expo.sed
himself, his symptoms became aggravated : dulnessover greater part of right side. 8th: Delirium: skin yellow. He
became steadily weaker and died on the 25th. Post-mortem examination : Eight lung adherent at apex and anteriorly,
caruified, containing several snuill abscesses, and compressed against the anterior wall by seventy-five ounces of
pleuritic effusion and lymiih-flakes ; left lung adherent at apex and posteriorly, some hypostatic congestion. Liver
congested and with patches of recent lymph on its upper surface. — Donglas Hospital, Washington, D. C.
Case 131. — Private Lewis H. Sloue, Co. H, 8th Mich., was admitted July 24, 1864, from City Point hospital. Va.,
with bronchitis. The sputa had a bad odor. Ho died August 16. /'o«f-)«oi-(ew examination : Larynx, heart and left
lung healthy. Eight lung universallj" adherent and of a livid-red color; its lower lobe very soft in texture, resembling
the spleen; a portion of the lobe occupied by an abscess of gangrenous appearance containing about six ounces of
fetid pus. Liver fatty; spleen firm; kidneys normal. — Fairfax Seminary Hospital, Ta.
Case 132, — Private John Brodder, 29th Colored Troops ; age 21 ; was admitted March 0, 1865, with i>neumonia.
The patient was restless : complained of pain in the chest and coughed considerably; there was duluess on percus-
sion over the lower lobe of the left lung. A blister, cough mixture and Dover's powder were prescribed. On the 13th
the pulse was 100, tongue dry, skin hot and expectoration stringy and tenacious. Poultices, stimulants and beef-
extract were ordered. Diarrhoea set in on the 17th, the pulse rose to 120, and the patient became slightly delirious,
Xext day the delirium increased ; respiration 44 ; sputa streaked with blood. He died on the 19th, Post-mortem exam-
ination : There were pleuritic adhesions on both sides. Four abscesses the size of walnuts were found in the upper
lobe of the right lung; the lower lobe was in a state of gray hepatization. The left lung was congested, its lower
portion hepatized. The pericardium contained two ounces of serum. The other viscera were normal. — Act. Ass't
Surgeon S. D, Tiiining, L'Oiireiture Hospital, Alexandria, Va.
Case 133. — Private Peter Keough, Co. F, 58th N. Y.; age 23: was admitted Feb. 2, 1864, He had been sud-
denly attacked with great pain in the lower portion of both lungs, Eesiiiration was frequent and very painful, the
pulse rapid and the patient nnich prostrated. He was treated with alcoholic stimulants and small doses of quinine
and morphia, with belladonna plasters to the chest and nourishment. He died on the 17th, Post-mortem examina-
tion: The right lung was adherent and contained a large abscess in its lower lobe; there were some adhesions and
much serum on the left side of the chest. The pericardium was filled with effused liquid. The liver was enlarged. —
Act. Jss'f Surgeon L. L. To:ier, Ladies' Home Hospital, X. Y. City.
Case 13t.— Private Jno, H, Lamberton, Co, M, llth K, Y, Cav.; admitted Feb. 26, 1864. Pneumonia. Died
March 1. Post-mortem examination: Body emaciated. There was a large abscess filled with pus in the lower lobe of
the left lung ; its upper lobe was adherent. The liver was much enlarged, weighing nearly eight pounds. The other
viscera appeared healthy. — Act. Ass't Surgeon A. D. Buggies, Harewood Hospital, Washington, I). C.
Case 135.— Private Lewis Swarer, Co. A, 98th Pa.; admitted April 21, 1863. Typhoid pneumonia. Died 23d.
Post-mortem examination: Body much emaciated; jiarotid and submaxillary glands in a state of suppnration. The
pleural sacs were partly obliterated by adhesions and contained straw-colored serum; the lower lobe of the right
lung was hepatized, the middle and upper lobes infiltrated with pus ; an abscess in the left lung conununicated with the
pericardium, in which was a large quantity of pus. The liver was enlarged, pale and f;itty: the gall-bladder nearly
empty: the spleen normal; the mesentery wasted; the stomach and intestines pallid and empty. — Act. Ass't .burgeon '
Thos. H. Elliott, Hareuood Hospital, Washington, D. C.
Three in gangrene.
Case 136.— Private Augustus Adderhold, Co. C, 1st Wis. Arfy: was admitted Jan. 27, 1864, Died Feb, 7, Post-
mortem examination: The brain and its membranes were healthy, but the Pacchionian bodies were enlarged and
PXEUMU.XIA. 777
hail almost peiforateil the skull-cap. Tlioie was some plemitic cons^cstion liiit no adhesion; the upper and luidillo
jiarts of both lungs were soliditied, lilack on secti(ui, with here and there a dirty yellow color and gangrenous odor;
I he lungs weighed eighty-two ounces. Tlu heart was enlarged and llahby and contained a dark-colored lilirinous
clot in each ventricle. The liver was enlarged, weighing eighty ounces ; the large intestine was somewhat congested.
The other viscera were normal. — Act. Asa't Surgcuit K. J.Saniph; Hosj>itul So. 19, XasliviUe, Teiin.
C.\SE 137.— Private Kobeit Mickey, Co. C, lUh Pa.; admitted Jan. 17, 1865, with bronchitis. Died 24th. Post-
iiiniltm examination; The right lung, thirty-four ounces, was gangrenous: the left, eighteen ounces, adherent at its
apex: a large abscess nnder the jiarietal pleura contained a jjint of pus and extended to the first lumbar vertebra.
The heart was healthy: the liver pale, presenting the nutmeg appearance on section ; the spleen soft : the intestines
and kidneys normal. — FiJ'lh A. C. I'ithl i/us/(i(n?, Army of the Polomuc.
Cask ISS. — Pan. Vandercrook, Co. D, 17th Pa. Cav.; age 21; admitted .Juno 15, 1863. Diagnosis; Typhoid
fever. Un admission there was much fever with delirium and pneumonia of the right side. On the 20th he coughed
a good deal and expectorated profusely, the fever having meanwhile abated, leaving him rational. Hy the 27th ho
was noticeably gaining strength, but on the 29th his cough became constant, sputa profuse, grumous and fetid and
the odor of his breath intolerable. He grew rapidly worse, and died July 3. rost-nwrtan examination: Pleuritic
adhesions on right side, involving lower lobe; gangrene of half of right lung and inflannuation and softening of
the other "naif: tubercular deposits in apices of lungs. — Act. Ass't Suryeon IP. J. H<i:elloii, Fairfax Svininarii. Va.
Two ill li<i»<fuclioii of the liiiigs.
Case 139. — Private John Lerton. Co. D, 1st K. Teun., had suffered from cough, fever and diarrhn-a for some
time prior to admission, March 23, 18()3. He was pale, emaciated and very weak; tongue sliglitly furred: appetite
poor; skin dry and harsh; pulse 100; stools frequent. 24th; Pain in chest; cough: dulness and gurgling over left
side. 30th: Pulse 120; expectoration free. Ai)ril I: Pulse very feeble; prolonged cough with copious purulent
sputa; vomiting. The disease steadily intensified. Died 15th. /'o.rt-mor(fm examination ; Much emaciation. Left
lung entirely suppurated and non-existent, the pleural cavity filled with sero-pus : old adhesions on right side;
bronchial glands enlarged, some indurated. — Hospilat So. 23, yashriUf, Tinn.
C.\SE 140.— Private Elisha Bedsaul, Co. I, 63d Va., rebel; age 30; was admitted Jan. 27, 1864, witli eonsump-
tiou. Died March 9. Post-mortem examination; The right pleural cavity contained seventy ounces of purulent
linuid; lower lobe of the left 'uug slightly hepatized. The heart, liver, spleen and kidneys were normal. — llnsintal
So. 1, Sashcillc, Teiiii.
Ten cases of coexisting tubercle.
C.\SK 141. — Private Lewis Mailing, Co. B, 180th Ohio; age 43; was admitted Feb. 1, 1865. Severe dyspuu?a;
prostration; pulse feeble, 120; sordes on teeth and gums; expectoration difficult, rust-colored; large crepitation and
dulness over lower part of right lung. Died 4th. Post-mortem examination: Etlusiou with several bands of adhe-
sion in right pleural cavity; apex of lung containing tubercular deposit, yellow and hard, surrounded by well-marked
congestion, middle lobe somewhat congested, lower lobe consolidated, granular, friable and nntmeg-colorcd; apex
of left lung tuberculous, remainder healthy. Other viscera healthy. — Douglas Hospital, Washington, D. C.
C.\SE 142. — Private John Vallian, Co. l\, 63d Ga.; admitted Nov. 29, 1864. Much emaciated: countenance
anxious; tongne dark-brown with edges and tii> red; bowels loose; skin dry; great thirst; dulness over right side;
vesicular murmur absent and respiratory motion almost imperceptible; mouth and liml>s showing signs of scurvy.
Died 30th. Post-mortem examination: Kight lung hepatized and containing calcareous masses, left lung with tuber-
cular masses in its apex. Heart enlarged, its walls thinned and fatty. Liver and stomach, small and large intestines,
greatly congested; large intestine thickened and lumen contracted to three-quarters of an inch; mesenteric glands
enlarged. — Act. Ass't Surgeon M. Hale, Ilock Island Hosjiital, III.
C.t.SE 143. — John Kemper, substitute, age 44; admitted July 20, 1864. He caught cold about a week before
admission, while en route to his regiment. His countenance was pale and he suffered from cough, dyspnoea and acute
diarrha-a. There was dulness over the apex of the right and lower part of the left lung. The heart-sounds were
mutUed and indistinct, but a clear metallic sound was heard over the apex during the first beat. The diarrlicea waa
checked, but the cough and dyspufra became so distressing that the patient had to sit up constantly. From August
15 till death, on the 30th, the heart-sounds could not be heard or the pulsation felt. Post-mortem examination: The
upper anterior edge of the left lung .adhered to the right costal cartilages, the outer inferior edge to the left costal
wall, the inner inferior edge to the diaphragm; a long membranous band stretched outward, forward and slightly
upward from the anterior surface of the upper lolre to the parietal pleura about the third rib; the lung was com-
pressed by two pints of liquid, but a space of half-gallon capacity remained anterior to the effused liquid. The heart
was rolled over to the right side so that the outer side of the left ventricle presented forward under the anterior edge
of the left lung, and the anterior surface of the right ventricle was pushed under the adherent inner edge of the right
middle lobe. The right lung was compressed anteriorly and adherent by its entire outer surface to the parietal
pleura ; its apex contained ,a cartilaginous-walled abscess the size of a small orange, .md its remaining parts were dark-
ened by close, black, mottling deposits; the middle lobe and lower lobe posteriorly were crepitant and dark-red.
The substance of the left lung was speckled with scattered tubercular deposits of the size of raisins and also with
dark deposits as on the right side; the anterior edge of the lower lobe contained two abscesses of the size, respectively,
of a walnut and of a raisin. The heart was enlarged, pale and softened; a large black coagulum, tipped with fibrin,
Med, Hist., Pt. 111—98
78 PXEUMOXIA.
filled its right side. The liver was large, smooth ou its surface, granular, dotted clay-yellow: the spleen of normal
size, light-colored, bloodless, softened: kidneys small: intestines healthy. — TJiinl Division Hosjiital, Alejcandria, Va.
Case 144. — Private Consider Cole, Co. B, 32d Me.: age 4.5: admitted Fell. 10, 1865, much debilitated; cough;
dyspua>a: duluess over both lungs. April 2: Dyspufea urgent ; extremities cold: face livid; crepitant rales distinct
on both sides. 7th: Died. /"o.iNmorfeni examiuation: Miliary tubercle in upper lobes of both lungs: lower lobes con-
gested: pleune firmly adherent. Liverenlarged, fawn-colored, tiitty; mesenteric glands enlarged, some calcareous. —
Thin! Dii-i-iion JlosjiitciJ, Jltxandria, Va.
C.iSE 145. — Private Theodore Seifert, 9th Ohio Cav.; age 18; admitted March 8, 1864. I'neumonia. Progressed
favorably until the 16th, when jaundice set in. Died 23d. Fost-mortcm examination : Much emaciation. Both lungs
adherent and bronchial tubes inflamed; lower lobe of left lung posteriorly hepatized, exuding on section a bloody
liquid or a grayish frothy fluid; upper lobe friable, its apex containing tubercle; apex of right lung presenting
cicatrices of old tubercles; base of lower lobe disorganized. Heart hypertrophied ; left ventricle three-quarters of
an inch thick. Liver and kidneys normal; sideeu enlarged. — Eo^inUd Xo. 8, Xashville, Tcnn,
C.\SE 146. — Private William B. Gerry, Signal corps, C. S. A.; age 18; admitted Oct. 27,1863, for acute pneumonia of
three days' duration : Pain in chest ; cough with viscid expectoration: fever; much emaciation and weakness. Decem-
ber 15: Walkingabout ; cough subsiding: diarrhfea; emaciation and weakness. 20th: Jaundice and diarrba>a. Jan.
1, 1864: Cough and expectoration ; evidences of phthisis ; passages frequent and thin. He gradually failed, and died
February 4. Post-mortem examination: The left lung was congested, its apex tilled with hard tubercle and its centre
containing a cavity the size of a small hickory nut filled with pus; the right lung was congested but free from
tubercle. The colon and lower portion of the ileum exhibited much arterial injection, the former presenting one
small ulcer. The spleen was much enlarged. The mesenteric glands were enlarged and tuberculous. The other
organs were apparently healthy. — Act. Ass't Surgeon G. McC. Miller, Hospital, Point Lool-out, Mil.
C.\SE 147. — Richard Bush, colored; age 13: admitted May 27, 1864, with pneumonia. Died July 18. Post-
mortem examination: Both lungs Avere extensively adheient and appeared to be in the third stage of pneumonia,
presenting also tubercular deposits, especially in the upper lobes. A gallon of serum was found in the chest and
abdomen. — Hospital, Alexandria, Va.
Case 148. — Recruit Henry Hackett ; admitted Oct. 31, 1864, with pain, labored breathing and dulness or percus-
sion over the left side of the chest. Ipecacuanha, stimulants and counter-irritants were employed. Died \ovem-
ber 9, Post-mortem examination: The left lung was in a state of gray hepatization and the pleural cavity contained
four pints of liquid; the right lung was nuich congested. Both lungs, the bronchial glands and the sjdeen contained
tubercular deposits. The other viscera appeared to be normal. — Aet. Ass't Surgeon W. E. Fletcher, L'Ourerture Hos2>ital,
Alexandria, Va.
Case 149.— Private William C. Stevens, Co. B, 14th U. S. Inf ; admitted Aug. 10, 1862. Typhoid pneumonia.
Died 22d. Post-murtem examination: The pleura of both lungs was iutlamed and covered with recent pseudomem-
brane ; the lungs were much congested and had extravasated patches in several places ; miliary tubercles were diffused
throughout their parenchyma. The other organs appeared natural. — Aet. Ass't Surgeon J. Leidy, Satterlee Sosjiital,
Plnladelplna, Pa.
Case 150. — Private Solomon P. Herudon, Co.E, 81st Ind.; age 40; admitted March 19, 1864, with severe cough,
dyspncea and pain in the right side of the chest. April 12: Respiration hurried, labored and superficial. He sank
rapidly, and died ou the 15th. Post-mortem examination: Pleural cavity contained over two pints of sero-purulent
liquid; lungs adherent to jiarietes by plastic exudation; upper lobe of right lung contained a large vomica sur-
rounded by tubercles filled with calcareous deposits: left lung congested and in part hepatized. Spleen enlarged,
weighing nearly two pounds, friable. — Hospital, Madison, Ind.
Six cases in uhich tin hrain or its membranes were inflamed.
Case 151. — Private Orlando Xewkirk, Co. A, 43d N. Y.; age 25: admitted Jnly 30, 1863, having been in low
condition and delirious with typhoid pneumonia for ten days previous. He sutfered from diarrha>a with frequent
vomiting. Died August 6. Post-mortem examination: The brain weighed fifty-four ounces and was soft; the poste-
rior portion of the cerebrum was intensely red; the ventricles contained half a drachm of bloody liquid. The trachea
was filled with frothy .secretion, congested purplish in its lower portion and at its bifurcation enlarged and softened.
The mucous membrane of the epiglottis and upper half of the larynx was purple : in the lower half it was pale. The
right lung, thirty-one ounces, was slightly congested, intermingled with dark spots, but its base was hepatized red
and the centre of its third lobe was grayish, solid and heavier than water. The lower portion of the first lobe of the
left lung was covered with a layer of recent lymph and its substance was hepatized gray; the second lobe was dark-
blue externally and ou section reddish-purple and solidified in nodular masses; the lung weighed thirty-four ounces.
The heart contained mixed clots and the pericardium eleven drachms of fluid. The liver and pancreas were healthy;
the spleen large and soft. The mucous membrane of the stomach was parti-colored with a deep purplish patch in the
centre. Peyer's patches and the solitary glands in the large as well as the small intestine were congested, but neither
ulcerated nor elevated. The kidneys were much congested and firm, their pelves pale but with numerous injected
points. — Ass't Surgeon Harrison Allen, V. S. A., Lincoln Hospital, TTashington, D. C.
Case 152. — Private Joseph Lynch, Co. D, 99tli X. Y.; age 44; admitted March 11, 1865, insensible. Muttering
delirium, jactitation, coma and death on 18th. Post-mortem examination: Capillary congestion of cerebrum, serum
in lateral ventricles and congestion of floor of fourth ventricle. Right lung black posteriorly, dark-red anteriorly.
PNEUMONIA. 779
lowest lolie solidified: left Iniig congested, eoeliymosed sjiot under uleiira in anterior portion of lowei lolic. Wliite
clots in l>oth ventricles. Spleen enlarged: kidneys ami Uowels congested. — .lus'l Siiri/roii Gio. M. MtCill. l'. S. .J.,
yatiumit llvupital, Btilliiiiore, Md.
C.vsE 153.— Private John Iia Pickett, Co. D, Utli 111.; age 1.5; admitted May 28, 1864. Died .lune IT. /'«»(-
mortem examination: Brain inllamed. Riglit lung liepatized, especially in lower lolie: .slight pleuiiiie adhesions.
Intestines inllamed throughout. — JJospilul Xu. 8, yaahrilli; Tcnn.
Cask 151.— Private .\hraliam (iohhoney, Co. C. 77ih Pa.: age 25: admitted March 25, ISiil, delirious and almost
moribund. Died 30tli. I'oslmoylvm examination: Dura mater very dry and showing signs of inliammalion: lymph
deposit on araelinoi<l: three ounces of reddish serum in the memljiaues. Hoth lungs were adherent au<l the pleural
cavities contained ertusion : the upju'r lolie of the left lung was iulilt rated with pus, the upper lobe of the other he])-
atized red. The heart was full of Iilack clotted blood. Liver much congested, nutmeg; spleen normal: kidneys
enlarged, congested and granular. — Hospital Xu. S, Xanhi-ille, Tenn.
C.\SK 155.— Corp'l William Clark, Co. A, 2d Tenn. Cav.; admitted Aiiril 9, 18G1, wilh a swelling in the neck
which supjjurated under the right inferior maxilla. Died May 2. rost-iiwrlim examination: Membranes of brain
slightly inllamed. Kight lung liepatized red in its lower lol)o and presenting some tubercles, slight adhesions and
six ounces of lii[uid with a mass of lymph in the pleural cavity; left lung normal lint for .some jw.t(-m«)-(i-»i congestion.
Heart, liver, spleen and kidneys normal. Colon congested. Purulent discharge from abscess in neck jirofuse ; tissues
beneath superlicial fascia intiltrated and disorganized for a space four inches long by three wide. — JJoKpilal Xo. 8,
Xashrille, 'J'fun.
C.\SK 156.— Private Peter Gargon. Co. E, 10th X. Y. Cav.: age 43; .fdmitted and died March 23, 1805. Diagnosis:
Syjihilis. I'osl-morltm examination: Some ecchymoses along region of spine. Brain weighed forty -eight ounces and
a half; ventricles filled with serum and lymph. Mouth, pharynx and larynx intlanied; a-dema of glottis. Right
lung, eighteen ounces, lower lobe partially hepatized; left lung, twenty-nine ounces, lower lobe hepatized red, part
of upper gray. Heart normal. Stomach normal : duodenum slightly inflamed ; some glairy mucus in small intestine;
hard Idaek f;eces impacting large intestine, by which, in some places, the mucous membraiui was slightly congested,
in others disorganized. Liver forty-seven ounces and a half; spleen six ounces; kidneys each four ounces and a
half. — Lincoln Uosjiitul, irasliin//loii. I). C.
.VXAI.YSIS OK TIIK POST-MOUTKM APIT..VI!A\CES IX TIIHKE IirXDKED CASES OI' ACUTE I.OHAH I'NKUMO.NIA.
-V general view of the pathological characters of the acute lobar cases has already been outlined by the method
adopteil for their presentation. Those giving no details save of congestion, hepatization, etc., have been illustrated
by typical selections. Those that terminated in abscess, gangrene, liquefaction of the lungs, etc., as well as those
complicated with co-existing tubercular, nuilarial or enteric disease, or by the supervention of other inllannnations,
as of the pericardium, peritoneum, parotids, etc., have been pointed out incidentally as they were submitted.
Included among these cases are probably some which might have been placed with propriety in the series of
secondary pneumonias, pre-existing bronchitis or chronic pueumonitic processes having been possibly connected with
their development.
The terms of the record are fre<iuently indefinite. In some cases a lung or portion of a lung is descrilied as
normal, healthy or crepitant : but usually only those parts that were found to have undergone change had their con-
dition recorded. The absence of a specific statement to the contrary must therefore, be assumed to imply a healthy
condition in certain of the lobes or lungs.
Localization' of the pxeumoxitic coxditioxs. — The right lung alone was aftected in 51 ca.ses or 17.0 per cent.
of the whole number; the left in 35 cases or 11.7 per cent.; while both were implicated in 214 cases or 71.3 per cent.
The right lung was, therefore, aftected in 265 cases or 88.3 per cent., — the left in 249 cases or 83.0 per cent, of the
whole number.
Viewing the lungs as divided into upper and lower lobar masses, by considering the middle lobe of the right
Inng as a part of the upper lobe, the relative fretjuency of the affection of the lobes may be expressed as follows: In
every hundred cases the upper lobe of the left lung was abnormal 66.0 times, of the right lung 76.7 times; the lower
lobe of the left lung 79.3 times, of the right lung 84.7 times. These percentages are derived from the table on page 780.
The apices and anterior margins of the lungs svitt'ered least. They were frequently pervious and uncongested
when the lung generally was consolidated; sometimes they were emphysematous. The lower lobes were not only
more fre(iucntly but more intensely aflfeeted than the upper; congestion of the latter and hepatization or softening
of the former were often associated. A few exceptional instances occurred in w hicli the lower lobe was uuafiected
and the upper di.seased. A few also were noted in which, as in 68, the middle lobe of the right lung remained healthy
while its other lobes were completely hepatized.
ClRCCMSCRlBED PVRUl.EXT ACCU.MULATIOXS OU ABSCESSES are Said to have been [iresent in twenty-foui nf the
cases, 116-1,35 and 101. 104, 143 and 146. They were situated in both lungs in time cases, 116, 117 and 129, in which
they constituted the characteristic morbid appearances. They were also situated in both lungs in (he three eases, 121,
128 and 143, but an intense engorgement is described as the principal pathological change in the first of these, solid-
ification of the i)ulmonary tissue in the second and tubercular deposits in the last. The abscesses were confined to
the right lung in the tiro cases, 126 and 130, constituting the characteristic feature in the former only, the lung in the
latter being carnified and the abscesses small. They were confined to the left lung in the four cases, 104, 125, 127
and 135: in 125 the lung was solidified and the abscesses incipient, but in the others the purulent deposits were the
780
PNEUMONIA.
prominent apjiearances ; in 135 tho abscess conininnicated ^yitb the pericardial sac, which also contained pns, and
the opposite lunj; was in the condition of so-called piirulent infiltration; in 10-1 the patient appears to have been suf-
focated bv the rupture of the abscess into the trachea. One lobe onlj- was the site of the abscesses in the remaining
twelce cases. In no case was the depo.sit situated in the upper lobe of the left lung. In one case, 134, it occupied the
lower lobe of the left lung; in another, 146, in which the lung was congested, a small abscess was discovered in its
middle. Abscesses were confined to the upper lobe of the right lung in the four cases, 101, 122, 124 and 132, — in the
first associated with purulent infiltration of the lower lobe, in the second forming a small collection in a hepatized
lun<'', and in the other two constituting the chief morbid feature of the lobe. Abscesses were coufined to the lower
lobe of the right lung in six cases : In 123 thej' were small in a hepatized tissue; in the others, 118, 119, 120, 131 and
133, they assumed a greater prominence, — in 131 the abscess was foul-smelling and gangrenous, in 119 the pleura was.
covered with pns, and in 120 the lesion was sequent to inflammation of the ear and of the cerebral substance.
Table LVIII.
Localizafion and specification of the morbid conditions found in the lungs in 300 cases of acute lobar
pneumonia.
Total number of cases
LiiDg said to have been Iit-althy
Couditiou of lung not stated, but lie;iltliy iiiftTeiitially
Lungs presumably normal
Lungs reported as diseased
Eight lung.
Left lung.
300
3(10
13 1
1^2
14
37
35 1
2US I
51
249
Ec'portetl condition of lobes in diseased lungs.
Congi\stion, engorgement, redema and splenization
Inflammation and solidification
Hepatization
Red hepatization
Gray hepatization
Purulent infiltration, softening and liquefaction
Compression, collapse, caroificatiou
Abscess (a)
Gangrene
Stated morbid condition
Normal or healthy
Couditiou not stated, but presumably normal
Lobes of diseased lungs
Upperand ^
middle. ^°^^
254
3
8
Upper.
198
7
44
Lower.
74
13
06
24
31
11
10
238
3
S
(ft) lu the lobes stated the abscesses formed the prominent anatomical phenomena ; abscesses were found in the lobes of other cases in which the gen-
eral characteristic was hepatization, solidification, etc.
Apoplectic extravasations or ixfahctioxs were reported in cases 6.^, 100 and 112.
G.vNGREXE of the LUNG was present in the three cases, 11.5, 136 and 137; the abscess in case 131 was also said
to have been gangrenous.
Tubercle was ohserved in eighteen of the cases, 141-150 and 27, 84, 95, 96, 110, 125, 138 and 1.55. The num-
ber of these cases might have been increased by drawing on the records of consumption ; but in most of those just
submitted death resulted from jineurnonia in the non-tuberculous portions of the pulmonary tissue.
The extent op the engorge.ment or solidification of the lung was frequently inilicated by a statement
of the weight of the organ. In case 69 the left lung weighed ninety-two and a quarter ounces, the maximum recorded ;
in 24 it weighed seventy-five ounces; in 68 the right lung weighed seventy-three ounces.
The TRxVCHEA and bronchial tubes were rarely mentioned; in a few instances they were said to have con-
tained mucus, rusty sputa or inirnlent matter. lu case 104 the air-tubes were flooded with pus by the rupture of a
pulmonary abscess.
Laryngitis was present in the six cases, 23-27 and 15G. In the last-mentioned case syphilitic disease is said
to have been present ; in 23 and 24 the vocal cords were ulcerated; in 25 laryngotomy was performed on account of
tumefaction of the lining membrane; in 26 the epiglottis and epiglottidean folds were much swollen and the mucous
membrane of the larynx and trachea of a bright-red color; in 27 laryngitis and pneumonia resulted from exposure at
night during intoxication.
Concomitant pleurlsy.— In Ihirty-cUjld of the fifty-one cases in which the right lung alone was aft'ected there
was a coincident pleurisy, which in one case involved both sides. In i)(ifn(i/-0Hcof the thirty-five cases in which the
left lung was alone inflamed there was a coincident pleurisy, which involved both sacs in four of the cases. There
was also a coincident pleurisy in one hundred and tliirtij-nine of the two hundred and fourteen cases in which the pneu-
monia was double, but the pleurisy is reported as having affected both sides in only seventy-six of these cases, one
side only in the remaining sixty-three, — the right side in thirty-four, the left in twenty-nine cases.
PNEL'MOXIA.
"Si
I'ltiuisy was tliiis pivsoiit in one hundreci and ninety-eight or 66 per cent, of the tlircc hundred cases, aftccting two
buudied and sevciity-iiiiio ol' the six hundred ])Icural sacs: and as the right Inn;; was more frequently the seat of
engorgement and exudative processes, so the light pleura particiiiatoil in the uiorhid action with greater frequency
than the left, the former having heen atfeeted in one hundred and lifty-two or M.' per cent, of the cases, the latter
in one hundred and twenty-seven or 1^.3 percent of the cases. The following tabular statemeut i)reseuts the reported
pleural conditions in tlie two hundred and seventy nine afl'ected cases:
G lutiauied ; 6
121-' adiiesions only,
186 adherent.
'23 lymph-coated,
lit liquid eoUeetions,
I'.i with lymph coating on unadhereut parts,
."iD with licjuid collections,
1 with ecchymosis of the membrane:
lit lymjih-coated only,
1 with undeserihed liquid,
1 with serous cti'usicui,
1 with purulent collections,
1 with ecchymosis of the nienibraues;
28 of unstated appearance,
10 serum,
111 turbid seniMi.
4 )iiiuiuleut si'iuui.
I> puruli'nt matter.
1 i>loodv serum,
2 blood':
f 5 with lymph only.
5 with etiusi'd seium,
2 with tintrd scium.
1
1 with purulent collections; |^
~ uudeseribed eli'usion.
f-'
) 11 serous llqiiiil.
S 6 turbid li(|iiid.
|_ 6 purulent liquid;
186
23
64
279
2T'.i Total number of atfeeted sacs in 300 cases of pneumonia,
The adhesions were usually described as recent; but it is iirobable that in some of the cases tabulated they
antedated the fatal pneumonic attack. Interlobar adhesions were frequently found when there was no extensive
attachment to the thoracic walls. In case 72 serum became sacculated by incomplete adhesions. A large patch of
exuded lymph in case 6 had attained a thickness of half an inch. Liquid collections generally compressed the lung
towards the upper and back part of the cavity, but in 130 the right lung was compressed against the anterior wall
of the chest by seventy-five ounces of yellowish serum containing llakes of lymph. In 113 the effused liquid caused
displacement of the heart. In 119 the purulent collection in the pleural cavity was derived from an abscess in the
lower lobe of the right lung. In 71 the left pleura contained two quarts of pus. In 70 the right side was lined with
a iiyogenic membrane and coutained one and a half gallons of pus. The left sac, in 139, was filled with purulent
serum, the lung having been destroyed. In 38 and 110 the right pleural cavities were distended with purulent nuit-
ter, the quantity in the latter having been recorded as seventy ounces. Bloody serum filled the right pleural sac in
case 2. Hemorrhage into the pleura was the immediate cause of death in 114 and 11.5; five q\iarts were extra vasated
into the left cavity in the former, in the latter the thorax is said to have been full of blood. In 137 a large aliscess
containing a pint of pus was found under the i)arietal pleura, extending to the first lumbar vertebra.
The PKUICARDIUM is mentioned in sixty of the recorded cases, in three of which it is said to have been normal
or healthy. In twenty-five nothing is noted save the presence of a small and probably normal quantity of pericar-
Jial liquid. In the thirty-two cases, 70-96, 55, 104, 110, 125 and 135, an increased quantity or change in the iiuality
of the contained liquid, with or without adhesion or exudation of lymph, gave evidence of inflammatory or other
morbid conditions. In tweh-e of these cases there was much clfusion: In 76 and 91, six ounces; in 55, 75, 77 and 84,
eight ounces; in 74, ten ounces; in 110, a pint, and in 83 a large quantity; in 125 the pericardium was reported full
of fluid; in 71 distended, and in 94 the quantity of the effused licjuid is not stated. In 55 the efl'usion may have
been of a passive character; the patient was greatly ])rostrated and died comatose probably from a similar ett'usiou
into the cranial cavity. In some of the other cases the excess of pericardial liquid may have originated in this man-
ner, but in the greater number the presence of turbidity from llakes of lymph or the association of a villous, rough-
ened or reticulated condition of the serous surface attested its iutlammatory character; in 76 and 91 the surface was
villous; in &1 thickened; in 74, 75 and 77 reticulated, and in 71 thickly coated with lymph. In iliire of the cases the
liquid in the sac was of an unusual quality: In 92 it consisted of bloody serum; in 86 of liquid having the color of
mulberry juice, and in 135 of purulent nuitter derived from a pulmonary abscess. In nine cases, 70, 73, 78, 80, 82,
85, 87, 88 and 104, the pericardial lining was thickened and roughened by exuded lymph without adhesion and with
little effusion. In nmst of these the surface of the heart is specially mentioned as affected; but in 80 the lymph-
coating is said to have been present on the parietal as well as the visceral surface; in 89 the lymph was disposed in
small patches. Adhesions were found in four ca.ses: In 95 the pericardium adhered to the heart; in 72 the adhe-
sion did not involve the ai>ex; in 89, on the contrary, the apex was attached to the sac by a narrow band; in 90 the
connection was efiected by stringy deposits. Of the four remaining cases the pericardium is said to liave been
iuHamed in 79 and 81; to have presented dark-purple spots and old adhesious in 93, and tubercular granules in 96.
The EN"i)OC.\Ki>lVM was seldom mentioned in these cases of pericardial implication ; in 77 it is said to have been
unchanged; but there were evidences of antecedent inflammation in 93 and of recent inflammation in 82.
The CARDIAC SunsTAN'CK. — In addition to the cases just mentioned, in which the condition of the heart is
782 PNEUMONIA.
partly mulerstooil from statements made hi connection with the pericardium, the heart is noted in eighty-eight cases,
in lifty-live of whicli it is said to have been normal. Of the i-cmaining thirty-three it was flabby in thirteen, in three
of which it was soft, in one fatty, in one pale, in one atrophied and in one enlarged. It was large in scren cases, in
one of which it was said to have been soft. It was fatty in /re, hypertrophied in one, small in one, pale and thin in
one, discolored in one and displaced in one. In tuo cases calcareous deposits were found in the valves, and in one —
{Specimen 336, Army Medical Museum) — a caulitlower excrescence was found in the left ventricle attached to the
thickened aortic valves.
The CONTEXTS OF THE HEAKT were noted in ninety-one cases. Fibrinous clots were found in fifttj-four: In the
cavities of both sides in ten cases; of the right side in fourteen and of the left side in two cases : in twenty-eight the
chambers containing the clots were not particularized. Mixed clots were recorded in eiylit cases; in three on both
sides, in one on the right and in another on the left; in three cases the side was not specified. Two cases had soft
clots; in the right cavities in one case, the cavities unspecified in the other. Black clots were found in seven eases,
the location in six being unrecorded and in one on the left side. Undescribed clots were found in seventeen cases; in
the right side in five and in both sides in three cases, while in nine the containing chambers were not recorded. The
heart was said to have been full of blood in one case, of fluid blood in a second, and of black blood in a third.
The condition of the liver was reported in one hundred and sixty cases, in flfty-four of which it was healthy or
normal. Of the remaining one hundred and six cases it was said to have been large or enlarged in fifty-nine ; in six
of these it was also congested, in six soft, in three iJale, and in four fatty. Of the remaining forty-seven cases it
was described as engorged in one, congested in nine, inflamed in one, adherent in one, covered with false membranes
in one, pale in five, fatty in eleven, soft in six, hard and gi'ay in one, mottled in tivo, bronzed in one, cirrhosed in three,
small and waxy in one, and in one, ca.se 112. there were fibrinous nuisses on the surface of the organ extending into its
glandular tissue. Abscesses were found in the three remaining cases: in one, which has not been submitted, the
purulent deposits were small ; in another, 102, the abscess had discharged its contents into the peritoneal cavity, and
in the third, 120, abscesses in the liver and lungs wore consecutive to the cerebral extension of tympanic disease.
The weight of the liver was noted in thirty-seven cases, the average amounting to 71. G ounces, — the maximum, nearly
eight pounds, in case 134, the minimum, 28.5 ounces, in an unsubmitted case.
The SPLEEN was the subject of report in one hundred and forty-one cases, in forty-one of which it was said to have
been healthy. Of the remaining one hundred cases it was reported large or enlarged in seventy-tliree, — in one of these
it was pale; in one of a dark-mahogany color; in five congested; in ten softened, and in ten puljjy and almost jiulta-
ceous. Of the twenty-seven remaining cases two were anwmic; seven small, one of which was of a chocolate color;
one flabby ; one congested; twelve softened ; two pulpy: one, case 104, broken dowu and infiltrated with pus, and one
tubeiisulous. The weight of the spleen was recorded in fifty-three cases, the average being 12.8 ounces. The maxi-
mum weight, two and a half pounds, was noted in case 47; in 44 the congested organ is said to have been five times
larger than normal; in 150 it weighed nearly two pounds. The minimum weight, 3.5 ounces, is recorded in 9.5.
The condition of the p.vscreas was recorded in thirty-five cases: normal in thirty-two; whitish in one; con-
gested in one, and large in one.
The kidneys were noted as healthy in seventy-six of one hundred and twenty-three cases in which their con-
dition appears to have been observed. Of the remaining forty-seven cases the kidneys were enlarged in seventeen, in
seven of which they were said to have been also fatty, in two congested and in one, case 61, softened and much con-
gested. In twenty cases they were reported congested; in/ire fatty; in one granular: pus was found in the jielvis in
one case ; abscesses were noted in two cases — in one, not submitted, the abscess, about the size of a hulled walnut,
occupied the upper part of the left kidney, the right being unatt'ected : in the other, case 12ft, both glands were degen-
erated and contained many abscesses. In one instance, case 40, but one kidney was discovered — on the left side-
weighing ten and a half ounces. The weight of the kidneys was reported in twenty-five cases exclusive of case 40.
The average weight of the right kidney was 5.9 ounces, of the left 6.3 ounces. The maximum weights were noted in
case 80, the right 9 ounces, the left 10 ounces; the minimum weights occurred in an unsubmitted case, the right 3
ounces, the left 3.5 ounces.
The STOMACH was the subject of report in eighty-five cases, in seventy-one of which it was said to have been
healthy, while in two the only morbid appearance noted was an nnusual distention. The mucous membrane of the
remaining twelve cases was said to have been pale in one, congested in foiiv, injected in one, injected, thickened and
softened in one, inflamed in two, discolored in two and yellow and soft in one.
The condition of the ILEUM or .SMALL INTE.STINE was stated in one hundred and fifty-five cases. This part of
the alimentary canal was healthy in ninety of the cases. Of the remaining sixty-five cases mention is made of the
intestine as a whole in forty-three, while in twenty-two the record restricts the morbid lesions to the lowest division of
the tube. Of the forty-three cases in which the small intestine is indicated as the site of diseased conditions, in five
the gut is said merely to have been distended; in two its lining membrane was pale; in two softened; in two dis-
colored; in one hyperaemic; in twenty congested; in two injected, with thickening and softening in one of them; in
six inflamed, in one of which, 30, there was pigmentation of the agminated glands, and in another, case 53, an
approach to the gangrenous condition; in two, 86 and 151, the patches of Peyer were congested or prominent, and iu
one, case 96, the intestine was thought to have been tuberculous. Of the twenty-two cases in which the ileum was
specially n;entioned its mucous membrane was said to have been congested, injected or inflamed in eiyht, thickened and
softened in one, punctated like the shaven-beard in two and ulcerated in./'o«>' cases, 52, 54, .55 and 109. The agminated
glands were mentioned as dark-colored but not elevated iu one; pigmented iu two; thickened in two, and ulcerated
in two, 50 and 51.
PXEUMOXIA. 783
The condition of the i..vni!K intkstink was noted in one luiiuhcd and twonty-uiue cases, in eighty-six of which
it was normal, in fonr distended and in two contracted. Of the remaining thirty-seven cases there was injection,
congestion or inlhuiiiiiatioii in (i(('«^i/-//ir(r, in three of which, 52, 57 anil lit!, the niucons memhrane was nleerated.
ricers were also present in six other cases. The memhrane was reported thickened and softened in four cases, diseased
in one, pale in one and tnherenlons in liro.
The soLir.MiY ioi.I-ICI.es, w itliont speciticatiou of their locality, were recorded as enlarged or disorganized in
the six cases 5(>-t)0 and 99.
There are evidences of PKiilTOXiTis in six of the cases: The abdominal viscera were more or less agglutinated
in i), 97 and 99: in tUo two cases, 73 and 85, pleurisy and pericarditis-were associated with an inflamed condition
of the serous lining of the abdomen — an exudation of recent lymph in one and a degeneration of the exudation into
puriforn\ liquid in the other; in 98 the serous mciubraue was softened and its sac contained purulent matter.
The condition of the niJAlx or its MEMnit.vXKS is stated in sixty-one of the cases. In twenty-one it was normal.
The records fail to note the anlc-mortcm condition of the majority of these cases, but in 63, in which the brain was
said to have been normal, there was unconsciousness. In forty ca.ses an abnormity was observed. In thirli/ the brain
or its membranes were injected or congested, with, in some instances, an effusion of scrum in the subarachnoid space
or ventricles, and with occasionally a softened condition of the cerebral substance; one of these, 28, was a e;ise of
delirium tremens. In the remaining ten cases the evidence of encephalic iullammation was more delined: In 29, also
a case of delirium tremens, and in Gl, the arachnoid was opaque, lu 109 there seems to bo a flaw in the record, — the
interior of the longitudinal sinus is given as the site of the exuded lymph. In 1.53 the brain, and in 155 its mem-
branes, are said to have been intiamed. Lymph was found on the arachnoid in 151 and on the lining of the lateral
ventricles in 156. In 151 the posterior part of the hemispheres was Tnteusely red and the ventricles contained a
bloody liquid: in this case delirium was jircsent for ten days before death. In 30 there were patches of pus on the
surface of an opaque arachnoid, yet there was no headache or dizziness and the patient was rational to the end;
irritability of the stomach was the only peculiar symptom in this case. In ease 120 the inflannnation of the brain was
probably a seiiuel of disease of the ear. *
The r.\l!OTii>s. — The right ]>arotid was swollen in case 111. In two cases the gland was inliltrate.l with pns — in
112 on the left and in 113 on the right side. In 135 abscesses were observed in the parotid and submaxillary glands.
Occlusion of veins. — la case 69 the left common iliac was plugged by a libriuous clot three inches long.
Secondary Pneumonias. — The records contain one hundred and thirty-rtve cases of
lobular pneumonia, consecutive to acute bronchitis or other morbid processes in the lungs of
men whose vitality was reduced b}' previous attacks of disease. One hundred and one of
these, or about three-fourths of the whole number, were associated with the specific poison
of measles. Cases 1-34 were unconnected with the eruptive fever. Gangrene is recorded
in 11. Syphilitic laryngitis was possibly the point of departure of the fatal pneumonia in
33. Death from heart-clot is suggested in 34. Typhoid symptoms appeared in several of
these cases with no implication of the small intestine. Delirium sometimes occurred uncon-
nected with observable lesions of the brain ; in 26, which was characterized by furious delirium,
the brain and its membranes are said to have been healthy. In others, as in 30, cerebral
lesions were found after death, although during life the intellect was unaffected.
Broncho-piHumonia icilh no notable compJicatioti, — ilcrtii cases.
it
Case 1. — Private Harry C. Meaker, Co. E, 28th Mich.; age 17; admitted .Jan. 26, 1865, from regimental hosiiital
Willi acute bronchitis. Died February 5, of pneumonia, rost-mortein examination : Pleura' normal ; lungs filled with
blood; trachea and bronchi filled w ith frothy serum, inflamed, roughened and thickened. Omentum slightly injected;
liver enlarged and pale; other organs normal. — Second Division Hospital, AUxanch-ia, Va.
Case 2. — Private Dala Kratzer, Co. F, "Sth Ind., was admitted Jan. 19, 1864, with rheumatism, and died Feb-
ruary 11. of bronchitis and pulmonary congestion. P«.s/-Hio)-(eHi examination: A bony plate two inches in length, one
to three-fourths of an inch in breadth, and irregular in outline and thickness, was contained between the layers of
the anterior portion of the falx cerebri.— [^^/wcimcH 314, Med. Sec, Army Medical Museum.] There were moderately
strong pleuritic adhesions on the right side: both lungs were congested and o-dematous. The pericardium contained
about an ounce and a half of serum: the heart was rather flabby and the mitral valves somewhat thickened. The
liver, seventy-eight ounces, was fatty; the spleen, nine ounces and a half, contained a firm tumor about the size of a
walnut, the interior of which was cheesy with a calcareous admixture and the exterior of a cartilaginous firnniess, —
[Sprcimrn 313,] The kidneys weighed eight ounces each. The stomach and duodeuum were much inflamed. — Siinjcon
Caleb IT. Hornor, V. S. J'., Hospital Xo. 1, Xaslnillc, Tenn.
C.VSE 3.— Private Marcus L. McVay , Co. D, 174th Ohio ; age 40 ; admitted Feb. 6, 1865, with bronchitis. Died 9th.
PoKt-mvrtem examination : Lungs much inflamed, partly liepatized in their middle and upper portions ; air-tubes filled
with tough mucus streaked with blood. Heart somewhat hypertrophied; pericardium distended with serum. —
Stanton Hospital, If'ashington, I). C.
784 PNEUMOXIA.
Case 4. — Private Wm. Cliristman, Co. G, 67th Pa.; age 20; was admitted May 1, 186-i, witb gastro-euteritis.
Died 11th. rost-mortcm examination: The brain was soft; its ventricles contained bnt little serum. The mucous
membrane of the larynx and trachea was much congested. The right lung, thirty-seven ounces, presented many
spots of lobular pneumonia ; the left, thirty-two ounces, contained much bronchial secretion. The heart was flabby,
a large fibrinous clot in its right ventricle. The liver was flabby and ana>mic ; the spleen, eight ounces, was soft and
pulpy: the pancreas normal: kidneys flabby. The cesophagus, stomach and large intestine were healthy: the lower
part of the ileum congested but not ulcerated. — Act. Jss'l Surgeon H. M. Dmn, Lincoln Bospital, Washington, D. C.
C.\SE 5. — Private Solomon llunn, Co. K, 2d Colored Cav.; age 60; admitted Aug. 17, 1864, with rheumatism.
He recovered, but on account of hi.s ago was recommended for discharge. While waiting action on this reeonnnenda-
tion he became att'ected, Jan. 12, 1865, with cough and considerable swelling of the uvula and soft palate. He failed
rapidly, refused to take medicine, and died on the 24th. Post-mortem examination: Body well developed, muscular
and of healthy appearance. The lungs were much conge.sted and infiltrated with blood; the bronchial tubes inflamed.
The right ventricle of the heart contained a fibrinous clot and the left dark clots. The liver was large. The other
abdominal viscera were normal. — Act. Ass't Surgeon Otto Shittler, Suinmit Hospital, Philadeljihia, Pa.
Case 6.— Private "\Vm. H. Hickson, Co. C, 3d Pa. Heavy Art'y; age 24 ; admitted Jan. 10, 1865, from Prince street
prison with pain in the right hypochondrium and shoulder; tongue pale, furred lightly, white at base; skin yellow;
some frontal headache; constipation; pulse 80; slight cough. He says he has had several attacks of inflammation
of liver. Died January 27. Pont-mortein examination: Eight lung mostly crepitant, anterior edge of middle lobe
quite so, firm, elastic, grayish-yellow color with fine pigmented spots, occasional white spots and some smooth-walled
ramifying cavities filled with pus; left lung hardened in places, a cicatrix in the apex and a cavity filled with iius
situated deep within the lung. — Third Dirision Ilospilal, Alexandria, Va.
Cake 7.— Wm. H. Hammersly, Co. D, 12th V. S. Art'y; admitted Dec. 30, 1862. Jan. 5, 1863 : Fever, cough. 10th :
Severe pneumonia of left side. 12th: Subcrepitant rales on both sides; dyspncra; severe prostration ; nervous agita-
tion. 14th: Died. Pos(-Hiorte)i examination: Lungs contained many hepatized jiatches; mucous membrane of bron-
chial tubes reddened and containing pus; cheesy bronchial glands on left side. Fibrinous clot in left ventricle,
becoming black and soft in the pulmonary artery. Liver fatty. — Lincoln Hosjntal, Washington, D. C.
Case 8. — Private Patrick Mahaer, Co. K, 11th N. J.; age 20; was admitted Jan. 13, 1865, with typhoid pneu-
monia. Dulness with tubular respiration on both sides, specially marked over the lower part of the right lung and
the upper part of the left; breathing short and hurried; cough severe; sputa thick, yellow and very oftensive; pulse
130 and weak; tongue furred brown, darker in the centre than elsewhere; teeth covered with sordes; skin sallow,
hot and dry; bowels relaxed; urine scanty and high-colored. A blister over the chest gave some relief; warm fomenta-
tions were afterwards applied. Expectorants, diaphoretics and sustaining measures were employed but without
benefit; the patient became delirious, frequently covering his head with the bedclothes and begging not to be shot.
He died on the 27th. Post-mortem examination: The lower lobe of the right lung was liepatized gray and quite soft.
The bronchial tubes generally were dilated and had thickened walls and a brownish-red lining. The heart was nor-
mal and contained the usual clots. Liver nutmeg; spleen pale; kidneys pale and fatty. — Hospital, Alexandria, Va.
Case 9. — Post-mortem examination of J. Karl, a colored soldier, begun thirty minutes after death and ended
twenty-four hours after, March 4, 1864: When the heart was opened but little blood flowed out and this could
readily be stopped by lifting uj) the edge of the cut. No trace of deposit was felt in any jiart of the right chambers
orpulmor^ary artery. When opened next day two small black coagula were found in the pericardiun! ; in the right
side was found, in black coagulum, a perfect cast of the chambers and pulmonary artery and of a bubble of air occu-
pying the anterior part ; the left ventricle was empty but for a small yellow fat-like clot at its apex and a similar one
in its auricle. The lower lobe of the left lung was rather deeply congested, being semi-solid; the upper lobe was
crepitant but slightly injected; the surface had bubbles of emphysema scattered under the serous membrane. The
right lung was also congested though crepitant ; its lower lobe was thoroughly solidified, and in its iiosterior and
lower parts the air-tubes were dilated, filled with pus and surrounded by a dense, non-crepitant, dark-red substance. —
Act. Ass't Surgeon W. C. Minor, Knight Hospital, Xew Haven, Conn.
Case 10. — Post-mortem examination of Wm. Baker, a colored soldier, March 5, 1864: Heart filled with black
coagula. Ujiper lobe of left lung, with excejition of anterior edge, soft, easily crushed, of a gray dirty color and
semipurnlent; lower lobe, with exception of anterior edge, of a deep liver-color and solid, the minuter bronchial
tubes showing white and prominent on its section; the excepted portions of this lung were filled with air but only
part of the upper lolie was properly crepitant; its surface had some recent lymph eftused on the anterior and outer
surfaces. Lower lobe of right lung hepatized but partly crepitant ; upper deeply congested ; middle injected. Some
frothy nuicus in primary bronchi. — Act. AsaH Surgeon W. C. Minor, Knight Hospital, JS'ew Haven, Conn.
Case 11.— Private John Cable, Co. I, 134th Pa.; age 22; admitted Dec. 23, 1862, with a gunshot wound. Died
Feb. 1, 1863. Post-mortem examination: Right lung, twenty-three ounces and a half: a greenish gangrenous lump
one inch and a half long and half an inch thick in the posterior portion surrounded by gray lobules, and, posterior
to it, some consolidation: lower lobe solidified posteriorly in one-third of its extent. Left lung, sixteen ounces,
solidified in its lower lobe and presenting a creamy, sacculated mass; bronchial tubes much inflamed and containing
pus. Fibrinous clot in right and dark clot in left cavities of heart. —Lincoln Hospital, Washington, D. C.
Broncho-jnienmonia n-ith implication w/ (Ac jj/chco, — Jifteen cases.
Case 12.— Post-mortem examination of Friday Kanawka, a Sandwich Islander, Feb. 25, 1864: Emphysema and
yellow eft'usion in lower part of anterior mediastinum, apparently from right lung; slight effusion in pericardial
PNEUMONIA. 7S5
caviiv: fibriuoiis clots in l)Oth sidcsof the lu-art. The left lung had recent adhesions behind; its snlistance was crep-
itant but congested, and spotted throughout with a somewhat more solid and deeper red substance, usually, if not
always, havini; in its centre a hypertrophied bronchus filled with yellow puriform tluid; on section these bronchial
points protruded from the pulmonary sulistance. The right lung was crejiitant only in the two upper lobes, which
were, however, congested and had red, carnified tissue around the enlarged bronchial tubes; the lower lobe was more
solidified and its inferior posterior angle and edge had an (edematous, exsanguine and translucent mass of a dirty-
greeuish color; the bronchial lining was intensely iutlamed and its secretion, examined by the microscope, consisted
of vast numbers of granules, fat globules — some of which were twice the-diameter of a blood- corpuscle — and pus and
blood-cells; in one portion, taken from the ledeniatous part spoken of, au extremely minute nematoid worm was
seen. — Act. Aas't Surgeon W. C. Minor, Knight Hospital, Xeic Uaren, Conn.
Case 13. — Post-mortem examination of Levi Parker, a colored soldier, March 23, 18G4: The pericardium con-
tained four ounces of lluid : the heart was flabby and distended on the right side by a soft, semi-diaphanous, fat-like
clot: the tricuspid valve was covered on its free edges with warty growths, some au inch or more in length; at the
bifurcation of the left ])ulnionary artery was found a smooth lump the size of a filbert and of the same consistence
as the warty growths. The lower lobe of the left lung had a tract on its anterior and outer aspect of red hepatiza-
tion standing inwards toward the root of the lung; the rest of the lung was of a soft texture, cre])itant, injected
with blood and spotted with black points like the lung of an old person. The right lung was adherent and much
flattened against the ribs: its upper end had enlarged bronchial tubes filled with jius; the lung had a deep-red
injected appearance with the exception of the anterior edge of the middle lobe, which was more natural. — Jet. Jss't
Surgeon JV. C. Minor, Knight Hospital, Xeic Haven, Conn.
Case 14. — Private Francis Demarest, Co. K, 30th (colored) Conn.: died Feb. 18, 1804. Post-mortem examination
one hour after death: Heart large and distended with fluid blood. Left lung slightly coated with lymi)h. hepatizcd
in masses about the size of a lemon and elsewhere softened and of a gray color: right lung softened iind gray. — Act.
Ass't Surgeon TT. C. Minor, Knight Hospital, Xiw Uaren, Conn.
Case l.l. — Post-mortem examination of James S. Hawley, a colored soldier, commenced twenty minutes after
death and finished six hours afterwards, Feb. 20, 1864: The blood was wholly fluid in the right side of the heart.
The opening in the ventricle was sewed up so that no blood flowed out. the sternum replaced and the skin sewed over
till five hours and a half after, when a uniform red clot, like red current .jelly, only opaque, was found in the right
ventricle, laminated and adherent by interlacements; the right auricle contained a dark clot, also slightly adherent;
the superior cava a black eoagulum : the left ventricle a small band of white clot reaching up the aorta and in some
places grading otl" into a red or black eoagulum; the left auricle a black eoagulum. From some of the pulmonary
vessels at the root of the lungs a yellow, seniitransparent strip, about two inches long and a quarter to half an
inch wide, came out upon cutting through them, but none were observed in the pulmonary substance. Left lung.
with recent interlobar adhesions and exudations, congested throughout, showing a rich purjile marbling which
became vermilion on exposure to the air, bronchially but not vesicularly crepitant and with emphysematous bulhe
as large as a walnut on the anterior margin : right lung similarly congested, but with streaks of hepatization in the
substance of the middle and lower lobes and softening in the latter posteriorly. — Act. Ass't Surgeon W. C. Minor,
Knight Hospital, .>'(>ir Haren, Conn.
Case 16.— Private Julius F. Searle, Co. E, 14th Conn.: age 20: died Feb. 22, 1864. Post-mortem examination
begnn a quarter of an hour after death and finished six hours thereafter : The pericardium contained over two ounces
of serum with a small lymph-dei)osit : when cut into, warm fluid blood flowed from the right ventricle ; no clot was
felt: a slimy layer on the posterior wall, when brought up, proved to be light-colored and stringy; most of the escaped
blood coagulated within a minute about the heart. At the end of six hours the blood eflused into the pericardium
had formed two layers, one semi-transparent and dull red, the other of a lighter color. In the right ventricle a dark-
red eoagulum with indications of a surface layer was found, and on the anterior wall a layer of white clot interlacing
with the lacerti teretes, identical in appearance with the white clots observed in previous autopsies; the right auricle
had a dark-red eoagulum also, with indications of surface layering: the superior cava had a black-red eoagulum
without separation of fibrin: the left auricle had a narrow white band reaching through the mitral valve and along
the aorta as a round white-mottled cord about one-third of au inch in diameter and nearly six inches long, gradually
flattening and merging into a mass of dark-red eoagulum. The left lung, unadherent, was congested throughout, and
when pressed minute bubbles came from its small bronchial tubes. The right lung was adherent behind; the upper
lobe congested; the middle lobe crepitant but gorged ; the lower hepatized and softened; the bronchial tubes inflamed
and filled with niucas. — Act. Ass't Surgeon W. C. Minor, Knight Hospital, Xeiv Haven, Conn.
Case 17. — Post-mortem examination of George W. Williams, a colored soldier, begun about forty-five minutes
after death and ended eight hours and a half thereafter, Feb. 24. 1864 : Body warm when first ojiened, and in a state of
rigor when opened the second time. Not more than one ounce of fluid in pericardium ; no indication of inflammation.
The finger, inserted through an incision into the right ventricle, discovered a firm clot on the anterior ])art. The
cat was sewed up. When opened again a rather soft, quite yellow and seniitransparent fibrinous clot was found in
the apex of the ventricle and along the anterior wall, between the triglochin valves into the auricle and up the
conns arteriosus to just above the semilunar valves; with this clot was a mass the size of a large coffee-bean, of firm
external texture, which burst on pressure, giving issue to a yellow creamy puriform fluid: a soft black eoagulum
filled the right auricle and vena- cava> as far as could be felt. The left lung had its lower lobe slightly adherent,
semisolidified, gray, finely mottled with red : its vessels filled with blood : the bronchial tubes enlarged near the sur-
fl»ce, both behind and in front: near the apex was a dark irregular thick-walled cavity the size of a butternut, filled
Med. Hist., Pt. Ill— 99
786 PNEUMOXIA.
with a thick dark fluid containing polvnucleated pus-cells twice or thrice the size of blood-discs; the upper lobe had
on the anterior part of the interlobar tissure a dark spot of blood coagulation; the rest of the lung was congested
but crepitant. The right luug had the three lobes congested — the lower one most, the middle one least ; a small dark
thick-walled cavity in the posterior lower edge adhered to the diaphragm ; the upper lobe had on its upper edge a
gray-colored spot of shrunken, hardened tissue full of enlarged bronchi filled with pus; two spots of dark solidifica-
tion, like the one on the opposite side, were on the anterior lower edge of the upper lobe. It was observable that the
walls of the miuute bronchi were hypertrophied, so that a thin section of lung had a shotty feeling; that their dila-
tation was greater in the newly congested tissue than in the partly solidified, and that they were there also fuller of
pus. — Act. Ass't Suryeon W. C. Minor, Kiiif/ht Hospital, Xew Haven, Conn.
Case 18. — Private John Harris, Co. B, 8th Conn.; died March 3, 1864. rost-inortem examination begun forty-
five minutes after death and ended sixteen hours later: When first opened the right side of the heart was distended
with fluid blood. Sixteen hours afterwards it was filled with black coagulated blood having a yellow, fat-like, semi-
transparent clot on its anterior face in the conus, pulmonary artery and auricle; the left ventricle had a mixed yel-
low and white clot extending through the mitral valve and up the aorta. The left lung was nou-crepitant and
(edematous except in the anterior edge just above the fissure, and there was some recent lymph on its anterior face;
its upper lobe was marked superficially into purplish blocks about one-third of an inch in diameter by subserous
vessels containing a clear fluid only, and its substance was hepatized, some of the parts looking as if they had been
decolorized by soaking; the lower lobe was, if anything, more intensely hepatized than the upper; the minute bron-
chial tubes were of a pale-violet color inside, the larger were slightly injected, none were hypertrophied or prominent
on section. The right pleural cavity was distended with ettusion ; the lung had recent lymph on its inner face and
was of a dark-jmrple color; its upper lobe was solid, dark-brown, somewhat soft but not edematous, and so closely
united to the middle lobe that the fissure was almost obliterated; the lower lobe was softer than the others, but in
no part was there any purulent deposit; the minute bronchi seemed largely obliterated but were not hypertrophied
nor distended; the mucous membrane of the primary and secondary tubes was inflamed and covered with a san-
guinolent fluid which consisted of epithelial cells, fat corpuscles, white blood-discs or pus-cells and very few gran-
ules,— in this last respect contrasting markedly with the case of Kanawka, — case 12, supra. — Act. Asu't Surgeon IT. C.
Alinor, Knight Hospital, Xew Haven, Conn.
Case 19. — Private Moses Williams, Co. A, 29th (colored) Conu., died Feb. 4, 1864. Post-mortem examination:
Pericardium filled with fluid, its pleural aspect injected but its serous surface pale; both sides of heart contained
mixed white and black clots. The left lung had recent adhesions on its posterior surface, which was blotched with
bright-red subserous spots; its substance was pale-red, softened and infiltrated with a reddish muco-purulent liijuid;
from many of the arteries white clots like those in the heart were drawn out; only its apex and interior and inferior
edges crepitated freely. The right lung was slightly adherent but had none of the bright-red subserous markings;
its substance was lobularly solidified. — Act. Ass't Surgeon TV. C. Minor, Knight Hospital, Xew Haven, Conn.
Case 20.— Private Simon P. Mead, Co. 1, 140th Ind.; admitted Feb. 3, 1865, with symptoms of bronchitis. 12th:
Expectoration diflicult; sputa streaked with blood, tenacious. 14th: Dyspucea increased, loth: Small and large
crei)itation in both lungs. 16th: Involuntary stools; delirium; sputa obstructing air-passages. 17tli: Sputa rusty;
dyspnoea increased, — died. Fost-mortem examination : Three pints of serum with lymph-flakes in right pleura : lung
adherent, thirty-six ounces and a half, lower lobe hepatized in patches, upper lobes engorged ; left lung twenty-nine
ounces, somewhat engorged ; bronchi of both lungs much congested and filled with tenacious sputa ; eft'usion in peri-
cardium: liver eighty-four ounces ; spleen eleven ounces; intestines normal. — Douglas Hospital, Washington, D. C.
Case 21. — Samuel Bingham; citizen of Georgia; rebel prisoner ; age66; admitted Feb. 26, 1864, with pulmonary
emphysema. Died March 16. Po-sZ-iHoi/cm examination : A quart of serum in each pleural cavity; lower lobe of right
lung collapsed and covered with lymph ; bronchitis on both sides. Ossific deposits in mitral valve. Liver sixty-one
ounces, fatty; spleen six ounces and a half, soft; kidneys normal. — Hosj>ital A'o. 1, Nashville, Tenn.
Case 22.— Serg't William B. Graham, Co. B, 2d U. S. Sharpshooters; age 26; admitted June 19, 1863. He had
been absent from his regiment about two months with cough and pain in the left lung. Died 30th. rost-mortem
examination : Moderate inflammation of tracheal mucous membrane ; more aggravated inflammation in the bronchi,
extending into the smallest tubes. Recent jineumonia in both lungs, especially in the lower lobes and posteriorly;
pulmonary tissue, except at the apices and exterior iiart of the upper lobes of both lungs, more or less hardened and
resembling washed flesh but everywhere pervious to air; air-cells and bronchi filled with abundant clear, viscid,
yellowish mucus; lungs attached to the walls of the chest by recent adhesions, thin over the upper lobes but thick
and yellowish-white over the lower lobes; pleural sacs contained a moderate quantity of serum. Spleen full-sized
and flabby. Lower ileum showing moderate dift'used inflammation in irregular patches, witli slight thickening of a
few of the lower patches of Peyer: slight dittused inflammation in the colon. Other organs apparently normal. — Act.
Ass't Surgeon J. Leidij, Satterlee Hospital, rhiladelphia , Pa.
Case 23. — Private James W. Bates, Co. F, 25th N. Y. Cav.; age 53; was admitted Dec. 5, 1864, with acute
bronchitis. Counter-irritants, expectorants and stimulants were employed. He died on the 18th. Post-mortem exam-
ination : Body well developed. The trachea and larynx contained a quantity of frothy rust-colored sputa. There
were slight pleuritic adhesions on both sides and each cavity contained about an ounce of thin liquid. Both lungs
were greatly congested; on section a large quantity of frothy rust-colored fluid exuded, but no portion of either lung
sank in water; the right lung weighed fifty-two ounces, the left twenty-eight and a half. The left cavities of the
heart contained small fibrinous clots. The liver was considerably congested and weighed fifty-three ounces and a
half; the spleen seven ounces. There were cysts in both kidneys ; the pelves were distended and the ureters enlarged
PNEUMONIA. 1^1
to iiliout half an iiu'li in (Uainetor. The intosiines weio normal. ISjieciniens 455 and loO, A. M. M., are from ihis case,
ami show tho enlargement of the pelves and distention of the ureters, together with the eysts, the largest of which
isaboiit the size of a shellbark.J — Jc(. Jss't Siirgioii II, M. Dcuii, Lincoln Uospilitl, Wtishhiijlon, I>. C.
C.\SE 24.— Serg't Grover R. Wixom, Co. (i, 5tli Mieli. Cav.; age 35; admitted March 25, 18i;i, with typhoid
pneumonia. Died 2t>tli. I'ost-mortiin examinution : Kight lung, tliirty-one ounces, with old adhesions and lobular
pneumonia scattered throughout ; left lung, forty-live ounces, with recent adhesions, hepatization of upper lobe and
upper part of lower lobe, and much congestion of the remainder of the lung. Epiglottis vascular and (edematous;
trachea and bronchial tubes congested. — Lincoln Hosj)i(<i/, irashington, D.<.'.
Case 25. — Private David 11. Porter, Co. G, 8th Tenu.; ago 20; a man of robust and vigorous frame, was admit ted
Ian. .W, 18(>5, complaining of a dry hacking cough and severe pain in the leftside of the chest. His tongue was coated,
pulso small anil hard, respiration hurried and painful, — a friction sound was heard over the seat of tho p.tin. Hot
fomentations were applied and Dover's powder administered. Free diaphoresis resulted and the pain was relieved.
On February 1 ho had a dull pain in tho left side, with cough and rusty tenacious sputa ; ercpitation was heard over
the alVected part: the pulse was bounding and the skin dry. Vera! rum viride and ipecacuanha were prescribed with
warm fomentations. On tho 3d there was marked dullness on pcreussion, with bronchial respiration over the lower
part of the U'ft lung aiul moist rules over tho upjier ])arl of tho left and whole of the right lung. Ipecacuanha, sweet
spirit of nitre ami acetate of ammonia were prescribed. Next day the patient became delirious, the countenance livid,
respiration hurried and pulse soft and rapid. Stiniulants were given, but he died on the 5th. Post-mortem examina-
tion : The lower lobe of tho left lung was hepatized and hound to the parietes by recent adhesions; tho bronchial
tubes on both sides were inflamed. Tho other organs were normal. — Hospital, Alexandria, Va.
Cask 2G.— Private Madison T. Sharon, Co. L, 2d Tenn. Cav., was admitted April 10, 18(>1, with well-marked
lironchitls. In a few days the inllammation extended to the lung-substance and the fever assunu^d a low character;
tongue dry. sordes on teeth : low delirium at lirst, aftcrwarils furious. Died IHth. roxl-morltm examination ; lirain
and memliraiu's healthy. Kight lung hepatized posteriorly and extravasated blood in pleural cavity; left lung
posteriorly slightly inflamed. Liver large but noruud. Bowels healthy. — Hospital Ao. 8, Ximliritle, Tcnn.
lironfJio-pncnmoniu n-ilh atatvd cereliral lesions, — six ca,^es.
Cask 27. — See case of Private James Might, Co. D, 23d Ohio, No. 57 of the post-mort<m records of the jiaroxys.
mal fevers, sujiru, page 131. In this case broncho-pneumonia was the imnu'diate cause of death.
Case 28. — Private Austin Vacon, Co. G, 186th N. Y.; admitted for burial Fob. 5, 1865, I'osl-mortem examina-
tion: There was a slight opacity in the visceral arachnoid near tho vertex; the floor of the fourth ventricle was con-
gested. The left lung, sixteen and a half ounces, was healthy but for a lobulated portion so congested as to be
nearly of the specific gravity of water. On the right side the lobes were inter-adherent by means of extensive flakes
of lymph: the parietal and diaphragmatic layers were thickly covered with lymph, but there was little efl'usiou into
the sac; the hiiig weighed twenty-nine ounces and inferiorly contained a congested mass, portions of which sank in
water. The hc;irt was normal; its right chambers contained a clot. The liver, forty-eight and a half ounces, was
light-coloreil generally, but exhibited dark congestions on its inferior surface; the contents of tho gall-liladder were
light-colored ; the spleen and kidneys were normal in size, the former somewhat congested. The stom.ich was darkly
congested ; there were some small ulcers in the ileum ; the large intestine was congested in portions. No other lesion
was observed. — Ass't Surgeon Geo. M. McGill, V. S. A,, Xalioiuil Uonpitul, Baltimore, Aid.
Case 29. — Samuel Leonuou; age 23; privateCo. G, 21st 111.; admitted March 16, 1865. Pulse (juick and weak:
respiration hprried ; tongue brown and dry; dulness over lower part of left lung. Died ItUh. I'ost-mortcm examina-
tion: Opacity of visceral arachnoid and serum in .sac; congested vessels on floor of fourth ventricle. Sero-purulent
liiiuid in pleural sacs: solidified nodulatious, surrounded by serous infiltratior. in right lung; abscess, witli caseous
puruloid liquid in upi>er part of left lung and nodules containing pus in other parts. Mixed clots in right cavities
of heart; black clots in left cavities. Enlargement of spleen and congestion of ileum and kidneys. — Ass't Surgeon
Geo, M, McGill, U. S, A,, Xational Hospital, Baltimore, Md,
Ca.sk 30, — Henry lirockmeyer, private Co. E, 1st Md.; age 44; admitted March 22, 1865, having been sick about
three weeks. Dyspucea: expectoration ofl'ensive, ]mruloid; countenance slightly venous, anxious; jiulse fieiiuent
anil feeble: intellect unafiected ; dulness and absence of respiratory murmur over whole of left side. Died suddenly
next nuirning, after making some slight exertion, I'osl-mortem examination: Pia mater congested; cerebrum soft-
ened ; lining of lateral and fou rt h ventricles opacified ; arborescences and blood-specks one-quarter of a line in diameter
in posterior horn of right ventricle; fornix softened ; pons and corpora striata congested. Mixed clots, chiefly white,
in both sides of heart, extending into vessels. Pleuritic adhesions on both sides; lower lobe of left lung breaking
up into a puruloid pulp, upper lobe dark-colored and containing a consolidated nodule; left lung seventy ounces,
right twenty-nine: bronchial tubes on both sides reddened. Kidneys congested; albuuieu in urine. Ileum congested. —
Ass't Surgeon Geo. M. McGill, U. S. -J., Xational Hospital, Baltimore, Md.
Case 31.— Private .Sydenham Stahl, Co. C, 11th Md.: admitted April 28, 1865. Died May 12, of capillary liion-
ehitis. Post-mortem examination: Indications of congestion of tho brain. In the posterior jtart of the left lung
niiiuerous minute nodules reseml>ling miliary tubercles occupied the cent 3 of pulmonary lobules in association with
their bronchial tubes, which were dark-purjjle internally and filled with a bluish-white puruloid liquid : the bron-
chioles were thickened in several instances and themselves gave rise to a miliary appearance. Mixed clots in both
sides of the heart. — Ass'l Surgeon Geo, M. McGill, U. S. A., Xational Hospital, Baltimore, Md.
788 PNEUMONIA.
Case 32. — Private Stephen M. Smith, Co. A, 30th (colored) Conu. Died Feb. 24, 1864. Post-mortem examina-
tion: No blood on vertical section of scalp; effusion under arachnoid and lymph-deposits at vertex: hardening and
injection of brain; ett'nsiou in ventricles and injection of walls; eft'usion about pons and medulla. Pericardium con-
tained two ounces of serum ; right side of heart a •n-ell-formed yellow, semitransparent clot ; left side a smaller one.
Left lung congested but crepitant: right softened, deeply congested and filled with blackish-green points but still
somewhat crepitant. Bronchi on both sides intensely intlamed, tilled with pus and tubularly enlarged near the pul-
monary surface. — Act. AssH Surgeon W. C. Minor, Knif/ht Hospital, New Haven, Conn.
Broncho-jineiimonia from si/philis, — one case.
C.\SE 33. — Private Freeman Dwyer, Co. D, 11th Vt.; age 33; admitted Nov. 21, 1864, with gonorrhoea. Fur-
loughed December 26. Returned Jan. 22, 1865. Died March 14, of syphilis. Pos/-»iortf»i examination: Slight circular
discolorations on body and liml)s. Dura mater at base slightly intlamed; small serous effusion in ventricles. Nares
and pharynx normal : glottis a-dematous; mucous membrane of larynx and trachea thickened and intlamed, this con-
dition extending into the bronchioles, where were some small gangrenous patches. Eight lung, thirty ounces, hepa-
tized gray except in a small portion of the upper lobe; left lung, twenty ounces, hepatized red in adjacent portions
of each lobe. Mucous membrane of oesophagus inflamed, ulcerated in patches, gangrenous in its lower part; cardiac
end of stomach somewhat inflamed; ileum congested and ulcerated; mesenteric glands and large intestine healthy.
Liver, spleen and kidneys enlarged. — Lincoln Hospital, Washington, D. C.
Bronclio-pneumonia — death from heart-clot? — one case.
Case 34. — Private George Washington (Indian), Co. L, 9th Kans. Cav.; age 30; admitted Feb. 9, 1864, with
acute bronchitis. The lieart-sounds were indistinct and there was no radial or temporal pulse; appetite good. After
a few days the sputa became opaque and viscid and the breathing difiicult. On the 2oth the heart -sounds could not
be heard at the priecordia. He died next daj-. Pos(-7)ior(f)« examination: Pleune inflamed, thickened and adlierent;
three ounces of serum in left cavity; scattered patches of hepatization in both lungs, large and small bronchial tubes
filled with a milky fluid. Heart enlarged and flabby; its right ventricle distended with coagulated blood and a large
clot of grayish color and firm consistency, interwoven with the niusculi pectinati, passing through the auriculo-ven-
tricular opening into the ventricle, filling one-third of its cavity, interdigitating firmly with its fleshy columns and
thence passing into the artery; walls of the right side of heart much thinned and dilated; a small clot in the left
ventricle similar to that on the right side, but not so intimately connected with the fleshy columns, extending more
than twelve inclies along the aorta, where it gradually tapered to a point and at the arch subdividing and passing into
the large vessels there originating. — Hospital, Fort Scott, Kansas.
Se*cntij-o>ie cases associated tcith the specific j'oison of measles, presenting little of interest heijond a specification of the appear-
ance and locality of the affected parts of the lung.
Case 33. — Private James Acles, Co. I, llOtli Ind.; age 15; was admitted Feb. 1, 1865, with measles. The erup-
tion did not appear. Death took place on the 7th. Post-mortem examination: Hepatization of the middle and lower
lobes of the right and lower lobe of the left lung. Heart normal. — Stanton Hospital, Washington, D. C.
C.A.SE 36. — Private Allen Rinehart, Co. K, 21st Ky., was admitted March 14, 1864, with measles. Pneumonia
set in on the 26th, and death took place on the 31st. Post-mortem examination: There was some eft'usion beneath
the cerebral membranes. The upper lobe of the left lung was hepatized gray and the pleural cavity contained much
effused liquid; the upper part of the right lung was hepatized red, the lower part congested. The pericardium con-
tained three ounces of serum. The kidneys were normal. — Hospital Xo. 8, Xashville, Tenn.
Case 37. — Private Robert Nelson, Co. K, Gunter's Ark. Reg't, died suddenly in barracks during the night, Dec.
9, 1864. He had recently been under treatment for measles. Post-mortem examination: Skin purplish; body stout
and muscular. Three ounces of bloody serum in the membranes of the lirain; many pnncta vasculosa; red hepatiza-
tion, with adhesion of the posterior portion of the right lung; congestion of the left lung, with strong adhesions to
:the intercostal spaces; large fibrinous clots in the right side of the heart; enlargement and softening of the liver. —
Act. Ass't Surgeon J. E. Brooke, Pock Island Hospital, III.
Case 38.— Private Jacob Brunor, Co. C, 51st Pa.; age 18 ; was admitted April 9, 1865, with measles. Pneumonia
■and jaundice appeared on May 16, and death occurred on the 20th. Post-mortem examination: The pleural surfaces
were adherent; the left lung hepatized; the middle and lower lobes of the right congested. The liver was congested;
.the spleen enlarged and softened. All the liquids of the body were yellowish. — Third Dirision Hospital, Alexandria, To.
Case 39.— Private Thomas Yarnel, Co. I, 4th Tenn. Cav.; admitted April 10, 1864, with acnte bronchitis. On
the 13th, when the eruption of measles appeared, the patient had cough, labored Ijreathing and moist rales on both
sides of the chest. Two days later the eruption faded and shortly after the tongue became dry and cracked and the
pulse feeble. On the 18th respiration was frequent and the lips and finger-nails bluish. Some time before death, on
the evening of this day, the tongue became so swollen as to prevent closure of the mouth; it was incised on both
sides and bled i^rofusely. Post-mortem examination: The left pleural cavity contained much serum; the upi)er lobe
of the lung was congested, the lower lobe hepatized red; the right cavity and lung were similarly affected but in a
less degree. The tongue was flabby; the mucous membrane of the larynx and epiglottis much congested. The abdom-
inal viscera were normal. — Hospital Xo. 8, Xashrille, Tenn.
Case 40. — Private Henry Blotkamp, Co. C, 152d Ind.: age 17: was admitted March 22, 1865, with pleuro-
L
PNEUMONIA. 789
piiciiiiuHiia, occvuTinsr aftor measles. He improved to Ajiiil It!, when the febrile symptoms became aji^ravatod, lejul-
iii^ to a fatal issue on the 22(1. I'OKt-mortcm e.xaminatiou: liody emaciated. The mucous membrane of the larynx
and trachea was inllamed and thickened: the left pleural cavity was filled with sero-pus; the upper lobe of the
lung was adherent, hepatized and infiltrated with pus and the lower lobe collapsed. The heart was somewhat dis-
placed to the right side. The liver was enlarged and of a pale-ehocolate color. The mucous meiul)rane of the ileum
was inflamed and thickened; the mesenteric glands enlarged. — Cumberland Uospilal, J/rf.
C.\SE 41.— Edward K. Eoyce, Co. A, 168th X. Y., was admitted Feb. 8, 1863, with sore throat, cough and ajjlionia,
following measles. He was much prostrated; had high fever, dyspncva and nuico-purnlent sputa. He died on the
ITtli. runt-mortem examination: Hoth lungs were emphysematous and contained scattered small hard nodules; the
bronchial mucous membrane was reddened and the bronchioles tilled with muco-pns. The heart contained white
c''jts. — Ladien' Home Uotijiilal, X. T. City.
Cask 42. — Private Levi Sandford, Co. C. 10th Teun. Cav., was admitted Fel). 21, 1861, with mcash-s, and died
on the 26th. rost-mnrtcm examination: The brain was healthy. The lungs weighed forty-one ounces; the left was
adherent and hepatized. the lower lobe of the right hepatized; the bronchial tubes inllamed. The liver was dark-
colored: the spleen weighed ten ounces and was very dark, soft and congested. The other organs appeared healthy. —
Jet. Jmi't Surgeon S. J/. Olden, Uospital Xo. 19, ytishviUe, Tenii.
Case 43. — Private John T. Rockwood, Co. A, 4th Mich. Cav.; admitted Feb. IS, 1S61, with measles, l)ii>d 24lh,
Post-mortem examin:ition: The brain and its membranes were healthy. The lungs were congested and weighed lifty-
two ounces. The heart was healthy and contained dark lluid blood in its right cavities. The stomach was injected.
The other organs appeared nonnal. — Act. Akd'I Surijeon K. J. Sample, JJonpital Xo. 19, XnnhriUe, Tenii,
Cask 44. — Private John Hobby, Co. H, 13th Tenn, Cav,, was admitted Feb, G, 1861, with measles, and cliid on
the 23d. Posl-murlim examination: The veins of the cerebral membranes were engorged. The lungs weighed fifty-
one ounces ; the left was hepatized ; the bronchi iutiamed. The heart contained Ebrinous clots. The stomach was
inllamed; the small intestine inllamed and thickened iu patches; tlieliverand spleen softened but not enlarged; the
kidneys and large intestine normal. — Act. Asa't Surr/eon J. E. Marnh, Hospital Xo. 19, Xanhville, Tenn.
Case 45. — Private J. W, Stuckey.Co. I, Cothlnd., was admitted Feb. 13, 1864, with measles, and died on the2.ith.
Poat-mortem examination: The brain and its membranes were normal. The left pleural cavity was lined with pale
yellow lymph and contained thirty-six ounces of serum and pus; the left lung was congested and (edematous;
together the lungs weighed forty-one ounces. The heart was healthy. The mucous membrane of the stomach was
congested. The spleen weighed ten ounces. The other viscera were normal. The blood in the veins was lluid. —
Jet. Jss't Surt/eon K. J. 5omj)/(, Tlunpital Xo. 19, Xunhrille, Tenn.
Case 46. — Private Thomas J. Murray, Co. F, 9th Teun. Cav., was admitted Jan. 30, 1S64, with measles.
During convalescence severe symptoms of imeumonia set in aud death took place February 22. No symptom of dis-
ease of the kidney was observed during his sickness. Post-mortem examination: The brain and its membranes were
normal. There were pleuritic adhesions on the left side and exuded lymph on the right. The lungs, forty-five ounces,
were hepatized and their bronchial tubes inllamed and filled with pus. The heart was soft and flabby; both auricles
contained fibrinous clots. There were some peritorieal adhesions on the left side. The stomach was highly inllanu'd.
The right kidney weighed fourteen ounces and contained in its upper part a large cyst filled with liiiuid. Tin- other
organs appeared normal. — Act. Ans't Surgeon S. M. Olden, Hospital Xo. 19, Xashvilh; Tenn.
Case 47. — Private William Jones, Co. H, 0th E. Tenn. Cav., was admitted Jan. 29, 1864, with acute bronchitis,
following measles. On the 31st typhoid symptoms ajipeared, and during the last two days of life there was mut-
tering delirium. He died February 7. Post-mortem examination: The brain and its membranes were injected. The
mucous membrane of the trachea aud bronchial tubes was much inflamed. The lungs weighed fifty-one ounces; the
left lung was adherent and its upper lobe nearly solid. There were fibrinous clots in the right cavities of the heart.
The peritoneal cavity contained four ounces of liijuid. The stomach was healthy; the mucous lining of the intes-
tines, small and large, was inflamed. The other viscera were normal. The blood iu the veins was fluid. — Act. Ass't
Surgeon If'm. Stemmirmun, Hospital Xo. 19, Xashrillc, Tenn.
Case 48. — Private George Clamniond, Co. C, 1st E. Tenn. Cav., was admitted Feb. 11, 1.S64. wiili measles.
Typhoid symptoms supervened and death took place on the 22d, Post-mortem examination: The Iirain and its mem-
branes were congested. The lungs weighed forty-five ounces; their bronchial tubes were inflamed. The heart con-
tained a fibrinons clot. The ciecum was inflamed. The other viscera ajipeared healthy. The blood in the veins was
flnid. — Jet. Ass't Surgeon Geo. If. L'oberts, Hospital Xo. 19, Xashrille, Tenn.
Case 49. — Private James H. Mallow, Co. H, 31st Mo., was admitted Feb. 26, 1864, with measles. He was niialilo
to speak: the surface of his body was of a bluish-purple color. He died twelve hours after adnii.ssion. Post-mortem,
examination: The brain was healthy. The lungs weighed forty-six ounces and presented general bronchitis and
pnenmonia of the left lower lobe. The stomach was inflamed and thickened; the small intestine slightly reddened
throughout, the lower portion of the large intestine inflamed but not ulcerated. The liver weighed sixty-smen
ODnccs: the spleen twenty-six ounces; the kidneys twelve ounces. The blood was fluid. — Act. Ass't Sunjcnn ,S'. M.
Olden, Hospital Xo. 19, Xashrille, Tenn.
Case 50.— Private John B. Talbot, Co. H.Gtli Mich Cav.; age 23 ; admitted Feb. 13, 1864, with pleuro-pneumonia,
following measles. Died 29th. Post-mortem examination : The lower lobe of the right lung was hepatized red and
presented on section a number of small superficial abscesses. ISpecimen 345, Med. Sec, Army Medical Museuni.] The
pleura was thickened. The kidneys were fatty. — Surgeon E. Venlleij, U. S. Vols., Third Dirision Hospital, Alexandria, Va.
790 PNEUMOiS'IA.
Case 51. — Private William H. Stalker, Co. I, 61st N. Y., was admitted April 20. 1864, ^vitb measles, and died
May 3. Post-mortem examination: Eight lung adherent and hepatized, its upper lolje infiltrated with pus; left lung.
heart and abdominal viscera normal. — Act. Ass't Surgeon Jas. D. Linton, Hareicood Mospital, Washington, D. C.
Case 52. — Private Daniel Sl^eiser, Co. G, 39th 111., ^vas admitted April 4, 1864, with measles, and died on the 14th.
Post-mortem examination: Eight lung hepatized gray; left much congested; liver and kidneys healthy; spleen cou-
gested, weighing thirteen ounces. — Act. Ass't Surgeon C. W. Fillmore, Hareivood Hospital, Washington, D. C.
Case 53. — Private Stephen Keach, Co. A, 10th Md.; age 20 ; was admitted March 24, 1864, with measles, and died
April 5. Post-mortem examination: Both lungs were in the third stage of pneumonia ; the pleural sacs contained
effusion and the pericardium three ounces of liquid. — Act. Ass't Surgeon B. B. Miles, Jarvis Hosjjital, Baltimore, Md.
Case 54. — Private G. W. Tillett, Co. L, 1st Conn. Cav.; age 28 ; admitted Feb. 14, 1864, with double pneumonia
consecutive to measles. Died 21st. Post-mortem examiuation: The right lung was softened and the left infiltrated
with fetid matter. The pericardium contained two ounces of serum and the ventricles of the heart fibrinous clots.
The liver was natural; the gall-bladder empty. — Act. Ass't Surgeon B. B. Miles, Jarvis Hospital, Baltimore, Md.
Case 55. — Private David J. French, Co. H, 152d Ind.; age 16; was admitted March 22, 1865, with measles. The
eruption was well marked and the patient's face so swollen that he could scarcely open his eyes ; respiration hurried,
gasping; pulse 120. He died on the 27th. Po.5(-mor(e»i examination : The upper lobe of the right lung was congested,
the middle lobe and portions of the lower lobe heijatized; the lower border of the upper lobe and the whole of the
lower lobe of the left lung were also hepatized. The liver and spleen were large and congested. — let. Ass't Surgeon
Thos. /'. Clement, Cumherland Hospital, Md.
Case 56. — Corp'l AVilliam Little, Co. E, 31st Me.: age 18; was admitted ilay 7, 1864, with pleuropneumonia.
He had been treated in the AVolfe street hospital, Alexandria, Va., from April 27 as a case of measles. On admission
he was delirious and very restless ; his skin hot and dry, tongue dry and covered with a brownish coat ; teeth covered
with sordes ; he had cough, dyspnoea and a profuse expectoration of dark-colored muco-purulent matter. The dyspnoea
increased and the surface of the body became bluish. Death occurred on the 8th. Post-mortem examination : Su"-
gillation posteriorly and discoloration in each iliac fossa. The left pleural cavity contained twenty ounces of serum
mixed with lymph; the lungs were much congested posteriorly, portions of their tissue being heavier than water:
there was a small abscess in the lower lobe of the left lung. The heart, liver, kidneys and intestines were apparently
healthy. — Act. Ass't Sui-geon Charles Carter, Turner's Lane Hospital, Philadel2>hia, Pa.
C.iSE 57. — J. H. Mathews, Government employe ; age .58 ; was admitted March 30, 1864, with measles, the eiuption
just appearing. Next day the patient was quite hoarse and had cough with mucous expectoration ; the eruption was
well marked. He became nostalgic on the 8th, his cough troublesome, expectoration muco-purulent, pulse frequeut
and feeble and tongue clean and red. Next day the tongue was dry and brown, and there was a good deal of febrile
excitement with diarrhoea. Death took place on the 13th. Post-mortem examination: The cerebral membranes were
congested and contained a slight eft'nsion, but the ventricles were empty. The right pleural cavity contained fourteen
ounces of sero-fibrinous liquid; the right lung was congested generally and hepatized in its upper lobe; the parenchyma
of the left lung was healthy; the mucous membrane of the bronchial tubes was congested and thickened. The heart
was normal. The mucous membrane of the colon was congested ; the other abdominal viscera normal. — Surgeon Francis
Salter, C S. Vols., Chattanooga Hospital, Tenn.
C.iSE 58. — Private J. T. Moore, Co. F, 98th 111.; age 19 ; was aduiitted March 31, 1864, with measles. The eruptioi
made its appearance on the day before admission ; it was not very marked and for some days there was no serious
symptom. Diarrhoea set in on April 6, and the patient became sleepy and stupid; he complained of headache, but
did not cough much, although crepitation was heard over the right lung. Coma supervened next day, and he died in
the evening. Post-mortem examination: The membranes of the brain were congested. The middle lobe of the right
lung was hepatized, as was also the lower part of the upper lobe of the left lung. The mucous membrane of the
bronchial tubes was red and thickened. The kidneys were large ; the other viscera normal. — Surgeon Frauds Sah'rr.
V. S. Vols., Chattanooga HosjJital, Tenn.
Case 59.— Private Wilford Overly, Co. II, 33d Ohio; age 19; was admitted April 6, 1864, with the eruption of
measles present but not well marked. On the 8th the patient had an attack of epistaxis: he had also some diarrhoea
and a cough with mucous expectoration. Next day the eruption disappeared, the tongue became dry and cracked
and sibilant rales were heard on both sides of the chest. Turpentine emulsion was given every three hours, with beef-
tea, chicken broth and arrowroot. On the 12th the mouth was dry, tongue fissured, voice hoarse, pulse 80, respira-
tion 32, the skin bathed in a profuse sweat and the diarrhoea checked. On the 13th the patient was quite nervous;
his pulse 104 and feeble; respiration 30. A sponge-bath was prescribed. He was anxious and nervous next day;
sibilant rales were heard on the right side and mucous rales on the left ; diarrhoea was present ; pulse 120; respiration
56, with a rattling in the trachea which could be heard at a distance. Aromatic and alcoholic stimulants were given.
Death occurred on the 16th, preceded by great nervousness and anxiety, cold sweats, increased rapidity of breathing
and failure of the pulse. Post-mortem examination: The membranes of the brain were much congested; there were
three patches of effused blood, each as large as a three-cent piece, on the upper surface of the cerebrum, and on the
lower surface of the cerebellum a similar patch two inches in diameter; the lateral ventricles contained an ounce of
serum. The left lung was compressed by forty-eight ounces of sero-fihrinons fluid and its lower part as well as the
lower lobe of the right lung was in a state of retl hepatization ; the mucous membrane of the bronchial tubes was red
and thickened. The heart aad abdominal viscera presenteol nothing abnormal. — Surgeon Francis Sidter, U. S. Vols.,
Chattanooga Hosjrilal, Tenn.
PXKUiMONIA. 791
Case 60.— Private Fiankliu Wallace, Co. H, 12tli Teiiii. Cav.; age IG; admitted March 28, 1801, with measles.
Died April 4. Posl-moitem examination: There was inteii.so Iironchitis ou both sides; the right lung weighed thirty
oiiuces, the left twent.v-oue ounces. The heart was tlabby. The large intestine was ulcerated ; the other alidoniinal
viscera healthy. — Uotpitul Xo. 1, XasliviUc, Tiiin.
Case 61. — Private .Tames ,T. Kus.sell, Co. E, 1st Middle Tenn. Cav.; age 25; Avas admitted Nov. 16, 1802, with
pneumouia consecutive to measles. Pulse small, wiry, ISO; respiration hurried and very dilUcuU; lips livid; sputa
otien.sive and tongue pale, soli, llabhy and slightly coated; ho had frequent watery discliarges from the bowels and
considerable delirium. Death occurred on the 2"ith. Vosl-morlem examination : Hody moderately emaciated. A large
portion of the right lung was hepatized red and gray; the left was much congested; the mucous membrane of the
bronchial tubes reddened. The pericardium was extensively adherent; to the heart, which was largo but otherwise
normal: the aorta was dilated and atheromatous. The liver was congested and firm; the gall-bliidder tilled with
bile: the spleen soft and dark; the kidneys large. The stomach contained 8i.\- ounces of slimy lluid; the duodenum,
jejunum and large intestine were normal; the lower portion of the ileum reddened. — Uospital Xo. 6, Xushville, Tiiin.
Case 62.— Private John Stanton, Co. D, 1st Tenn. Cav.; age 21; was admitted Oct. 2, 1862, with measles. The
attack left him atfected with hoarseness, cough, copious expectoration and diarrluea. lie died on the 2.")th. Post-
moiliM examination: The right lung was hcpati/ed throughout, the left in lobular masses. The colon was much
contracted, appearing in its whole length like a cord about tlui'O-fourths of an inch in diameter and having its sac-
culated form entirely obliterated, its coats thickened and its mucous membrane of a dark-chocolate color; it contained
liquid fa'ces of natural appearance. — Siivgeon K. SuiJ'l, V. S. A., Uoxintal Xo. 11, Xashiille, Tom.
Case G3. — Private Samuel Armstrong, Co. E, 9th E. Teniv. Cav., was admitted Feb. 1, 1861, with nuaslcs.
Owing to exposure the eruption disappeared suddenly on the day of admission and bronchial and enteric inllamma-
tions were immediately developed. The patient rapidly sank into a typhoid condition and died delirious on the 6th.
Poxt-inorlim examination: The pia mater was exceedingly congested and the puncta vasculosa in the brain-substance
unusually well marked. The lungs weighed forty-one ounces; the n))per and posterior portions of both were he])a-
tlzed and the bronchial tubes tilled with a sanio-purulent fluid. The heart contained well-washed fibrinous clots in
all Its cavities. The nuicous membrane of the stomach was engorged with blood; the small intestine much inllamed.
the ascending and transverse colon thickened, softened and congested. The solid viscera of the abdomen apjiorired
healthy. — Act. Ass't Surgeon C. S. Merrill, Uospital Xo. 19, Xushville, Tenn.
Case 61.— Private Henry H. Eley, Co. A, 9th E. Tenn. Cav.; admitted Feb. 3, 1864, with measles. Died 22d.
rosl-mortem examination : The brain was somewhat softened and the ])ia mater injected. Both lungs were extensively
adherent: the right lung and the upper lobe of the left were congested and the l)ronchial tubes inflamed. The spleen
weighed nine ounces and the kidneys fonrteon. The other organs appeared healthy. The blood was fluid — .Jc(.
Ass'l Surgeon S. il. Olden, Uospiltil Xo. 19, Xashvillc, Tenn.
Case 65. — Private Thomas Grimes, Co. A, 9th Tenn. Cav., was admitted .Ian. 29, 1864, with measles, from which
he recovered so far as to be able to be np and about the ward. On February 15 lung symptoms of an aggravated
character were developed, and death occurred next d:iy. rosl-mortem examination: The membranes of the brain
were slightly injected. The pleural cavities contained thirty ounces of turbid liquid; the lungs weighed forty-six
ounces; the right was hepatized, the left was congested and had an a.bsce.ss in Its upper lobo. Nothing notable was
observed in the other organs. The blood was fluid. — Act. Ass't Surgeon S. M. Olden, Hospital Xo. 19, Xashville, 'Tenn.
Case 66. — Private Jasper Rice. Co. H, 10th E. Tenn. Cav., was admitted Jan. 27, 1864, with measles. Bronchial
anilentericinflammation with delirium supervened on the disappearance of the eruption. Death occurred February 8.
P«8(-iH0i-((>m examination : The membranes of the brain were congested and the puncta vasculosa unusually well marked.
The lungs were congested and weighed fifty-five ounces ; the right was adherent and the lower lolx! of the left partially
hepatized ; the bronchial tubes were much congested, thickened and softened. The heart was healthy. The liver was
enlarged and congested, the gall-bladder moderately full ; the spleen, nine ounces and a half, was somewhat softened;
the kidneys congested; the lining membrane of the ureters injected, thickened and softened ; the bladder healthy but
coittaiuing two ounces of turbid albuminous urine. The mucons membrane of the stomach was Injected and thick-
ened, of the lower portion of the ileum much inflamed, of the ascending colon and sigmoid flexure much iuflanu'd
and thickened. — Act. Asa't Surgeon C. S. Merrill, Hospital Xo. 19, Nashville, Tenn.
Case 67. — Private Joseph Reed, Co. G, 9th Tenn . Cav. , was admitted Feb. 19, 1864 , with measles. He was act i vely
delirious most of the time; dyspn(ea was a prominent symptom. Death occnrred on the 25th. Post-mortem examina-
tion : The brain was softened and its membranes injected. The lungs weighed fifty-four and a half ounces ; the lower
lobe of each was hepatized : the pleural surfaces on the right side were adherent ; the bronchial tubes Inflamed. The
cavities of the heart were dilated and their walls thickened; they were filled with fibrinous clots which extended
into the large vessels. The mucous iu(^ml)r;ine of the stomach w as reddened ; the Intestines were healthy. The liver
was enlarged, weighing seventy-three ounces, but was considered healthy; the other abdominal viscera were nor-
mal.—Jc/. Ass'l Surgeon S. M. Olden, Hospital A'o. 19, Xashrille, Tenn.
Case 68.— Private Abraham RInard, Co. B, l.'2d Ind.; age 18; was admitted March 23, 1.S65, with the eruption
of measles fading, ills tongue was dry and very red; pulse 104, sUIn dry and harsh, respiration hurried and cough
incessant ; he was very restless ami unable to speak abovea w hisp<!r. Death occurred April 2. Post-mortem e.xamina-
tiou : The left lung was hepatized and its apex infiltrated w Ith pus ; the right was hepatized in its upper lobe and
congested and infiltrated below. The pericardium contained three ounces of serum. The stomach and intestines
were enormously distended with flatus, but six inches of the descending colon and three inches of the sigmoid flexure
were contracted. The right kidney was congested. — Cumberland Hospital, Md.
792 PNEUMONIA.
Case 69. — Priy.ite Jolin C. Lang, Co. F, 59th 111.; age 17; admitted March 27, 1864, with measles. Died April 4.
Post-mortem examination : Both lungs were intensely congested, the left -sveighing twenty-six and the right thirty-
two ounces. The liver, sixty-seven ounces, seemed healthy; the spleen, eleven ounces, was of a dark-mahogany color.
The other viscera were normal. — Hospital Xo. 1, Kashvillc, Tcnii.
C.-VSE 70. — Private Stephen Martin, Co. F, 10th Ohio Cav.; age 18; admitted March 1, 18C4, with measles. Died
13th. Post-morlcm examination : There were tirm adhesions on the right side, bronchitic inflammation on both sides
and gray hepatization of the base of the left lung. The kidneys were slightly enlarged; the other viscera were
normal. — Hosin'al N.k 1, Xashvi I', Teiin.
Case 71.— Private Emmanuel Miller, Co. E, 9th Ohio Cav.; age 18: admitted Feb. 22, 1864, with measles. Died
April 1. Post-mortem examination : The right pleural cavity contained eleven ounces of liquid and the lung was
adherent, thickly coated with lymph and hepatized gray; the upper lobe of the left lung was partly hepatized. The
liver weighed seventy-three ounces; the spleen eleven and a half (funces : the kidneys six ounces each; the other
viscera appeared normal. — Hospital Xo. 1, Xashville, Tenn.
Case 72. — Private James "\V. Nelson, Co. E, 21st Ohio ; age 17 ; was admitted March 4, 1864, with measles, and
died on the 13th. Pos^-iiior/fm examination: Lungs congested and bronchial tubes inflamed. Heart healthy. Liver,
sixty-four ounces, infiltrated with fat ; spleen seven ounces ; right kidney six ounces, left seven and a half ounces. —
Hospital Xo. 1, Xashrille, Tenn.
Case 73. — Private Benjarain.F. Parker, Co. F, 12th Tenn. Cav.; age 20 ; was admitted March 6, 1864, with measles,
and died on the loth. Post-mortem examination : The bronchial tubes were inflamed and the lower parts of both lungs
hepatized. The liver weighed sixty-eight ounces; the spleen eleven and a half ounces; the other viscera were nor-
mal.— Hospital Xo. 1, Xashville, Tenn.
Case 74.— Private Hornson Penion, Co. C, 10th Tenn. Cav.; age 16; admitted March 2, 1864, with measles.
Died 23d. Post-mortem examination: There were livid spots on the face, neck and trunk. The right pleural cavity
contained thirty ounces of serum and showed other indications of high pleuritic inflammation; the lung was hepa-
tized gray posteriorly. The heart and abdominal viscera were normal. — Hospital Xo. 1, Xashville, Tenn.
Case 75. — Isaac Williamson, Government employ^; age 14; was admitted Oct. 26, 1864, with the eruption of
measles well out, and affected with whooping-cough which had troubled him for some months. Broncho-pneumonia
set in, and death occurred November 5. Post-mortem examination: The brain was healthy. The right lung was hep-
atized throughout, passing into the gray stage in the apex; the lower third of the left lung also was hepatized : the
bronchial tubes were inflamed and choked with bloody sputa. The heart and abdominal viscera were healthy. —
Hospital Xo. 8, Xashville, Tenn.
Case 76.— Private Peter M. Dowd, Co. B, 113th Ohio ; admitted March 2, 1864, with measles. Died 13th. Post-
mortem examination : The right pleural cavity contained serum ; the right lung was hepatized and adherent by recent
lymph: the left much congested and slightly adherent. The heart was healthy. The kidneys were congested; the
other abdominal viscera were healthy. — Hospiital Xo. 8, Xashville, Tenn.
Case 77. — Private George M. Higgins, Co. H, 12th Tenn. Cav.; age 18; w-as admitted March 6, 1864, with
measles, and died on the 19th. Post-mortem examination: There were many large livid spots on the face, neck and
trunk. The bronchial tubes on both sides were much inflamed; the right lung was congested posteriorly; the left
was hepatized red and largely adherent by recent lymph ; the pleural cavity was distended with seventy-seven ounces
of bloody serum. The pericardium contained four ounces of serum. The peritoneum was somewhat congested: the
liver weighed seveuty-five ounces; the other viscera were uoniia.].— Hospital Xo. 1, Xashville, Tenn.
Case 78. — Private Russell Hubbard, Co. F, 2d Mass.; admitted March 6, 1863, with pneumonia following measles.
Ho was treated at first with one-eighth of a grain of tartar emetic hourly and afterwards with calomel, opium and
ipecacuanha, with counter-irritation and nutritious diet. He died April 1. Post-mortem examination: The right
pleural surfaces were adherent in front and laterally; the sac contained a pint of turbid serum ; the middle and lower
lobes of the lung were in the third stage of inflammation ; the mucous coat of the bronchial tubes was reddened and
thickened. The pericardium contained six ounces of serum. — Third Division Hospital, Alexandria, Va.
Case 79. — Private Robert N. Peeples, Co. D, 9th Pa. Cav.; age 18; was admitted March 21,1864, with measles.
He was treated with spirit of nitre, acetate of ammonia, ipecacuanha and morphia, with counter-irritation, milk-
pituch and extra diet. He died April 2. Post-mortem examination; The right pleural sac contained a half pint of
serum, the left nearly a pint; the left lung was slightly adherent, its lower lobe hepatized. The pericardium con-
tamed an excess of serum. The liver, kidneys and spleen were healthy. — Third Division Hosjntal, Alexai.dria. Va.
Case 80. — Private Peter Reiser, Co. K, 29th Ind.; age 23; was admitted March 14, 1864, with measles, and died
ou the 28th. Post-mortem examination: The left pleural sac contained fifty ounces of straw-colored and somewhat
purulent serum ; the lung was adherent and coated with lymph ; its lower lobe was condensed. The vight pleura
contained thirty ounces of reddi.sh liquid ; the lung was much congested. The bronchial glands were enlarged. The
pericardium contained six ounces of greenish fluid and the veins of the heart were much distended. The liver was
congested; tlie spleen very large; the kidneys enlarged and granular. — Hospital Xo.S. Xashrille, Tenn.
Case 81. — Private James Colbert, Co. H, 10th Tenn. Cav.; age 18; a convalescent from measles, was admitted
March 4, 1864, with cough, accelerated pulse and breathing and lividity of countenance; there was some dulness
with sibilant rhonchus over the base of the left lung. He died on the 7th. Post-mortem examination : The right lung
was hepatized red and universally adherent; the lower lobe of the left lung was hepatized. The other viscera were
healthy. — Hospital Xo. 8, Xashville, Tenn.
PNEUMONIA. 793
Case 82.— Private John Clay, Co.G, 9th Mich.; age 21 ; wa.s .-iilmitted Feb. 28, 1864, with erysipelas of the face.
He recovered, but w.ns taken with measles followed by pneumonia. Death occurred JIarch 29. Post-mortem exami-
nation: The left lung was hepati/ed posteriorly iu its lower lobe. The right lung, heart, liver, spleen and kidneys
were normal. The intestines were not examined. — [Tosjiital Xo. 8, X(i!<liville, Tenn.
C.vSE 83.— Private James II. Smith, Co. C, 2Gth 111.; age 23; admitted March 2, 1861, with measles. Died 13th.
roHtmorteiit examination: There were firm pleuritic adhesions on the right side, bronchitis on both sides, and gray
hepatization at the base of each lung. The heart was healthy; the liver weighed seventy-six ounces, the spleen
twenty -four ounces; the kidneys were healthy. — HoKp'ttal Xo. 1, XashviUc, Tenn.
Cask 84.— Private William A. Fight, Co. D, 101th 111.; ago 26; waS admitted March 1, 1861, with measles, and
died on the 12th. Post-morttin examination: The left lung was hcpatized red and the bronchial tubes on both sides
were inflamed. The heart weighed thirteen and a half ounces: the liver seventy ounces; the spleen eight ounces;
the left kidney seven and a half ounces, the right five and a half. — Hospital Xo. 1, Xaslirille, Tenn.
Case 85. — Corp'l David C. Gays, Co. L, 9th Tenn. Cav.; age 17; was admitted March 13, 1861, with measles,
and died on the 21st. Post-mortem examination: Both lungs were adherent and much congested at the base and pos-
teriorly; the bronchial tubes were inflamed; the left pleura contained six ounces of liquid. The mucous lining of
the small intestine was congested. The other viscera were healthy. — Hospital Xo. 1, Xashville, Tenn.
CASt 86.— Private William Coins, Co. I, 9th Tenn. Cav.; admitted March 13, 1861, with measles. Died 30th.
Poft-morttm examination: There were pleuritic adhesions on botli sides; the right lung was liepatized gray in its
upper parts and red in its lower lobe; the left lung was hepatized gray In its apex and much engorged below. The
heart was healthy. The liver, seventy-eight ounces, was Infiltrated with fat ; the spleen and kidneys were normal.
There were patches of congestion In the lower two-thirds of the iU'um and in the ca'cum; the colon and rectum were
healthy. — Hospital Xo. 1, Xa.ihrilli-, Tenn.
Case 87.^Privato George HotVman, Co. C, 3(1 Ohio Cav.; age 19; was admitted .March 2, INUt, with measles,
and died on the 9th. Post-mortem examination : Extensive bronchitis in both lungs and red hepatization of the lower
lobe of the right lung. The lower ileum and large intestine were much congested; the other viscera appeared
healthy. — Hosjjital Xo. 1, Xashville Tenn.
Case 88.— Private Alfred J. Kite, Co. C, 9th Tenn. Cav.; age 25; admitted March 15, 1861, with measles. Died
16th. Post-mortem examination : The lungs were hepatized red and the bronchial mucous membrane on Ijoth sides
inflamed. The liver weighed sixty-seven ounces; the spleen sixteen ounces; the kidneys were pale and soft: the
other viscera normal. — Hos2>ital Xo. 1, Xashrille, Tenn.
Case 89.— Private John Jefters, Co. L, 9th Ohio Cav.; age 20; admitted Feb. 22, 1864, with measles. Died 28th.
Post-mortem examination: The left lung, twenty-nine ounces, was bound by strong adhesions, its upper lobe hepa-
tized gray and its lower lobe congested; the right lung, twelve ounces, was engorged in its upper lobe posteriorly,
its bronchial tubes much inflamed. There were large clots in the cavities of the heart. The liver adhered to the
diaphragm. The spleen, kidneys, stomach and intestines were healthy. — Hospital Xo. 1, Xasliville, Tenn.
Case 90. — Private George W. Bronson, Co. B, 143d Pa.; age 17; was admitted March 17, 1864, with measles
and pleuro-pneumoiiia. He died April 5. Post-mortem examination: The left jileural cavity was filled with serum
and the lung compressed, softened and covered with lymph. — Third Division Hospital, Alexandria, )'«.
Case 91. — Alfred E. Stephens, Government employe; age 24; admitted March 10, 1864. He was treated on
the expectant plan until the 21st, when, as the expectoration was scanty and the breathing laborious, carbonate
of ammonia and whi.skey-toddy were administered. Died 24th. Post-mortem examination: The right pleural cavity
contained eight ounces of serum and the lower lobe of the lung was hepatized and adherent; the left lung was
slightly adherent, softened and broken down. The liver was enlarged and presented the nutmeg appearance; the
spleen normal; the kidneys somewhat enlarged. — Hospital Xo. 8, Xashrille, Tenn.
Case 92.— Private Napoleon Price, Co. D, 13th E. Tenn. Cav., was admitted Feb. 16, 1864, with double bron-
chitis following measles. He died April 9. Four days before death he became unconscious and had subsultus ten-
diuuni. He was treated in secjueuco with Dover's powder and nitrate of potash, mercury with chalk, turpentine
emulsion, carbonate of ammonia, with milk-punch, beef-essence, and a blister to the nape of the neek. Post-mortem.
examination: Body much emaciated. The left lung was congested, as was also the lower lobe of the right lung; the
remainder of the right lung was hepatized red, passing in iiarts into the gray stage. The heart was p.-ile and con-
tained a fibrinous clot in its right ventricle. The liver, spleen and left kidney were healthy; the right kidney was
slightly inflamed; the ileum congested iu patches.— I/o.y«(«7 Xo. 8, Xashrille, Tenn.
Case 93.— Private William Lynch, Co. C, 90th Ohio; age .32; was admitted March 14, 1861, with measles.
\\ hile convalescing he was attacked with pneumonia and a few days later with pleurisy. He was treated with
expectorants, diuretics and warm poultices, followed, iu the progress of the case, by carbonate of ammonia and milk-
punch. He died on the 29th. Post-mortem examination: The left pleura contained thirteen ounces of serum and the
lung was hepatized in parts and firmly adherent; the right cavity contained thirty ounces of serum and the lung
was covered with organized lymph and hepatized in its middle and lower lobes. The heart was dilated, its left
ventricle hypertrophied. The liver was enlarged and of the nutmeg appearance; the spleen and mesenteric glands
enlarged; the kidneys healthy.— Hospital Xo. 8, Xashrille, Tenn.
Case 94.— Private William II. Robinson, Co. D, 71st Ohio, was admitted March 11, 1864, with measles. He
was taken with pain in the right side on the 25th, and died on the 29th. Post-mortem examination: The left lung
Med. Hist., Pt. Ill— 100
794 PNEVMOXIA.
was much congested: the right pleural cavity contained a large quantity of serum and the lung was hepatized red
and gray. The heart and spleen were healthy; the kidneys congested. — Bospital Xo. 8, XashvUle, Temi.
C.\SE 95. — Private James Dyre, Co. C, 12th Tenn. Cav.; age 18; was admitted Feb. 23, 1861, with pneumonia
following measles. He died March 3. Post-mortem examination: The right lung was hepatized red. passing in parts
into gray; the livonehial tubes of the left lung were injected. The heart was normal. The abdominal viscera were
not examined. — Hospital Xo. S, Xashvillc, Tenn.
Case 96. — Private William Davis, Co. D, 192d N. Y.; age 19; was admitted April 5, 1865, with a slight cough,
without fever, pain or other symptom. On the lOtli he had a chill, followed by febrile action, suffusion of the eyes,
cough and constipation. Four days later the eruption of measles appeared on the chest and face. He died on the
20th. Posi-mortcm examination : The left pleural cavity was filled with serum ; the left lung was coated with lymph,
congested generally and its lower lobe partially hepatized ; the right lung was congested ; the bronchial tubes of both
lungs were filled with muco-pus. The liver was congested. — Cumberland Honpilal, Md.
Case 97. — Private Edwin B. Awker, Co. (j, 193d Ohio; age 18; was admitted March 17, 1805, in feeble condi-
tion and with hiirried and difficult respiration following an attack of measles. He sank into a typhoid condition,
became comatose, and died on the 27th. Foil-mortcm examination: Both lungs hepatized and infiltrated with pus.
Heart normal. Liver enlarged; spleen twenty-seven ounces. — Cumberland Hospital, Md.
C.\SE 98. — B. L. Hamson, Co. C, 13th Ky.; admitted Feb. 19, 1865, with measles and pneumonia. Died March
11. Post-mortem examination: The upper lobes of both lungs were normal, the other parts highly congested. The
heart was normal. The stomach, liver, spleen and kidneys were healthy: the middle third of the ileum inflamed. —
Act. Ass't Siinjeon J. E. Brooke, Hospital, Pock Island, III.
Case 99.— Private A. K. Willard, Co. A, 8th Me. r age 18; was admitted April 29, 18G4, with the eruption of
measles just appearing. The mucous membrane of the throat was highly injected, but there was no marked cough
and no delirium, although the mind was dull. Pulmonary symptoms became prominent May 1; loud, .sonorous and
mucous rales were heard all over the chest posteriorly; delirium quickly followed, and the patient died at 2 p. M.
Post-mortem examination: Body greatly discolored, especially in the dependent parts. The brain was not examined.
The lungs were congested. Xo other abnormal appearance was observed. — Cuyler Hospital, Pliiladelpliia , Pa.
C.\SE 100.— Private William Six, Co. D, 174th Ohio; age 18; admitted Feb. 6, 1865, with measles. Died 11th.
Post-mortem examination: The lungs were congested and firmly adherent: the bronchial tubes filled with brownish-
white mucus. The left ventricle of the heart contained a firiEi clot. The liver was normal; the peritoneal covering
of the intestines congested. — Stanton Hospital, Waslmngton, D. C.
Case 101. — Private Edward Xewton, 5th N. Y. Heavy Art'y; age 19: was admitted March 5, 1864, with measles.
He died on the 12th. Post-mortem examination : The left x^leural sac contained much efiusion and the lung was exten-
sively adherent and hepatized. The duodenum was inflamed and there were ulcers in parts of the intestine. — Third
Division Hospital, Alexandria, Ta.
Case 102.— Private James Mallory, Co. A, 36th Ind.: admitted Feb. 19, 1864, with measles. Died 27th. Post-
mortem examination : The brain was healthy, its membranes engorged with blood. The lungs weighed fifty-four
ounces: the bronchial tul>es were inflamed to their ultimate ramifications. The heart contained a fibrinous clot.
The stomach and large intestine were healthy; the ileum inflamed. The spleen weighed tliirteen ounces : the other
viscera appeared normal. — Act. Ass't Surgeon Geo. TV. Poherts, Hospital Xo. 19, Xashrille, Tenn.
Case 103. — Private Alfred Vaughn, Co. D, 1st Tenn. Art'y; admitted Feb. 13, 1864, with broncho-pneumonia
after measles. Died 26th. Post-mortem examination: The membranes of the brain were somewhat injected. The
right pleural cavity contained fourteen ounces of liquid; the lungs weighed forty-four ounces; the lower lobe of the
left lung was hepatized ; the bronchial tubes inflamed throughout. The heart was flabby and contained fibrinous
clots. The liver, seventy-three ounces, was soft and mottled with gray; the spleen, nine ounces, was very soft; the
other viscera were healthy. The blood was fluid. — Act. Ass't Surgeon S. J/. Olden, Hospital Xo. 19, Xashrille, Tenn.
Case 104.— Private a. Carr, Co. F, 1st Conn. Cav.: age 16: was admitted Jan. 31, 18(U, with measles, and died
February 8. I'ost-niortem examination : The left lung was congested and tlie pleural cavity contained three ounces ot
pus; the right lung was infiltrated with pus. The pericardium contained four ounces of serum. The liver was hyper-
trophied and soft; the spleen soft and congested. — Act. Ass't Surgeon B. B. Miles, Jarris Hosjtital, Baltimore, Md.
Case 105. — Private Jacob Maust, Co. K, llGth Pa.; age 20; was admitted March 26, 1864, moribund from pneu-
monia after measles. He died on the 28th. Post-mortem examination; The left pleural cavity contained a pint of
serum and the lung was coated with thin pasty lymph, its lower lobe being partly hepatized. [Sjyecimen 343, Med.
Sec, Army Medical Museum.]— Siici/fow E. Bentley, U. S. Vols., Third D>vi.-<iun Hospital, Alexandria, Va.
Ten cases notable onli/ in having coejcisting tnhrrcle.
Case 106.— Private ^Villiam Wilcox, Co. D, 12th Tenn., was admitted Feb. 28, 1864, with measles, and died
March 27. Post-mortem examination; The right lung was hepatized, in some parts passing into the gray stage; the
upper lobe of the left lung was congested and its apex contained tubercle. The heart was normal. The spleen was
somewhat enlarged; the other abdominal viscera healthy.— Hospital Xo. 8, Xashrille, Tenn.
Case 107.— Corp'l Henry Walker, Co. A, 9th Tenn. Cav., was admitted March 19, 1864, with measles. After the
eruption faded cough, on the 30th, became severe and attended with frothy expectoration and mucous rales. On April3
crepitation was heard over the right lung. Death occurred on the 26th. Post-mortem examination: The lungs were
PNEUMONIA. " 795
lu-patized red, in some parts gray; miliary tuborclo was almiuhuit in the apex of eaili. The heart . spkHii and kidm-ys
were healthy; the ileum much congested. — Uosjiilal \o. H, ydshrillf, Teiin.
Cask 108. — Private Daniel C. Powell, Co. II, Ith Iowa, was admitted Mareli 111, lf<04. with measles. I'mnniouia
supervened, anil lie died Ajiril 3. Post-iiioilim examination : lioth lungs were adherent to the parietes, liepatized in
their lower and lilled with tubercle in their npjier parts ; there was an abscess in the upper lolie of tlie left lung. Tlie
heart, spleen and intestines were healthy, the kidneys somewhat engorged. — Suri/ion It. T. I'crsonn, \sl Jl'is. Car., Ilo-i-
pilul Xo. 8, yushiille, Teiiii.
Case 109.— Private Alfred P.Sisk, Co. II, 12th Teun. Cav.; age 18; was admiltod ilarch 9, 1861, with measles,
and died JIarch 17. ront-morlcm examination: The left lung contained much tubercle; the right lung posteriorly
was liepatized in patches: the bronchial tubes on both sides were highly inllamed and lilh'd witli nnico-pus. The
heart was healthy. The liver, ninety-two ounces, was light-yellow: the spleen, nineteen ounces. d:ii k and pulpy: tlie
kidneys healthy. — Ilosjiiliil Xo. 8, Xashvillf, Tcnii.
Cas^k 110— Private William II. Yerks, Co. I. fith X. Y. Heavy Arty: ago 115; was admitted Feb. 10, 18lil, with
scrofulous bubo. On March 5 he was attacked witli measles. Pleuro-pueumonia supervened and proved fatal on
the 23(1. 7'i).s(-iHi))-(rHi examination: Larynx and trachea inllamed. Left luughepatized throughout : right containing
uusofteued tubercle in its upper portion. — Third Dirisiun Hospital, .Ihxandria, Va.
Case 111. — Private Lemuel Carmlchael, Co. H, 9th E. Tenn. Cav., was admitted Feb. 6, 1801, with pncuMionia,
following the retrocession of measles, lie died on the 14th. rost-iiwrtcm examination: The membranes of tlic brain
were injected. There were firm adhesions and empyema on the left side; the lungs weighed fifty-one ounces and
were inllamed; the left lung was affected generally, the right partially: the apex of the right contained a few small
tubercles; the bronchial tubes were inflamed throughout. The right ventricle of the heart contained a large fibrinous
clot. The stou\ach was inlhimeil and thickened; the small intestine injected, the large intestine inllamed and thick-
ened. The liver was enlarged and softened; the spleen, four ounces, was pale and soft : the kidneys healthy. The
blood was fluid. — Jet. As^'t Surgeon S. M. Olden, Hospital Xo. 19, Xasltrille, Tenn.
Case 112. — Private James S. Weaver, Co. B, 9th E. Tenn. Cav.; admitted Fob. li, 18G1, with measlefe. Died 14th.
Posl-niorlim examination: The brain apjieared healthy. Tho lungs weighed tifty-oue ounces; pneumonia was general
in both : miliary tuliercle was deposited in tlie right lower lobe; the bronchial tubes were inflamed. Tho right side
of the heart contained clots. Tho stomach and intestines were dark and injected; the solid viscera dark-colored but
otherwise normal. The blood was dark and liuid. — Act. Ass't Surgeon S. M. Olden, Hospital Xo. 19, Xanlirille, Tenn.
Ca.se 113. — Private William H. Davis, Co. K, 10th Ohio Cav., was admitted Feb. 9, 18(!1, with measles, and died
on the lOth. ]'o-il-mortcm examination: The membranes of the brain were somewhat injected. The lungs adhered
to the costal pleura and were congested and filled with miliary tubercle; the lower lobe of the left lung was liepa-
tized; the right lung contained a cavity; tho bronchial tubes were inflamed. The heart was filled with coagula.
The stomach was congested ; the other viscera normal. — Act. Ass't Surgeon T. If. Hammond, Hosj'italXo.W, Xaahvillc, Tenn.
Case 114. — Private Henry P. Shoals, Co. 1, 1st Conn. Cav.; age 19 ; admitted Jan. 26, 1864, with measles. Died
March 7. I'osl-niortem examinafion: The right lung was condensed and the pleural sac contained fifteen ounces of
sernm; the left lung was adherent and liepatized, its apex tuberculous. The jiericardium contained four ounces of
clear serum. The liver was normal ; the spleen soft. — Jet. Ass't Surgeon B. B. Miles, Jarvis Hospital, Baltimore, Md.
Case 115.— Private Royal Kedick, Co. C, 1st Wis. Cav., was admitted Feb. 21, 1864, with measles, and died on
the 26th. Post-mortem examination: The brain was much injected and its niembi-aues engorged. There were recent
adhesions and twenty-four ounces of straw-colored serum in the right pleural cavity; the lungs weighed forty-eight
ounces; both were tuberculous, the right presenting absces.scs and the left cretaceous deposits; the bronchial tubes
were inllamed. The kidneys were congested ; the ileum inflamed; the other organs healthy. The blood in the veins
was fluid. — Jet. Ass't Surgeon Geo. W. Soherta, Hospital Xo. 19, Xashville, Tenn.
Tuo rases terminated in gangrene.
Case 116. — Private Henry Warner, Co. K. 1st Ohio Cav.; age 33; was admitted March 23, 1S64, convalescing
from measles. Pneumonia supervened, and death took place April 2. Post-mortem examination: The left lung was
adherent and gangrenous; the right healthy. The spleen and kidneys were healthy. — Hospital Xo. 8, Xashrille, Tenn.
Case 117.— Private John Mullen, Co. H, Gtli Mich. Cav.; age 16; was admitted Feb. 13, 1864, with measles. He
died on the 2.5th. Post-mortem examination: Kight pleural cavity lined with lymph and filled with liquid; circum-
scribed gangrene of the lower lobe of each lung. Other organs healthy. — Third Dirision Hospital, Alexandria, Va.
Four cases eomplicated with erijsipelas.
Case 118.— Private David Illand, Co. U, igist Ohio; age 23; was admitted Ai>ril 4, 1805, with acute bronchitis
after measles. On the lltli erysipelas, which was prevalent at this time, appeared on the face. Death took place on
the 14th. Post-mortem examination: Tho mucous membrane of the larynx and trachea was inflamed and thickened:
the epiglottis (edematous. The lungs were congest(Ml and the bronchial tubes loaded with muc()-])us. The liver was
congested and friable; the spleen congested and indurated: tlic iiiiicous membrane of the ileum inflamed, tbickencd
and easily removed. — Cumberland Hospital, Md.
Case 119.— Private W. H. Skuggs, Co. K, 21st Ky.; age ^li; admitted March 14, 1864. Erysipelas set in on ihc
22d, and he died delirious on tho 24th. Post-mortem examination: The brain was congested. The bronchial tubes
were inflamed; the lungs congested and somewhat adherent; each pleural sac was distended with thirty ounces of
796 PIIEUMONIA.
liquid. The pericanlium contained six ounces of serum. The liver i^resented the nutmeg appearance; the spleen
and kidneys -n-ore normal.— -ffo.sjjHai ^'o. 8, Xashvilk, Tenii.
Case 120. — E. C. Taylor, Co. A, 27th Ala., was admitted March 3, 18G.5, with measles. He was attacked on the
7th with erysipelas of the face, and died on the 10th. rost-moi-tem examination: The tongue was lilack and fissured,
shortened and thickened; the (esophagus reddened and coated with dark patches. The left Inng Avas hepatized red,
softened in its upper andpo-sterior portions and tuberculous iu its apex; the right lung was engorged. Other organs
normal. — Act. AssH Siirijcon JV. MaWteus, Hosjjital, Itotk Island, III.
C'.vSE 121. — Private Frederick A. Blackman, Co. H, 28th Mich.; age 17; W4S admitted Jan. 30, 1865, with fever
and eoryza. The eruption of measles appeared next day, followed on February 2 by pneumonic symptoms in the
lower lobe of the right lung and on the 6th by jileurisy on the left side. The fever abated on the 10th, but the area
of dulness on the left side of the chest extended as high as the fourth rib. On the 14th erysipelas of the face set in,
and on the 18th the patient died. Post-mortem examination : The left pleura, which was covered with soft whitish
exudation, contained one pint and a half of serum; the lower lobe of the left lung was much engorged; the lower
lobe of the right lung hepatized. The other organs were normal. — Third Dirision Hospital, Ahxandria, Va.
Ill four cnsis intlniininitioii of the hraiii or its iiiciiihraiies iras ohscrced.
Case 122.— Private John GriflBth, Co. H, 128th N. Y.; age 16; was admitted April 3, 1864, with measles, and
died on the 9th. Post-mortem examination: The eruption was faintly visible iu some parts of the body. The mem-
branes of the brain gave exit to a quantity of blood and serum; the sinuses were filled with blood ; the upper sur-
face of the hemispheres was covered with patches of soft and recent exudation; the puneta vasculosa were marked;
a small blood-clot was found beneath the anterior commissure; the lateral ventricles contained a half ounce of serum
and the choroid vessels and velum interpositum were congested; a slight recent exudation was observed along the
fissure of Sylvius, the vessels of which were congested ; the pons Varolii was softened ; the cerebellar puneta marked.
The lobesof the right lung were interadherent and hepatized gray except in the anterior part of the lower lobe, which
was congested; the left lung was adherent to the costal pleura and hepatized in its posterior part; together the lungs
weighed seventy ounces. The bronchial glands were enlarged, yellowish and softened; those at the bifurcation of
the right primary bronchus were softened into a reddish-brown mass. The mucous membrane of the trachea was
iiright-red in color. The heart contained dark clots. The liver and spleen were healthy: the kidneys congested.
The stomach was congested at its cardiac extremity; the duodenum and jejunum reddened ; the ileum and large intes-
tine of a dark port-wine color in patches; the solitary follicles thickened. — Hospital Xo. 1, Xashrille, Tenn.
Case 123. — Private Elijah Matosh, Co. B, 130th Ind.; age 37; was admitted March 30, 1864, with measles, and
died April 9. Post-mortem examination: Some bloody serum was found in the membranes of the brain; a little soft
and recent exudation on the upper surface of the hemisiiheres ; many puneta vasculosa ; some liquid in the lateral
(ventricles; congestion of the choroid plexus and velum interpositum; softening of the cerebellum and pons. The
.-iiterior border of each lung was adherent to the pericardium ; the lungs presented large bluish-brown patches which,
when cut into, exuded bloody serum; they weighed tifty-seven ounces. The trachea and bronchi were much con-
gested and the bronchioles filled with purulent liquid ; the bronchial glands were enlarged, greenish-gray in color
and softened. The heart contained a yellow clot in (he right ventricle. The liver and kidneys were congested; the
spleen healthy; the ileum and part of the ca'Cum and rectum darkly congested. — Hosjiital Xo. 1, Xashrille, Tom.
Case 124. — Private Harvey Bales, Co. G, 9th Tenn. Cav.; a robust man, about 30 years of age; was admitted
Jan. 30, 1864, with bronchitis following measles. Head synqitoms of a sthenic character soon appeared, and death
occurred February 4. Posf-morfem examination: The membi'anes of the brain were inflamed, as shown bythe presence
of coagulable lymph, strawberry-colored, iu small quantity in the lateral ventricles and congestion of the choroid
plexus. The lungs were congested and weighed sixty-three ounces ; the bronchi were inflamed and charged with pus ;
the apex of the right lung was adherent. The pei'icardium contained one ounce of bloody serum; the endocardium
was stained red and the ventricles filled with fibrinous clots. The mucous coat of the stomach was dark-colored,
inflamed and thickened; the intestines healthy. The liver was normal; the spleen weighed nine ounces; the kidneys
were congested; the urine normal. — Act. Ass't Surgeon G. 71'. Poberts, Hospital Xo. 19, Xashrille, Tenn.
Case 125. — Private Robert Smith, Co. E, 59th Ind.; age 20 ; was admitted April 8, 1864, with measles. The erup-
tion had appeared on the 1st and was no longer visible. On the 10th the patient had diarrha^a and cough with muco-
purulent expectoration. Low delirium with much prostration was developed on the 12th; the tongue became dry
on the tip and middle, red and moist on the edges ; the teeth covered with dark sordes ; the respiration much accel-
erated and the pulse ultimately imperceptible. He died comatose on the 16th. Post-mortem examination: The mem-
branes of the brain were congested ; the pia mater was opaque along the course of the vessels, and there was a slight
exudation of fibrin on the surface of the brain. The right pleural cavity contained fourteen ounces of sero-iibrinous
fluid and there were some pleuritic adhesions ; the upper and middle lobes of the right lung were hepatized red, and
towards the apex the upper lobe contained a quantity of cheesy tubercle which was for the most part immediately
beneath the pleura, extending only about a quarter of an inch into the parenchyma ; the left lung was normal ; the
mucous membrane of the bronchial tubes was inflamed in both lungs. The stomach was injected in patches and
contained about thirty-two ounces of greenish liquid. The other viscera were normal. — Chattanooga Hospital, Tenn.
Six doubtfully u-itk iiiphoid fever.
Case 126.— Private Robert P. Patterson, Co. H, 123d Ind.; age 21; was admitted April 3, 1864, and died on
the 9th Post-mortem examination: The membranes were readily detached from the brain ; the subarachnoid space.
PNEUMONIA. ■ 797
contained two ounces of liquid and the lateral ventricles a half ounce; the cerebral veins were injected and the
choroid jjlexus and velum interiiositnni congested; there were many vascular points in the cerebrum and cerebellum;
the gray substance was softened. The lungs weighed fifty-three ounces and were congested posteriorly and hepatized
in patches. The larynx and trachea were congested; the bronchi congested and charged with mueo-pus; the bron-
chial glands softened. The riglit side of the heart contained fibrinous clots. The liver and spleen were healthy; the
kidneys congested. The small intestine was congested and its glands thickened. — Ilospitnl Xu. 1, Xtishvillc, Tani.
C.vsE 127. — Private Juo. H. Kobbinson, Co. 15, 31st Ky.; age 21; was aduiilted March V^, 1864, with measles,
and died April 10, rost-mortim examination : l!ody emaciated; slcin jaundiced, particularly on tlic face. Lungs col-
lapsed: left lung adherent at base, the lower lobe hepatized and at various points softened and infiltrated with
puruloid liquid and the upper lobe congested in its posterior part; right lung congested posteriorly; bronchioles
tilled with yellow mucus; larynx healthy; trachea slightly congested. Liver much softened and lining membrane
of hepatic veins deep-red, nearly jiurple; spleen normal in size but pale-pink in color. Mucous membrane of snuiU
intestine pale and presenting ol)long patches of thickened glands at irregular distances as far as the ileoca'cal valve,
near which the solitary follicles became (juite distinct. — Uonjiital Xo. 1, Xashrillc, Tenn.
C.\SF, 128. — Private John Priest, Co, F, 3tjth Ohio; age IS; was admitted March 14, 18154, with measles. Diar-
rhtca supervened on the 20th, with considerable bronchial trouble and hoarseness of voice; but in a day or two the
patient iuiprovtd and was able to be up ami abnut the ward. On April 1 he was obliged to return to bed, and delirium
supervened during the night. Cough became troublesome: nnicous rales were heard on the left side, and on the 4th,
the delirium continuing meanwhile, the pulse was 100 and the respiration 50, Sweet spirit of nitre, paregoric elixir
and cyanide of potassium were prescribed, with cold applications to the head. Death occurred on the 7th, Post-
mortem examination : The membranes of the brain were congested. The left pleural sac contained thirty-two ounces
of tluid ; the left lung was compressed, carnified and coated with lymph ; the right lung was slightly congested. The
liver was fatty. The mucous membrane of the stonuich was injected ; Peyers patches, near the ileociecai valve, were
enlarged. The remaining viscera were normal. — Surycon Fnineis Saltm; C S. Vols., Chattanooga Hospital, Tiini.
C.\SE 129. — Private William Sugars. Co, H, 132d Ohio; age 21; was admitted June 15, 1864, with enteritis con-
secutive to measles. On the 2;tth the abdomen was tender, the bowels loose and the chest i)aiuful on the right side;
there was much tliirst and the tongue was furred and brown. On .July 4 the bowels were less irritable and the
cough slight, notwithstanding some dyspncea. On the morning of the 7th delirium was present but subsided by 11
A. M. At 2.30 r. M. his limbs becam<< suddenly drawn u)), his head bent on his shoulders, eyes open and glaring, face
turgid and the veins everywhere much engorged. Death followed almost instantly, rost-mortem examination; The
cerebrum was softened and its vessels sonunvhat injected. The lower lobe of the right lung was much congested,
the middle lobe healthy, the upper lobe hepatized red posteriorly and gray anteriorly; the lower lobe of the left lung
was hepatized gray in its posterior and lower part and elsewhere thoroughly engorged, the upper lobe congested
posteriorly; the bronchial mucous membrane was much inflamed; the right luug weighed twenty-eight and a half
ounces, the left twenty-five ounces. The pericardium contained four oiinces of liquid; the heart was fiabby; its
right ventricle contained a large fibrinous clot extending into the pulmonary artery and its left ventricle a smaller
but similar clot. The liver was flal)by ; tlie spleen, ten ounces, was soft and pulpy; the solitary follicles w ere enlarged,
and a Peyer's patch just above the ileoca'cal valve was somewhat thickened. — Lincoln Honpital, Wnshinijton, D. C.
C.X.SE 130.— Private William A. Kager, Co. B, 13th Pa. Car.; age 15 ; was admitted March 23, 1864, with measles.
He was treated with sweet spirit of nitre, acetate of amnumia, ipecacuanha, morphia, stimulants, expectorants, opi-
ates occasionally to check diarrhcoa, turpentine stupes to the chest and throat, sinapisms to the feet, and warm sponge-
bathing followed by brisk hand-rubbing; beef-tea and milk-punch were also given. At times the patient's face
became livid during attacks of dyspncea. He vomited several lumbricoid worms. Death occurred April 4, rost-
mortem examination : The lungs were emphysematous and the bronchioles filled with secretion. The pericardium
contained an excess of liquid and the ventricles large fibrinous clots; Peyer's patches were somewhat thickened.
The other organs were healthy, No lumbricoid worms were found, — Tlnrd Division Hospital, Alexandria, Va.
C.^SE 131.— Private Luther Mitting, Co, H, 28th Mich,; age 19; was admitted Feb, 11, 1865, with measles. The
eruption disappeared on the 19th, and next day the patient had much pain in the chest and a cough with copious
blood-stroaked sputa. On the 23d he had severe diarrhoea, hurried breathing, sordcs on the teeth and delirium. He
died on the 25th. Post-mortem examination : There were no adhesions, Imt the pleural cavity contained a small quan-
tity of serum ; the lungs were small and congested; the posterior part of the lower lobe of the right hing sank in
water and a bloody liuid escaped from it on section. There was an excess of serum in the pericardium; the heart
contained clots. The peritoneum was thickened; the liver enlarged and congested; the gall-bladder distended.
There were patches of congestion in the small intestine and the agminated glands were softened. — Third Oivision
Hospital, Jlexandria, Va.
Three leith laryngitis.
Case 132.— Private Henry Morin, Co. H, 192d Ohio: age 16; was admitted March 31, 1865, with syphilis and
pneumonia following measles. He was aphonic, his skin hot, pulse 110, breathing labored. Typhoid symptoms
developed April 8. and death occurred on the 15th. Post-mortem examination : Larynx and trachea intlamed through-
out; epiglottis O'dematous: vocal cords thickened. Lower lobe of left lung adherent to costal pleura and diaphragm;
right lung congested and infiltrated with pus. — Act.Ass't Surgeon Sample Ford, Cumberland Hospital, Md.
Case 133.— Private Charles Arnold, Co, C, 19th Ohio; age 19; was admitted April 5, 1865, with severe dyspntea,
urgent dry cough, hoarsenetis, small and feeble pulse and copious diarrhoea occurring after measles. He died on the
798
PNEUMONIA.
ITtli. rost-morhm examination: Face and upper i^ait of body livid. The thyroid slann was en.arsed and infiltrated
with pus: the epiglottis a'dematous ; the larynx, trachea and bronchi infiltrated, thickened and filled with tenacious
mucus and bloody serum. The right lung was coated with, lymph and infiltrated Avith pus : the upi)er lobe of the
left lung was congested but pervious to air, and the lower lobe was hepatized. The liver and spleen were normal.
The stomach was congested and presented a large ulcer near the cardiac end; the ileum, near its termiuatioii, was
inflamed and thickened; the stomach and colon were much distended with air. — Cumberland Hospital, Md.
C'.\SE 134. — Private Johu H. McMichael, Co. K, 5th Pa. Cav.; age 19 ; was admitted March 11, 18G4, with pleurisy
and laryngitis consecutive to measles. Hot pediluvia were employed, with cups to the chest and tobacco poultice to
the larynx; saline cathartics were followed by wine of ipecacuanha, stimulants and beef-tea. He died on the 23d.
Post-mortfin examination: Larynx and trachea inflamed and filled with tenacious mucus: right lung collapsed and
friable, its lower lobe thickly coated with pseudomembrane — [Specimeri 342, Med. Sec, Army Medical Museum]: left
lung slightly congested. — Snrijco)i E. Bentleij, V. S. Vols., Third Dirisioii Hospital, Alexandria, Ta.
One case douhtftiUi/ wilh pericarditis.
Case 135. — Private Joseph Watts, Co. I, 1st Tenn. Art'y, was admitted Feb. 13, 1864, with severe pneumonia
consecutive to measles. Death occurred on the 23d. Posi-mocfem examination: The brain was congested. The lungs
were bound by recent adhesions and weighed fifty-eight ounces ; the upper lobe of each was hepatized ; the bronchial
tubes inflamed. The pericardium was adherent over the right auricle; the heart contained a large fibrinous clot in
each side. The peritoneum was inflamed and adherent ; the stomach and small intestine inflamed and thickened,
the upper portion of the large intestine ulcerated. The solid viscera appeared noruuil. — Act. Ass't f'uryeon !S. M.
Olden, Hospital Xo. 19, yashviUc, Tenn.
AX.\LYSIS OF THE POST-MOr.TEM APPEAK.VXCES IX OXE IIUXPRED AXD THIRTY-FIVE C.\SES OF SECOXDAUY rXETMOXlA.
The following tabulation presents the stated conditions of the LUXGS in the one hundred and thirty-five cases:
Kight lung.
Left lung.
Upper
lobe.
Lower
lobe.
Upper Lower
lobe. 1 lobe.
Congestion or engorgement _
32
54
31
C5
6
40 34
43 CO
f, G
1 1
1 2
Gangrene _
i
1
1
1
2
2
1
1
2
Emphysema _ ^ _
1 1
! 1 t
Collapse
1 2
Compression _ _ _
Diseased conditions
98
3
34
no !
2
23
'.lo 109 t
4 3
31) I 23
Not stated
Total
135
135
135 1 135
In acccKrdance with the numbers in this statement the left lung was affected in its npper lobe in 70.4 per cent,
of the cases, iii its lower lobe in 80.7 per cent.: and the corresponding lobes of the right lung in 72.6 and 81.5 per cent,
respectively. The greater liability of the lower lobes to hypera-mic conditions is shown in the.se cases, as in the lobar
series ; but the predilection for the right lung, evident in the latter, is not here so strongly marked. Both lungs are,
perhaps, equally susceptible to invasion by the products of inflammatory processes in the air-passages. This is shown
by the few cases in which one lung is said to have been normal or healthy and the other diseased. In two cases, 82
and 116, the right lung was normal, although in the latter the opposite lung was gangrenous; and in three cases, 51,
57 and 125, the left was normal although the right was hepatized and more or less infiltrated with purulent matter.
The lower and posterior portions of each lung were more freriuently the site of congestion and lobular solidification
than the np^er and anterior portions; and where both were aftected the diseased conditions were generally mora
advanced in the former than in the latter situation. Cases 22, 31 and 122 may be indicated among many as illus-
trating this general law in the distribution of lobular pneumonia. But exceptional instances occurred, as in cases
24, 36, 135 and 129; in the last mentioned the middle lobe of the right lung is said to have been healthy, the lower
congested and the upper hepatized, red in its posterior portion and gray anteriorly.
In some of the cases in which the condition of neither of the lungs is specified the existence of pneumonia may
be questioned, as in 48, 60 and 102, in which the weight of the lungs is the only evidence of pulmonic disease as con-
tra.-distinguished from capillary bronchitis; so also in the emphysenux of 130 and the tubercular deposits of 115.
Cases in which the lung or a portion of it is said to have been condensed, collapsed or compressed always pre-
sented an associated causative pleurisy, as in 22, in which both lungs were aftected: 114 and 134, the right lung: 90
and 128, the left lung; 21, the lower lobe of the right lung, and 40 and 80, the lower lobe of the left lung.
CilicrMSCKiBED ruKUi.EXT coLLECTioxs Were rare: The left lung in case 6. the lower lobe of the right lung
in 50, the upper lobe of the left in 65 and the lower lobe in 56 presented cavities containing purulent matter. In addi-
tion to these, abscesses were found in the tubercular cases 108 and 115; cheesy abscesses were observed in 29 and
cheesy tubercle in 125.
PNEUMONIA. 799
TriiEHcn.Ai! DEPOSITS are said to have l)oon ol)scive(l in the twelve cases, 106-115 and IL'O and iLTi. They were
coi'ilined to the apex in lOG and 107, to the rijj;ht lower lobo in 112. Abscesses were noted in the K'I't lung in IMS and
abscesses and cretefications respectively in the right and left side in ll.'i.
tiAXUKKNK was noted in three cases, forming a nia.-s in tlie right lung in 11, ati'ecting the left lung in lUi and
the lower lobes of both lungs in 117.
The TKACllK.v and iiuoxchial TcnKs are mentioned in seventy-five of the cases. They are said to have been
vascular in one, reddened in m"x and congested in liijhl ; in many of these the mucous membrane was regarded as thick-
ened and softened. Iwfiflij ca.ses the tubes were recorded as inllamed, in one of which, 33, the lining membrane was
gangrenous in patches; in two eases, fi and 8, the tubes were dilated; in one, US, the membrane was thickened and
ledeniatous. In the renniining seven cases the contents only of the tubes were noted — secretion in 130, brownish-white
nuicns in 100, yellow mucus in l'i7, nnnus streaked with blood in 3, a milky lluid in 31, rusty sputa in U'3 and mnco-
purnleiit matter in 96. In ten of these seventy live cases the larynx participated in the inliammatory action : Cases
4.2.!. 21, 33, 30, 10, 110, 118, 126 and 133; in the last-mentioned ease the thyroid gland was infiltrated with pus.
Hesides these the larynx and trachea were, in 132, inllamed, their mucous lueuibrane tliickeiu'd an<l (cdematcnis, and
in 131 intlamed and full of tenacious mucus.
In a few cases the condition of the iiuoxchial c.laxds was stated : Caseous in 7, large in 80, enlarged, yellowish
and softened in 122, soft, large and of a greenish color in 123 and softened in 126.
Recent inflammation of the pleuual memhraxes is noted in seventy-five of the eases, or .").">. 5 per cent, of the
total number: In thirty-luo on both sides; in tieeniij on the right and in iieentij-lhree on the left side. The rei>orted
conditions were as follows;
B..II1 M.lo!^. Itigbt side. Left BiJ.'.
Adhesion 13 5 6
Krt'usion of serum, sometimes turbid 7 3 4
Exudation of lymph 1 4 3
Adhesion and etlusion 8 5 2
Adhesion and exudation .. 1 .
Exndat ion and effusion 2 1 5
iSero-purulcnt collection 1 .. 1
Purulent nialter .. .. 2
Extravasated blood .. 1
32 20 23
Total of pleuritic complications 75
A<lhesion was frequently mentioned as the only result of the recent pleurisy; but in a nuiubcr of cases it was
associated with an exudation of lymph on the unadheient surfaces, or with an etfusion of serum, sometimes turbid
from flakes of lymph and occasionally sero-purnlent or bloody. Effused liquid was present in the cases already stated
as having the lung or a portion of it condensed or compressed. In some instances the character or quantity of the
liquid was noted: It was turbid in 56, 57, 59 and 65; seio-purulent in 29 and 40. Each sac contained 30 ounces of
liiiuid in 119 and the left sac 32 ounces in 128; the left sac contained 50 ounces of somewhat purulent serum and the
right 30 ounces of reddish serum in case 80, and in case 77 the thoracic cavity contained 77 ounces of bloody serum.
Pus is said to have been present in the left cavities in 104 and 111 and extravasated blood in the right pleura of 26.
The condition of the rEKlCARDif.M was noted in twenty-four of the cases. In twelve the sac contained a small
•luantity of serosity, insufficient to suggest the likelihood of inflammatory conditions. In most of the cases in which
the liquid was aVmormal in quantity or quality, or the membrane altered, the pleural membranes were likewise
involved. In 78, with coincident pleurisy of the right side, the pericardial liquid measured six ounces; the same
quantity was found in 119, with pleuritic effusion on both sides; an excess was noted in 79 and 131 and six ounces
of a greenish li<iuid in 80, in all of which cases both pleural sacs were affected. In 16, in which a normal quantity
of pericardial serosity is said to have contained some flakes of lymph, the right lung was adherent. In 77 and 135,
in which the peritoneum was involved as well as the pleura;, the pericardium in the one case contained 4 ounces of
serum and in the other was adherent over the right auricle. On the other hand, no mention is made of pleural
inflammation in case 3, which had the pericardium distended; in 130, which presented an excess of liquid, or in 124.
in which an ounce of bloody serum was reported. The adherent pericardium in 61 evidently antedated the fatal attack.
It will be seen from tliesc .stutenients that decided pericarditis was by no means so
frequently associated w'ith secondary pneumonias as with the acute lobar cases. Pleurisy,
it is true, was somewhat more common in the lobar pneumonias, but this is insufficient to
explain their marked preponderance in well-defined pericarditic complications. In the
secondary pneumonias contiguity to the morbid processes in progress in the lungs and pleura?
may be accepted in explanation of the excess of liquid in the pericardial sac; but as the
secondary cases did not present in the pericardium the plastic exudations and sero-purulent
liquids so commonly observed in the lobar cases, these_ inflammatory results in the latter
must be referred to a more potent influence than contiguity of inflamed tissues.*
• See iH/ra, i«ige 805.
800 PNEUMONIA.
The HEART was meutioued in forty-one cases. In twenty-nine of these it was normal or healthy — in one, 61,
notwitlistandiuj; the existence of extensive adhesions. It was i-ejiresented as flabby in five of the remaining twelve
cases, 2, 4, 13, 103 and 129; soft and flabby in one, 46; large and flabby in one, 34; pale in one, 92; hypertrophied in
three, 3, 67 and 93, and displaced in one, 40, by eft'usion in the left pleural cavity.
The CONTEXTS OF THE HEART were noted in forty-five cases. In fire the heart is said to have contained clots
the appearance of which is not stated, in fire fibrinous clots and in one dark clots. Both sides contained filiriuous
clots in ten and mixed clots in_^re. Fibrinous clots were found in the right side in nine in which the contents of the
left side were not specified, and in two in which the left was occupied by dark clots; mixed clots in the right in tico,
with the opposite side unstated in one and containing dark clots in the other; dark clots in the right in two, with
fibrinous clots in the left in one and mixed clots in the other; clots of unspecified character in the right iu one and
fluid blood in unother, in both of which the contents of the left side were nnnoted. The chambers of the left side
contained fibrinous clots in tn-o cases in which the contents of the right side were unrecorded.
The LIVER was the subject of report in ninety cases, in forty-nine of which it was normal. Of the remaining
forty-one cases it was reported large in twelve, iu three of which it was pale or light-yellow in color and in three
softened ; fatty in ten, in one of which it was increased in size ; congested in eleven, in three of which it was enlarged,
and in one friable. It was dark-colored in two, soft in two, soft and mottled in one, flabby iu one, flabby and ana'uiic
in one and adherent to the diaphragm in one. Its weight was reported in eighteen instances, the maximum, ninety-
two ounces, in 109 ; the minimum, forty-eight and a half ounces, iu 28, — the average seventy-two and one-half ounces.
The SPLEEN' was noted in eighty-eight cases, in forty-seven of which it was regarded as normal. Of the remaining
forty-one cases it was large in ticenty-foiir, in six of which it was soft, in one flal)by and in one dark-colored; softened
in seven, in one of which it was jiale, in two dark-colored and in one pulpy; congested in six, iu one of which it was
also large, iu one hard and in two soft; pale in two cases and dark-colored in one; in one, ca.se 2, it contained a small
cheesy and cretaceous tumor. Its weight was noted in twenty-five cases, the maximum, twenty-seven ounces, iu 97;
the minimum, four ounces, in 111, — the average, twelve ounces ; it weighed twenty -sis ounces iu 49, twenty-four ounces
in 83 and nineteen ounces in 109.
The KIDNEYS were noted in eighty cases, iu fifty-four of which they were normal or healthy and in twenty-
six altered. They were large in five cases, large and granular in one, fatty iu two, flabby in one, pale and soft in one,
dark-colored in one and congested in tweire, in one of which, 68, the right kidney ouly was affected. In one, 92, the
left kidney was healthy, the right inflamed; in one, 23. the pelves were distended and the ureters enlarged; and m
one, 46, a large cyst with liquid contents was found in the right kidney, which weighed fourteen ounces.
The condition of the stom.vch was noted in twenty-six cases, iu five of which this organ was said to have been
norma! and in one distended. Of the remaining twenty cases its mucous lining was reported as injected in four, iu
oue of which, 125, it contained thirty-two ounces of a greenish fluid ; engorged in one; reddened in one; congested iu
pve, in oue of which, 28, it was of a dark color, and iu oue, 133, it presented a large ulcer near its cardiac extremity;
and inflamed iu nine, iu one of which, a syjihilitic subject, case 33, it was associated with ulceration and gaugrene of
the mucous membrane of the tpsophagus.
The ILEU.M or s.mall intestine was noted in seventy-six instances, in thirty-nine of which a healthy condition
was present, while in one distention was the only abnormity recorded. Of the remaining thirty-six cases the small
intestine is the subject of report in twelve, the ileum in twenty-four. The mucous membrane of the smaJl intestine is
said to have been reddened in one case, 49; injected in (mo, 111 and 112; congested in tliree, 85, 126 and 131, in the
second of which the glands were thickened and in the last softened ; inflamed in four, 44, 47, 63 and 135 ; ulcerated in
one, 101, and in one, 127, the mucous membrane was pale, although the jiatches of Peyer and solitary follicles were
prominent. Of the twenty-four cases in which the ileum was reported as the site of the lesion its mucous membrane
was reddened in one, 61; congested generally or iu circumscribed patches in ten, 4, 27, 29, 30, 86, 87, 92, 107, 122 and
123, iu one of which, 122, the membrane was of a dark iiort-wine color and its solitary follicles thickened; inflamed
in eight, 22, 40, 66, 98, 102, 115, 118 and 133, in the first of which the patches of Peyer were slightly thickened ; ulcer-
ated in tivo, 28 and 33 ; and in three the condition of the glands only was stated, the agminated glands being thickened
in 128 and 130, and the solitary follicles much enlarged, with thickening of one of the patches of Peyer near the
ileocajcal valve, iu 129.
The L.iRGE intestine was noted in sixty-four of the cases, in forty-four of which it was normal and in two
distended. Of the remainiug eighteen cases its mucous membrane was injected in one ; congested in sei'eu, 28,57, 63,
86, 87, 122 and 123, — the congestion forming dark port-wine colored patches, with thickening of the solitary follicles
in 122, and affecting the caecum only in 86 ; infiamed in six, 22, 47, 48, 49, 66 and 111, the ca-cum only being implicated
in 48; ulcerated in two, 60 and 135; pigmented iu the sigmoid flexure in one, 27, and contracted iu one, 62, into a
thickened nnsacculated tube three-quarters of an inch in diameter, lined with a dark chocolate-colored mucosa, but
containing liquid f;cces of a natural appearance.
The PERITONEUM was congested in 77 and 100, thickened in 131, and adherent in 46 and 135.
The nuAiN and its membraxes appear to have been examined in forty-four of the cases, in eight of which,
cases 26, 42, 43, 45, 46, 49, 75 and 112, they were said to have been normal or healthy, — in seven of these cases the
symptoms that l^receded death are not stated, but iu one, 26, a low delirium, which afterwards became furious, is
noted in the clinical record. Of the thirty-six cases in which an encephalic abnormity is mentioned, the brain is said
to have been soft iu one, case 4 ; softened and somewhat injected iu one, 129, and congested in three, 31, 119 and 135.
The membranes are said to have been engorged, injected or congested in the nine cases, 44, 57, 58, 65, 102, 103, 111,
PXEUMONIA. 801
113 ami 128, in one of which, 102, the liraiu was regarded as healthy. In one, case 36, there was eft'usion under the
membranes. The hraiu and its nienil)ranes are said to have been injected or engorged in the fire cases, 47, 48, 63, 66
and 115; and the pia mater congested, with the brain-sul>stnuce softened, in the tieo cases 64 and67. In the remaining
fourteen cases some details of the cnrephalic lesions were recorded: lu 126 there was congestion and softening of the
brain with eft'nsion nndcr the arachnoid: in 37 the piincta vasoiilosa were marked an<l the membranes contained
three onnces of bloody sernni: in 33 there is said to have been a slight inllcmniation of the dnra mater at the base
of the brain: in 27 thickening of the membranes at the foramen of Hichat and distention of the ventricles; in 28 and
29 slight opacity of the visceral arachnoid near the vertt'X and congestion of the lloor of the fonrtli ventricle; in 30
softening of the cerebrum, congestion of the pia mater and of the substance of the pons and corpora striata, and
opacily of the lining membrane of the ventricles. Dejiosits of lymph were noted on the vertex in 32; on the hemis-
pheres, with much congestion and effusion of bloody serum, in 122, 123 and 124 ; and on the brain and along the track
tif the vessels in 12r>. In .">SI congestion of the membranes was associated with patches of elVused blood under the
arachnoid and bloody serum in the ventricles. In case 2 a bony plale two inches in length, one-fourth to three-fourths
of an inch in width, and of irregular outline and thickness, was found in the anterior portion of the falx cerebri.
Delirium was present in many of these cases, as in 27, 47, 63, 66, 67, 119, 124, 125, 128 and 129; in the last-men-
tioned case the patient became rational before death. Coma was present in 58, and tyjdioid sym|)toms, which prob-
ably imply a low delirium, in 48. In many cases the record is silent as to the symptoms that attended the fatal illness;
but in a few, as 29, 57 and 65, no reference was made to cerebral symptoms, although the condition of the patient was
briefly described. In ."i9 great nervousness and anxiety were tlR' only symptoms refcrrilile to a cerebral lesion, and in
30 the intellect was unalVected notwithstanding a marked implication of the brain and its membranes.
Pathology of Pneumonia. — From the most remote and dark ages of medical history
the disease now known as lobar pneumonia, although sometimes confounded with other pul-
monary and pleuritic afl'ections, has been recognized as an inflammation of the lungs. If an y
views of the nature of disease were held to be established, that which regarded this disease
as an inflammation was certainly one of them. Whatever theory of inflammation prevailed,
pneumonia, witli its solidification of the pulmonary tissue and its rust-colored tenacious expec-
toration, was always considered an idiopathic inflammation attended with a constitutional dis-
turbance secondary to, and parallel with, the local affection. It was, in fact, taken as the
type of internal parenchymatous inflammations, and the treatment of inflammation, irrespec-
tive of locality, was based on the results of experiment and observation in pneumonic cases.
Xevertheless, of late years, there has been a marked tendency on the part of those on
the advance-lines of medical thought and inquiry to overturn this time-honored doctrine.
The grand impetus given to the germ theory of disease by the investigations of Pasteur, by
Davaine's discovery of the etiological relations of a certain bacillus to anthrax, and Ober-
meier's observations on the spirillum of relapsing fever, has contributed largely to tliis revo-
lutionary tendencv. Friedlander demonstrated the presence of a mici'ococcus in the croup-
ous exudate. This has been verified bv other observers; and it is claimed that cultures of
the organism, when injected into the lungs of mice and rabbits, have occasioned pneumonia
as it occurs in man, with associated pleurisy and fibrinous pericarditis. E.\dierich, by culture
experiments, found this particular micrococcus in a foul organic filling between the floors and
underlying ceilings of a house in which pneumonia had prevailed.* Some investigators have
been so impressed with the results of these inquiries as to deny the existence of a pneumonia
resulting from exposure to cold and dampness, insisting on a parasitic origin of the disease,
which they regard as a local affection so long as the micrococci do not extend beyond the
pulmonary tissues, and as a specific infectious disease when the circulation becomes invaded. f
Meanwhile, certain medical authorities, apparently uninfluenced by the inquiries into
the life-history of Friedlander's micrococcus, but biassed chieflv bv clinical and general
etiological considerations, have concluded that lobar pneumonia is in all instances an acute
specific disease analogous to typhoid fever, and that the exudation in the air-cells is the ana-
tomical characteristic of the one, as the affection of the patches of Peyer constitutes that of
• Tmtirltrillf drr Mnliciii, Bl. II, 1884, page 153. tTiUlMOX and S£e, Da Pneitmimia Aigua, Paris, 1885.
Med, Hist., Pt. UI— 101
802 PNEUMONIA.
the other. "W. H. Draper advocated this view in this country in 1866.* Juergensen
urged it in his article on Croupous Pneumonia in Ziemssen's Cj'clopedia, baling on it the
system of treatment which is derived from the following proposition in relation to self-limited
diseases: Nature cures, and the only duty of the physician is to maintain life until this cure
is affected ! Again, in two of the text-books on the Practice of Medicine, published in tliis
country daring the year 1884, that of A. L. LooMis of E'ew York, and the fifth edition of
Flint's Practice, the doctrine of a specific disease — a pneumonic fever — .supersedes that of an
acute inflammation with symptomatic fever.
But certain of the arguments seem strained to serve a purpose, — at all events they are
not sustained by tlie medical experiences of tlie war. Thus, pneumonia is held to be some-
thing other than a simple inflammation, since it diff'ers in its seasonal and geographical dis-
tribution from bronchitis, which is undoubtedly a simple inflammation. Juergensen gives
a diagram based on the admissions for twenty years to the Vienna hospital, sljowing pneu-
monia rising to a maximum in April and May, while catarrh of the respiratory organs is rep-
resented as fallins; durino- those months from a maximum in March. As to the difference
in the geographical distribution of pneumonia and the respiratory catarrhs, he considers it
unnecessary to say more than that the latter increase in frequency as we progress to higher
latitudes, while this is not the case with the former, and that Ziemssen and Hirsch are in
accord on this point. LooMis asserts that cold does not influence the prevalence of pneu-
monia as it would were the disease, like bronchitis, a local inflammation. Wet and cold,
according to his statement, increase the frequency of bronchitis, but not that of pneumonia.
He gives, however, no statistics to establish this point. Flint does not dwell on its seasonal
difference from bronchitis, but agrees with LooMis in asserting; the disease to be vastly more
frequent in the Southern than in the Northern States. The statistics of the war do not
authorize these positive statements. There was, on tlie contrary, such a general agreement
between the prevalence and distribution of catarrhal and pneumonic affections as to suggest
that the causes of both were intimately associated with cold and dampness, whether seasonal
or climatic. Juergensen states, as one of the arguments which serve to disconnect pneu-
monia from pleurisy and lironchitis, that the cases of pneumonia in which tliere has Vjeen a
previous exposure to cold or other influences of an injurious character are so few that it is
hardly possible to regard these influences as exciting causes. Nevertheless, the pneumonias
of our camps were invariably attributed to exposure to cold and wet.
But, overlooking the evident weakness of the argument drawn from prevalence, distribu-
tion and obscurity of the exciting cause, there are others, derived from the clinical history
of the disease, which give plausibility to the doctrine of a pneumonic fever. First: The
chill and the access of the pyrexia in advance of the local action are the phenomena of a
specific fever. The antecedence of the fever may be denied on the assumption that its very
existence presupposes the existence of pneumonic invasion, circumscribed as yet, and difficult
of detection by physical exploration, especially when deeply seated in the pulmonar}- tissue.
This cannot be met directly, but it may be met indirectly by the second argument: The
want of correspondence between the intensity of the local and general disturbances is incon-
sistent with the theory of an idiopathic inflammation. Exception may be taken to this on
the ground tliat the accompanying fever is modified by the constitutional state, and that an
extension of the disease may be unmarked bv a notable aggravation of the febrile disturb-
* Before the New York Academy of Mediciut*. Sijc its Bulletiu, Vol. II, 1SC2-GG. p. 517.
PNEUMONIA. 803
ance, as the system has become unable to sustain a corresponding symptomatic action. This
objection may be allowed in the advanced stage of the disease, but it cannot hold gooil in
the early period, when the local inflammation has to be assumed in the absence of all signs
of its presence except the highly febrile state. If the first proposition — the precedence of
the fever, be denied, the second — the want of a correspondence between the local and general
symptoms, cannot be assailed. The third and strongest argument in favor of a specific doc-
trine is found in the characteristic or typical course of the disease to a sudden termination
bv a crisis while the inflammatory conditions in the luni<; are at their height.
But although an unknown constitutional cause is claimed for the pyrexia, the local
lesions are regarded by these authors as a true inflammation of the lung. None of them
doubt the inflammatory character of the local processes. Yet there appears to be every
reason for doinej so, in view of the well known observations that wounds of the luno' and
irritants applied to the organ, or inhaled or injected into it — in a word, the ordinary exciting
causes of inflammatory action in other tissues — do not induce the local processes in question.
These facts have been brought forward by every writer iir support of the doctrine that jineu-
monia is not an idiopathic inflammation, but a specific disease with a local inflammatory
lesion. But if they have any meaning at all in this connection they have more than has been
claimed for them. They indicate not only that pneumonia is not a local inflammation with
a symptomatic fever, but that it is not an inflammation, no matter how it is regarded,
whether as a local disease or the local expression of a constitutional state. This appears to
be one of the strongest arguments in favor of the doctrine of a specific constitutional affec-
tion. Pneumonia is not a local inflammation with a symptomatic pyrexia, because it has
been shown by many experiments not to be an inflammation. The fever associated with it
must therefore depend on some otlier cause; but as there is no other local lesion to which it
may be attributed, it must be regarded as the result of some impression or influence affect-
ing the system at large, — a fever which, as it is associated with well-developed changes in
the lungs, may appropriately be called, as of old, pneumonic or lung fever.
Inflammation is essentially a perversion of the nutrition of a tissue. An increased quan-
tity of blood flows to the afl'ected part, increased exudation and migration of the corpuscular
elements take place through tlie walls of the capillaries and the ordinary processes of tlie
part become intensified : — inflammation is present. In accordance with the nature and dura-
tion of the exciting cause and the anatomical cliaracters and relations of the affected tissue,
the inflammatory process terminates in one or other of certain well-known ways. But in
all this the motive power is the plastic force. The nutritive processes ordinarily carried on
in the tissues are stimulated and their results more or less perverted.
But these are neither the conditions nor actions that are present in pneumonia. In a
true inflammation of the lungs the capillary system of its nutritive arteries is involved.
When those supplying its mucous membrane are implicated, there is a catarrhal inflamma-
tion with many secondary developments in the lobules due to peculiarities of structure and
anatomical relationship. Peribronchitis, interstitial pneumonia and the conservative thick-
ening of the pulmonary tissue, which circumscribes morbid accumulations, are examples of
true pulmonary inflammation. But in pneumonia there is no perversion or modification of
the action of the nutritive forces, as these forces are not concerned in the distribution of the
blood which constitutes the pneumonic congestion. The close-set ca^jillary net-work on the
walls of the intercellular passages and air-cells which becomes surcharged with blood during
804 PNEUMONIA.
the earlv stage of a lobar pneumonia lonns a part of the mechanism of decarbonization and
oxygenation. Its function is to expose blood for puritication, which, while impure, is inca-
pable of sustaining the nutritive processes. Certain causes induce congestion of this capil-
lary net- work, but these causes are not causes of inflammation, nor is the resulting congestion
the arterial congestion which leads to inflammatory consequences. Causes of inflammation
affect the capillary system into wliicli the arterial and jilastic blood is received for formative
and reparative purposes, but in pneumonia the causative inliuence is felt l)y the venous blood
and the vessels in which it flows.
Xo doubt the results of the pulmonic congestion are similar to those of an arterial inflam-
matory hyperieinia in so far as there is a transudation in both instances from the surcharged
vessels, and this similarity is heightened bva similaritv m the subsequent processes of removal :
but it cannot be said that pneumonia is an inflammation modified by the peculiar anatomical
characteristics of its site, for the proximate cause of the transudation — the congestion — is,
as has been stated, not occasioned by the causes of inflammation, and neither the anatomical
nor the physiological domains invaded are those affected in the inflammatory process. The
nutritive vessels, the intercellular structures, and the plastic forces operating in and by these
are concerned in inflammation; — the pulmonary capillary net-work, the air-cells, which
are histologically as much outside of the body as the cutaneous surface, and the process of
oxygenation are involved in pneumonia. The luilrnonary transudation is, therefore, not a
true inflammatory exudation. Sir Andrew Clark has observed this. He has pointed out
that when recent tlie pneumonic exudation consists of the elements of a capillary blood-
clot, not of an exudation.* These are leucocytes, red-blood discs, hyaline globules and
granule cells. The number of blood-discs often exceeds that of the leucocytes, and many of
the latter may be proved to be reallv blood-discs undergoins; histological changes. The alve-
olar walls are pale, not engorged, and their vessels are. many of them, occluded, not dis-
tended as in inflaihmation; the nutritive arterial supply is not involved. He therefore
claims that the consolidation is the result of an active congestion in which the unsupported
bloodvessels give way and permit, with a slight exudation, the extravasation of all the ele-
ments of the blood before the inflammatory process can be completed by cell-proliferation
and textural development. He considers it an aborted inflammation; but, if the arguments
just submitted are of value, it is not even this, as there has been no inflammation to abort.
The febrile action of pneumonia, being unconnected with inflammation of the lung or of
any otiier organ or tissue, must be referred to some specific influence affecting the general
system. What this influence may be is as unknown as the cause of typhoid fever. For
convenience it may be called a miasm, meaning thereby a something which affects the
system in this particular manner. The biologists urge the acceptance of Fkiedlaxdee's
micrococcus; but it does not appear that this is other than an accidental presence, which,
by its association with the pneumonic miasm, or, as in the case of the similarly accidental
micrococcus of diphtheria, by the assumption of isathogenic qualities either by itself or the
products of its growth, may become of importance as facilitating the spread of the disease
in such instances as at Benton Barracks, Mo., f where an infectious character was recorded.
Clinically, pneumonia was intimately associated with typhoid fever; and it appears to
have been produced as a secondary result of the tvithoid poison. The depraved condition
of the blood in typhoid fever seemed capable of inducing changes in the lungs of a nature
"Sec Medical Times and Gazelle, \ oh 11, ISSi, i>. Sii. fSirpya, i>ligf 156. '
PNEUMONIA. 805
similar to those produced by the pneumonic miasm. But the uncomplicated cases of pneu-
monia may not be referred for causation to the influence of the typhoid poison. This prop-
osition is sustained by the want of correspondence observed in the periods of prevalence ( f
the two diseases. Comparing the line of prevalence of pneumonia — diagram facing page
722 — with the irregular line of typhoid — diagram facing page 199 — among our white troops,
there i.s no evidence of similarity, — this is due to the exhaustion of the susceptibility of our
soldiers to the typhoid miasm; — but when the line of pneumonia is compared with that of
tvphoid in civil communities, where the accumulation of material susceptible to the (yphoid
influence is a regular and readily calculated quantity, both are found to present a seasonal
wave.'-' There is, however, no correspondence between the Avaves. The period of pneu-
monic prevalence embraces the winter and spring months, that of typhoid prevalence the late
autumnal and early winter months. In August, September and October, when the typhoid
wave is sweeping over the United States, pneumonia is at its minimum. Moreover, were the
two diseases due to the same cause, typhoid fever should have supervened on pneumonia in
the individual case at certain periods as frequently as pneumonia at other periods on tyjihoid
fever. But this was not the fact: — Ti/phoid symj)toms were common in pneumonia, but not
a true typhoid fever; and these typhoid symptoms have been satisfactorily referred to other
conditions than the mere presence of the typhoid miasm in the system.f
The occurrence of pneumonia in other febrile diseases, as in malarial cases, typhus and
the eruptive fevers, indicates its dependence on the depravation of the blood produced by
specific febrile miasms rather than on the presence of one particular miasm, as that of typhoid
fever. But these secondary cases do not explain the occurrence of the primary and uncom-
plicated cases of pneumonia in which there is no lesion save that of the lung. For these
there must be assumed a miasm which operates like other miasms in deteriorating tlie blood
without producing, as they do, specific lesions in other parts of the system — in fact, a pneu-
monic miasm.
The attendance of cerebro-spinal meningitis on pneumonia, as on other specific iebrile
diseases, J sustains the claim of the latter afi'ection to an individuality as evident and posi-
tive as that of typhoid fever, small-pox or any of the others, although the condition of sys-
tem produced by these febrile miasms often induces congestions and transudations in the
lungs similar to those which are the proper results of a pneumonic fever.
The frequency of defined pericarditis in acute lobar cases, as compared with its infre-
quency in catarrhal or secondary pneumonias, cannot be ascribed to a participation in the
inflammatory processes of contiguous tissues, since pleuritic inflammation was nearly as often
associated with the one series of cases as with the other. But pericarditis, like cerebro-
spinal meningitis, may be referred to the influence of a pneumonic among other febrile miasms.
Treatment. — Pneumonia was regarded during the war as an inflammation of the lungs
with a symptomatic fever ; but our medical officers were unsuccessful in their efforts to quiet
the inflammatory action or allay the febrile disturbance until a period of apparently natural
defervescence had arrived. This, together with the injurious results of all attempts at sup-
pressing the disease by active antiphlogistic measures, and the great tendency of the patient
to fall into an asthenic state, reduced the attending physicians in many instances to the
necessity of adopting a method of treatment similar to that advocated at a later day by
JuERGENSEN§ as based on the doctrine of a specific and self-limited disease.
* See diagram in Dotc, page 20O, ni^ra. tS<.'e«t/>rff, page 475. JSee ««pra, page G08. g See m^ra, page 802.
806 PKETJMOI^IA.
An antilysis of the history of two liundred and fifty pneumonic patients, including acute
lobar and catarrlial cases, treated in thirty hospitals, shows that the practice consisted of an
effort to aliav the febrile excitement by means which would not at the same time danger-
ously lower the vital powers, after which measures were taken to facilitate the absorption
and extrusion of morbid products while support and stimulants were administered with a
liberal hand. It is manifest from the records that our army medical officers did not differ in
their views as to the indications to be fulfilled during the continuance of the fever in acute lobar
cases or in the active stage of lobular or secondary pneumonia : — To prevent the extension of
the inflammation, to restrain exudation in the parts already affected, and to palliate suffering,
if the measures adopted to arrest or moderate the disease failed to relieve the distressing
symptoms. But there was much uncertainty with regard to the best means of fulfilling
these indications.
In some cases at the West End hospital,' Cincinnati, Ohio, a purely expectant treat-
ment was adopted: Dry cups and hot fomentations were used, and the patient protected from
injurious influences until the pulse and febrile heat became reduced. In the Satterlee hos-
pital of Philadelphia a method of treatment, which was in its essence expectant, consisted
of the administration of one-sixth of a grain of sulphate of morphia in half a fluidounce of
Mindererus spirit every three hours. A method occasionally adopted at Hospital ISTo. 8,
l!^ashville, Tenn., consisted of a teaspoonful of paregoric every three hours, with a drink of
acetate and bitartrate of potash and poultices to the affected side of the chest. Dover's
powder, at intervals and especially at night, usually formed part of the expectant as well as
of more active sj^stems of treatment, and is frequently reported as having allayed restless-
ness, promoted sleep and exercised a favorable influence on the progress of the disease;
sometimes it formed the main portion of the treatment during the febrile continuance. At
Rock Island hospital, 111., it was frequently given in conjunction with camphor and quinine
on account of the prevalence of the malarial cachexia among the prisoners. Surgeon E.
McDonnell, 2d X. Y. Art'y, in a rejDort dated April 7, 1862, commends the use of opium:
I have had some had cases of typhoid fever complicated with pneumonia and some cases of pleuro-pneumonla,
which, though obstinate at first, eventually yielded to treatment, and, uuder the continued use of nutriment and stim-
ulants, did well. My experience in the use of opium in the treatment of pneumonia in civil practice has been favor-
able, and it has been equally gratifying in my military practice. I must here remark that I think less injury results
from the too early administration of stimulants than from their use too late in the disease.
Treatment was sometimes begun by the administration of a cathartic, usually Epsom
salt, compound cathartic pill, or blue-pill; but generally the bowels had, on admission,
already been acted on. The purgative was followed in some cases by acetate of ammonia
and sweet spirit of nitre, as in case I of the submitted records. In the hospitals of Alex-
andria, Va., treatment in some instances was begun by the exhibition of two grains of tartar
emetic and twenty grains of ipecacuanha. This was followed at intervals during the pyrexia
by two drachms each of camphor-water and solution of citrate of potash.
■ AVith or without an aperient or purgative the acute cases were frequently treated by
neutral saline solutions, as of citrate or nitrate of potash alone or with veratrum viride or
sometimes digitalis. The reduction in the pulse-rate under the action of veratrum viride is
often noticed, as from 96 on one day to 70 on the next; but, as in all cases in which a favor-
able influence was apparently exercised the day of the disease is not definitely stated, the
question remains unsettled whether the favorable result -would not have occurred had no
medication been adopted. In case 13, submitted above, its use, continued for five or six
PNEUMONIA. 807
days, was considered to have benefited the patient; but the violence of tlie attai'k would
probably have terminated in that time in the absence of the remedy. Besides, in .several
instances, including case 4, it docs not appear to have been eflicacious. Two or three drops
of the tincture were usually given three or four times a day, but occasionally it was com-
bined with other remedies. Sometinies later in the attack, in felirile recurrences or exacer-
bations, the American hellebore was a component of the expectorant mixture exhibited.
Digitalis was seldom given except in conjunction with other remedies, usually tartar
emetic. Here, also, a favorable change following the administration of the medicines can be
hut doubtfully attributed to their inliuence. In oiie instance, at the Satterlee li<ispital, in
which the pulse fell from 108 on the second day of the disease to 88 on the third, it i-ose to 104
on the following day notwithstanding the use of the mixture, and continued at that rate until
recovery bv crisis took place on the seventh day.
Aconite appears to have been seldom employed; it was used in one of the two hundred
and tifty cases, but the condition of the patient is stated neither before nor after its exhiliitioii.
But tartar emetic formed the chief reliance during the early period of the attack, ft
was given in small doses, generally from one-sixteenth to one-fourth of a grain, every two
or three hours. The large doses recommended by Rasoki, Laennec and Stokes were in
no instance employed.'-' It was presci-ibed with sweet spirit of nitre and moi-pliia, with
Epsom salt, acetate of ammonia, citrate of potash or ipecacuanha.
The tartar emetic treatment was usually continued for several days, when, if the disease
did not yield, it was replaced by some of the remedies already mentioned or by mercurials,
provided no tvphoid symptoms were manifested in the meantime. The oliject of the mer-
curial treatment was evidently to allay fever, subdue inflammatory action and promote
absorption in the probably now consolidated lung. Small doses of blue-pill and opium,
calomel and opium, or calomel and Dover's powder, with or without nitre and ipecacuanha.
were administered; rarely the iodide was employed. But tlie remedy was seldom carrii-d
to the extent of proiUicing distinct constitutional manifestations.
As mercurials were generally exhibited later in the progre.ss of the disease and corre-
spondingly nearer to the natural termination of the acute attack, we are prepared to find
that a strict adherence to the letter of the records indicates this plan of treatment as of
greater value than any other in relieving symptoms and removing the disease. Case 1, sul)-
uiitted above.f may be taken as an illustration. Here the antimonial produced no satisfac-
• RAsniti of Gfiieva, in 1808, esUiblished the mojcrn system of subduing inflammatory action by tartar emetic. In pneumonia large doses were given
with or without previous depletion. From twelve to twenty-four grains were .administered in twelve hours, and the doses were increased until several
drachms were taken daily. Very satisfactory results are said to have followed this practice ; but Laexxkc claimed a les.sene(I mortality when the remedy
yens given in smaller doses, .\fter general depletion, which he regarde<l as allaying for a time the violence of the inflammatory action and giving oppor-
tunity for the tartar emetic to act, he administered one grain every hour for twelve hours ; then the patient was iiermitted to renuiin quiet for seven or
eiglit houn* ; but if the case was severe the medication was continued without intei-mission until an amendment was perceptible as well by the physical
signs as by the general symptoms. See his Ti-t^utise on the Diseases of the Cheat, Forbes's translation, New York, 1838, p. 2G0. Stokes, at the Meath hos-
pital, generally began with four or six grains on the first day. This was increased by one or two grains daily until ten, twelve or fifteen grains were
given in thi- twenty-four hours. For the reduction of the ordinary inflammations of the lung it was seldom necessary to give more than twenty-five or
thirty gniius in this manner. See his IWatise on lite Diseitses of the Chest, Phila., 18-14, p. 308. It does not appear that this mode of trealnierit found favor
in the i'nilfil States. KuF.RLK, Phila., 18.11, T'ol. I, \K 2'J:i, allirms iiaiiseatiu'j doses of tartar emetic to be generally highly useful in diminishing the
action of llie heart and arteries and in promoting expectoration. He refers to the treatment by large doses, but seems to have had no personal experience
of its use. "NVoon, Phila., 1847, Vol. II, p. 47, taught that tartar emetic in small doses was a safe and useful adjuvant to the lancet when not contra-
Indicnted Ity tlie existence of nausea or vomiting ; he discountenanced the use of the Uasorian method as being attended with nmny dangerw. l>irKSos,
Phila., 185-1, p. CIO, also ottjecttnl to tlie heroic method, and sought to procure its advantjiges with less risk liy the administration of one-fourth or one-
half of a grain ever)* two or three hours, lie preferred, however, to substitute for the antimonial other sedative relaxant and diaphoretic medicines of
a safer and less irritant character. Surgeon Charles Tbipleb, U. S. A., at a meeting of the New York Academy of Medicine, Nov. 1.3, 1805, — lliilletin of
the .Iciiiriiiy, Vol. II, ISIM-OC, p. 526,— stated that many years ago, while stationed at a recruiting depot iu Kentucky, pneumonia prevailed among the
men. Seventeen cas<'S, all terminating favorably, were treated during one winter. During the formative stage he gave tartar emetic, beginning with
quarter-gn»in doses, which were fn-iiueutly repeated and increasetl until the point of tolerance was reaclie<l. Dry cuppiug in mild cases, wet eujiping in
severe ra.*es, with hot fomentations over the whole chest were employed. He had given veratrum viride in some of the cases, but was cautious in its
administration, having seen dangerous prostration from even small doses. In the stage of resolntiou calomo) and opium were resorted to in eonjunctioa
with blisters. Dr. Tbivler said that this plan of treatment was subseiiuently adhered to by him. t Page 732.
808 PNEUMONIA.
torv results, even when on tlie fourth day its dose was doubled, for on the next dav its use
was abandoned with the fever still high. Calomel was given, and on the following day a
favorable change was manifested. But when the calomel treatment was adopted from the
onset its seeminti beneficial influence was not so manifest.
On account of the inefficacy of medication during the continuance of the febrile condi-
tion many of the cases, especially those of some duration, show by the clianges in the treat-
ment from day to day the uncertainty of the physician and his desire to benefit the patient
without exposing him to any risk of harm from the means employed. Thus, small doses of
antimonials gave place to mercurials or vice versa, or the change was made from one to a
combination of both, or to an abandonment of both in favor of neutral mixtures with vera-
trum viride or ipecacuanha and morphia.
On one point, however, there was great unanimity. — general depletion was rarolv em-
ployed as an antagonist to the febrile state. Medical olficers recognized the adynamic influences
that affected the troops and declined, in a disease which was so frequently fatal by asthenia,
to purchase temporary relief at the expense of an impoverishment of an already deteriorated
blood. Death from apnoea was rare, occurring seldom except in those congestive cases
in which a rapid progress to insensibility and a fatal result was attributed rather to the
influence of a specific poison, generally the malarial, than to the causes of ordinary pneu-
monia. In but one of the two hundred and fifty cases was general bleeding considered
advisable for the safety of the patient during the continuance of the active symptoms. This
case, iSTo. 2 of those submitted above, appears to have been a typical instance of lobar pneu-
monia. In case 15 venesection was employed, but not to subdue fever; it was tried as a
last resource for the relief of urgent dyspnoea in the progress of secondary pneumonia. Tem-
porary benefit followed the operation, but the fatal result was not averted. Among the
occasional notes made by medical officers on their monthly or quarterly reports, the follow-
ing contain the only recommendation of sreneral bleeding that has been discovered:
Surgeon M. R. Gage, 25th TTis., Dec. 31, 1862. — » » » » Since that period [early in December, 1862] cases
of congestion of the lungs have been quite numerous, but under the following plan of treatment hare been mostly
brought to a successful issue. First, the administration of tartar emetic ad nauseam, giving the remedy every one,
two or three hours, according to the urgency of the symptoms, and making thorough counter-irritation to the thoracic
region. Free catharsis is induced by podophyllin and calomel in those cases in which the tartar emetic does not
itself sutficiently act upon the bowels for depletory and revulsive purposes. One case of congestion of the lungs
proved fotal while on the march across the bleak prairies from Mankati to Maiona in severely cold weather. I did not
see the case; but am informed that the patient was almost at once overwhelmed, the attack proving fatal in a few
hours. Doubtless venesection might have been in this instance very properly practiced, but whether or not success-
fully of course cannot be said. « * « Veratrum viride is sometimes made use of, but I think does not act with
that promptness and efficiency which long experience has shown to result from the administration of tartar emetic
Surgeon M. E. Gage, 25th Wis., ifarch 31, 1863. — In most cases this disease is ushered in by slight or severe
chills, soon followed by increased heat of surface and severe febrile symptoms. There will also be found often pain
in the loins and a stitch in one or both sides of the chest, accompanied with cough, and in many cases dyspna?a and
great pectoral oppression. In the beginning the cough wUl be dry and harsh, but there soon appears a frothy mucous
expectoration, which becomes in a short time the rust-colored sputa so characteristic of this complaint. A full and
bounding pulse shows the excited state of the circulation. If the case be ushered in with symptoms of great severity
venesection is promptly resorted to and is, we believe, the only reliable means of arresting or controlling the disease.
The bleeding should not be stinted but liberal: a large opening should be made in the vein and a full, free stream
allowed to tiow until syncope is established. This course, it must be understood, is applicable only to those who are
healthy and plethoric, and when the onset of the affection threatens imminent peril to the integrity of the organs
attacked. In the case of a feeble constitution, or when the pulmonary organs are already affected by tuberculosis,
there would be doubt as to the propriety of bloodletting, or, if decided upon, a manifest impropriety in carrying it to
the extent just indicated. After the bleeding tartar emetic is administered ad nauseam : cathartics may also be brought
into requisition, and are invaluable adjuncts in pursuing the treatment already shadowed forth: Dover's powder,
ipecacuanha and calomel, in alterative doses, are of the first importance in assisting the efforts of nature to clear the
affected lung from the inflammatory products deposited in the air-cells. Cupping over the pectoral region may be
PNEUMONIA. 809
cuiployi'il in the eaily stages to good advaiitago; lieuelit may also l)e derived from the ap)ilicatioii of sinapisms and
at a hiter jieriod from lilisters. The patient toward the end of the attack may require a supporting course, such as
beef-tea, wine, iiuinine, etc. [During tlie quarter ending March 81, 18ti3, Surgeon Uage treated in his regimental hos-
pital eighty-eight cases of pneumonia, six of which terminated fatally.]
But even in the congestive case.s recourse was more frequently had to quinine, blisters
and stimulants than to general depletion, as is illustrated by the following extract from a
report of Surgeon J. E. Sanborn, 27th Iowa, dated at Jackson, Tenn., April 30, 1863:
Our most alarming case has been that of Lieut, li , of Co. K, a man of nmst e.Kcellent habits. A violent
chill was followeil by fever of extraordinary .severity and duration. This was .soon broken up by the use of iiuinine.
Within forty-eight liouns was developed severe pneumonia (congestion.') of the right lung, which, for a few hours,
thnatened to be speedily fatal ; but he was rescued from this innuinent danger by the prompt use of blisters, with
stinuilants of brandy, carbonate of ammonia and quinine. He is now convalescent.
Generally the severity of the chest symptoms in the acute stage of pneumonia was
sought to be relieved by hot fomentations, poultices, dry cups, and sometimes by tlie local
abstraction of blood.* In other cases, where the risks attending the exposure incident to-
fomentation were conceived to outweigh the benefits to be derived from it, the patient was
encased in a padded oiled-silk jacket. But the details of treatment are so meagre that it is
impossible to say, from the records, not only that any of these measures had a favorable
influence on the progress of the disease, but even that they effected the primary intent of
alleviating the distress of the patient.
Although the treatment during fever was timorous, vacillating and tending to expect-
ancy, the occurrence of a sudden or general depression, or the onset of ataxic symptoms,
removed all uncertainty as to the line of action.
On the subsidence of the arterial excitement the removal of the pneumonic products
had to be effected. Generally this process in primary or lobar pneumonia was regarded as
one of absorption which would take place with a rapidity and efficiency proportioned to the
strength and vitality of the system. The patient was therefore supported with the best
nourishment which the hospital aflforded and with mild stimulants and tonic remedies, while
care was exercised to avoid the slight exposures that were so prone to cause relapses or
induce secondary catarrhal affections in the air-cells. Hence, we find beef-essence, chicken-
broth, raw eggs, wine-whey, sherry, catawba, whiskey-toddies, milk-punch, eggnog, brandy,
beer, porter, quinine, compound tincture of cinchona, citrate of iron and quinine, tincture of
iron, etc., appearing generally on the records at this stage of the disease; generally, also,
blisters were applied to promote absorption.
But when there remained a cough with expectoration, leading to the supposition that
the material exuded in the air-cells or the disintegrated pulmonary tissue was thus in part
to be removed, small doses of expectorant medicines were embraced in the treatment. Syrup
of ipecacuanha and squill, compound syrup of squill, compound liquorice mixture and syrup
<>f tolu, with or without paregoric, were the remedies commonly prescribed.
In many cases the continuance of cough, expectoration and more or less pain, with inter-
current febrile attacks, indicated the existence of secondary inflammation. During the usually
prolonged duration of these cases good nourishment, expectorants and counter-irritants were
employed, with an incidental return to tartar emetic or mercury and hot fomentations or
cups in the event of a febrile accession. Senega and wild cherry were largely used. Chloride
of ammonium was also employed in many of these cases alone or in conjunction with mercury
•Thp remoTiil of l«o to four ounces of blood l.j- Ilie aiiplication of wet cnps to the eide was said to have promptly and pormancntly relieved the
pain in pnciinionir attacks among tli? prisoners at Camp Douglas, III.— Sec J. H. Hoilisteb in Chicago Medical Examiner, Vol. Ill, 1862, p. SSI.
Mei>. Hist., Pt. 111—102
810 PLEURISY.
or expectorants. Donovan's solution was recommended by one medical officer.* Sinapisms,
turpentine stupes, pitch, wai-ming and belladonna plasters, croton-oil and cantharides were
used as local applications in accordance with the apparent requirements of the individual
case. Hectic fever appears alwavs to have suggested the use of aromatic sulphuric acid.
When typhoid symptoms were manifested in the progress of an acute pneumonia tur-
pentine was administered, with support and active stimulation. The turpentine was given
in doses of fifteen drops, frequently repeated, as in typhoid fever. Sometimes it was com-
bined with other remedies, as the clilorate of potash. Tincture of cantharides with whiskey
was used at Rock Island hospital, with what effect the records do not demonstrate.
Carbonate of ammonia appears to have been held in great esteem when ataxic symp-
toms were developed in the course of secondary or catarrhal intlaramations.f The cases are
exceptional in which it was not employed. It was generally administered with some expec-
torant or with the extract of wild cherry. The records do not afford the materials for
determinina; its value.
At the Rock Island hospital relief to the oppressed breathing was sought to be obtained
by inhalations of iodine, turpentine, ether, alcohol and chloroform; and in some cases in
which the patient was threatened with suffocation from inability to clear the air-passages,
recourse was had cautiously to the use of the fumes of burning cayenne pepper, from which,
it is said, much relief was exj^erienced.
X.— PLEURISY.
The clinical records of iileurisv consist merelv of names, dates of attack and return to
duty, and occasional notes of treatment. .Po.s^-7no?-^e??i observations have been preserved in
forty-five cases, six of wliich were connected with measles; but as the rate of fatality of
pleurisy was only 1.8 per cent, these histories give no idea of the character of the 31,852
cases that were reported among the white troops during the war, although they may be
accepted as fairh^ illustrating the nature of the 590 fatal cases. , At the same time the want
of records of the milder cases may be construed as evidence of their freedom from notable
peculiarities. Of the thirty-nine fatal cases on record, both sides of the chest were affected
in twelve; the right side chiefly in fifteen; the left side in twelve. The pericardium was
frequently involved in the inflammatory action, especially where both pleural membranes
were affected. Pericarditis was probably present in seven of the twelve cases of double
pleurisy; in two of the fifteen in which the right side was the site of the disease, and in two
of the twelve in which the left side was attacked.
Double Pleurisies. — Case 1 is a rapid case in which death occurred within nineteen
hours after the termination of the initiatory chill: in 2 the thorax contained 210 ounces of
sanguinolent serum; in 3 pus was present in both cavities; in 4 the right pleural cavity
contained eleven pints of purulent liquid, the left three pints of flocculent serum; in 5 the
*J. H. HoLLisTER, in the article cited in List note, says: — "My attention was early called by Dr. AViner to the use of Donovan's solution in the
treatment of pneumonia. I watched its effects in about seventy-five cases ; as many as forty I treated with this medicine alone in connection with a
nutritious diet, and I must say that in most instances I was charmed by the result. The tonic effect of the arsenious element and its stimulation of
the capillaiy system fulfilled an important indication. The mercurial alterative was here exhibited sufficiently to fully meet the necessity of the case,
while the glandular stimulation of the iodine seemed to complete the reciuircmeut. It is contraindicated where there is decided irritability of the
stomach and bowels, or where, in the advanced stage of the disease, the system is greatly prostrated. The dose is from ten to thirty drops in milk every
two hours."
t -i. Pattox of Vinccnncs, lud.,— .-IniOTc<ra Journal Me<Ucat Sciences, N. S., LX, 1870, p. 370,— reports favorable results in pneumonia from the car-
bonate of ammonia given in live to ten-grain doses every two hours continuously from the beginning of the attack. He claims to have treated 9G cases
in this way with only two deaths, and cites the experience of neighboring physicians as, with his own, aggregating 309 cises thus treated, of which only
8 were fatal.
PLEURISY. 811
characteristics of the attack were not recorded; in 6 and 7 both sides of the chest contained
effused serum, and there was a large eflfusion in the pericardium, amounting to one pint in
ihe former and to one quart in tlie hitter instance; in 8 simih\r effusions were associated witli
thickening of the pericardium, and in 9, 10 and 11 with distinct evidence of pericarditis;
in 12 there were deposits of pus in the peritoneum along with the pleuritic adhesions and
purulent layers, thickening of the pericardium and turbidity of its contained serum.
Case 1. — Private Charles Headley, Co. B, 32<1 N. Y.: age 25: was admitted Nov. 10, 1862, couvalescing from a
woHud of the hack. On the night of the It'th the patient sU'i)t hcfore an open window, and next morning was seized
witli a chill which lasted until 4 p. M. and was followed by high fever with a pulse of 120, hot and dry skin, anxious
countenance and emharrassed hreathing. There was duluess on the left side, especially over the anterior and lower
part of the lung, where also the respiratory murmur was feeble: tubular breathing was heard in the upper part of
the lung: dulness was marked also on the right side. Quinine and Dover's powder were given and wet cups a])plied
to the chest. The patient grew rapidly worse, bis couuteuauce becoming dark, respiration labored, pulse about 110
and almost imperceptible, and the area of duluess on the left side increased. He died at 11 a. m. of the 21st. Posl-
mortim examination : Body well developed. The left pleural cavity was distended with serum and the lung, which
was pressed forward, was about throe inches thick and covered with a layer of lymph about a quarter of an inch
thick: otherwise the lung was healthy. The right side contained elfused serum, but the lung was healthy. The
other organs were normal. — HoKjiitul, Frederick, Md.
Case 2.— Corp"l William H. Braman, Co. H, 28th lud.; age 20; admitted Feb. 18, 1865, exhausted: Respiration
hurried: cough dry; pulse hard; tongue coated: voice sharp and tremulous; left side comparatively uu)tionless:
dnlnesson percnssiou; much pain: decubitus dorsal. March 5: Tongueclean; appetite better; more cheerful. Heart
appeared to be pressed forward and upward under the sternum; decubitus left dorsal. Ho liecame worse, and died
on the 12th. rost-mortcm examination: Left pleura tirmly adherent to sternum and ribs: lungs much compressed:
heart pressed over to right side, adherent in places: bronchial tubes of right side iuHamed: two hundred and forty
ounces of bloody seruiu in the thorax. — Third Dirisioii Hospital. Alexandria, Ta.
CxSB 3. — llezekiah Ilulsey, a citizen of Jackson County, Alabama: admitted .Jan. fi, 18&t. Died Februarys.
Posl-morlem examination: Extensive pleuritic adhesions on both sides; right pleural cavity contained four pints of
pus, left three pints; lungs collapsed; heart healthy. — IJosj>ilal So. 1, Xashville, Tcun.
C.vSE 1. — Private Erastus W. Bailey, Co. F, 12th Ohio Cav., was received Sept. 16, 1861, from hospital at Lex-
ington. Ky., where he had been under treatment four mouths for pleurisy. He was so feeble as to be entirely helpless.
His boily and u]>per extremities were exceedingly emaciated aud his feet and legs swollen to their utuujst extent.
He could rest only by supporting his head upon somethiug placed before him while sitting in his chair, he had some
cough aud expectorated small quantities of highly oti'eusive sanguineous, purulent mucus, which foruu'd sordes on
the teeth and lips; he had also chronic diarrluea, with hemorrhage from the bowels and occasional bu'inojitysis ;iud
epistaxis. He was unable to take either stimulants or nourishment, and the entire body gave olian oti'eusive cadaveric
odor. He died ninety hours after admission. Post-mortem examination discovered eleven pints of fetid, purulent
liquid iu the right pleural cavity, the serous surface being thickly covered with dirty-looking lymph; the lung was
adherent to the mediastinum, compressed to an inch and a half in thickness, caruilied and impermeable to air except
a small portion of the apex, in which faint crepitus could be detected. The left pleura coutained about three pints
of serous fluid mixed with flocculi of lymph; the lung was compressed and closely adherent to the posterior aud lateral
costal pleura by firm adhesions: the lower lobe and part of the upper were quite hepatized, with occasional emphyse-
matous patches resembling blebs or blisters on the surface; the permeable portion contained frothy mucus com-
mingled with purulent fluid similar to that found in the right pleural cavity. Both luugs were infiltrated with
tuberculous matter in various stages of softening, but contaiued no cavities. The pericardial sac was normal. The
right side of the heart was enlarged aud the ven;e cava? and pulmonary artery distended. The portal system was
Intensely engorged, but inesented no evidence of iuHammatory action. A preserved portion of the mesentery and
ileum presents the appearance of a carefully prepared arterial aud venous injection of the parts. The liver was
abnormally large and lirm, of an olive-green color mottled with brown aud highly congested; the gall-bladiler was
empty: the spleen and |)anereas normal. The kidneys were somewhat enlarged aud congested ; their section presented
numerous hemorrhagic spots, and the entire structure contaiued miueral concretions, some of which were of consid-
erable size: many of the Malpighian bodies were tinged with blood and the tubular cones deeply congested; the
ureters aud bladder were normal. The alimentary canal presented no evidence of ulceration, but was intensely con-
gested: the mesenteric glands were eularged and contained tuberculous deposits. It is remarkable that in his dis-
eased condition the poor fellow was able to endure the fatiguing journey from Lexington to this jilace. For days
prior to his death the respiratory function must have been performed by a portion of the lung not exceeding one-
eighth of its ordinary bulk. The congestion of the venous and portal system and hypertrophy or distention of the
right side of the heart and its appendages were evidently consequent to the obstructed pulmonary circulation, and
the anasarcous condition of the extremities a natural sequence of their dependent iiosition in the relaxed and dibili-
tated condition of the physical organism. — Sitryeon Jan. C. Il'hitehill, V. S. f'., Marine Iloapital, Ciitcinnuli, Ohio.'
CvsE 5. — Serg't B. F. Kirby, Co. C, 61st Va. Cav.; admitted Jan. 4, 1864. Died 12th. Posl-mortem examination:
*Thi(< case was piil>Ushed by F. C. Plvn'KCTT, Cincinnati LnnctI and Otaerrer, Vol. VII, new series, 1804, p. 376.
812 PLEURISY.
There was receut pleurisy ou Ijot'a sides, bu>. no pneumonia. The lieart was healthy. The peritoneum covering the
liver and spleen \vas coated with fresh flakes of lymph : the liver and kidneys were healthy; the spleen of moderate
size and very firm. — AssH Surgeon Barrisoii AUfn, V. S. A., Lintoln Hospital, Washington, D. C.
Case 6.— James Demovill, Co. C, 10th Mo. Cav.; age 2,'!; admitted Feb. 22, 1X63, having been affected with
some asthmatic trouble for three months. Kespiratiou became hurried and labored, and he die<l on the 26th. I'ost-
moi-tcm examination: About two quarts of serum in the pleiir:e, a pint in the pericardium: no lymph. — Liiiitun Hos-
piliil, St. Louis, Mo.
t'.vSK 7. — Private William Dodson, Ferguson's Ark. Eegt. Pleurisy and pericarditis. Died Jan. 19, 1865. Vost-
uwrtem examination: There was pleuritic effusion on both sides, with collapse of both lungs. The pericardium con-
tained a quart of serum. — Act. Ass't Surgeon H. C. yewlirk, Hospital, Hock Island, III.
Case 8. — Private Thomas Barnett, Co. IC. 10th West Ya.; age 52; was admitted Oct. 16, 1864, with chronic
rheumatism and night blindness. He could walk about; his appetite was good: his wrist-joints were much swollen
and painful. He improved until November 12, when he was attacked with diarrhcea and Jaundice. As the yellow
color was disappearing, on the 25th he was seized with severe pain in the right side and dyspniea, which became
extreme on the 26th, when he died, rost-morteiii examination: Body much emaciated. Thorax fille<l with serum,
compressing the lungs ; right pleura costalis mnch reddened ; jjerieardium thickened and containing serum. Remain-
ing viscera normal. — AasH Surgeon David Shaner, &th West Va., Cumberland Hospital, Md.
Case 9.— Corp'l Franklin C. Palfrey, Co. G, 6th U. S. Inf., was admitted Dec. 30, 1862, with scurvy. He died
Feb. 19, 1863. Post-mortem examination: The right lung was adherent and filled with tubercle; the left lung was
also adherent, but the adhesions formed a sac which contained more than two pints of serum. The heart was noriual ,
but the pericardium showed marks of recent inflaramatiou and was full of serum. Altogether there were six pints
of liquid in the serous cavities of the thorax. Abdominal viscera normal. — -Harewood Hosj)itul, Washington, D. C.
Case 10. — Corp'l William Hiuton, Co. E, 5th Pa. Reserves; age 35; admitted July 31, 1862, with a gunshot
wound of the right arm Died October 4, of pleurisy and pericarditis. Post-mortem examination: Body not emaci-
ated ; lower extremities cedematous ; the right arm had been removed at the shoulder-joint. The right lung was adhe-
rent at the upper and back part, but the serous sac in its lower part was covered with a thick pyogenic membrane
and contained a quart or more of thick pus which compressed the lung and pushed the heart over nearly to the left
of the median line. There were recent pleuritic adhesions on the left side, and the cavity contained over a pint of
clear serum, but the lung-substance was unaiiected. The pericardium contained about six ounces of liquid and was
partiallj' adherent to the surface of the heart, which was exceedingly rough from pseudomembranous vegetations.
[See Specimen 68, Med. Sec, Army Medical Museum.] The liver was in a state of incipient cirrhosis; its right lobe
was flattened above, apparently from the purulent accumulation in the chest. The remaining organs appeared normal.
The patient having had symptoms of pyiemia, the left external iliac and femoral veins were examined and found
to he distended with a fibrinous clot closely adherent to their walls; in several ])arts the clot appeared to be under-
going degradation into granular imruloid matter. — Act. Ass't Surgeon J. Leidg, Sutterlee Hospital, Philadelphia, Pa.
Case 11. — Private Jno. MoPlauson, Co. E, 10th Ohio Cav.; age 30; was admitted May 6, 1864, with congestion
of the lower lobe of the right lung, upper lobe of the left lung and suspected eft'usion : High fever, pulse 130, tongue
black, pain in breast, dyspncea and dulness over the whole of the chest. He improved for a few days, hut ou the 9th
pain in the left side became more acute, dyspnoea increased and the pulse quickened. 11th: Sinking fast; extremi-
tiescold; pulse very quick; mind rational. 12th: Died. Pos(-mor(fm examination : Chest abnormally prominent
and containing fifty-four ounces of sero-purulent fluid ; congestion of lungs and extensive pleuritic adhesions ; peri-
cardium showing inflammatory appearances, including six ounces of fluid. — Hospital, Madison, Ind.
Case 12. — Pri vate William T.Morrow, Co. F, 48th Tenu. Died Feb. 18,1865. Po-s^Hiorfciii examination: There
was inflammation of the pleura on both sides, with slight adhesions and patches of pus at several places; the lower
lobe of the left lung was enlarged and slightly inflamed. There was inflammation and thickening of the pericar-
dium, which contained four ounces of turbid serum. Small thrombi were found in the heart. The peritoneum was
inflamed and presented occasional deposits of pus. — Act. AssH Surgeon J. M. Witherwax, Hospital, Bock Island, III.
The PLEUPvisiES OF THE EIGHT SIDE uiav be indexed as follows: — In the seven cases,
13-19, effused serum or adhesion from plastic exudation was mainly confined to the right side;
m 20 and 21 the contained tluid was sero-purulent, and in the four cases, 22-25, purulfut, its
quantity in 24 and 25 being respectively twenty-one and eighteen pints. The pericardium
was distended in 26 and distinctly inflamed in 27.
Case 13. — Private John Robinson, Co. 0, 112th Pa., was admitted Feb. 24, 1864, having been sick for four days
with pain in the side, cough and shortness of breath. The right side was dull as high as the fourth rib, above which
large mucous rales were heard; the cough was frequent and the expectoration a thick mucus. On March 4 the
pain in the right side became aggravated and the dulness extended higher up. A blister was applied, and quinine
and beef-tea prescribed. On the 12th dulness was complete on the right side, which was immobile during respiration ;
the superficial veins were distended and there was considerable dyspnoea, the face being jjurplish, the pulse 120 and
the respiration 40. At 9 P. M. the symptoms appeared so urgent, the pulse having risen to 132 and the respiration to
60, that a valvular opening was made in the integument covering the sixth intercostal space near the angles of the
ribs and a trocar was introduced. There was at first some obstruction to the flow, hut by passing a probe into the
PLEURISY. 813
eaiuila straw-colored seniiii to the ainoiint <i twenty-four ounces was witluliawu. the chest became clear auterioily
anil the (ty.s])n(ea diniinisheil; but the iiatient beinj; much i>rostrateil, it was tliou-jht best to close the wounil by
adhesive strips and a compress without reuuivin^ the whole ol'the lluid. He died on the loth. J'u.it-moiltiii examina-
tion: The rijtht pleural sac contained twenty-four ounces of bloody serum : the lunjx was compressed nf:ainst the spine
Biid the upper lobe consolidated : thick f.ilse nivmbranes covered (he pleura and soft bridles of e.\uded material Ira-
sorsed the cavity in every direction. The left luug was congested by hypostasis. The heart was healthy. The other
oiitans were not c.\aniined. — Jel. Juk'I Siirgcoii J. D. Uall, Filbert street Hospital, Phila<Ulj)liiti, Fa.
Case 14. — Private Richard Williams, Co. G, 9th Mich. Cav., a paroled prisoner from Uichmond. Va.: af;e ^2:
was admitted April IH. 18li4, with chronic diarrluva. He died on the 2i5th. Fost-iiiorteiii examination : The ri^ht lung
was collapsed and covered by a thin layer of pasty lymph [Spcvinicii 340, Med. Sec, Army Medical Mu.seum]. the i.leural
cavity being tilled with serum. The left lung was hepatized in its lower lobe and had miliary tubercle in its upper
lobe. The heart was llabby and contained large clots; there waseftnsion in the pericardium. The liver was normal;
the gall-bladiler empty: the intestines inllamed; the kidneys hypertrophied. — Jorris Ho»j>itiil, Baltimore, Mil.
Case 15.— Private Isaac Davis, Co. I, 9th V. R. Corps, was admitted Feb. 23, 1864, and died March 31. Post-
mortem examination: Body not much enuiciatcd. The right pleural sac contained six pints of serum ; the lung was
collapsed and bad old adhesions on its inner, upper and posterior surfaces and recent adhesions on its outer surface.
The left luug was everywhere adherent, some of the adhesions appearing to V>e recent, and its lower lobe was hepa-
tized.— Act. Ass'l Surgeon X. T. Martin, Harcwood Hosintal, Washington, I). C.
Case l(i.— Private Joseph Hurlburt. Co. F, 9th East Teun. Cav.; admitted Jan. 30, 1864. Died February 27. Fost-
niorlem examination: The brain was healthy. The right lung was collapsed by the pressure of eighty ounces of etVu.sed
serum in the. jileural cavity. The heart was hypertrophied, its endocardium inllamed and its valves thickened. The
spleen weighed twelve and a half ounces. The other abdominal viscera were normal. — H(fspital Xo. 19,Xasln-ille, Tenn.
Cask 17. — Private Jacob Uray, Co. (J, 1st Ga.: age 50; admitted Jan. 27, 1864. Died February 14. I'ost-morirm
examination: Sixty-six ounces of serum in the right pleural cavity; eleven ounces in the left, with soft lymph coating
the serous surfaces: the right luug tubercular and inllamed around the deposits, a large vomica in its ai)ex : a few dor-
mant tubercles in the left lung. Four ounces of serum in the pericardium; nine ounces in the peritoneum; liver,
kidneys and intestines healthy: spleen softened. — Hospital Xo. 1, Xushrille, Tenn.
Case 18.— Private Herman Raatz, Co. F. 26th Wis.; admitted Jan. 22, 1863, with remittent fever. Died February
1. Post-mortem examination: Body greatly emaciated; excoriations on the back over the bony prominences. There
was a copious sero]>urulent collection in the right pleural cavity; the luug adhered at its lower and anterior jiarts
to the parietal i>leura: tubercles were scattered through its substance, but were most numerous in the upper lobe,
where, also, were found some small and one or two large cavities. The upper lobe of the left lung contained a few
small tubercles; the rest of the lung was healthy. The only abnormities observed in the abdominal cavity were
slight engorgement of some of the mesenteric glands and a rather unusual injection of the omentum and mesentery. —
lliird DirisioH Hospital, Alexandria, 1'a.
C.\SE 19. — Private Luman A. Johnson, Co. H, 4th X. V. Heavy Art 'y; age 22; was admitted from the Army of the
Potomac Nov. 7. 1864, with typhoid pneumonia, and died December 8. Post-mortem examination: Body much emaciated.
The left pleural sac contained a few ounces of bloody serum, the membrane being firm, opaiiue and thickened by
deposits of lymph; the right cavity was obliterated by lirm fibrinous adhesions: both lungs were studded with
tubercles. The oppo.sed surfaces of the pericardium were so firmly adherent that it was almost impossil>le to sejia-
rate them; the external surface of the heart was studded with minute granulations resembling tubercle, which did
not penetrate the cardiac substance, but ai)])eared to be in or immediately l)eneath the pericardium. The spleen, ten
ounces, contained minute yellowish- white tubercle-liiie bodies. The liver, forty-eight ounces, was very light in color;
the kidneys appeared to be normal. The mucous membrane of the intestines was much congested. — Act. Aas't Surgeon
H. M. Ikan, Lincoln Hospital, Washington, D. C.
Case 20. — Private Alexander H. Day, Co. C, 1st Me. Cav.: age 57: admitted Jan. 12, IStU. Diagnosis: Pneu-
monia. Diei> 30tli. Post-mortem examination: Right lung compressed, solid, lower part congested; right jileura
umcli thickened, a strong fibroid adhesion, apparently of long standing, separating it into two cavities containing
twenty-four ounces of serum, lymph and pus. — Third Dirision Hospital, Alexandria, Va.
Case 21. — Private Michael Fonl, 57tli X. Y.; age 21; was admitted Feb. 17, 1864; Much prostrated; cheeks
dusky: lips livid: tongue coated darkly; sordes on teeth; pulse frequent and quick; respiration abdominal and fre-
quent: could speak only by inspiring at every few words; sharp pain in lower part of right chest; mucous rales
generally dift'used. He died on the 20th. Post-mortem examination; Left lung healthy; right pleura containing
four pints of serum, pus and lymph; right upper lobe compressed; middle lobe compressed and adherent by fibrinous
bands: lower lobe closely adherent; lung-substance soft and friable; pleurisy more severe in diaphragmatic i)ortion.
Heart healthy: three to four ounces of serum in pericardium. — Third Dirision Hospital, Alexandria, Va.
C.vsE 22.— Private Bennett Bunton, Co. E, 5th Tenn.; age 34; admitted May 22, 1864: Emaciated; typhoid
delirium; pulse small, (juick and wiry: dulness over right side: absence of respiratory and vocal sounds; enlarge-
ment of liver. Died on day of admission. Post-mortem examination: Purulent collection in right pleural cavity;
right lung compressed ; liver hypertrophied. — Je^ Ass^l Surgeon M. E. Gleason, Hospital, Sock Island, III.
Case 23. — Private John Kenyon. Co. B. 19th X. Y.; age 19: was pumittcd Sept. 3, 1862. In a few days he was
seized with chills fidlowed by high fever, which abated at the same hour daily but was never entirely absent. Some
days later he complained of pain in the right side and of difliculty in breathing. He was treated with opium, quinine
81-4 FLKURISY.
and diaphoretics. On Novemljer 22 his pnlse was feeble, 120, skin cokl, respiration 48 and face highly flushed; he
was delirious at night; pain in the right side was increased on breathing and there was duluess anteriorly and pos-
teriorly. A mush poultice was applied and brandy and beef-essence prescribed. The expectoration became tenacious
and somewhat rusty on the 21th and respiration increased to 54, but the nocturnal delirium ceased. The bowels at
this time became relaxed. Carbonate of ammonia, wild cherry and morphia were prescribed. His condition was but
little changed during the next ten days; cough was very troublesome, but the expectoration became more copious,
somewhat less tenacious and less rusty in color; emaciation was noticeable and the case began to resemble one of
tuberculosis. On December 8 profuse jierspiration occurred. On the 13th the expectoration became greenish and
diarrhrt'a set in. On the 16th the patient slept a good deal and was much oppressed, the perspiration continuing.
He died on the 17th. Post-mortvin examination: The brain was healthy. The right lung was collapsed to about the
size of the fist, the pleura everywhere forming a roughened pyogenic membrane [SiHcimen 334, Med. Sec, Anny Medical
JIuseum] and its cavity containing about one and a half gallons of pus. The left side was free from jileurisy; the
lung was somewhat inflamed, especially along the anterior border; its bronchial mucous membrane was inflamed and
the bronchioles filled with muco-jras. The heart and pericardium were normal. The liver was impressed by the
purulent accumulation in the right jjleura and the interlobular vessels were so much congested as to give the organ
a strongly mottled appearance. The stomach, spleen, pauci-eas, kidneys and suprarenal bodies were healthy. The
small intestine was of a rather brighter pink than natural and jiresented several patches of moderate inflammation
with ecchymoses. The cecum was inflamed, rose-red, and showed a multitude of scattered ecchymoses about the size
of pin-heads ; the remainder of the large intestine had several irregular small patches of moderate inflammation accom-
panied by ecchymoses. — Act. AssH Sui-t/eon J. Leidij, Saltciiee Hos2>ital, Philadelphia, Pa.
C.\SE 24. — Private David Hassack, Co. A, 139th Pa.; age 19; was on light duty after recovery from a flesh wound
of the arm when, on Jan. 7, 1865, he had a severe attack of pleurisy. Ten wet cups were applied to the right side of
the chest and about sixteen ounces of blood withdrawn, after which a cathartic was given, followed by repeated
doses of tartar emetic. The bowels were moved freely and next day the jiatient breathed with less difficulty. On
the 9th there was a recurrence of severe pain under the right nipple and great dyspnoja. Turpentine was applied to
the chest. Calomel was substituted for the antimony on the 15th, as the latter was producing excessive nausea.
Salivation was manifested on the 21st and the mercurial was discontinued. Milk-punch and beef-tea were prescribed
and a blister applied ; but the dyspnoea gradually became aggravated, and death took place February 15. Post-
mortem examination : The right lung was colIap.sed — about the size of the fist — and solidified ; the right pleural cavity
contained twenty-one pints of pus. — Act. Ass' t Surgeon I!. H. LongiviU, Mower Hospital, Philadelphia, Pa.
Ca-se 25.— Private Clark Martin, Co. B, 6th Ala. Cav.; admitted Nov. 3, 1864. Died December 14. Post mortem
examination: Body not much emaciated. There was great enlargement on the right side of the chest, which con-
tained over nine quarts of green pus; the lung was compressed to about three-quarters of an inch in thickness and
presented a brown, leathery appearance. — Act. Ass't Surgeon W. Matthews, Hospilal, Roch Island, III.
Case 26. — Private Andrew J. Orr, Co. E, 25th Tex. Cav.; was admitted Jan. 24, 1863, with chronic diarrhiea
and erysipelas. He died March 30. Post-mortem examination : The right pleural cavity was tilled with lymph, serum
and pus. The pericardium was distended with serum; the heart was large, weighing thirteen ounces, its right ven-
tricle dilated, i.ts walls thinned and the mitral and tricuspid valves insufficient. The liver was enlarged to double
its usual size. — City Hospital, St. Louis, Mo.
Case 27. — Private James N. Parsons, Co. E, 124th N. Y.; age 27; was admitted June 18, 1863, complaining of
rheumatic pains from which he said he had suffered since December, 1862. He was in good flesh and had an excellent
appetite. On June 22 he was attacked with pleurisy of the right side, for which a blister and active cathartic were
prescribed, followed by doses night and morning of calomel, hyoscyamiis and ipecacuanha and a mixture containing
veratrum viride. The pain and cough became much lessened and the patient decidedly improved, whereupon, ou
the 27th, quinia in tonic doses was substituted for the ether medicines. Next day he was racked with an almost
incessant and painful cough and was obliged to maintain a sitting posture; his pulse was 120 and feeble; skin cool,
moist, almost clammy and tongue coated. Percussion yielded a dull sound over the whole of the right lung, more
marked over its lower portion. A cough mixture, milk-punch and beef-tea were prescribed, with poultices to the
chest. On the 29tli the sputa became rust-colored and a slight diarrha>al attack was noted, which continued during
the 30th. Astringents and one ounce of whiskey every hour were prescribed; but the patient failed rapidly, and
died July 1. Post-mortem- examination: The right pleural sac was lined with a pseudomembranous deposit from
three to four lines in thickness and contained a large quantity of serum; the lung was condensed and adherent in
many places. The base of the left lung was hepatized. The pericardium was lined with a pseudomembrane similar
to that found on the right pleura. — Act. Ass't Surgeon Geo. B. Botjd, Mower Hospital, Philadelphia, Pa.
Pleurisy of'THE left side. — Of tlie cases in which the left side was chiefly affected
the meinbraues were closely adherent in 28; serum distended the cavity and compressed
the lung in the four cases, 29-32, displacing the heart in the first-mentioned case; lymph
and pus were present 'in 33 and pus in 34-36, the quantity in the last having amounted to
eighty-eight ounces; in 37 and 38, with lymph, pus or serum in 'the pleural cavity, the
pericardium was said to be inflamed in one case and filled with serum in the other, while
in 39, in whicli the pus contained in the pleura had an e.Kit through an opening in the sixth
PLEURISY. 815
intercostal space, there was purulent matter in the pericardial sac, wliich was roughened on
its serous surface.
Case 28.— Piivato jrenitt C. Frost, Co. G, 89tb \. Y.; ago 19; was aibuittLHl Dec. lo, 1862, with symptoms of
typUoiil fever: Xervous disturbance with an irritable pulse of over 100, dyspiuea, cough with a copious yellowish-
white, tenacious expectoration, dulness with moist rales over the left side of the chest and a diarrho-a of three to
fi le stools daily. Stimulants, expectorants, astringents and nourishment were prescribed. Kor a short time toward
theeudof December the jiatient appeared to be improvin-;: but the diarrhrea returned on several occasions after being
lempiirarily cheeked, antl the prostration increased. About January 11 the cough became dry. He died on the oOth.
riist-mortaii examination: liody extremely emaciated. There were some slight recent adhesions at the lower and fore
part of tiie right lung, w Inch was otherwise healthy. The pleura of the left lung was in a state of tubercular degcn-
Liitiou: the deposit, :iveraging one-oighth of an inch in thickness, was especially dense at the apex of the lung,
whitish-yellow in color and fuiuly adherent to the surface of the lung and walls of the thorax; the substance of the
lung was congested but contained no tubercles. The bronchial glands were tubercular and very much enlarged.
The heart was flabby. The lower third of the ileum was intensely congested in patches and its mucous membrauo
softened, but Peyer's glands were not enlarged; the mesenteric glands were enlarged and dark-pnrple. The other
alidominal viscera wore apparently healthy.— Jc^ Ase't Surgwii rnaicis M. Leuis, Siitlcykc Ilospiia}, I'liilmhlphia, I'a.
Case 29.— Private Samuel Lyle, Co. D, llSth Colored Troops, was admitted .July 14, 1865. The patient was
weak and anaMuic : had a slight cough and expectorated glairy mucus. He had markeil dyspniea, which w as greatly
increa.sed on attempting to lie on the right side; he also had ;i tendency to syncope when in the erect position. The
left side of the chest was fuller than the other, — it did not expand on inspiration, its intercostal spaces bulged some-
what, it gave a dull sound on percussion and yielded no respiratory sounds on auscultation. The right side was dull
over the fourth and fifth ribs for a distance of three inches to the right of the median line; the other parts of this
side had a noruuil resonance, but tubular breathing was heard in the lower lobe of the lung, coarse mucous rales in
the middle and upper lobes and a slight friction sound near the angles of the fourth, fifth, sixth and seventh ribs; pul-
sation was very perceptible two inches to the right of the sternum, between the fifth and sixth ribs, and at this point
the heart-sounds were most distinctly heard,— the first short, the second natural. The patient was treated with iron
and fiuiuine, bitartrate of potassa, squill, sv.eet spirit of nitre and opiates. At the end of a week his appetite was
somewhat improved and the dyspncea lessened ; but after this he gradually failed, the dyspna-a increased, the bulging
of the intercostal spaces became iiu)re marked and pali)itatiou of the heart occurred in freciueut paroxysms. He died
August 19. Post-morlcm examination: The left pleural cavity contained five quarts of bloody serum, while there
remained of the lungonly small, friable, shreddy portions of tissue adhering to the costal pleura and showing no indi-
cation of the presence of tubercular deposit. The right lung was healthy, but was adherent near the angles of the
fourth, fifth, sixth and seventh ribs; the pleural cavity contained four ounces of yellow serum. The heart was so
displaced that the right auricle lay beneath the fifth intercostal space and the apex pointed downward and to the
right; the inner surface of the pericardium was roughened by fibrinous deposit and the sac contained four ounces of
bloody serum; the walls of both ventricles were thin and flabby; the endocardium was healthy. The liver was
enlarged ami very pale; the spleen healthy. The kidneys, one-third larger than natural, were soft in substance and
roughened on their outer surface. — Ass't Surgeon Orin A. Horr, 114(/i Colored Iroo])S, Brownsville, Texas.
Case 30.— Private John Clinton, 27th Colored Troops ; age 23; was admitted Nov. 13, 1864, delirious and in an
extremely prostrate condition from typhoid pneumonia. Three days after admission the delirium subsided; but the
patient continued to sink, and died on the 20th. Opiates, stimulants, nourishing food and counter-irritation were
employed in the treatment. Posl-mortcm examination: The right lung was normal; the lower part of the left lung
was greatly congested, its surface dotted with coagnlable lymph and bound to the thoracic ]>arietes by numerous
recent adhesions; the left pleural cavity contained a large quantity of serum. The heait ami abdominal viscera
were normal.— Jc/. Ass'l Surgeon II'. ff. Drury, Seminary llosjnUil, Colnmbns, Ohio.
Case 31.— Private I'honms A. \Vilson, Co. A, 12th Tenn. Cav., was admitted Jan. 23, 1864. He died February 23.
Po$l-morleni examination ; The brain and its membranes were healthy. The right lung, twenty-two ounces, was adhe-
rent and contained softened tubercles in its upper lobe; the left lung was collapsed by eighteen ounces of turbid
fcenim in the pleural cavity and its large bronchial tubes were inflamed and thickened. The heart contained large
white clots. The spleen weighed fourteen ounces; the kidneys were soft and friable; the bladder contained an ounce
of turbid urine. The otherviscera were healthy. — Act. Jsa't Surgeon Wm. Stemmerman, Hosjyital Xo. 19, Xasliville, Tenn.
Case 32— Private Barney Gruber, Co. H, 23d Ky.; age 26; was admitted Jan. 18, 1862. He was decidedly iaf ,
and was said to have been stout, healthy and fit for all duty one week before admission. He seemed apathetic and
complained one day that he felt pain all over, and next day that he felt no pain at all ; pulse about 120; tongue moist
but covered in the centre with a thin white coat, red on the edges and tip; not the least appetite; not much thirst;
some cough with a little thin, white expectoration ; duluess over the lower part of the thorax. Diagnosis — bronchitis
and probable pleurisy. The bowels were inactive and had to be moved every three or four days by mild purgatives;
expectorant and antiphlogistic remedies were borne badly; mustard poultices over the entire thorax and fomentations
nnder oiled-silk gave no relief.- Stimulants were more agreeable, but didnot mitigate the symptoms notably; we did
not bleed nor blister him. The patient grew gradually weaker, and died quietly February 12. I'osi-morlem examina-
tion; The mucous memlirane of the bronchial tubes was thickened and injected; the lower margin of the left lung
was hepatized, but the remainder of the lung was permeable to air; the pleura was thickened throughout, partic-
816 PLEUEISY.
nlarly below, and contained about a gallon of inodorous brownish liquid The pericardium and heart were normal.
The liver was enlarged and fatty.— Surr/eoii J. Slrotliotte, 2'dd Ky.
Case 33. — Private Henry Stegman, Co. C, 146th lud.; age 47; was admitted Aug. 12, 18G2, having been sick for
several weeks. His skin was hot and dry, tongue coated, jiulse 120 and rather full : there was pain ou pressure over
the liver and spleen; the abdomen was tympanitic but not tender, uor did the patient suffer from diarrhoea; suda-
mina covered the abdomen and thorax and an occasional rose-colored spot was observed. On September 1 he had a
sharp pain in the left side, with friction sounds anteriorly; pulse 120. A blister was applied. The patient had a large
bedsore. Quinine and whiskey were prescribed. On the 4th the left side of the thorax was enlarged by pleuritic
elfusiou. He died on the 6th. Post-mortem examination: The pia mater was injected and the arachnoid somewhat
opaque near the vertex. A quantity of liquid was found in the left pleural sac and flakes of tough elastic lymph
were firmly adherent to its lining membrane, especially over the lower lobe of the lung; the pulmonary substance
was generally collapsed and non-crepitant, dark-colored, tough, flexible and of greater specific gravity than water;
but a portion of the substance adjacent to that which sank in water, and' apparently of the same character, was
readily inflated. In the upper part of the lower lobe of the right lung, under the pleura, there was about half an
ounce of very dark, mobile, frothy fluid, loculated but not sharply defined and having a peculiar odor; this lung was
generally crepitant, but posteriorly and inferiorly it was somewhat congested and dark-colored. The right lung
weighed fifteen and a half ounces, the left twenty-one and a half. The bronchial glands were slightly engorged.
Fibrinous clots were found in both sides of the heart. The liver was flaccid and light-colored but presented some
superficial ecchymosed spots; the spleen, nine ounces, was soft and light-colored; the pancreas flabby, pale and
irregularly congested; the kidneys somewhat injected. The intestines were slightly discolored by bile, the stomach
only presenting some appearances of congestion . — Ass't Surgeon Geo. M. McGiU, Hicks Hospital, Baltimore, Aid.
Case 34. — Private James J. Sanders, Co. K,19th V. R. Corps, was admitted April 22, 1864, with chronic pleurisy,
and died May 2. Post-mortem examination: The cavity of the chest contained four quarts of purulent li(iuid; the
left lung, collapsed and coated with pseudomembrane, was completely broken down by suppuration — [Specimen 339,
Med. Sec, Army Medical Museum] ; the upper lobe of the right lung was inflamed. — Act. Ass't Surgeon T. Cunningham,
Sherbnrn Jiarraoks Hospital, Washington, D. C.
C.iSK 35. — Private Michael Murphy, Co. B, 3d Mich.; age 20; was admitted Dec. 12, 1862, for epilepsy, having
had five or six fits, while with his regiment, during the previous eight months. He was pale, weak and emaciated.
On the 16th he went to bed complaining of a severe cold and sore throat; his skin was hot and pulse frequent, 145.
Next day there was slight dulness with crepitant rales indistinctly heard over the lower lobe of the left lung, pneu-
monitic expectoration and pain, for which, ou the 18th, a blister was applied. On the 20th the pulse fell to 108, the
tongue became cleaner, the sputa less rust-colored; the patient felt much better, although the lung continued dull
on percussion. Six days later he became suddenly worse, expectorating enormous quantities of matter of the color
and consistency of custard ; his pulse was 145 and very feeble ; respiration 60, and the left side universally dull. He
died February 1, continuing to the last to expectorate large quantities of custard-like matter. He was treated with
carbonate of ammonia, milk-puneh, beef-essence and a grain of blue-pill three times daily; quininewas subsequently
given. Post-mortem examination : The brain exhibited no evidence of disease, but was much paler on the surface than
usual. The heart was somewhat enlarged, mainly from a dilatation of the right ventricle, the walls of which were
two lines thick; its cavity was filled with a large white clot; the pericardium contained about a gill of liquid. The
right lung was healthy; the left lung, attached by its anterior border to the front of the chest, was completely col-
lapsed, though the upper lobe was still pervious to air — [Specimen 341, Med. Sec, Army Medical Museum]; the back
part of the pleural cavity was lined with a thick pyogenic membrane and contained several quarts of pus; another
•distinct cavity, lined with a similar membrane and containing half a pint of pus, existed in the lower part of the
upper lobe; no tubercles were present; the bronchial mucous membrane was inflamed, but there appeared to be no
inflammation of the tissue of the lung. The liver was large, light-brown and flabby; the gall bladder empty; the
spleen large, dull-red and flabby; the kidneys normal. The mucous membrane of the ileum was more or less inflamed ;
the general redness was accompanied by one patch, about eighteen inches long, of intense redness, together with
several large ecchymosed spots. The colon was moderately inflamed. The intestinal glands were healthy. — Act. Ass't
Si.ryeon J.Lcidy, Satterlee Hospital, Philadelphia, Pa.
Case 36.— Private Hugh T. Keys, Co. F, llGth 111.; age 37; admitted March 6, 1864. Died 8th. Post-mortem
examination: Kiglit lung firmly adherent; left lung compressed by eighty-eight ounces of purulent serum and covered
largely with lymph. Heart, ten ounces, soft, flabby, yellow. Liver and kidneys fatty; other organs normal. — Hos-
pital Xo. 1, Xusht'ille, Tenn.
Case 37.— Private Elijah Herd, Co. B, 5th«Ky. (rebel): admitted Jan. 4, 1864. Died 16th. Post-mortem exam-
ination: Right pleura slightly adherent; left pleura strongly adherent behind and below, with a pint and a half of
deep-yellow pus and a large mass of disorganized lymph in its cavity; lung collapsed. Pericardium inflamed and con-
taining three ounces of serum. Intestines inflamed and mesenteric glands enlarged. — Hospital Ko. 1, A'ashrillc, Tenn.
Case 38.— Private Mar,shall T. Johnson, Co. I, 140th Pa.; age 19; was admitted Aug. 22, 1863, complaining of
Blight cough and diarrhoea, weakness and loss of appetite. Quinine and tincture of iron were prescribed, with good
diet and a mixture containing wild-cherry bark and morphia. He was found dead in bed on the morning of the 27th.
Post-mortem examination: The left pleural cavity and the pericardium were filled with serous effusion; in the former
there were also large masses of semi-organized lymph. The other viscera were healthy. — Act. Ass't Surgeon M. Stovell,
Hospital No. 1, Annapolis, Md.
PLEURISY. 817
Case 39.— Private (Jcoige W. Benton, Co. 1\ 14lh X. Y. Heavy Ait'.v; age 18; was ailmitteil Dec-. 27, 18l>4, as a
case of ]iueunionia. He improved ami was considered convalescent on Jan. 2o, 186.5; hut on Febrnary 20 he was again
taken with fever, ])ain in the left side and cough, which Viecame increased during the course of the following day,
when friction sounils were heard over the heart. The pain was less severe on the 22d, hut the patient had some heail-
ache and o'dema of the limhs. He had been treated with acetate of aninionia and sweet si)irit of nitre: hut on this
day hlue-pill with hicarhonate of soda was prescribed. Dvsimiea and cough were troublesome on the 2Hd, the latter
being attended with an expectoration of glairy nmcus. Tartar emetic, brandy and beef-t^>a were prescribed. The
paiu was much aggravated on the 2")!h and there was dulness over the left side. A blister was applied. An abscess
pointed March 0. in the sixth intercostal space: it was opened on the Xth and discharged two i|uarts of jius. The
patient died on the 12th. Poiil-iiioi-lrm examination : The left lung was adherent anteriorly and coated with p.seudo-
membrane posteriorly: it was partly collapsed by the pns which had escaped through the perforation in the chest-
wall, lietween the fourth and fifth ribs pus had found its way through the inti'rcostal muscles hut had not reached
the skin. The pericardium contained some purulent liquid, and botli pericardium and lu^art were covered with tough
layers of yellow lymph. ISpccinun No. 521, Med. Sec, Army Medical Museum, shows the lung with the perforation
through the chest-wall.] — Act. Jss't Surgeon XT. H. Combs, Emory Hospital, Washington, D. C*
Pi-EriuSY coxSKCfTivE TO ME.\SLES.— C.vSE 40.— Private Isaac David, Co. A, 81st Ohio: age l!i: was admitted
March 22, ISlii, witli measles. The eruption was slight; it made its appearance two days before admission and dis-
appeared on the 24th. The patient had sore throat and cough with nnicous expectoration. Senega, paregoric and
sweet spirit of nitre were prescribed. On the 31st the patient was 8aliv:ited, altliough he had been taking no mer-
curial: his throat continued sore and there was some diarrh<i-a, but the cough was somewhat better. On April 2
mucous rales were heard on both sides of the thorax : the patient sulVered from \k\ui in the bowels during the previous
night and did not sleep well; his tongue was dark and coated and there was great nervous excitement. Extract of
hyoscyamns was substituted for the senega mixture. Next day there was considerable febrile action, and on the 4th
great nervous excitemeut, hoarseness and cough, but no diarrlicea. Turpentine emulsion was prescribed. On the
5th there was great dyspncea, with a whistling sound in the larynx; the fauces were inflamed and a point of nlcera-
tiou was observed. A blister was applied over the larynx. He was much better on the 8th, his appetite good and
bowels regular, but on the following day he was seized with paiu in both sides of the chest below the nipples: his
cough was hacking and painful, sputa scanty, mucous and tenacious, respiration 48 and pulse 120. He died ou the
10th. rott-morliiit examination: The membranes of the brain were congested, but there was no elfusion in them or
in the ventricles: the superficial cerebral veins contained a number of free fibrinous coagula each about a quarter of
au inch in length ; the choroid plexus was soft. The right pleural cavity contained thirty-four ounces of sero-filirin-
ous etfusiou; the lung was comjjressed but not inflamed. The left pleura and luug were normal. The other viscera
presented no nuirked lesion. — .Shiv/toh Francis Salter, U.S. I'oli., Chattanooga Hospital, Tinn.
C.vSE 41. — Private William H. Shatlbrd, Co. C, 71st Ohio; age 18; was admitted March 12, 1864, with measles.
The eruption was not well marked and disappeared soon after admission. Cough then became troublesome and he
had four to eight loose stools daily. Senega, paregoric and sweet spirit of nitre were prescribed, with beef-tea and
arrow-root. The diarrho'a continued, and ou the 26th turpentine emulsion was substituted for the expectorant mix-
ture. To this, on April 1, mercury with chalk, opium and ipecacuanha were added. Next day he was somewhat
•The folIowiDg .ire abstracted from the serial medical literature of the period : — AV. H. Tkiplett, Woodstock, \a., in the liivhmond ami Lomsrille
Vnlienl JnHrvat, Vol. V, 18r.8, j». II), givi>s the following ca^e of chronic pleurisy treated by paraceutcsii* and injections; — John H , a farmer, but at
the lime of the origin of his malady a Coufederate soldier, was attacked by pleiuisy of the left side early in 1S03. After this he suffered from a severe
coogh, and waj* under tr^-atnient iu hospital at Winchester, Va., from whence ho was sent to his home. He was much eniaciati'd aud enfeebled and his
rcspinitiuu, which was always quick, was rejulily disturbed, physical exertion or hasty nu>vements causing great dyspna-a. AVhen the case came under
ol^-'r^ation. two and a half years after its connncncement, the pulse was 100 and ft-eble. The circumference of the affected side was three inches greater
than that of the other at corresi>onding levels. Its intercostal spaces were distend<'d and the dulness over its whole surface extended two inches to the
right of the median line. The disjilaccd heart pulsated at a point com'spouding with the right nipple. .-Vn unnatural fulness of the epiga-stric and left
hypochondriac n^gions was also present, aud no respiratory sounds were delected in the left lung. Night-sweats were profuse, and the general condition
of the patient was l>ccoming wot^e rather than better. In September, 18C.",, paracwitesis was performed between the fifth and sixth ribs with Flint's
mpinnitus, and twelve pints of nKldish-looking serum mingled with pus corpuscles wore removed. The operation greatly relieved the patient, whose
heart w;is f,»unil tjeating bi-neath the stenium, but no respiration was heai^ in the left lung. Five weeks after this the fluid had reaccumulated with
Ifnewcl suffering to the patient. A second operation brought away a (plant ity of liquid ecjual to the first, but of a pumleut and offensive character; and
every other day thereafter three or four iiints of offensive pns were drawn from the chest. The patient again suflered from i)rofuso night-sweats, and
the case seemeil appn>nchinga fatal termination. Tonics and stimulants, with animal diet, were admiuister^-d. The pleural cavity was washed out with
« weak solution of acetate of lead, but as this did not reduce the purulent discharge an injection was employed consisting of two drachms of tincture
of iodine and half an ounce of chlorinated soila solution iu a pint of teijid water. Every otht-r day the proportion of iodine was increased until it reached
one uoDce to two of water. I'nder this treatment the discharge assumed a healthier character and was reduced to half a pint a ilay; the patient's strength
iM-^an to improve, he gained in flesh, and his voice became full and strong. Finally, the local treatment consisted of wa-shing out the ]dcural cavity with
warm water and then throwing into it a pint of tepid water holding in solution two grains of sulphate of zinc to the ounce. When the latter was evacu-
ated at the end of forty-eight hours it was found little affected. After each injection the jiatient was rolled from side to side to promote the contact of the
Ii<pii.l with every ]iortiou of the diseased surface. The history of the case terminates five mouths after the first operation with the statement that the
left hmg remained unchange.1.— Lieut. Henry 11. Carter, Co. .\, 2Cth Ind., had suffered fnun an attack of acute pleurisy for four nionths before he was
first ^-vn by 31. T. C'lel.ixd, Kewana, Ind. The jiatient's pulse was 120, respiration so difliciilt that a lying iiosturt? could not be assumed, counteuaiico
paleand anxious an<i extremities cold and (edematous; there w:is dulness over the left side with unusual fulness of the intercostal siwices; the heart was
displacol three inches to the right of its nonual position, and its action was so violent as to shake the Ijody of the luttient. The removal of a gallon of
»rro-purulent liquid, by puncture between the sixth and seventh ribs, at once relieved the urgency of the symptoms. The discharge continued for five
days, after which the pulmonary and cardiac embarrassment returned, and an abscess was found pointing iK-'tween the third and fourth ril»8. A second
operation removed .»ire tj^lhtu of pnrt ptit. .K tent was introduced and a tonic and supjiorting treatment I'Ursued. In October, 1804, when the case was
r^porteil. the jiatient was able to ride out in a buggj-. He was gaining strength and had an excellent appetite. — Cincinnati Lancet ami Olnercer, Vol. VII,
new series. 1SC4. \k ,V.0.
Med. Hist., Pt. 111—103
818 CONSUMPTION.
better, and on the 4th the diarrhoea was checked, but the patient comjilaiued of pain in the right side below the nipple.
Sinapisms were applied. The congh became aggravated, the expectoration muco-purulent, the respiration hurried
and the pulse small, rapid and feeble. Death on the 8th was preceded by stupor. Post-mortem examination: The
membranes of the lirain were congested but there was no liquid in the ventricles. Both pleural cavities contained
serum and lymph, in all thirty-four ounces. The lungs were coated with coagulable lymph: their parenchyma was
normal, but the bronchial mucous membrane was red and thickened. The trachea was full of mucus. The right
ventricle of the heart was distended with white fibrinous clots; the left was empty. The stomach contained half a
pint of dark-green liciuid; its mucous membrane was thickly covered with mucus. The kidneys were normal in size;
there was no ditt'erence in color between their cortical and medullary substance.^Jss"t Surgeon Theodore A. McGraw,
U. S. Vols., Chattanooga Hospital, Tenn.
Case 42. — Private E. J. Powell, Co. K, 180th Ohio; age 18; admitted Feb. ,5, 1865, with intense fever, dyspnoea,
red eruption on face and congestion of fauces, tonsils, mouth and tongue. 6th: Eruption of measles on body and
lower extremities, with abatement of fever and continuance of dyspntea; thick, bloody, tenacious sputa, very diffi-
cult to remove from mouth and throat; tlulness of left side and bronchial respiration. 14th:' Died. Post-mortem
examination: Strong adhesions of left lung posteriorly with pseudomembraue elsewhere, and thirty-six ounces of
yellow flocculent serum in the cavity; bronchial tubes red and injected. — Douglas Hospital, Washington, D. C.
C.\SE 43. — Private Henry Bates, Co. A, 31st Ohio ; age 19; admitted March 25, 1864, from barracks with measles.
Died April 1. Post-mortem examination: Extensive bronchitis in both lungs; thirty-two ounces of liquid in left
pleural cavity. Other organs normal. — Hospital No. 1, Nashville, Tenn.
Case 44. — Private Larcom McCann, Co. F, 10th East Tenn. Cav.; age 18; admitted Jan. 27, 1864, with measles,
from which he recovered; attacked with mumps, from which also he recovered. March 19: Sudden delirium; pain
in the left side, gradually becoming worse. He was treated for remittent fever. 24th: Died. Post-mortem exam-
ination: Arachnitis; one ounce of liquid in ventricles. Pericarditis; six ounces of liquid in pericardium. Left lung
compressed in lower lobe by the pericardial efl'usion ; both lungs coated with recent lymph and twenty ounces of
serum in each pleural sac. Liver much congested. Other viscera normal. — Hospital No. 8, Nashville, Tenn.
Case 45.— Private David Garland, Co. B, 13th East Tenn. Cav.; age 36; admitted Feb. 4, 1864, with measles.
Died March 16. l^ost-mortem examination: Recent pleuritic adhesions on left side. Heart weighing nine ounces;
liver forty-one ounces; spleen three ounces and a half; kidneys each four ounces and a half— all healthy. Lower
ileum congested in patches; large intestine presenting several small ulcers. — Hospital No. 1, Nashrille, Tenn.
II.— CONSUMPTION.
Prevalence, etc. — During the five and one-sixth years covered by the statistics 13,499
cases were reported among the white troops under the heading Consumption in the Tuber-
cukir Order of Constitutional Diseases; and of these 5,286 terminated in death. The
average annual rates per thousand of strength were 6.1 and 2.2, respectively. This number
of cases includes an unknown but certainly large percentage of individuals whose consump-
tive tendencies were so marked at the period of enlistment that they should not have been
received into the service. On reaching their regiments from the recruiting depots their
names were placed on the sick report by the regimental medical officers, and proceedings
were instituted to eflfect their discharge. Carelessness on the part of recruiting officers added
considerably to the statistics of consumption. But, on the other hand, the reported number
fails to show many of the cases in wliich consumption was truly a development of the hard-
ships and exposures of military life. Men were taken sick with diari'lioea and dysentery,
ontinued fevers, measles, bronchitis, pneumonia and other diseases, and their cases were
reported under these headings. Months afterwards they died or were discharged on account
of tubercular disease of the lungs, although their names had never appeared in the list of
those taken sick with consumption. Thus is explained the apparent inconsistency of the sta-
tistical records of consumption, which show 13,499 cases with 5,286 deaths, and 20,403 dis-
charges among the white troops. Deducting the deaths from the cases, there remain 8,213
consumptives available for discharge; but the actual discharges were 12,190 in excess of
this number. Tliis excess permits some idea to be formed of the number of men in wliom
tubercular disease was developed during the progress of their military service. It consisted
of the cases that supervened on other diseases and were treated in and discharged from the
c
A
CONSUMPTION. 819
general hospitals. The cases that ended fatally in the hospitals may also be pn^perly cred-
ited as a result of the war, — for, as a rule, the regiments were relieved of their consumptive
recruits by discharge, not by death. . There were, therefore, at least 12,190 + 5,286= 17,476
cases of consumption that may be accepted as truly resulting from the exposures, fatigues
and privations of the war.
But these numbers by no means indicate the extent to which tubercular disease per-
vaded our armies. Tubercle was frequently found in the lungs of men who died of other
diseases. Thus, in 30 of 435 cases of pneumonia and in 16 of 330 cases of the paroxysmal
and continued fevers, in which post-mortem observation was directed to the condition of the
lungs, these organs were found to be tuberculous. According to Dr. Woodw.ved, tubercular
deposits were observed in the lungs in 106 of 667 cases of diarrhcea and dysentery. '=' The
pulmonaiy complication in many of these undoubtedly antedated the diarrhoeal attack, but
in otiiers, and particularly in chronic cases, it is probable that the protracted intestinal dis-
ease favored the development of the pulmonary tubercle.f- If the proportion of tuberculous
lungs found hy post-mortem investigation in cases of diarrhoea and dysentery be assumed to
have existed in the whole number, 37,794, of white soldiers who died of these intestinal dis-
orders, no less than 6,000 of them would have to be considered tuberculous.
Among the colored troops the reported cases numbered 1,331, the deaths 1,211, — equal
to the respective annual rates of 7.2 and 6.3 per thousand of strength. Deducting the
deaths from the cases, there were left for discharge or other disposition 120 consumptives,
the actual number of discharges having been 592. The relatively large number of deaths
among the colored troops has already been explained as duo to their homeless condition
during the war period.^ Their discharge would have deprived them, in most instances, of
the only home they had in which to die.
The lines indicating monthly variations in prevalence — diagram facing page 828, — are
of little value, as they are of necessity drawn from the reported cases. The records do not
furnish data for the distribution by months of the 12,190 cases that supervened on other dis-
eases among the white troops or the 472 similar cases among the colored troops. The rates
for the white commands were higher from the beginning of the war to A[arch, 1863, than
during the subsequent months. The height of the line during the former period appears to
show the influence of the irregularities at the recruiting depots. The army of the United
States attained its maximum strength, under the calls of the President for troops, in the month
stated. The lower level of the remainder of the line may be regarded as that proportion of
the reported cases wliich was truly due to the exposures of active service. The irregularities
of the line expressing prevalence among the colored troops appear also to be more intimately
connected with the enrollment of the men than with their subsequent exposures.
The Clinical records consist of eighty-five fragments, which, with few exceptions, pre-
'sent little of interest. Cough, for instance, is very generally noted, and, as the cases had
usually made considerable progress before reaching the hospital where the record was written,,
it is frequently characterized as severe or harassing. The expectorated matters are also noted:
as scanti/, frothy, mucous, lohite or tenacious, but more generally as copious, free, muco--
pui-ulcnt, ycHoiv or prirulent, and each of these is not unfrequently qualified as streaked,
stained, tinged or mixed xvith blood. In two cases the presence of tubercular matter in the ^
sputa is asserted. The site of pain, as in the upper part of the chest, is frequently men--
• P»rt Second of this work, p. 535. t B><^ P"*' 678. ! Supra, page 2s.
320 CONSUMPTION.
tioned but its character seldom. Tiie phi/sical signs occasionally noted were diminished
resonance in the infraclavicular region extending downward, with enfeeblement of the res-
piratory murmur and 20rolongation of the expiratory sound, and absence of vesicidar respira-
tion foilowed by bronchial breathing, crackling, mucous rales, cavernous respiration and
gurgling. The pulse was reported frequent or frequent and feeble. Palpitation and dysp-
noea also appear in tbe records with emaciation and debility, caused hj fever, cough, loss of
sleep, diarrhcea and perspirations. Heredity is mentioned with some frequency, and occa-
sionally there is a reference to the limited capacity of the chest, hifraclavicular depression
and aphonia. Fistula in cmo caused much irritation in one case in which, after some
hesitation, an operation was performed, the official record closing with the patient's dis-
charge three months afterwards. Au amelioration of tlie symptoms occurring soon after
the arrival of a case in hosoital is occasionally ascribed to improved hygienic conditions.
The disease is mentioned as having been developed after attacks ol p>neumonia, measles,
diarrhcea, dysentery, typhoid and mcdarial fevers. The cases terminated in discharge or
death. In one case only was the patient returned to duty, but, as shown by the regimental
records, he did not continue long in a serviceable condition :
Corp'l Gilbert Alexander, Co. C', 108tli III.; age 20; was admitted Sept. 23, 1863, with consumption. He was
pale and emaciated; bad hectic fever, night-sweats, nocturnal cough, yellow, blood-streaked sputa, darting pains
through the chest, shortness of breath and excitable pulse. Under cod-liver oil, whiskej- and full diet he improved,
regaining his appetite and iJesh. His cough bad entirely disappeared, when he was returned to duty Feb. 16, 1864. —
Hosjntul, Qiiiiicjj, III. [This man returned to his regiment about the middle of March, 1864, from hospital at St. Louis,
Mo., having been absent in various lio.spitals about twelve months. He was reported as tit for duty; but, afterexposure
at night, he complained of violent headache. This was relieved by means of an active cathartic; but another day's
duty produced a relax^se with listlessness. He complained of little except the headache. He was taken into the reg-
imental hospital and treated with mercurial and saline purgatives, an antiphlogistic regimen and blisters to the spine
and nape of the neck. No improvement resulted. As the powers of the system seemed failing, quinine and stimu-
lants were employed. The left side became paralysed, and three days later, March 30, 1864, the patient died, coma
having supervened in the meantime.]
The three special cases submitted below are by some member of the staff of tlie Satter-
lee hospital, Philadelphia, Pa."'"
Private David T. Billings, Co. B, 2d Me.; age 27; born in Maine of healthy parents; was admitted Aug. 12, 1862,
with intermittent fever contracted on the Chickahominy. His thorax was well developed and his general appearance
presented no suspicion of the tubercular diathesis. Under the administration of quinine his febrile paroxysms were
averted. On November 12, when the officer who makes the report took charge of his case, he was taking fifteen
drops of tincture of iron and two grains of quinine three times a day. He complained of excessive debility and a
.slight backing cough accompanied by a duml) ague, which caused an aggravation of his malaise and cough every
third day. Dulness was found over the upjier lobe of the right lung, with prolonged expiration and bronchial breath-
ing, bnt no crackling or rales. Over the upper lobe of the left lung a slight friction sound was audible. The matter
expectorated was slight, nummular and increased on every third day. The secretions were generally normal, but
occasionally he had nocturnal perspirations att'ecting the upper part of the body. The iron and (luinine were con-
tinued with the addition of cod-liver oil and counter-irritation. On the 25th he was seized with violent hienioptysis,
which recurred for ten days, always on the day of the expected paroxysm. This was controlled by veratrum viride
with aromatic sulphuric acid. On December 8 some crackling was audible in the right side, the left lung being in
its normal condition. Cough was increased and there was some purulent expectoration. The intermittent malaise
persisted, with an increased cough on theday of the suppressed paroxysm. Qtiiniue was ordered in increased doses —
ten grains at one dose for three consecutive mornings; after that ten grains every seventh day for four weeks, and
lastly, the same dose twice repeated after the lapse of fourteen days. Under this treatment the patient improved
rapidly. On Jan. 7, 1863, on account of the weak and rapid action of the heart, the tincture of iron was resumed
in doses of ten drops three times a day, and on the 10th the haemoptysis returned and the cough increased, but showed
no intermittency in its character. Quinine and iron were now omitted, and under cod-liver oil, counter-irritation and
favorable hygienic influences the improvement in the patient's condition became marked. On February 1 the dulness,
prolonged expiration and crackling had entirely disappeared, and the cough and expectoration were but trifling. His
general condition had so improved as to lead to the belief that recovery was probable. As the lung aft'ectiou disap-
peared 2>t'>'i J«i»s« with the removal of the malarial symptoms, the reporter regards this and other similar cases as
*TIie record of tbcse cases is unsigned. Act. Ass't Surgeon L. K. Baldwin was, at the time of their entry, the attending physician of Ward E
of tlie Satterli.'C hospital, in wliich tliese patients were treated.
CONSUMPTION. 821
tendiiij; to show that in the cachectic eoiulitioii of the blood consequent upon mahirial poisoning certain pliysical
signs manifest themselves in the lungs, coinciding in every way with the usual concomitants of tuberculosis. Ho
believes that these local conditions would finally end in tuberculosis, and that they resemble those conditions which
are found in other organs, the liver, spleen and kidneys, as the conseiinence of malarial poisoning. He says : — " Under
the use of the remedies generally employed in miasmatic aft'ections they yield most readily, and it is to this circum-
stance that we may owe, perhaps, t he benelicial employment of arsenic, wJiich has been extolled as a remedy by some
writers in incipient tuberculosis. The error which most writers and practitioners have fallen into in reference to
tuberculosis originates in the fact that the formation of tubercle is always considered by them as due to a peculiar
cachexia of a specific character. Kecently souu- writers have described a scrofulous induration and stitVeniug of the
summit of the lungs simulating tuberculosis and giving rise to many of the physical signs of that malady. I believe
that there are various conditions of the blood in which a local engorgement, if not properly treated, may tiually give
rise to tubercular formations, and in cases w here there is no hereditary taint and wlicre the usual chaiacteristic pro-
dromes of a tubercular cachexia are wanting. Under modern enthusiasm for the unusual in pathology we seem to
overlook the fact that the blood is the lluid tissue and the tissues are solidified blood. A local pathogenic process
may contaminate the blood as well as a depraved blood-disease the tissues whii-ii it is toconstitulo. Tlie.se facts should
not be overlooked in our diagnosis and treutnu-nt of tuberculosis. In the eases to which reference has been made
the malarial blood-contamination may have depraved a portion of the lung, and this focus of disease may have served
to keep up the cachectic condition. Kemedies which antagonize the blood poisoning would not ensure a return to
health: the local complications must also l>e removed. In many cases of supposed tuberculosis, where all attention
has been previously paid to the constitutional symptoms, I have effected a cure only by adiling a local treatment."
Josei)h Heading: age 25; born in Xew Jersey of healthy parents; was seized with remittent fever from expo-
sure on the Chickahominy. and was two months in a hospital near Washington previous to bis transfer to this hos-
pital Dec. 12, 1862. On admission he was exceedingly emaciated, with Habby nnisdes l)Ut with a fine thoracic con-
fornialiou. He complained of having paroxysms of fever, preceded by a slight rigor every other day, with a very
annoying cough and considerable expectoration of a purulent character occurring with perspiration as soon as the
fever subsided. A slight luemoptysis had occurred about two weeks before his entry, and he had been informed by
his previous medical attendant that his c^se was one of incipient )>hthisis. There was dulness over the upper lobe
of the right lung, with prolonged expiration and much gurgling audible in front of the clavicle; there was also some
dulness over the upper lobe of the left lung, with a Jerking sound on expiration. Cardiac action was tumultuous and
with an ana-tnic nnirtnur; the pulse averaged about 96, but during the paroxysms of the fever it reached 120 per
minute. The treatment consisted of generous diet, quinine (as given in the case of liillings), cod-liver oil and milk-
punch, with the external application of tincture of iodine. On Jan. 1, 1863, the malarial complication was eftec-
tually removed, but the pulmonary symptoms remained about the .same. To meet the ana-mic complication tincture
of iron in doses of fifteen drops three times a day was added to the treatment, but, as on the 6th, he complained of
considerable stricture over the chest, and on that day had a return of Inemoptysis, which yielded to the inllueucc of
ieratrum viride ajid aromatic .sulphuric acid, tlie use of the iron was suspended. "He has improved rapidly since
then ; his cough has much diminished; there is but slight expectoration and it has lost its purulent character. Phys-
ical examination revealed, on the 2.5th, an almost entire disappearance of the dulness over the upper lobe of the left
lung and also of the gurgling sound heard over the summit of the right lung: the prolonged expiration continued in
that lung with dulness on percussion, but a wonderful alleviation had undoubtedly taken place. The iiatient has
continued to improve and gives every evidence of returning health ; his cough and expectoration have entirely disap-
peareil, while the emaciation and debility conse(iuent upon his illness remain. I have no doubt but that, with time
and proper care, he will eventually recover. In this case there was no evidence of any scrofulous cachexia, and the.
patient's whole aftection seemed to have resulted from the malarial iuduence."
George A. Case: age 25; born in Xew York State of healthy parents, contracted intermittent fever on the Chick-
ahominy in June, 1862, and was admitted into hospital on August 10. At an examination of the patient, November
12. the following points were noted: Considerable emaciation; dingy appearance; well-developed thorax: strongly
incurved nails; well-marked red line around the gums: shortness of breathing, the slightest exercise bringing on
violent cardiac palpitations with an aiuemic blowing sound; two attacks of hiemojitysis since the beginning of his
sickness: pulse about 90: he has paroxysms of coughing (which he thinks are aggravated every second d.ay) with a
slight purulent expectoration often streaked with blood; no chills, while such sliglit perspirations as occur are con-
fined to the upper i)ortion of the body; some dry crackling over apex of left lung: increased dulness and bronchiiU
respiration over apex of right lung; expiration prolonged and jerking. Thinking that there might be still some
malarial aftection wbich, if removed, would enhance the patient's chance of recovery, quinine was given, as in the ease
of Billings, and was supplemented with cod-liver oil, generous diet and the external use of tincture of iodine. The
patient improved rapidly and the paroxysmal character of the cough entirely disappeared; but finding, about Decem-
ber 20. that the excessive irritability of the heart and the blowing sound continued, iron in the form of Vallefs mass,
three grains three times a day, was prescribed. On Jan. 6, 1863, the iron was discontinued on account of extreme
stricture felt by the patient over the chest with an increase of bloody expectoration and some slight febrile action.
Cups were applied to the spine and the quinine and cod-liver oil were continued. On tlie 8th the patient's condition
was thus stated: Dulness diminished: gurgling ceased: slight cough continuing with a little mucous expectoration
but no bloody streaks; llesh and strength returning rapidly.
The object of the Satterlee reporter in recording tliese three cases, to which, he Sciys, he
might have added the histories of four others of a similar character, was to suggest that they
322 CONi?UMPTION.
tended to subvert the doctrine of a pathogenic antagonism between tlie causes of miasmatic
diseases and the tubercular development. He continues as follows:
These cases, from their symiitoms and the signs yielded by physical exploration, induce a medical man to view
them as veritable cases of incipient tiibcrcnlosis. On the other hand, the nnusual venosity of the blood in malarial
aft'ections, a circnmstanee pointed out by Rokitanski as proving an obstacle to the formation of tubercle, seems to
militate against the view assigning to these cases a tubercular origin, and to renuire that they be attributed to those
venous congestions causing hypertrophy and o'demation of the spleen and lungs as the result of malarial poisoning.
It might bo suggested that the administration of tlie iron in these cases liad proved advantageous by relieving the
eugorgeu\ent of tlie lungs. It is well known that TKOfSSEAU's experience has led him to eschew chalybeate remedies
in the treatment of confirmed jihthisis, he having become convinced that in such cases they pronuite a tendency to
hsemoptysis and increase the inlhiuimatory process around the tubercle, hastening its nltimate softening. The writer,
attribnting the ha-moptysis and the aggravation of tlie symptoms to the iron administered, immediately suspended
its use. Should further experience prove the ii'ou to act in this manner, it would tend to strengtlieu his view as to
the tubercular nature of the disease as well by confirming the views of TliOfsaE.vu as by a consideration of the
efficiency of the iron as a blood remedy in that condition of deterioration which produces enlargement of the liver,
spleen and other glandular organs. He considers that the conditions of the system in malarial poisoning arc just
such as would induce tuberculosis, general prostration of the system and defibrination of the blood — the body being
thus deprived of the proper material for the maintenance of its nutritive and the continuance of its organic functions.
These cases assail the doctrine enunciated by Boudin, that the vitiation of the blood
by the miasm of malarial fever is, within limits, preservative against tubercular develop-
ment.* At the same time they raise a question as to the value of iron in those lung diseases
that are attended with hsemoptysis.
In addition to these three cases there is, among the eighty-five cases constituting the
clinical records of consumption, but one instance in which this disease is said to have been
present in a malarious subject.
Private Andrew L. Lingers, Co. B, 24th X. J., was admitted Dee. 18, 1862, convalescing from intermittent fever,
and troubled with night-sweats and a cough with copious sputa, for which quinine and iiou were administered, and
pitch and iron plasters applied in sequence to the chest. On the 26th a slight dnlness was found under the right clav-
icle and .ievking respiration at the apex of the left lung. On Feb. 5, 1863, the dulness was greater under the left than
under the right clavicle. Cod-liver oil was ordered. He progressed slowly, at one time seeming to improve and at
another to grow worse, until the recoid of April 3 shows him free from cough on that particular day, althoug]^
there were pains in the left side of the chest, dulness in its upper third, harsh and jerking respiration at its summit
and posteriorly, with prolonged expiration and occasional crepitus, while the respiratory murmur on tlie right side
was feeble. He was discharged on the 14tli for debility and probable phthisis. — Satlcrlec Ilosjiitol, rhihnhljihia. Pa.
The post-morte7n records of consumption make occasional mention of chills and febrile
movement in their statements of the ante-mortem condition of the patients, but it is doubt-
ful whether these were of a malarial nature. In six cases the evidence of the malarial
presence is more definite, although by no means convincing; but the attending physicians
certainly regarded some of these cases as malarial, and their opinion is of value, although
*.l- C. M. BouDiN, Paris, 1S42 — Traitc des Fierres Intennilientes — attempted to subvert the generally received opiDion that the progress of tubercular
disease of the lungs is hasteueil by low temperatures and moistul"e, i. r., by cliuirtte, and ivtarded by a ivsidence in localities having a warm and equabli-
lemperatuiv ; aud proposed the doctrine that there is an antagonism between the liahulal poison and the tubciTular cachexia, — that tlie vitiation of thr
blood by the pathogenic matter of niai-sh fevers gives, within certain limits, an immunity from tubercular disease. 31. Bornix took credit to himself
for having develojwd this law of antjigonism. He claimed that not heat, noreoUi, nor moisture, nor latitude, etc., will explain the absence of tubercular
disease in certain localities ; but that it is connected with emanations fi-om the soil. In .Mgeria, in the delta of the Hhine and in the Italian maiTumia,
where fever is rife, consumption israi-e ; aud at >'aples, Blalta, tTibi-altarantU'orfn, which are free from fever. Ihonieic diseases aiveommon. He mentions
the oise of a eonsnmplive who, with two attendants, removed from the north of Kurope to llyeres, where shortly afterward his health became re-estab-
lished, while his two attendants were taken with intermittent fever. " Voila, j'esperc uu exemple fraj)paut d"un sol inareeageux qni gu^rit les poumons
do Tun et donue la tievre aux antres." But Dr. W. C. AVeli5 broached this subject long before Bornix wrote his treatise. On Dec. It, lSl'.i, be read a
IMH>er 0)1 PiibaoMan/ Coiiiumption and InlfriuilUttI Fever cltirtiy as dimifes oj>j>oKed lo each other^ Ijefore the Society for the Improvement of Medical and ehirurgi-
cal Knowledge. In this, which wiis published in the 'fraiimetiam of the Soeietity London, 1S12, p. 471, he cites seveml instances to prove that where agne>
are pre^■alent eonsumptiou is eompomlively nire, and that the decrease of agues in a locality h:is been followed by an incre.'ise in the number of consump-
tives. He exjilained this by assuming that the existence of one disease in the hmnau body — or even a tendency to one disease — often i-enders it less sus-
ceptible to the attiicks of another disease than if it wei-e five from all morbid imjiressions. He n-commended that the children of consumptive I'jirenls
be sent to schools in the fenny districts ; but the evidence on which this ivcommendation was nnule wjis [uirely lu-al-sjiv. It wjis stated, on the autluo-ity
of a clergyman named Leslie, that Euglish students at Liege, when affected with consumption, welx' sent to the swampy districts of Austrian Flanders,
where, after a few months, they almost invariably recovered their health ; aud an old Scotch officer, who had served long iu Flanders, was reimrted as
having statt-d that he had often seen consumptive i>ersons come, for the beuetit of their health, from the high and dry parts of the country to those which
were low, marshy and iufectwl with agues. On the other hand, the experience of Dr. L. H. W.vitn, at the Seamen's hospital ** /*re,i(/noiiy/j/,'' ojiposetl to
the doctrine of antagonism : The diseases coexisted iu manv cases, and ague was frequently reeoi-ded among the auleeed'ents of i>hthisis. — See Lniicet^ Vol.
II, 1864, p. 4Sa.
CONSUMPTION. 823
there may be no record of the facts on which it was based. It is difficult to disprove M.
Boudin's doctrine of antagonism by direct evidence, because the doctrine acknowledges
exceptional cases, and all testimony advanced for its refutation is subject to cliallenge as
e.xceptional if it cannot be thrown aside by impeaching its malarial character. It is well
known that our troops broke down with tubercular disease in malarious as well as in non-
malarious localities, and the following case shows that the assumed antagonism did not always
prevent the coexistence of the diseases in the individual :
Private John InKrabam, Co. C, 17tb U. f*. Inf.; age 23: was admitted Nov. 23, 1863, and died on the 2Gtlj. "«(..'-
morlem examination : The body was not much emaciated. The right lung weighed thirty-three ounces; the anterior
portion of tlie first and the whole of the second lobes were healthy; the apex of the first lobe was the seat of tuber-
cular deposit, aflccted in part with calcareous degeneration, and the jjosterior basilar portion of the same lobe was
tubercular and of an intense purple color, — the deposit had gone on to softening and to the formation of a cavity
about the size of a horse-chestnut: the third lobe was (edematous, friable, uoncreidtant and of a dark-i)urple color.
The left lung weighed twenty-four ounces and adhered to the costal pleura: its posterior portion was of a puri)le color
and contained softened tubercle; but there was no tubercle in the apex. One of the bronchial glands on this side was
tuberculous. The heart was normal and contained fluid blood. The liver was bronzed : the Bi)leen firm and of a dark-
mahogany color: the kidneys congested. The stomach was enormously distended — filled with a muddy-green (luid.
The mucous membrane of the intestines was intensely congested; there' was no ulceration nor were the patches of
Peyer elevated, but the solitary follicles of the small intestine were conspicuous and of a deejicr pnrjile color than
the adjacent membrane.— J»«'< Surgeon H. Allen, U. S. J., Lincoln Uoiipilal, JVanhington, V. C.
\i post-mortem appearances be of value in determining the cause of death this man died
oi malarial fever. Indeed, had the record of this case come under the observation of tlie
editor at an earlier period of his work, it would have added one to the comparatively few
cases of death from acute malarial poisoning that have been submitted. The testimony as
to the coexistence of tubercle is equally positive. It may be said, however, that Boudin's
view of the antagonism did not imply a reciprocal protection, but was limited to tlie preven-
tion of consumption by malaria. But, since he refers to the recovery of a consumptive when
taken to a malarious locality,* and since a removal to a malarious region, as originally urged
bv Wells,! is the practical application of the doctrine, it is important to know that this
exposure is not unattended with danger. If the post-mortem records of the paroxysmal fevers
are examined, thirty-seven cases (including seven with a possible typhoid element) will be
found in which attention was specially directed to the condition of the lungs. Tubercle was
observed in five of these cases, to wit: 61, 69, 84, 89 and 98. If the case of Ingraham,
just submitted, be included, pulmonary tubercle was recorded in six of thirty-eight malarial
cases. Tubercle was noted also in four of fifty-eight cases of continued malarial fever and
in one of fifty-one cases of typho-malarial fever| in which the condition of the lungs was
recorded. In all there were eleven ca.ses of tuberculosis in one hundred and forty-seven
malarial subjects whose luTlgs were examined after death from febrile accessions. But since
there was but one case of pulmonary tubercle in thirty-four cases of pure typhoid fever§ in
which the lungs were inspected, it must be inferred that the presence of the tubercular
cachexia afforded no protection against the influence of the malai-ial miasm.
The records afford no precise data bearing on the endemicity of consumption; but
American experience, aside from that of the war, suffices to show the fallacy of the doctrine
of'antagonism. Although the inhabitants of many malarious localities are singularly free
from tubercular disease, a glance at the records of the Health Office of Xew Orleans, La.,
will show that both diseases must be regarded as prevailing in that city to an unusual
extent. Its malarious site and surroundings do not prevent it from having a higher death-rate
from consumption than most of our large cities; its rate is exceeded only by those of New
•Se«not», J«ge82il»;w^ tS«- last nutf. XSvpa. fi^ t^ll. |S»pra. I«ip* 130.
824
CONSUMPTION.
York and Boston.'^' It i.s probable, therefore, that the frequently observed want of endemic
coincidence is due to a nonconcurrence of the causative conditions rather than to an antag-
onism on the part of the diseases or the miasms or germs which give rise to them.
Although the propriety of administering iron in tubercular disease of the lungs has
been questioned by Trousseau, Copland, Stille and others,-j- their objections to its use do
not appear to be sustained by the experience of the war, notwithstanding the cases submitted
from tlie records of the Satterlee hospital. The administration of iron in eleven of the eighty-
five cases constituting the clinical records of consumption was not followed by the occurrence
of hsemoptysis: in three of these the iodide was given and in eight the tincture of the sesqui-
chloride. On the other liand, hemorrhage was noted in eighteen of the cases, and in only
six of these had there been a prior use of the preparations of iron ; in three the hsemoptysis
occurred two or more weeks after the tincture was used, and in three — the Satterlee hospital
cases — the iron was charged with having occasioned this corajolication. In twelve there had
been no antecedent administration of iron; but, on the contrary, in four of the twelve the
hemorrhage was said to have been successfully treated by the persulphate or muriated tincture.
In only one of these was there a recurrence after the iron was used, and here the alarming
symptoms were suppressed by a continuance of the remedy. J The post-mortein records, as a
rule, do not enter into the particulars of the clinical history. There are, nevertheless, among
them twelve cases in which hsemoptysis is recorded, and one winch was characterized by profuse
and repeated hemorrhages from the nose and gums; but in only one of these is iron said to
have been given, and in this instance the untoward symptom preceded its administration.
The charges preferred against the chalybeate preparations in cases of phthisical hsemop-
tysis cannot be considered sustained; but from the fact that iron was not employed in many
of these pulmonary hemorrhages it may be inferred that there was a restriction on its use
in our army practice.
* The foUowinj^ tabulation, comparing tliG death-rate of Malarial Fevers and Consumption in some large cities of the U
Reports published in the BiiUelin of the Katloiud Board of TleaWt, Vols. 11 and III, illustrates this point :
lited States, compilr'd from
City.
Population.
Total mortality from—
Annual rates per 1,000 of popnla-
tion.
1
Consumption.
Malarial fevers.
Consumption,
Malarial fevers.
ISSO.
1881.
1880.
1881.
1880.
1881.
1880.
1881.
216, 140
362, 536
1, 206, 577
506, 689
846, 980
332, 190
2.56, 708
603, 304
:W0, 522
233, 956
846
1, 469
4,741
1,807
2, 692
1, 243
73S
848
784
788
850
l,.54l
6,302
1,121
2,758
900"
1,134
902
681
332
6
466
250
16
83
10
81
236
35
366
7
605
304
57
21
128
387
9
3.91
4.05
3.93
3.19
.3.18
3.74
2.89
1.68
2.23
3.37
3.93
4.25
4.3!)
2.98
3.20
3^52"
2.25
2. .57
2.48
1.54
.02
.39
.44
.02
.25
.03
.16
.69
.14
1.05
.02
.50
.54
.07
ros"
.25
1.10
.04
Brooklyn, X. Y
Philadelphi-a. Pa
Baltimore, Md
Cincinnati, Ohio
Chicago, 111
San Francisco, Cal
fTRorssEAi:— C^iHiVtt; JlA-rf/omf'—Trau slat ion by Sir J. Rose Cormack, Vol. V, Xcw Sydenham Society, London, 1872, p. 97— asserts that the admin-
istration of iron to persons having a tendency to tubercular disoase sometimes gives an appearance of flourishing health, which is, however, immediately
followed by a violent and rapidly fatal activity of the hitherto latent consfitutional disease. Copi.anp, in his Diciioimnj of Practical Medicine^ Vol. Ill,
London, 1858, p. 1150, says that the preparations of iron are contruindicated in the treatment of phthisis wlicn inflammatory complications or a tendency
to hncmoptysis are pi'esont; and that whenever, during their employment, the cough becomes hard and the respiration oppressed they should lie discon-
tinued. Tanner, in his Practice, London, 1S72, p. 573, and Still.';, Tlurajieutics ami Mati^ria Mcdica, Vol. I, Philadelphia. 1S74, p. 480, hold similar views.
Many writers do not refer to this subject : Among them may be mentioned Ebehle, 1S35 ; Dv.nglison, 1844; Bexxett, 1803 ; Aitkex, 18G6; Reyxolps, 1871;
Watson, 1872 ; Ruehle in ZicmsSKn''8 Cyclopedia, 1875, and Bristowe, 1876. Loomis, New York, 1884, restricts the use of iron in phthisical sulijects to
unjcmic cases in which the temperature is below 100° Fh. Flint, Philadelphia, 1884, p. 221, deuies that chalybeate tonics favor the recurrence of liaMuop-
tysis in phthisical cases, and holds tliat even had they this eff"ect it might be evidence for, rather than against their utility.
X ATKi^soy— Transactions Med. Society, Statv of Peuiisylcania, 18G3, p. 298— speaks with high favor of the pei-sulphate of iron in the treatment of
hieinoptysis. In his experience in public aud hospital practice its employment never failed of success. He considers it trustworthy, also, in hemorrhage
from otiier organs, as the stomach and bowels. It was givea in doses of five to ten drops every twenty or thirty minutes untii the discharge was checked,
after which it was continued for several days in less frequent aud diminished doses.
coKsuMPTio:^ 825
The Po:;iT-MORTKM RECORDS. — Froiu tlicse it appeiU's that our medical ollioers enter-
tained the views of Laen>-ec, which regarded tubercle as ot" two varieties, the gray or miliary
and the crude, yellow or cheesy, the latter originating by the aggregation of the former or
at times by infiltration. In many of tlie records may be found descriptions which tally with
ViKCHOW's caseation of lobular exudations in the air-cells and pulmonary corinective, and
tlie formation of cavities by its subsequent softening and elimination; but these deposits
were uniformly regarded during the war as tubercular. Selections from the records are here-
with submitted.
Twenty-five cases of pulmonary tubercle unsoftened, softened or in process of elimina-
tion were recorded. As for instance: —
C.v.<K 1. — Private Daniel BunUoksou, Co. I. 28tli Coloitd TioDps; a<;c lit; was admitted Dec. 7, 1><GI. Ili- was
debilitated; lie slept a great deal, and liis mind was dull. About Jan. S, 1865, liis eougli became very distressing and
I lie sputa thick, mucous and occasionally bloody. He died on the 15th. At the posl-iiwrlcm examination tubercles
were I'onnd in both lungs and jjleuritic adhesions on the left side. — L'Oinerluir llonpHul, Alexandria, T'a.
Cask 1.5.— Private Aaron Wyght, Co. I, 6th X. H.; age 40; admitted May 27, 1864, with much debility and
emaciation, diarrhcea, cough, tcdenia of lower extremities, and with dulness, tubular respiration, prolonged expira-
tion and marked infraclavicular depression on both sides. He walked about up to June 17, apparently improving
undercod-liver oil, tonics, stimulants and good diet, but on that day ho fainted and died in a few hours. I'oxl-morlem
examination: Tubercular iutiltration and cavities in both lungs: much mucus in bronchial tubes; pleuritic adhe-
sions on both sides posteriorly. No clots in heart. — Chestti- Ilotipihil, I'liiUnUlpUia, Pa.
C.^SF. 25. — Serg't John Kadeley, Co. F, loth Va.: age 26: treated in field lios])ital for four months; was admitted
Nov. 5, 1864, much emaciated, but with appetite good and bowels regular: Cough harassing; expectoration copious,
tiilu'rcular and purulent : dulness overthe left lung; cavernous respiration; a large abscess in the perina^nm, pointing
towards the scrotum and yielding a free purulent discharge. 19th: Diarrluea profuse, exhausting. 24th: Involun-
tary stools. 2oth: Died. Post-mortem examination: Emaciation extreme. Left lung transformed into a sac filled
with pus similar to the sputa; right lung infiltrated with tubercular deposits in various stages of development, —
those in the apex softening. Abdomen not examined. — Cumberland Hospital, Md.
Four cases of pjulmonary tubercle with attempts at cretefication were recorded as follow: —
C.\SE 26. — Private Robert L. Bennett, Co. D, lltli HI., was admitted May 3, 186.5, from Sherman's army by way
of New York: Cough with expectoration of a dark purulent matter; emaciation; no pain: no night-sweats; appetite
fair; pulse IdO: ])ectorilo(iuy under both clavicles, on the right extending four inches downwards; gurgling under
the middle of the sixth rib on the left; respiratory murmur puerile over the lower portions of both lungs. 22d; The
sound under the right clavicle was like that of a steam escape-pipe; expiration was twice as long as inspiration;
tympanitic resonance over upper lobes and dulness over lower lobes; respiratory mnrmur almost inaudible; pulse
120; occasional delirium. 23d; Died. Post-mortem examination: Complete pleuritic adhesion on both sides. Two
large cavities in upper lobe of right lung, one immediately under clavicle, the other four inches below, each as large
as a hen's egg, and eommunieatiug, of irregular shape and roughened interior; lower lobe congested. A large cavity
in left lung involving nearly the entire upper lobe; several cavities the size of filberts, a few cretaceous deposits
half an inch in diameter, and occasional patches of miliary tubercle in the lower lobe, the lower margin of which was
congested. Black clots in the heart and three ounces of straw-colored iluid in the pericardium. — Aet. Ass'l Surtfeon
A. A. Morrison, Hospital, Madison, Ind.
Cxsr. 27. — .Serg't William H. Crow, Co. D.llllhOliio: admitted Aug. 25, 1863, with jditliisis pulnionalis; Pnlse
W to 100; slight cough and expectoration ; great prostration ; little ajipetite. He became gradually weaker, and died
on the 30th. Post-mortem examination: Lung-tissue healthy except lower lobe of left lung, which contained much
tubercular matter, some of which was hard and cretaceous, .some cheesy and some broken down into pus; there was
also a large vomica containing pus and dark grumous liquid. Heart healthy. — Hospital, Madison, Ind.
Cask 28. — Private Louis Dauncr, Co. K, 20th Conn.; admitted March 11, 1864. with chronic pulmonary disease
and feeble heart. Died 1.5th. Post-mortem examination: Body much emaciated. Left lung universally adherent,
iiiormously enlarged and containing darkly mottled melanotic tubercle cretefied ; no serum in pleural cavity; right
lung similarly conditioned but not to so great an extent; the lower portion nearly healthy; four ounces of dark-yellow
serum in pleural cavity. Pericardium contained eight ounces of serum of a clear light-straw color; heart half the
:u)rmal size, walls thin, atrophied and fatty, anterior surface gelatinous, but no pericarditis; valves thickened, espe-
cially the mitral, and covered with fibrinous deposits. — Hospital, Tullahoma, Tenu.
Case 29.— Private William F. Browning, Co. D, .5th Tcnn.; age 20 ; admitted Sept. 11. 1864, with chronic bron-
chitis: Pulse 100: tongue slightly coated: thirst, anorexia and some tendency to diarrluea; clearness on percussion;
moist rales; labored respiration; aphonia and frequent cough with expectoration of tough mucus. He failed grad-
ually, and died December 4. Posi-morfcm examination: Great emaciation. Pleuritic adhesionson leftside; calcareous
tubercles filling both lungs; niuco-purulent matter in smaller bronchial tubes. Abdominal viscera normal. — Act. Ass'l
Surgeon H. C. yeirkirl,-, Hospital, Pock Island, III.
Med. Hist., Pt. 111—104
826 noNSUMPTiON.
Death in the majority of these twenty-uine cases was the result of the tubercuLar
destruction of the lungs and the concurrent prostration of the system. In forty-two cases,
however, inflammatory or pseudo-inflammatory congestions and exudations, with more or less
implication of the pleura, sometimes the rupture into it of tubercular abscesses, aided in cut-
tino- short the historv of the individual, as in the following:
Case 41. — Private James .Tolinson, Co. D, 39th Colored Troops: age 22; was admitted Oct. 1(5, 1864, witli rheu-
matism. He performed light duty about the ward for some time, but ou December 5 had a bilious attack from which
his recovery was so unsatisfactory that on the 30tli his case was considered one of typhoid fever. The febrile symp-
toms were, however, obscure, — there was diarrhiea with umbilical pain, feeble pulse, moist tongue, slight but constant
cough and copious expectoration. Dulness was noticed, Jan. 4, 1805, over the upper and anterior part of the right
lung. He died suddenly on the evening of the 6th, on retiring to bed after having been to the clo.se-stool. Fost-morlem
examination: The right lung was much congested and infiltrated with tubercle; the left was hepatized gray. The
heart was small and both its ventricles were empty. The liver appeared healthy. The ileum and colon were con-
siderably inflamed and distended with gas. — Siitnmit Souse Hosjntal, l^hllcidelxjhia, I'd.
Case 48. — Private John Anderson, Co. F, 18th Mo.: admitted Sept. 22, 1863, having suffered for six months
from lung disease: Much emaciated — weight reduced from 180 to 100 pounds; copious mueo-purulent sputa; gurgling
rales in right lung posteriorly and comparative absence of respiratory murmur over both lungs. Died 26th. Post-
mortem examination: Extensive tubercular infiltration of both lungs, but especially the right; hepatization, purulent
infiltration and many abscesses; plenne adherent posteriorly. — Union Sosjtital, Memphis, Tenn.
Case 57. — Private Israel Young, Co. E, 1st Va. Art'y; age 18; admitted Feb. 4, 1865, much emaciated. Died 10th.
Post-mortem examination : Pleuritic eti'usion in right sac ; right lung compressed, adherent at apex and to diaphragm,
filled with vomicEe; left lung tuberculous. — Third Divi^on Hospital, Alexandria, Va.
Case 67. — Private William Toss, Co. B, 114th Ohio; age 18; was taken sick about M.arch 1, 1863, with what
was called remittent fever. 21st: Admitted. 23d: Died. Post-mortem examination: Abscess in apex of left lung,
communicating with pleural sac; much tubercular deposit in both lungs. — Luwson Hospital, St. Louis, ilo.
Case 68. — Private Balthaser Giuder, Co. C, 6th Conn., was admitted from Richmond, Va., March 24, 1804, with
pneumonia of the right side. He complained of diarrhcea, general weakness and wakefulness ; he coughed and
expectorated a good deal of yellowish-gray matter tinged with blood, but had no pain; his pulse was regular and
not much accelerated; his skin moist. Muriate of ammonia was administered. After a day or two he began to
improve and continued to do so until April 2d, when the attending physician, hastily summoned at 4 p. M., found him
pale and ghastly, with difficult respiration, accelerated pulse and bubbling sounds in the right side of the chest.
Brandy was given, but he became several times faint, and died at 11 P. M. Post-mortem examination : The right lung
was bound in part by old adhesions but was not much collapsed; its upper lobe was infiltrated with tubercle in
various stages of softening; some cavities in the apex contained viscid yellowish tubercular masses, and one, larger
than a goose's egg, in the middle of the lobe, communicated with the pleural cavity. The upper lobe of the left lung
was also infiltrated and presented some small vomica-, but none of them communicated with the pleura. The heart
was smaller than normal, flaccid and pulpy; it did not contain any coagulum. The blood was discolored, thin and
serous. — Ass't Surgeon H. Loewenthal, U. S. Vols., Hospital Xo. 1, Annapolis, ltd.
Case 69. — Serg't John Donagan, Co. K, 4th U. S. Inf.; age 27; was admitted Jan. 12, 1865, in the last stages
of consumption. The physical signs indicated the affection of both lungs, — metallic tinkling was heard ou the right
side. He died February 2. Post-mortem examination: The larynx and trachea contained a considerable quantity of
purulent liquid The right lung, forty-eight ounces and a half, was studded with tubercle and had a large cavity
in the anterior part of its lower lobe, communicating by an opening with the cavity of the pleura, which contained
fourteen ounces of a purulent liquid slightly mixed with blood. The left lung, thirty-eight ounces and a half, had a
large cavity in its apex; its lower lobe was studded with miliary tubercle. Both ventricles of the heart and the right
auricle contained large, firm, fibrinous clots; the left auricle contained a small quantity of very black tluid blood.
The spleen was somewhat softened and weighed twelve ounces. The liver, kidneys and mesenteric glands were nor-
mal in appearance. — Act. Ass't Surgeon H. M. Dean, Lincoln Hospital, Washington, D. C.
Case 70. — Private Solon Herring, Co. H, 15th Tenn.; age 26; admitted Oct. 20, 1864. He had no known heredi-
tary taint, but had sufl'ered from cough, expectoration and night-sweats at intervals from early youth. In July, 1864,
having exposed himself to a draught while perspiring, he experienced pain in both sides of the chest and dyspncea.
On admission the subclavian region on the right was highly resonant, on the left dull; the posterior right scapular
region was dull, while the left gave a cracked-pot sound ; harsh, deep, sonorous rales were heard on the right side, but
on the left the respiratory murmur was almost imperceptible; there was a friction sound over the heart synchronous
with its beating. He became emaciated, suffered from hectic, and died December 23. Post-mortem examination : Right
lung somewhat emphysematous, apex puckered and containing miliary tubercle; left lung, hollowed into a cavern
the size of a large cocoanut, communicating with the pleural cavity and containing two quarts of pus. Pericardium
thickened and containing si.x ounces of serum, cardiac portion roughened by shaggy lymph. Liver adhering slightly
to the diaphragm, which was adherent to the lung above, — Act. Ass't Surgeon W. Matthews, Hospital, Pod: Island, III.
In a larg;e number of cases diarrhoea or dvsenterv contributed to the fatal result, altl
iouo;l:
coxsrMPTioN. 827
the record does not affirm the invasion ot' the intestinal morabrano by the tubercular deposit.
These may be found among the post-mortem records of diarrha-a and dysentery. A few-
cases that escaped observation when tliose records were pnMislied constitute cases 72-80 of
the series at present under consideration.
In certain cases the tubercuhxr infection was manifested by developments in other or<rans
than the lungs and bronchial glands. The mesenteric ghinds were said to have been aflected
in cases 81-87: the great emaciation in some of these, as 85-87, was considered worthy of
special note. In others, as 88-94, the intestines were the seat of tubercular deposits "and
ulcerations, which, in the last-mentioned case, perforated the ileum and caused deatK by
peritoneal inflammation.
In some instances, 95-104, the spleen, or the spleen and liver or other abdominal
viscera, were involved in the tubercular manifestations without the stated existence of i«eri-
toneal inflammation; and in two cases, 105, 106, the peritoneum itself was said to have
been tuberculous, although there is no mention of diffuse inflammatory associations; in 106
the tubercular deposit on the serous coat of the intestine is said to have caused ulceration
of the muscular tunic and thickening of the subjacent mucous layer. But in most of the
cases of general abdominal invasion, 107-1 21 , inflammation of the peritoneum was developed
and often constituted the immediate cause of the fatal event. In some the abdominal viscera
were soldered into a large conglobate tumor, as in 117-121 ; in the last-meationed case the
intestinal contents escaped into the peritoneal cavity; but although the intestine appeared
to have been perforated in 120, there was no leakage of its contents on account of the close-
ness of the adhesions and the firmness of the adventitious membranes.
In other cases, 122-128, the brain or its membranes were known or suspected to have
participated in the morbid processes. In others again, as 129-133, affections of the cerv-
ical, axillary or inguinal glands, and of the bones and joint*, manifested the constitutional
nature of the disease; in the last-mentioned case the lungs were unaffiected. Lastly, a few
cases, apparently of acute general tuberculosis, are presented: In 134 the symptoms were
merely those of anajmia; in 135 intermittent fever, in 136 remittent fever and in 137 typhoid
fever were suggested by the symptoms; but in 138, in which the tubercular manifestations
were mainh* confined to the lungs, the pulmonary symptoms were clearly defined.
C.\SE 134. — Private Hiram Maj;i)oii. Co. F, 2(1 111. Light Arfy; age 19; ^vas admitled Jan. 28, 1865, much eiiiaci-
atfil from chronic diarrliii'a. contracted while within the enemy's lines. Chalk mixture, cateclm and logwood were
empKiyed with 1iraudy-i>uucli, and ahout February 10 the diarrhoea became checked : l>ut the ])atient continued weak
although every organ of the body seemed to be performing its function. He was several times examined for lung dis
ease by dift'erent medical officers, but there was no sign of tubercular invasion. He appeared simply ana'uiic and
had some exaggeration of the respiration. Iron and stimulants were administered, but ho did not improve. He died
suddenly March 9. rosl-niorlfin examination: The pleural surfaces were closely adherent and presented many scat-
tered abscesses: the lungs were crowded with miliary tubercles, but no abscess or vomica was found. The peritoneal
cavity contained tea ounces of serum : the liver was enlarged and adhered by fibrinous bands to the diaphragm : tho
mesenteric glands were much enlarged from deposit of cheese-like matter: the other abdominal viscera appeared
healthy. — Jcl. Ass'l Surgeon TV. Kcmpster, Patterson Park Hosintal, Baltimore, Md.
Case 13.^.— Private Thomas Stewart, Co. F, 8th Colored Troops, was admitted Feb. 22, 1864, with two gun-
shut wounds of the integuments of the lumbar region. These healed satisfactorily: but about two weeks after
admission the patient was seized with chills of an intermittent character, for which <iuininc and stimulants were
administered. Two weeks later the chills recurred and were followed by night-sweats, which yielded to (juinlne and
opiates. During the whole of his illness there was no alarming or troublesome symjitom exceiit loss of appetite and
a progressive weakness and emaciation, aiiparently due in part to defective assimilation. Death occurred May 11.
VoKl-mortrm examination: The heart was smaller than usual. The lungs and liver were studded with tubercles. The
Epleen, thirteen ounces, contained many large masses of unsoftened tubercular matter [Specimen 632, Med. Sec, Army
Medical Museum]. The peritonenm was studded with tubercles and its cavity contained two quarts of serum. The
stomach, gall-ldadder and pancreas were healthy. The small intestine was dilated and the transverse and descend-
828 CONSUMPTION.
ing colon coiitraetecl to three-fourths of an incli iu diameter; otherwise the intestines were healthy. — Jss't Siiri/eon
E. D. Buckman, U. S. V., Sospital, Beaufort, S. C.
Cxsv. 136.— Serg't J. H. Montcalm, Co. L, 14tU N. Y. Cav.; age 2.5; was admitted .Jnne 22, 1863, having suf-
fered from the 2d with recurring haemoptysis ; he had also had irregular chills and some febrile nmvement with consid-
erable prostration. Quinine i:i five-grain doses twice daily, tincture of iron, brandy, wine and morphine were pre-
scribed. At firsc the patient was supjiosed to have remittent fever; but it soon became evident that he was tuberculous,
although the pulmonary symptoms were slight. He died by asthenia August 9. Fosl-mortem examination: Both
lungs were filled with isolated tubercles, some of which had undergone softening; but there were no cavities. — Act.
Ass't Surgeon Austin FUiil, Ladies' Home Hospital, Xcw Fork City.
C'.v.SE 137. — Private Abram Gardner, Co. K, 128th N. Y.; age 26 ; was admitted Nov. 4, 1862, with typhoid fever,
and died on the 16th. J'ont-tnortcm examination: Tubercular deijosits were found in the lungs. The stomach and
small intestine were normal; the mucous membrane of the ascending colon was much congested. — AssH Surgeon C.
H. Andrus, V2Sth X. Y. Vuh., Stewart's A/ansion, Baltimore, Md.
Case 138. — Private Michael Corcoran (alias Coughlan ). 1st Mich. Cav., was admitted Jnne 27, 1864, immediately
after having had a hemorrhage from the lungs. During the two days following admission he had several attacks of
pulmonary hemorrhage, losing in all over two quarts of blood. He had no cough, and weighed about one hundred
and eighty i)Ounds; but his mother, he said, had died of consumption. Shortly after admission tubercle was recog-
nized at the apex of the left luug. The disease ran a rapid course; Ijoth lungs became involved in front and behind.
He lost fifty or sixty pounds in weight during his illness. Death occurred August 27. Post-mortem examination : Both
lungs adhered firmly to the walls of the chest and were filled with crude tubercle; the left was more extensively
diseased than the right and had a cavity in its apex. [A section of the lower lobe of this lung forms S2>ecimen 404,.
Med. Sec, Army Medical Museum.] — Act. AssH Surgeon Darid L. HaiglH, Douglas Hosxiitul, Wasliington. D. C.
Treatment. — The method of treatment generally adopted embraced the administration
of cod-liver oil, tonics and stimulants, with extra or generous diet, warm clothing and exer-
cise when admissible. The oil was frequently given with wdiiskey, generally after meals,
the largest dose prescribed being half an ounce of the former to one of the latter three times
a day. Among the stimulants employed were whiskey, brandy-punch, milk-punch, sherry
wine, wine-whej^ beer and ^^orter. The preparations of cinchona, and the iodide, citrate and
muriated tincture of iron were the tonics most frequently used. Other remedies were occa-
sionally administered when called for by the necessities of the case.
Febrile exacerbations in malarious subjects were treated by liberal doses of quinine,
but when the pyrexia was referred to local processes nitrate of potash and Dover's jiowder,
citrate of potash or acetate of ammonia, witli or without aconite, were the remedies used;
sometimes tartar emetic was exhibited in small doses as prescribed in pneumonia.
For restlessness and cough at night some opiate was given, frequently Dover's powder,
paregoric or morphia, or tlie opiate was jorescribed in conjunction with other remedies. Muri-
ate of ammonia was occasionally given, and also chlorate of potash.
The injurious effects of constipation were met by the u$e of castor oil, small doses of
calomel with rhubarb or jalap, blue-pill, compound cathartic or compound colocynth pills.
Diarrlicea was treated by opium with or without chalk, catechu, tannin, acetate of lead, sul-
phate of copper, nitrate of silver, etc.; enemata of laudanum were frequently given in severe
cases. Aromatic sulphuric acid was sometimes employed to control diarrhoea, but more fre-
quently to suppress colliquative sweats, in which case it was usually associated with quinine.
The internal medication of hi?emoptysis consisted of veratrum viride, dilute sulphuric
acid or the muriated tincture or persulphate of iron.
When the vital powers began to fail recourse was had to carl^onate of ammonia, usually
with quinine, and the free use of alcoholic stimulants.
Among the external applications employed, according to the requirements of the indi-
vidual case, were wet and dry cups, emollient cataplasms, iron, pitch and conium plasters,
sinapisms, tincture of iodine, croton oil and cantharides. Iodine with chloroform and alco-
hol was used by inhalation at Rock Island prison hospital.
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RHEUMATIC AFFECTIOKS. 829
III.— RHEUMATIC AFFECTIONS.
I.-ACUTE RHEUMATISM.
A prio'ri reasoning leads to tlie conclusion that actite rheumalisin innst have Ijcen a
disease of frequent occurrence among our troops during the war. Its connection with cold
antl dampness — a connection which explains its greater frequency among the poorer tlian
ihe wealthier classes of civil life — suggests its frequency among men who were so often
unsheltered and otherwise unprotected as our soldiers on active service. If the statistics
could he accepted without question, tiiis aiilici})alion jnight he regarded as fullilled. Acute
rheumatism was credited with 1 1 ■").•')•") 1 attacks among the white troops during five and one-
sixth years — a number equal to 65.3 cases annually in every thousand men, and with 18,399
cases among the colored troops during the three years of their service — a number equal to
100 cases annually per thousand of strength.
But Ass't Surgeon Lehlbacii, Ttli X. .T., after a series of campaigns with the Excelsior
Brigade, regarded as a popular error the opinion tliat acute rheumatism was a prevalent
disease among our troops on active service.
Certain it is, be says, that we often see reptinients exposeil'to damp, wet, cold, siuldrn uikI violi'iit changes of
temperature, and obligedto sleep on wet grimud with but scant iiiotectiou,aud no cases of acute ihcuiualisnifollow.*
If the reported figures be accepted at their face value. Dr. Lehlbacii's experience must
have been exceptional. But was it so? or did the acute rheumatism of the Monthly Reports
include cases that were not veritable cases of rheumatic fever? The statistics themselves
offer some evidence on this [loint. The fatal cases among the white troops numbered 283,
among the colored troops 98, a fatality of .2 and .53 per cent., respectively. If LooMis
be correct in his assertion that three per cent, is the average death-rate in acute rheumatism.f
the cases reported as acute rheumatism by our medical officers were not all cases of acute
articular rheumatism. Even if all the fatal cases of endocarditis and pericarditis — 109 and
250, respectively, among the white troops, and 22 and Go among the colored troops — be
charced to the account of acute rheumatism, the averao-e death-rate of the disease would be
raised to only .44 per cent, among the white and 1.0 per cent, among the colored soldiers.
It is probable, therefore, that the reported cases include a large number of slight or subacute
attacks in the progress of chronic cases and of those acutely painful but apyrexial forms of
so-called muscular rheumatism known as lumbago, pleurodynia, etc.
Acute rheumatism shows in its monthly rates a greater prevalence in that period of
the war during which new levies were sent to the field than later, wlicii these levies had
become inured to the hardships of active service; — the decided fall in tlic rates during the
early months of 1863 may be thus explained. Slightly marked seasonal variations may be
observed in the line of prevalence among the white troops, the minima extending over the
montlis of June, July and August. Irregularities in the line of prevalence among the colored
men appear connected rather with the exposure of new troops than with seasonal changes.
Few CLINICAL or POST-MORTEJi RECORDS of acute rheumatism have been preserved.
The following are submitted :
Case 1.— Private Patrick Hngbes, Co. G, 28th Mass.: admitted .Ian. 24, 18<)2: Qnict but sleepless: backless
painful: ankles still swollen and sore; pulse accelerated; skin somewhat hot; tongue slightly coated. Treatment
continued. 25tli: Slept but little on account of pain; ankles slightly swollen but very painful ; left knee almost well,
♦ itrdical ami Snrgicat Reporler, Pliila., Vol. XI, 18G4, p. 2.30. t Page 800 of bis Pmclleiil MnUr.hic.
830 ' EHEUMATIC AFFECTIONS.
liiit right knee hot, swollen and painful: pulse accelerated ; skin hot; tongue moist and comparatively clean. Adrachm
of sulphate of magnesia and ten grains of nitrate of potash five times a day, with light diet, 26th: Rested well;
both knees hot and somewhat swollen, hut the right only painful; ankles sound; tongue slightly coated; pulse 80.
Continue treatment. 27th: Rested well; pain only in the left knee, which is enlarged from eft'usion ; pul.se about 60,
very irregular; skin hot; pain in the region of the heart. Continue nitrate of potash with colchicum, 28th: Rested
■well; appears well: pulse regular: tongue slightly coated; complainsof pain in his left crotch, otherwise well. Con-
tinue treatment. May be returned to quarters to-moTTOW.— Hospital 28th Mass.
C'.^SE 2, — Private John CJoodwin, Co, I, 28th Mass.; admitted Jan. 24, 1862: Tongue thickly coated with white
fur; pulso not particularly accelerated but full; slept better last night; feet and ankles swollen but no longer pain-
ful: right knee less swollen and less painful; left knee worse. Continue light diet. 2.5th: Spent the night poorly on
account of pain in left knee: ankle and right knee well; swelling generally disappearing except in left knee; pulse
regular; tongue white-coated, tipped with red. Adrachm of sulphate of magnesia and ten grains of nitrate of potash
five times a day; light diet. 26th: Spent the night comfortably; pulse regular: tongue slightly white and coated:
left knee painful, somewhat swollen and hot; other joints unaft'ected. Continue treatment. 27th: Slept well; no
pain, but a sensation of weakness in knees. Continue treatment. 28th: Rested well: tongue somewhat coated; pain
and swelling gone. Returned to duty. — Hospital 2Sth J/oss,
C.\SE 3. — Private William AVhite, Co. A, 4th Pa. Reserves; age 32; was admitted -^ug. 19, 1862, with diarrhcea.
On November 8 he had fever, headache, coated tongue and pain in the joints. Wine of colchicum with opium was
given every three hours: Dover's powder at bedtime; tincture of iodine and flaxseed poultices to the joints. Next
day a dose of sulphate of magnesia was given. On the 10th pain, inflammation and fever were lessened. On the 11th
the patient was free from fever, and on the 12th the articular swellings were subsiding. Next day the fever returned;
pul.se frequent and feeble; less swelling. Discontinued iodine and jioultices; gave a half ounce of solution of acetate
of ammonia every three hours. On the 14th the fever had subsided; the tongue was cleaning; the pulse stronger:
appetite good. The acetate was disused on the 22d, but the colchicum was continued in doses of thirty droi)S until
March 6, when iodide of potassium was substituted; compound tincture of cinchona was given during part of the
time. On the 9th the patient was considered cured, but he was retained on light duty in the ward until September 4,
when he was transferred to the 2d Co. 1st Batt. Invalid Corps. — Satterlee Hospital, FMladelphia, Pa.
Case 4, — Serg't AVilliam Copps, Co, D, 88th Pa,, was admitted July 26, 1863, with acute rheumatism. He had
suffered from previous attacks of this disease. On admission: Fever; pain in the left leg and back and some swell-
ing of the ankle and knee: pain in the left breast and palpitation; tongue slightly coated: bowels constipated.
Gave one and a half ounces of sulphate of magnesia and half an ounce of sweet spirit of nitre in two ounces of water, —
to take a tablespoonful every two hours until the bowels are moved; afterwards ten grains of Dover's jiowder every six
hours. 28th: Pain in back and leg; palpitation intermitting; lessfever: pulse90; appetite better, .\pply fly-blister,
4 by 6, to back; dress with olive oil. Gave three drachms of acetate of potash and one ounce of sweet spirit of nitre
in two ounces of water, — to take a tablespoonful every six hours. 30th: .ipiietite good; bowels regular; pain in leg;
less pain in back. August 1: Pain in breast. Gave three grains of sulphate of quinine in an ounce of whiskey three
times daily, 6th: Pains in chest and V)ack; much palpitation; appetite good; bowels regular. 7th: Palpitation at
intervals; great nervous prostration. Gave one-twentieth of a grain of strychnine three times daily, 9th: Lesspal-
pitation; much pain in back and limbs. Gave one drachm of iodide of potassium in one ounce each of wine of col-
chicum and water, — to take one fluid drachm three times daily, loth: Much better; pain in back and limbs relieved;
some palpitation on exertion. Stopped treatment. On duty as nurse, September 14: Returned to duty, — Second
Division Hospital, Alexandria , Va.
Case .5. — Private Alexander Moore. Co. F, 69th Pa.; age 52; was admitted Ajvril 5. 1864, having been suft'eriug
from rheumatism while at home on furlough. Knees and wrists swollen and painful : swelling extending from knees
down the legs. Four grains of Dover's powder every three hours; beef-tea; wrapped limbs in cotton. 9th: One
drachm of laudanum, one and a half drachms of wine of colchicum and two drachms of Rochelle salt in six ounces of
water, — to take a tablespoonful every three hours: packed the limbs with lint soaked in solution of bicarbonate of
soda, half an ounce to a pint of water. 12th: Swelling much reduced; slight pain in pr.necordia but no change in
sounds. Applied three wet cups, drawing about an ounce and a half of blood. 15th: Increased colchicum; gave a
bottle of porter daily, 19th : Five grains of iodide of potassium three times a day, 24th: Added one ounce of laud-
anum to the pintof alkaline solution forexternal use, 26th: Swelling and pain much diminished, Mayl: Twodrops
of tincture of aconite every three hours. 15th: Swelling of arms returning. Junel: Arms and hands oedematous:
applied moderate pressure with bandages. 7th: Ten drops of tincture of iron three times a day. 15th: Swelling
somewhat reduced: applied tincture of iodine externally, to be repeated every second day; warm bath. 23d: Gave
two grains of quinine three times a day. 26th: Sitting up ; much better. July 28: Regaining use of arms slowly;
wrist-joints stiff. Transferred to 16th and Filbert streets — [Diagnosis — acute rheumati.sm. November 1 : Furloughed.
21st: Returned from furlough. 29th: Transferred to Haddington: Diagnosis — chronic rheumatism. February 18,
1865. Discharged because of chronic rheumatism causing distortion and deformity of joints of fingers of both hands
and left knee-joint,] — South street Hospital, Philadelphia, Pa.
Deatli was generally clue to an implication of tlie lit'uvt : in case 7, however, it ap})ears
to have resulted from erysipelas and pneumonia. In case 83* of the records of pneumonia
the fatal lung affection supervened on acute articular rheumatism.
* See siipra^ p^ge 770.
KHHUMATIC AFFECTIONS. 831
Cask (i. — Private Jesse Rice, Co. E, lltli Va.: afji" 2i>; was adniittcil Sept. 23, 1863, with pain in tho clicst, cougb
anil occasional Ijlootly expectoration. On Feb. 3, IMtU, ho was attacked with acnto rheuniatisni. the knee-joints
lifconiin^ painful anil swollen. On the .Tth, as the condition of the knees impioved, his feet and ankles became
swollen and he was seized with cardiac pain and dyspncea. while tViction sounds were heard on auscultation. These
.symptoms continued with increasini; grax ity and much restlessness, and on the lltli the fiicliou sounds were obscured
by pericardial ett'usiou. He gradually sank, and died on the 2(!th. T'ont-iiiorlim examinaliou: 'riic lun^s were com-
pressed; tlie lower lobe of I he rinht lull!; was hepatized and adhered to the diaphrajjui. 'I'lu' left pleura was adherent
to tlie pericardium, which was thickened, covered with |ilastic lymi)h and disirtidrd willi forty ounces of t\irbid
serum. The abdominal viscera were healthy. — Ciimhcrhiml Ilimpiliil, MiL
C.\SK 7. — Private I!. S. Kunyon, Co. F, 90th N. Y.; a^e 24; was admitted Aug. 29, 1864. He had much fever
and his wrists and ankles were swollen, painful, tender and doughy. Small doses of Kochello salt and morphia
were given every four hours, and tincture of iodine u.sed as a local application twice daily. He continued with little
cliange until September 2, when the pulse, still rapid, became weak, and fluctuation was detected over both wrist-
joints: there were also many small abscesses in the subcutaneous tissue of the face and chest. Brandy was prescribed.
Next day sordes appeared on the teeth, the tongue became dry and brown, the throat dry, parched and somewliat
intlamed, deglutition diHicult, respiration disturbed and the expectoration rust-colored, wliile slight dulness was
found over the right lung and lower lobe of the left lung. On the 4th erysipelas was develojied on the face: jiulso
i:!0, feeble : abscesses continued to form. Tincture of iodine was applied to the erysipelatous jiatch, and a jiill of iion
and <iuinine given four times daily. Next day he was worse: low delirium had developed: respiiation 30: skin cold
and clammy: pulse aluuist imperce))til>le: erysipelas spreading. He died on the morning of the 7th. rost-iiiorlcm
examination: The wrist-joints were filled with purulent matter: on incising the integuments of the arm at various
points pus escaped from the sulicutaneous tissues. There were slight pleuritic adhesions on both sides: the right
lung was congested: the lower lobe of the left hepatized. The aortic valves were somewhat congested. The liver
was normal in size, nutmeg in appearance, softened and easily broken down : the spleen enlarged, softened and degen-
erating into pus; the kidneys healthy; the stomach and intestines distended with gas. — Hospital, Frederick, Mil.
C.\SE 8. — Private John Buck, Co. G, 7th Wis., was admitted March 19, 1865, with rheumatic fever. On April 4
he had diarrho'a and gastric irritation. Two days later dyspn<ea was added to his symptoms and his countenance
became anxious: the action of the heart was tumultuous, the area of cardiac dulness increased and the pulse small,
irregular and intermittent. Death occurred on the 8th. Post-mortem examination: The iiericardium, which was
thick and opaque, contained six ounces of serum and lymph: the endocardium was injected; the chorda" tendinea' in
the right ventricle showed some adherent fibrin; the left ventricle contained a fibrinous clot. — Act. .Is«'l .S'iov/moi J.
H. Broinilotr, Harcitood Ilospitul, Washinijton, I). C
Case 9. — Serg't WilliamP.Tragausee, Co. A. 1st Conn.C'av.; age24: was admitted Dec. 2, 1863, with diphtheria.
He was improving under quinine and chlorate of potash internally, the latter being also used, alternating with
nitrate of silver, as a local application, when he was attacked with acute rheumatism, the knees and elbows being
specially atVected. He stated that he had been subject to attacks of this kind all his life. Saline cathartics were
employed and the patient seemed in a fair way to recovery, when, on the 22d, he was seized with sharp cutting pains
in the liladder and side, and died half an hour afterwards. Post-mortem examination : An enoruuius pericardial effu-
sion with S(une adhesion was found ; the heart was coated with an irregular layer of lymph. — [Sjxiimiii 214, Med. See.
Army Medical Museum.] — .let. Ass't Surijeon B. Ji. Miles, Jarvis Ilospitul, Baltimore, Md.
Case 10. — Henry Koberts, colored ; age 28; was admitted Dec. 29, 1865, with articular rheumatism, the elbows,
wrists and knees being affected. Subsequently .symptoms of heart disease set in ; he became dropsical, and died in
.\pril, 1866. Post-mortem examination: The areolar tissne of the body was loaded with serum, as was also the peri-
toneal cavity. The right lung weighed thirty-six ounces, the left forty-two ounces ; both were hepatized in their lower
parts. The pericardium contained twenty-three ounces of liquid ; heart and pericardium weighed fifty-two ounces,—
the heart, after the removal of the pericardium and clots, weighed thirty-live and a half ounces; the aortic valves
were ulcerated, — [Specimen 801, Med. Sec. , Army Medical Museum]. The liver was fatty and somewhat cirrhosed ; the
right kidney showed a singular cicatrix on its outer edge; the left was lobulated, — [Specimen X02]. The intestines
and spleen were normal. — Siirr/eon E. Bentleij, TJ. S. Vols., Sloiiijh Ilospitnl, Alexandria, Va.
Case 11.— Private Orvill S. Stocknell, Co. A, 36th N. Y., was admitted Oct. 29, 1862, with ilroi)sy from cardiac
disea.se supervening on acute rheumatism. He complained of i)ain in the pru'cordia, iialpitations. headache and ver-
tigo; the area of cardiac dulness was increased: he had anasarca, enormous distention of th(^ abdomen and at times
a distressing cough. He died suddenly November 9. Post-mortem examination: The areolar tissue was everywhere
full of liquid and the abdominal cavity contained a gallon and a half of serum. The pericardium was greatly dis-
tended with serum in which were Hakes of lymph: the surface of the heart was coated with lymph; the ventricular
walls hypertrophied: the semilunar valves normal; the mitral and tricuspid thickened. The lungs were congested.
The liver and kidneys appeared healthy. — Hospital, Alexandria, Fn.
Case 12. — Private Edwin M. Dudley, 5th Mass. Bafy: age 20: was admitted Oct. 5, 1864, with organic disease
of the heart. His comrades rejxirted that he hail a short time before sutiered from an attack of articular rheurua-
tism. He was aua^mie and had anasarca, dyspniea and a rapid and tumultuous action of the heart unaccompanied
by any decided bellows murmur: his pulse was rapid and irregular: tongue covered with a thin gray coat; face tur-
gid and expression anxious; he preferred the sitting posture. The symptoms became aggravated, the heart's action
riore tumultuous and irregular and the dyspnoea greatly increased; he complained of imi)erfect vision and roaring
sounds in his ears. He died on the 7th. Post-mortem examination: There were adhesions aiul a small quantity of
832 RHEUMATIC AFFECTIONS.
lujiiid in the riglit pleura; both lungs were congested. The iiericardium contained two ounces of liquid; the heart
was greatly dilated, Iiut there was no juarked thickening of its walls; the right side and the great veins were filled
witli venous Mood ; the left side contained dark blood with large tlakes of lymph entangled among the muscular col-
umns; small, firm, wart-like excrescences were found on the mitral valve and large ones on the aortic valves, — [Spcci-
vicn 472, Med. Sec, Army Medical Museum] ; the endocardium was red and injected. The liver presented a fine nutme"
apiiearance; the gall-bladder was nearly filled with viscid bile: the spleen was healthy, although bound down in the
left hypochondrium by recent adhesions. The kidneys, stomach, small and large intestines were congested Ad,
Ans't Siiri/eon O. P. Sweet, Carver Sos2)ital. Wash'nirjton, D. C.
II.— CHRONIC RHEUMATISM.
Briefly, the statistics of chronic rheumatism are as follows: Among the white troops
109,187 cases were reported, of which 192 or .18 per cent, terminated in death, and 11,779
or 10.8 per cent, in discharge for disability. In every thousand men there occurred annually
an average of 49 cases, 4.87 of which were discharged as unfit for service and .44 died, chieflv
from affections of the heart ; many finished their term of service as cooks and nurses in hos-
pitals, and others were transferred to the Invalid Corps. There remained, however, a consid-
erable number of cases that were apparently returned to duty, but it is doubtful if many of
these were really cured. In a majority of the cases the men affected were known to have
been elderly, and to have suffered more or less from the disease before their enlistment.
On exposure they became temporarily crippled. Under favorable conditions they so far
recovered as to be able to resunie duty, but on a subsequent exposure they were again taken
on the sick report as new cases. The 49 reported annually per thousand of strength do not
therefoi'e represent that number of chronic rheumatics, but merely that number of attacks
in a smaller numbei' of men predisposed to attack. The discliarges caused bv this disease
constituted 8.62 per cent, of the whole number of discharges reported as occasioned Ijy spe-
cified diseases.'''
Among tlie colored ti-oops 13,726 cases were reported during their three vears of .service.
Of these 137 or 1 per cent, resulted in death, and 874 or 6.37 percent, in discliarge. The
average annual rate of cases per thousand of strength was 74.8, with 4.26 discharges and
2.14 deaths. Discharges for chronic rheumatism constituted 18.1 per cent, of the whole
number of discharges for specified diseases.
The line showing monthly variations in prevalence among the white troops is similar
in its outline to that of acute rheumatism, having a liigher elevation in the earlier period
than later, when recruiting; was less activelv carried on, — see diag;ram faciiis pao-e 828. The
fall in the level of the line during the early months of 1863 is even more marked than in
that of the acute disease; but subsequently the seasonal variations, which are indicated by
the rise and fall of the line of acute rheumatism, are not so well defined in the line of the
chionic cases. This is perhaps due rather to the failure of the minimum to fall than of the
maximum to rise. It seems probable that the exposures of active service in summer had a
greater influence in determining a return of the chronic trouble than in developing an attack
of the acute disease. The general similaritv in the fluctuations of acute and chronic rheuma-
tism among the colored troops is also noticeable.
Under the term chronic rheumatism were gathered all those tedious cases of 2Jainful,
stiff and perhaps slightly tumid joints, unaccompanied by the febrile condition, which, if not
caused, were certainly aggravated, by ex^Dosure to cold and wet. These cases were properly
aggregated under the rheumatismal heading. Others also, in which the fibrous tissues of
the muscular system, of the periosteum and nervous sheaths became implicated, were no
*See Table XI, s»pm, p. 27, for a statement of tbe relative prominence of sitecified diseases in the causation of disability.
RHEUMATIC AFFECTIONS. 833
doubt properly classified in this manner. But the line of demarcation between a rheumatic
intlammation and a chronic non-specific inflammation of these tissues was not clearly defined.
Hence all obscure and painful affections of the locomotor apparatus were usually rei)orted as
chronic rheumatism. Indeed, in many cases of so-called muscular rheumatism it was impos-
sible to determine whether the muscles or their nervous supply were primarily implicated.
There was, therefore, ample room for difl'erence of ojjinion iiL-forming a diagnosis. That which
was regarded by one medical officer as muscular rheumatism affecting the lower extremities,
might be considered hv another as the result of a meningeal inflammation of the lower ijart of
the spinal cord, due less perhaps to exposure than to injury from over-exertion and the weight
of the cartridge-box and other articles of equipment. Thus, Act. Ass't Surgeon Klapp was
struck with the fact that among the large number of rheumatics admitted into the military
hospital, corner of Sixth and Master streets, Philadelphia, there was no affection of the joints;
the disease was manifested by neuralgic pains. In his opinion the morbid process had its seat
in the spinal membranes, and more or less tenderness was readily discovered in his cases in
certain parts or along the whole track of the spine, according as the muecular pains were
confined to one locality or were general in their distribution.* In this way a connection
is established between chronic articular rheumatism on the one hand and spinal meningitis
with its paralytic results on the other. In the cases that will be submitted hereafter paraly-
sis from exposure, when seen in its progress to recover}^, was occasionally, as in case 11, f
regarded as chronic rheumatism.
The well recognized connection between muscular pains and the scorbutic cachexia at
one time led many of our medical officers to suspect their rheumatic cases of having a scor-
butic origin. After the alarm of scurvy in the Army of the Potomac in the summer of 1862,
all obscure cases of pain in the muscles, bones or joints were closely examined with reference
to a possible scorbutic taint, and a single case of tumid gums in the regiment or brigade was
accepted as an explanation in full. This view was, indeed, officially promulgated in the
Eleventh Array Corps by the Medical Director of that command, | in a communication which
represented the doctrine as pretty clearly established by evidence on file in the office of the
Surgeon General of the Army. This evidence has been submitted in the article on scurvy. §
It leaves no doubt of the frequency of pains in the muscles, bones and joints, especially of
•Act. Ass't Surgeon Joseph Kl.\pp— 3f«/ica/ and Surgical Reporter^ Philadelphia, Vol. VIII, 1862, p. 508 — states that a large majority of the cases
ailmittiM to the huiipital, Sixth and Mast<'r8trcetfS, Philadelphia, weifof a rheumatic nature, and in none was there an affr-clion of the joiuts. The disease,
iwnti-d in the ejiinal membranes, was attended with severe neuralgic jiiins in various imrt^ of the body, Iiut with nu perceptible swelling in any of the
affiitt'd parts. Why the dif*ease asiunied a cbanuii-r so unusual iu civil life is regarded as of interest. If due gimply to exposure and ordinarj- fatigue
ii *bould have beeu attended, as in private life, with at least some share of articular affection. That it was not due sok-Iy to an enfeebled condition of the
»yst*-m is considered evident from the fact that ourtyyjioid cases did notconii)iain of such jwiius until they had in some measure recovered their strength.
Dr. Kl.\pp suggests that an explanation of the frequency of the spinal affection in soldiers may be futmd in the burdens they have to carrj'and the man-
ner of carrying them, in the lung or forced marches and ot!ier exhausting services of the field, with cold from exposure night and day to the inclemencies
and chang(^>s of the weather, while the system thus worn out is suiiplied with a diet not always suitable for the recovery of its tone. Tenderness was found
along the whole spine, or in certain n-gions wlience originated the neni-s of the affected parts. He holds tliat by keeping this fact in mind we may dis-
cover the s«.'at of many of those anomalous affections of the chest and abdomen otherwise puzzling and annoying. A very few of the patientd complained
of [Mitns ab4>ut the head ; a few were troubled with thoracic pains, but mure with lains about the atnlomen, and these last were attended with excessive
arusibility of the surface. Sometimes the rheumatic affection simulated disease of the lungs or heart, but physical exploration readily detected its spinal
origin. Functional disturlfance of tlie liver with jaundice was found only iu a few instances, but dyspepsia and diarrha?a, from an irritable condition of
tlie stomach and bowels, were present in many of the cast's. One of the most troublesome, although infrequent, symptoms was a functional derangement
(rf the kidneys, simulating organic disease so closely that its true origin was determined only by the most careful examination. Neuralgia of the legs with
fartial {Kimlysis and frequently wasting of the mascles was found nearly in everj'case. The most efficient treatment consisted of cupping, generally dry,
along the f:pine, followed by {Niintingwith tincture of iodine alone or with fifteen grains of vemtrum in ejich fluid ounce ; internally, iodide of potassium,
tlnctnn? of cimicifuga, tincture of stramonium and i«regoric were adniinistered 6<-paniteIy or in conjunction. Other remedies, as quinine, carbonate of
iron, extract of belladonna, ferrocyanuret of iron and quinine, and pho'<i)hate of ammonia, had comixiratively no effect. Dover's powder at Ijedtime gave
relief fur the night ; and frictions with turjientinu liniment and laudanum over the affected riartswere of temporary service. To relieve the ucnous affec-
tion of the chest antisfBtmiodics were uad ; and in hefiatic derangements fivi* drops of uitro-muriatic acid three times a day always afforded relief. Bis-
muth, ma^ne^ia and moriihia were employed to allay irritability of the stomach, and tincture of catechu with paregoric was always used with advantage.
vTico the kidneys were implicate"], a combination of fluid extract uf buchu with tincture uf hyoscyamus and sweet spirit of nitre was given.
+ /«fra, poge (XiO. I See nipro, page 704. gSee the reports of Norbis, Wooduvll, etc., nipra^ page 689 et seq.
Med. Hist., Pt. Ill— 105
834 RHEUMATIC AFFECTIONS.
the lower extremities, as symptomatic of a scorbutic condition of tlie system, but fails to
establish the proposition that many of the cases regarded and treated as chronic rheumatism
were in reality cases of incipient scurvy. On the other hand, the anticipation of a scorbutic
invasion was viewed with so much alarm by our medical ofEcers that errors of diagnosis
were as likelv to have occurred on this side of the C|uestion as on tlie otlier.
The well known views of Dr. Woodwakd, stamped as they were with a semi-ofEci<d
authority derived from his position in charge of the medical records of the army, gave a
strong impetus to this doctrine of an all-pervading scorbutic taint as the source of a large
number of the cases of so-called rheumatism. While acknowledging the existence of rheu-
matic affections in the army, he held that the majority of the cases regarded as such by our
medical officers were in reality in no way allied to rheumatism except in the presence of a
single symptom — pain. These cases he aggregated in a se23arate chapter of his work on
Camp Diseases under the title of pseudo-rheumatic affections. He divided them into live
groups: — 1, Scorbutic cases; 2, malarial cases; 3, those due to a conjunction of scurvy and
malaria; 4, myalgic cases, and 5, malingerers. The first group lie considered the most
characteristic of the pseudo-rheumatic affections.
The disease begins with malaise, languor and general indisposition to exertion. By-and-bj- vague pains make
their appearance in various portions of the body. These pains are sometimes acute and cutting, sometimes dull and
heavy, but very often do not at first amount to more than a sense of soreness in the parts affected.
They may be located iu any part of the body, but their most common seat is in the thighs and legs and in the
small of the back. The last is esijecially the characteristic seat of the disorder and is more uniformly involved tbau
any other portion of the body.
The pain and soreness is at first slight, so that although the patient may occasionally come to the surgeon for
treatment he continues to do military duty. Very often indeed he does not apply for trtatraeut at all in this earlv
stage, and when he first comes to sick-call, inquiry shows that he has suffered from more or less pain for several
weeks or even longer.
As the disease progresses the pain becomes more severe, and, if it is seated in the back or the lower extremi-
ties, the patient becomes quite unfit for duty. Sometimes he is coufined to his bed, but most frecjuently he hobbles
about with the help of a stick.
Occasionally he retains a perfectly healthy appearance, a normal appetite, and all the functions are performed
with regularity. It is to be feared that very many of such patients are malingerers, as will be indicated more fully
hereafter. In the majority of cases, however, more or less well-marked symptoms of constitutional disturbance
accompany the gradual development of pain. A peculiar pallid, clay-like appearance of the countenance, a tendency
towards emaciation, palpitation of the heart — especially after any exertion — the large, cool, smooth, pale tongue,
already several times alluded to, and more or less diarrhcea, occurring sometimes from time to time, sometimes per-
sistently, are among the most constant symptoms. Occasionally the gums are more or less spongy or are hardened
and bluish, sometimes they bleed when pressed by the finger: in some cases also more or less induration of the sub-
cutaneous tissue occurs, especially iu the neighborhood of the knee-joint, the indurated portion being somewhat
discolored, of a yellowish or bluish hue, like that of an old bruise: still more rarely purpura-like blotches of small
size may be encountered, especially on the lower extremities; but all these advanced phenomena of the scorbutic
condition have been comparatively rare among our troops.
The form of pseudo-rheumatism now under eousideration is most common among troops who have been ill
supplied with fresh vegetables, and is more or less common in accordance with the degree to which they have been
exposed to the conditions heretofore laid down as the ordinary causes of a scorbutic diathesis.
An examination of the joints fails to detect any of the stiffness, enlargement or deformity so common in chronic
rhenmatism. The only exception are the comparatively rare cases in which the scorbutic state is sufficiently advanced
to give rise to those peculiar bruise-like indurations above mentioned as occasionally present. This condition is,
however, so characteristic that it is readily recognized,— the peculiar dift'use induration, which pits slightly on pres-
sure, but not 80 much as in o'dema, and the yellowish, bluish and livid discoloration make the diagnosis easy.
There can be no doubt that the cases now under consideration are to be interpreted simply as examples of
incipient scurvy. From the neuralgic character of the pain, which is so prominent a symptom, they might in fact be
designated as scorbutic neuralgia. Originating under precisely the same circumstances as other forms of scorbutic
disease, they will be found to disappear under ihe use of a liberal antiscorl>utic regimen. This view, if correct, is of
the highest importance, as it inilicates at once a mode of treatment by which thousands of men, too often discharged
the service as incurable, may be saved to the army.
In another class of cases, which is perhaps equally common, the constitutional symptoms are entirely differ-
ent. The complexion is more or less icteroid in hue. and a peculiar aniemic pallor, conjoined with the evidences of
hepatic disorder, permits at once the recognition of the condition described in a previous chapter as chronic malarial
RHEUMATIC AFFECTIOXS. 835
poisonint;. More or less disorder of the bowels, in the shape of constipation or of slight diarrhea, is usnally present.
Tenderness and increased dulness of percussion in the region of the spleen indicate enlargement of that organ. Occa-
sional attacks of intermittent fever are common. In this class of patients the pain does not usually precede the
development of the constitutional symptoms; on the contrary, the latter often last for a considerable period of time
before the neuralgic phenomena make their appearance. Not unfreiiuently the pains are decidedly intermittent,
pursuing either a (|noti<liau or a tertian type.
This class of cases is most common among troops exposed to decided malarial intluences who have, however,
escaped the causes of scurvy, or who have uofbecn exposed to them for a suQicient time to develop the symptoms of
scorbutic disease.
In still a third class of cases, which up to the present time has been much more numerous than either of the
preceding conditions, the two groups of symptoms above described are variably commingled. The troops operating
in a malarial region and exposed more or less to the influences which develop tl:e scorbutic tendency, sutler from
pathological conditions resnltiug from both these sets of causes: with the icteroid hue, enlarged spleen and an»-mia
of chronic malarial conditions, the smooth, large tongue, irritable heart, clay-like countenance and loose bowels of
the scorbutic state are conjoined.
A certain number of these cases escape without the rheumatic pains under consideration* but a large number
are affected by them.
It appears probable that the great majority of the chronic cases of rheumatic pains occurring in the array
belong to one or another of the three categories sketched above.
lint there are other c:ises frequently reported as rheumatism which are more trifling in their nature and gen-
erally last but a short time. The patient, after some exposure, such as jiicket duty in the rain or sleeping in wet
clothes or on the damp ground, cxjieriences a slight chilliness, sometimes amounting to a rigor, and followed by
feverishness, furred tongue and some dryness of the skin. Accompanying these symptoms is some soreness and stifl-
ness of the muscles of the trunk and limbs, sometimes amounting to actual pain. This condition lasts two or three
days and then usually subsides, even when no treatment has been employed. These cases, spoken of familiarly as
colds in the limbs, constitute a very simple aftection and are not allied to true rheumatism. They probably consist
essentially in a state of congestion and irritation in the muscles aftected, resulting from the effects of the exposure.
The several diverse states thus briefly sketched constitute the great bulk of the cases of disease reported under
the head of rheumatism. There remains to be considered a very large group of cases often reported in the same class,
in which the most scientific examination fails to detect any disease whatever. The patients complain as loudly of
pain in the back and limbs as in the most decided cases of genuine rheumatism or of malarial and scorbutic neuralgia.
They stoop in their gait and limp about by the aid of sticks, but they appear well nourished, have a good appetite,
devour their full ration of food and present none of the grave constitutional symptoms described in connection with
the cachectic neuralgias we have considered. Xor are any of the symptoms of chronic rheumatism present. There
is no deformity, swelling, stiffness or immobility of the joints. Occasionally the patient pretends stiffnessof a joint,
sometimes of the elbow, more frefjuently of the knee. An attempt to execute passive motion meets with a resistance
which sometimes cleverly imitates the immobility of a rheumatic joint: but if he be put under the inflnence of an
aniesthetic, all rigidity disappears and the limb can be moved freely in every direction. These patients are more
apt to attribute their malady to a strain than the genuine cases, and tell frequently a pitiful story. The experienced
surgeon will very often detect them by this story alone; they whimper and even sob in an unmanly manner, which
•n itself alone should produce suspicion. This suspicion is confirmed by finding, on careful examination, that all the
constitutional symptoms of rheumatism, scorbutic and malarial disease are absent.
Examples of these various groups were seen by probably most medical oflBcers who
served in the field, but on behalf of these gentlemen it is claimed that they recognized the
causative influences of the scorbutic and malarial gi'oups and that they reported and treated
their cases accordingly. In fact, the cases which they reported as scurvy were precisely
those incipient cases of that disease which Dr. Woodward has indicated as constituting his
first and most characteristic group of the pseudo-rheumatic afiections. Cases of aggravated
scurvy seldom occurred except in the prisons; mild or incipient cases were a product chiefly
of war-camps and active campaigns; but the latter were rarely mistaken for rheumatic
disease. Of fifty-eight cases of scurvy that have been submitted only one, case 4, was recorded
on the hospital case-book as chronic rheumatism; and in not one of tlie cases of rheuma-
tism, to be submitted hereafter, is there a suggestion of a scorbutic connection. But the
roost convincing proof that incipient cases of scurvy were not reported as rheumatic afiec-
tions may be found in the want of relation between the periods of prevalence of scurvy and
rheumatism. If the cases in question contributed so largely to the statistics of rheumatism,
as has been assumed by Dr. Woodward in the establishment of his first and third groups
of the pseudo-rheumatic affections, the influence of a scorbutic prevalence would have been
836 RHEUMATIC AFFECTIONS.
markedlv impressed on the lines of prevalence of rheumatic disease; but nothing of this
kind is shown by the statistics. During the early months of the war, when scurvy was
practically absent from the ranks of the white regiments, rheumatism, acute and chronic,
prevailed to a greater extent than at later dates, when scurvy was evidently present in cer-
tain portions of the army. In July and August, 1862, when the scorbutic rate of the army
as a whole was raised to 4 monthly per thousand of strength by the outbreak among the
troops at Harrison's Landing, the rates of acute and chronic rheumatism experienced no
corresponding increase. In January, 1S63, when both acute and chronic rheumatism attained
their highest rate of prevalence, but few cases of scurvy were reported, although the pro-
fession was alive to the possibility of its occurrence. In April, 1866, when scurvy reached
its maximum of prevalence, there was no associated rise in the rate of prevalence of rheu-
matism. So, in July, August and September, 1864, the increased prevalence of scurvy
among the western troops corresponded with a seasonal minimum of acute rheumatism, and
a similar but less marked seasonal depression in the line of prevalence of the chronic disease.
These are the striking points in a comparison of the diagrammatic lines of prevalence of the
diseases in question. Closer investigation at intervening points, or a comparison of the lines
of prevalence among the colored troops, attests, by a similar want of correspondence, that the
cases reported under the term rheumatism had no association with the scorbutic cachexia.
In fact, excepting an occasional error in diagnosis, as in case 4 of the records of scurvy, the
whole of Dr. Woodward's first group, and the scorbutic proportion of his third group of
pseudo-rheumatic affections, were the cases of scurvy, not those of rheumatism, reported by
our medical officers as having occurred among the troops.
On similar evidence the malarial group of pseudo-rheumatic cases may be shown to
have been recognized, reported and treated as due to the influence of the malarial poison.
Congestion or irritation of the muscles or their nervous supply, due to exposure to cold
and wet, has already been indicated as forming part of the complex series of cases reoorted
under the title of rheumatism.
Malingerers, who made use of the subjective symptoms of chronic rheumatism to effect
their escape from the restraints, discomforts and dangers of military life, or to secure by a
subsequent re-enlistment the large bonus offered for recruits or substitutes, were perhaps in
most instances affected to some extent with the disease of which they complained. Their
malingering consisted of an exaggeration of the actual condition or of an asserted continu-
ance of the disability after its removal by hospital care and treatment. Although the records
present few cases of malingering, there was perhaps scarcely a regimental medical officer
whose experience did not include the persistent eftbrts of one or more men to be relieved
from the dangers of field service bv transfer to general hospital or discharge on certificate
of disability. As observed by Dr. Woodward, the rheumatic malingerer more frequently
attributed his malady to a strain or injury than the genuine sufferer. The following, from the
records of the hospital at Quincy, 111., may be taken as an illustration of these cases:
Case 13. — Benjamiu Sweet, Co. L, 119th 111.; age 52; was a(lmittedJalT27, 1863. He says he was hurt in attempt-
ing to mount a mule, and thinks he must have separated the peU'ic bones. The fact is he is old and has fulfilled the pur-
pose for which he was enlisted, that of counting one in making up the number of the regiment. I have no doubt his
captain would like to get rid of him, as he is not fit for the field. He was kept in hospital pending his transfer to the
Invalid Corps, but getting tired of waiting, he deserted, or went home to see his wife and children and was reported
as having deserted. October 14: He iias returned voluntarilj", and, having been handed over to the provost marshal.
will, I suppose, be sent to Springfield to cost the Government a few more dollars. He has complained of his back,
breast and legs; in fact every part of him has at one time or another been the seat of trouble. He has been treated
m-ith cups, blisters, tonics, strychnia and colchicum, full diet and plenty of exercise, but all to no purpose. He is
RHErMATIC AFFECTIONS. 837
one of the kiiul that cannot lie cured while in the niilitarj' service. [The regimental records show that this man was
recommended for discharge liy Surgeon Thomas MuNltoi: on the ground of " strain of tlu' jieh ic ligaments and old
age."] The discharge was granted Dec. 1, 1M13.
Cases of feigned disease frequently occasioned inueli menial avoitv to the attending
surgeon, who, by virtue of his office, became invested at once with the duties of j^rosecutor
and defender — representing on the one hand the interests of the man, on the other those of
the Government. Usuall)', however, close watching and vigorous treatment enabled him
to form an accurate diagnosis. But transfers from hospital to hospital often permitted the
malingerer to play his part over again for the study of a new medical superintendence, so
that ultimately he accumulated a history of continued disability which in itself became an
argument for his discharge on economic grounds.
The clinical history of chronic rheumatism consists of the twenty-one cases, 14 to 34,
inclusive, herewith submitted. Thirteen of these recovered so far as to be regarded as fit for
active military duty by the medical ofiicers who treated them, — and in one the subsequent dis-
charge of the soldier for a gunshot wound of the rig-ht foot-tends to corroborate this medical
opinion; in ten the evidence of a continued freedom from the rheumatic atTection consists of
the nonappearance of the names of the men on tlie Iiospital registers after the date of their
return to duty; in one the soldier was transferred to the Invalid Corps on account of his
age; and in one case, 24, the subsequent deatli of the patient from ho[iatic disease throws
a doubt on the nature of the pain and swelling of the limbs by which his previous attack of
so-called rheumatism was cliaracterized. Of the eight remainino- cases, one was transferred
to the Invalid Corps; six were discharged — in one of which, 30, there was permanent con-
traction of the thoracic and abdominal muscles, and in three, 31-33, a cardiac complication ;
in 34 death resulted from heart affection.
Case 14.— Captain J. L. Wyatt, Co. F, 101st 111.; age 38; was admitted Sept. 28, 18G3, with rheumatic pains of
four weeks' duration, following an attack of rheumatic fever. The thoracic viscera were healthy. Tincture of col-
chicnni in doses of fifteen minims was given, liut as no benefit was derived acetate of potash in fifteen-grain doses-
was used three times a day from October 3. After this the patient improved: he rested better at night, and by the
lltli was free from jiain and able to walk about. He was returned to duty on the I'Jth. [This olhcer was mustered
out with his company at the close of the war, June 7, 1865.] — Officers' Uosjjital, Loinnville, Kij.
Case 15.— Serg"t John W. Hunt, Co. E, lloth N. Y., was admitted March 28, 1863, from Stanton hospital, Wash-
ington, D. C. He had been attacked with fever in December, 18G2, after which he was sent to Convalescent Camp, Alex-
andria, Va., where he was taken with rheumatism, which persisted until the time of his admission into this hospital.
The right knee-joint and left hip and knee-joints were atTected ; he had also lumbago. Kocliello salt in drachm doses
gave no relief; iodide of potassium was substituted, and by May It the patient was decidedly better; his appetite
was good and he could walk with comparative comfort. Ho was returned to duty June 29. [This man's name does
not again appear on the sick reports.] — Ladies' Home Honpital, X F.
Case 1G.— Private Ira A. W. Cochrane, Co. E, 16th N. Y.; age 40; was admitted Aug. 10, 1862, for chronic rheu-
matism. The pain, which was chiefly seated in the lumbar region, disabled him from active motion ; he also complained
of more or less iiain in the upper and lower limbs. He had no marked disturbance of any organ or function. He was
treated with compound tincture of guaiacum and warming plaster to the loins. lie was considered convalescent
about the beginning of January, 1863, liut an attack of acute bronchitis from exposure delayed his return to duty until
February 10. [This man's name does not again appear on the sick reports.] — Saiterlc-e Hospital, PhllacMjMa, I'a.
Case 17. — Private William A. Elderkiu, Co. E, 1st Me.: age 22; was admitted Aug. 10, 1862, for chronic rheu-
matism, chieliy atVccting the limbs. He had sufTered from diarrhcea during the Peninsular campaign and was much
reduced in strength and flesh. Thediarrhtea after a time yielded to astringent and tonic treatment, but the rheuma-
tism continued. This was treated by colchieum and alkalies, anodynes atnight and careful attention to the state of
the skin. The pains in the limbs were unattended by swelling or redness and were most marked in the length of the
bones rather than in the joints. On account of the deteriorated condition of the patient's blood, evidenced by pallor
of the surface, slow and feeble circulation and general languor, iodide of potassium was prescril)ed with com])ound
syrup of sarsaparilla and good diet. Under this treatment the pains gradually ceased; his flesh and strength returned
with better rest at uight. During his convalescence he was troubled with dyspepsia accompanied with much gastro-
dynia. For this he took charcoal and prepared chalk in doses of five grains each three times a day with a carefully
regulated diet. He left the hospital to rejoin his regiment on March 4, 1863. [Ho was afterwards admitted into
838 RHEUMATIC AFFECTION'S.
Harewood hospital, 'Wasbingtoii, D. C, -n-ith a guiisliot wound of the right foot, and was discharged from service
April 23, lS6i.2—Satti'rh-e Hospital, rhUaMpliia, Pa.
Case 18.— Private Martin Perkins, Co. C, 37th N. T.; age 23; was admitted Dec. 12, 1862. The patient stated
that early in September he was taken with rigors followed hy rheumatic fever affecting all his joints: he had at the
same time a severe attack of dy.sentery which lasted till the end of Novemher. He now complains of constant pain
in the lower part of the back and left hip-joint, and is unable to walk withoitt the aid of a stick. Iodide of potassium
in five-grain doses three times a day. December 21 : Patient no better. Omit iodide and give Fowler's solution three
times a day. February 8: Stop arsenic, which has done no good, and give wine of colchicum three times a day.
11th: Somewhat better. Treatment continued; full diet. 19th: Colchicum stopped; no benefit. Givehalf an ouuce,
three times a day, of a solution of two ounces of Rochelle salt in eight ounces of water to which half au ounce of
liijuor morphia sulphatis has been added. 27th: Improved. April 17: Placed on guard duty. May 30: Returned to
duty. [His name does not again appear on the sick reports.] — Satterlce Sospilal, PhiladdiMa, Fa.
Case 19. — See ca.se of Corporal Emanuel Davis, Co. K, 137th N. Y., Ko. 30 of the clinical records of the con-
tinued fevers, »iq>ra, page 261. [His name does not apjiear on the sick reports after his recovery from this attack.]
Case 20.— Private John O. Sullivan, Co. E, 29th Wis.; age 22 : was admitted Sept. 23, 1863, with chronic rheu-
matism and diarrhcea. He complained of pain in the pra-cordial region; his skin was clear, eyes bright, tongue clean
and appetite good. He suffered in his knees, ankles and back. He was treated with icnlide of potassium, turpentine
emulsion and milk diet. He improved rapidly and was returned to duty December 2. [This man's name does not
again apjiear on the sick reports.] — HoKpUaJ, Quiiici/, III.
Case 21.— Private Eoswell H. Snook, Co. H, n9th 111.; age 2.5; was admitted Oct. 27, 1862, with pain in the
chest, left hii? and knee, of three or four weeks' duration. Tongue clean; pulse 80; left knee very painful. Two
grains of (iuiuLne and eight of Dover's powder to be given every four hours. 29th : Pain in right side of chest ; pulse
90. Eight grains of iodide of potassium at each meal. 30th: A grain and a half of quinine at each meal. Novemlierl:
Continue iodide ; omit quinine. December 6: Discharged to join regiment. [Report of Adjutant General of Illinois,
Vol. 7, p. 35, shows this man mustered out with his regiment June 15, 1865.] — Hospital, Qiii)icy, HI.
Case 22. — Private Benjamin L. Wierman, Co. B, 77th 111.; age 21; was admitted Xov. 2, 1861, fiom hospital at
Camp Butler, 111. He had been attacked with rheumatism in September, 1863, and had done no duty since that time.
The lameness is confined to the right knee-joint, which is much swollen. Give iodide of potassium and full diet.
December 7: Knee still swollen. Jan. 1, 1865: Improving; able to exercise. March 17: Returned to duty. [This
man's name does not again apjjear ou the report of sick.] — Hospital, Quincy, III.
C.4.SE 23. — Henry Stine, Co. G, 110th 111.; age 49; was admitted June 9, 1863, with chronic rheumatism, affecting
the back and lower extremities. His bowels were constipated. He improved under iodide of ])Ota.ssiuni and a nutritious
diet; the bowels became regular and the pain less severe. Kitric acid was afterwards administered and he speedily
recovered, but, on account of his age, was transferred to the Invalid Corps November 25. — Hospiia I, Quincij, III.
Case 24. — Frederick Staley, Co. M, 5th 111. Cav.; age 40; was admitted Sept. 25, 1863, having done no duty
since Xovember, 1862, when he was taken with rheumatism. On admission the patient was unable to leave his bed ;
the pain was confined to the lower extremities along the coarse of the sciatic nerve ; there was some swelling of the
limbs; his appetite was poor; bowels constijiated; tongue furred; pulse quick. He improved slow^ly under iodide
of potassium and a nutritious diet ; but subsequently, when nitric acid was administered, his recovery was rapid.
He was sent to his regiment December 2. [This man was admitted into Mcpherson hospital, Yicksburg, Miss., from
regimental hospital, Sept. 27, 1864, and died October 29, of portal congestion.] — Hospital, Quincy, III.
Ca.se 25. — Private Joseph AViser, Co. B, 2d Colo. Cav., was admitted Jan. 20, 1864, having been unfit for duty
for several months on account of rheumatism affecting his knees and ankles and to a less degree his neck and shoulders.
He was stout and well-built, yet worthless as a soldier. He was treated chiefly with nitrate of potash until April
15, when cinchona and colchicum w-ere used, with wet cups to the neck and knees and anodynes at night. Citric
acid was afterwards employed. On July 15 resort was had to guaiacum. On August 31, when cinchona was again
used, the patient was able to do light duty about the watds. He was transferred to ho.spital at Fort Leavenworth
October 12, and was returned to duty on the 28th. [This man's name does not again ajjpear on the hospital regis-
ters.]— Kansas City Hospital, Mo,
Case 26. — Captain P. F. Hansborough, 11th Ky. Cav.; age 45; was admitted from the field Nov. 1, 1864, having
suffered from rheumatism for four months and been unable to attend to duty for five weeks. The left hip and
knee-joint were affected. The attack was preceded by acidity of the stomach and indigestion, and accompanied by
torpidity of the liver. Compound cathartic pills were followed by thirty grains of nitrate of potash three times a
day in half a tumblerful of gruel ; Rochelle salt and bicarbonate of soda were afterwards employed to keep the bowels
soluble; Dover's powder was given at bedtime. Granville's lotion* was used ou the joiuts. By the 17th he had
improved very much, but the rheumatic pains continued to recur at intervals. Leave of absence was granted. [This
officer's name does not again apjiear on the sick rei^ort.] — Officers' Hospital, Louisville, Ky.
Case 27. — Joseph McMahon, Co. F, 52d 111.; age 32; was admitted April 27, 1863, with chronic rheumatism. He
was pale and aua'mie, feeble and unable to walk ou account of the swelling of his joints. He was treated with quinine,
iron and nutritious diet, and was kept in a good warm atmosiihere. He improved slowly, but ultimately was able to
walk about well. He was transferred to the 27th Co., 2d Batt., Invalid Corps, November 25. — Hospital, Quincy, III.
* An irritant consisting of liquor of ammonia, spirit of rosemary and tincture of camphor.
RHKUMATIC AFFECTIONS. 839
Cask 28. — Private Valentine Switzler, Co. B, 3!1tU X. Y.. liud rhenmatism for several months about the year
ISfjS. From that time till 1802 he hail comparatively good health, and served iu the field for eifjliteen conseeutivo
months. Aliout October, 1802. he had a second attack of rheumatism, which bccaiiio chronic, affecting cliielly the
knee and dhow-joints. He was admitted Oct. 21, 18G3. There was much thickening of the tissues about the joints,
with exquisite pain on motion. Iodide of potassium iu five-grain dose.s was given three times daily, and was gradu-
ally increased to fifteen grains. }Io improved slowly up to Jan. 2."), 18()4, when he could walk about with the aid of
a cane; but after this there was no further improvement. There was no heart disease. He was discharged from
service April 9. — Central Park Sosjiilal, Xiw York Citi/.
C.\SE 29.— Corp'l Levi T. Faulkner, Co. G, 121th 111.; age 28; was admitted .luly 9, 18G4, from Jefferson Bar-
racks. Mo. The patient stated that he had been lame since the winter of 1802-()3, and had done no duty since November
of the latter year. He had pain and lameness iu the lumbar region and lower limbs; headache; increased cardiac
impulse; paljiitation and dyspno'a; atrojihy of glutei muscles on both sides. The iodides of potassium and inni were
employed with full diet, liut no improvement took place, and on .Vugusi 11 he was sent to Springfield. 111., with a view
to hi- discharge. — IIos2>ital, (Jiiinci/, III.
Case 30. — Private August Lang, Co. E, 1st X. J. Cav.; ageol; coach painter; enlisted Aug. 20, 1861; contracted
rhouuiatism iu Xovember, but remained with his regiment; did no duty after January, 1803. April 22: Admitted to
Columbian College hospital. Washington. Blisters and cups were applied without relief. May 19: Transferred to
this hospital, arriving next day. 21st ; Five grains of iodide of potassium three times a day. 22d ; Troubled mostly
at night. Have a drachm of cod-liver oil three times a day and ajiplied a liniment of ammonia, laudanum and tincture
of aconite. 25th: Applied six wet cups to the right hip. June."): Stopped iodide of iiotassium; gave a tablespoonfnl
three times a day of a mixture containing n drachm of the tincture of aconite-root in six ounces of water. 9th:
Stojiped the aconite. 10th: Three drops of .solution of arsenite of potassium after each meal. IKtli : Applied six wet
cups between the shoulders. 23d: Used ward liniment. 2jtli: Gave warm bath. 29th: Pain on pressure, shooting
towards the heart. Applied a blister one inch square; continued arsenic and liniment. 30th: A tender point on
right side of spine opposite tenth dorsal vertebra. July 5: Gave a lotion consisting of one ounce of alcohol, three
ounces of water and one grain of corrosive sublimate, to be used three times a day. 15th: Stopped cod-liver oil. ICtli:
Suspended all treatment except the wash, which was continued until August 30, when it also was disused. Septem-
ber 10: Dover's powder at night. October 21: Fifteen drops of wine of colchicum three times a day. 22d : Four
compound cathartic pills. Xovember 21: Continued colchicum. 29th: Stopped colchicum. December -1: Ten grains
of blue-mass in two pills at once. 5th: Jaundice. Gave extract of dandelion and aronuitic syrup of rhubarb. ,Ian.
19, IKOl: Stopped treatment. March 20: (Javc three compound cathartic pills; also a liniment consisting of two
ounces each of ammonia and tincture of arnica, one and a half ounces of chloroform and four ounces of comixiund
tincture of soap. April 11: Discharged because of permanent contraction of the anterior abdominal ;iud thoracic
muscles following rheumatism. — Siiffcrhe Husxiilal, riiiladilphia, I'u.
Case 31.— Corp"! Jno. F. Slocum. Co. D, 1st K. I. Cav.; age 21: contracted rheumatism in the fall of 1802,
and was .idmitted May 7, 1803, from .ludieiary Square hospital, Washington. 9tli : Gave Fowler's solution: full diet.
10th: Dover's powder at night. 19th: Pulse 100, easily compressed; impulse of heart .jerking and felt iu two inter-
costal spaces; slight tenderness in cardiac region; pain on exertion ; unable to lie on left side; first sound deficient
in volume and strength; snti'ered severely from shooting pains in joints, hips and various parts of the body, (iave
one-sixtieth of a grain of digitaline twice a day. 29tli: Fowler's solution twice a day, digitaline once. .June 4:
Stopped arsenic; digitaline three times a day. 7th: Sulphate of magnesia. 19th: One-thirtieth of a grain of digi-
taline three times a day. 24th: Two grains of quinine four times a day. July 2: Two cathartic pills daily. 7th:
Stopped cathartic; dysentery. Gave suppositories. 10th: Gave one grain of oi>ium twice a day. August 17:
Recovered except swelling of right baud. To have it wrapped in carded cotton and oiled silk. 20th: Rheumatism
];as.sed to other joints. Applied iodine, glycerine and water; wrapped the joints in simple bandage and used cold
dotiche morning and uigbt. 21st; Discharged because of chronic rheumatism. — Saiierh-e Hospital, PInUidelxMa, Pa.
■ Ca.se 32.— Corp'l John Mockler, Co. C, 17th X. Y.; age 28: was admitted Dec. 8, 1804, from hospital at Jef-
fersonville, Ind. The patient stated that he had been taken with rheumatism at Atlanta, Ga., in X'oveniber. Ho
complains of pain mostly in the knees; he has dyspno'a on exertion and pain iu the left side of the chest; pulse 120,
feeble; impulseof the heart increased at the apex; sounds normal. Gave tonics ami full diet. Jan. 1, 18)i5: I'ulse
still rapid; ilyspniea aggravated: countenance livid. Tonics and antispasmodics. March 29: Xo better. Discharged
from service.— Z7o8j)i7a?, Quincij, III.
Case 33.— Private Euel Flanagan, Co. P., 89th 111.; age 34 : was admitted Oct. 24, 18G4, from hospital. Madison,
Ind.. where he had suffered from rheumatism for two months. He had some cardiac trouble; the inqiuLse was
increased and there was evidence of pericardial infiammation. Iodide of potassium was employed, but no imi)rove-
meiit was manifested. He was discharged March 23. 1805, as the second sound of the heart was indistinct and he
snft'ered from distressing dyspno-a.- i/uxj)i(<i;. (ju'mcij, III.
C.\SE 34.— Private William X". Sandt, Co. A, 115tli X. Y., was admitted Oct. 18, 1864, from Hampton hosi)ital
with chronic rheumatism. On December 2 he became aflected with diarilnea which lasted until the end of that
mouth, when he began to improve. On Jan. 18, 1805, from exposure he had a return of rhenmatism, diarrhoa and
some bronchial cough. Wine of colchicum was given, with diai>horetics, expectorants, astringents and opiates. The
diarrhiea persisted notwithstanding all treatment. On the 30tli the patient complained of slight pain in the ])ra-
cordia. On February 1 he had palpitation of the heart, intermittent pulse, 40 per minute, and ortliopntea. Next day
840 EHEUMATIC AFFECTIONS.
the pulse was ciuick and soft and there was much pain in the region of the diaphragm: his breathing was laboredr-
death occurred suddenly at 11 P. >i. — TThitehaU HosjjitaJ, Pa.
In the cases constituting the post-mortem records of chronic rheumatism death was
due to the implication of the heart in the three cases 35-37, and to the supervention of
choreic movements and pulmonary congestion in case 38.
Case 35. — Private Michael Collins, Co, M, 16th Jf. Y. Cav.; admitted July 13. 1804. Diagnosis: Chronic rheu-
matism. Died August 11. Post-moriem examination: The right lung and pleura were inflamed; there was marked
pericarditis: two large abscesses were found in the spleen. — Tliird Dirhion Hospital, Alexandria, Ta.
Case 36. — Private George Palmer. Co. K.27th Colored Troops; admitted Dec. 7, 1864. Died Feb. 10. 1865. He
had been troubled with diarrha?a, cough and chronic rheumatism up to February 8, on which date his pulse was 80,
respiration normal, tongue clean and appetite good: he had pain in the loins and shoulders, but was able to walk
about. On the evening of this day he had a chill with intense eardiac pain and dysjina'a ; the heart beat strongly,
150 per minute, and there was dulness with a friction sound and bellows murmur. Post-mortem examination: The
lower lobe of each lung, the omentum, spleen and kidneys were tuberculous; the mesenteric glands enlarged. There
was recent pericarditis with adhesions. — Act. Ass't Surgeon A. F. Pattee, VOuverture Hospital, Alexandria, Tu.
Case 37. — Private Calder Barnes, Co. C, 8th N. Y. Cav.; age 34 ; admitted March 25, 1865, with chronic rheu-
matism and heart disease. He had great dysimcea and the heart-sounds were obscured by a regurgitant murmur. He
died suddenly May 27. Post-mortem examination : The pericardium was closely and firmly adherent to the heart,
which was very large, weighing thirty ounces; the mitral and semilunar valves were thickened and covered with
warty vegetations. — Jarvis Hospital, Baltimore, J/rf.
Case 38. — Private Altimore Joiner, Co. C, 37th Colored Troops; age 33; was admitted Oct. 2, 1864, with rheu-
matism. He complained of cough and pain in the chest, which were relieved by treatment, but the rheumatic pains
persisted and the patient became weak and nervous. On Feb. 10, 1865, the record states that he seemed to be affected
with some nervous disease, manifested by twitchings of the mouth and hands. Colchicum, gentian, valerian, whiskey,
quinine and iron were employed. On March 3 some febrile action was set up, the pulse becoming full and the tongue
coated: for this citrate of potassa and morphia were prescribed. Next day eight ounces of brandy were given with
small doses of sweet spirit of nitre. On the 5th the fever had declined, but the nervous disorder was aggravated,
the patient having no command over his voluntary muscles and being unable to articulate distinctly. He died on
this day by asphyxia. Post-mortem examination: There was some superficial congestion of the brain but no organic
lesion. The heart was small and anaemic ; its right side contained venous blood. Both lungs were much engorged. —
Summit House Hospital, Philadelphia, Pa.
The following extracts relatino- to the causation and treatment of acute and chrnnic
rheumatism are submitted:
Surgeon J. M. EiCE, 2oth Mass., Xeiv Berne, X. C, ITarch 10, 1863. — Rheumatism aft'ecting the spinal region, hip
and legs is of frequent occurrence and obstinate in its character, yieldiug slowly to treatment.
Surgeon 3. Fraxklix Dyer, 19//i Mass., Dec. 31, 1861. — During this time [at Harrison's Landing, Oct. 21 to 23,
1862], for three days and nights our men were exposed to rain with little sleep and no shelter. These hardships
served to develop latent disease; several cases of chronic rheumatism and phthisis date their development from that
period. A few days subsequently we moved to higher ground, where we had the advantage of purer air, but many
suffered from severe colds by reason of the exposed position of the camp and insufficient clothing.
Surgeon AuGl'STUS R. Egbert, T~. S. Vols., Fort Eumholdt, C'al., Xor. 1, 1862. — The climate aggravates rheumatic
and pulmonic diseases. Eaiu falls nearly all the time from November to May.
Surgeon E. Griswold, 112(/i Pa., Fort Saratoga, V. C, June 5, 1862. — The sudden change from the comforts of
civil life to the privations and exposure of camp iu the middle of a winter so changeable as the last produced its
legitimate eftects on the health of the men. Kheumatism became prevalent, chronic cases greatly predominating.
Surgeon W. \Y. Browx, Ith X. H., Beaufort, S. C, June 30, 1862.— Most of the twenty-three cases left at Fort
Jefferson, Tortugas, Fla., were rheumatism of a subacute character; some of the men were quite feeble. Dysentery
was often immediately followed by rheumatic disease. As our meteorological register shows a limited range of tem-
perature we were surprised to see so much disease of a rheumatic character. Many men, hitherto strangers to it,
were disabled for several days, and nearly all who had any tendency from previous attacks were severely visited.
Act. Ass't Surgeon Tho.mas T. Smiley, iu commenting on the diseases met with at Hilton Head, S. C, in October,
1862, says that cases of rheumatism were not infrequent, but that nearly all were chronic and occurred in persons who
had been subject to rheumatic attacks before they entered the service. The disease affected the hands, shoulders,
feet, knees and every other part known to be liable to seizure. Many of the xiatients had done no duty for a year.
The ordinary remedies proved of little avail aud many of the cases had to be given up as hopeless.*
Surgeon A. H. L.VXPHIER, 106(7i III., Jackson, Tenn., Dec. 31, 1862. — Resident physicians tell me they have more
rheumatism aud intermittent fever than all other diseases together. I suppose that the low swampy surface of the
country will account for this fact. It is customary here to give large doses of quinine iu acute rheumatism, and the
practice is by no means unsuccessful.
* See Boston 3IeUical aud Siirykul Joiinml, Vol. LX VII (1SC3), p. 272.
KHEUMATIC AFFECTIONS. «41
Jss't Surf/eon C. P. Woor>. 6Gth .V. r., Sept. 30, 1862. — Rheumati.sm w.is quite jirevalent at Yoiktowii fnmi culil
auil exposuie to wet. The onliuaiy aiiti-rheuniatic remedies had very little eli'ect : colchicum aiitl ^iiiaiacum were tried
ill vaiu. Taking it for granted that this was due to a malarial comiilioatioii, I use<l a cathartic, followed by a grain
of opium and fire of ijuiuia, every four or six hours, with the happiest effect.
Surgeon D.wid Meiuutt. both I'a., Itcoiifort. S. C. May 10, 1863. — Acute rheumatism has assumed a malarial
character to a very great degree. Hence, quinine and capsicum are used with much advantage in conjunction with
iodide of potassium and acetic extract of colchicum. Chronic rheumatism has been also very prevalent, particularly
among men rather advanced in age, who, anxious to enlist, had not acknowledged, and perhaps took much trouble
to conceal, their liability to the disease. In this climate, warm during flie day and cool and damp at night, it has
liecomo very troublesome and assumed a periodic character.
Surijton M. R. Gage, 25/A Wis., CoUimhus, K;/., March 31, 1863. — Rheumatism has been of common occurrence
and in many cases of serious character. Lying upon the damp and moist earth, no doubt its cliief cause, is nearly
certain to re-develop the disease in those who have at any time previously suffered from its attacks. To these cases,
if fever be a dominant symptom, we administer at first an active purgative of which calomel is an important con-
stituent: this is followed by opium to allay suffering, and calomel as an alterative. When the mercurial taint is
manifested the calomel is omitted, but the opium is continued with small quantities of ipecacuanha, opening the
bowels at occasional intervals. When the acute symptoms have disappeared, colchicum is a serviceable addition to
the treatment. We give but little attention to topical applications in the acute form, believing them to be of little,
in fact, of no service.
Snrgcon J.\s. S. Wihtmike. nfilh lU., in ihejiild, Miss., Dec. 31,1862. — In connection with the usual remedies for
this disease, colchicum. tartar emetic, nitrate of potash, opium, etc., I dry cup the spine: and from this treatment my
patients not infrequently derive immediate and sensible benefit.
SurneoH Allkx F. Peck, Ut .V. M. Mounted Vols., fort Stanton, X. M., Ike. 31, 1862. — Cases of rheumatism were
quite common during the monthsof Xovember and December. They were chiefly of the scorbutic character; in some
most of the joints of the liody were affected and in others only one or two. 1 give sulphate of magnesia at once, —
half an ounce, with a drachm of magnesia. After the bowels have been well moved I give, three or fonr times a day,
thirty grains of bicarbonate of potash with ten grains of nitrate of potash and ten drops of laudanum. If these fail to
allay the pains, I give Dover's powder at bedtime. If the disease is confined to one or two joints great benefit is
deriveil from small blisters, frequently repeated : and when there is much prostration brandy two or three times a day,
with plentiful supplies of good nourishment, are required,
Snrijeon Jxo, I. S.Wlt.LE, 2(f CoU. Car., Fort Union, X. M., Sept. 1, 1862. — I succeed well in relieving the rheuma-
tism of this country by the use of syrup of bnchu, sassafras and iodide of potassium. I persevere in the use of this
until all lullammatory action ceases: and finally bring the system up with bitter tonics and iron.
Siirgion Wm. R. Blakeslee, lloth Pa., near Alexandria, Va., Oct. 20, 1862. — As regards the rheumatic cases, much
good was effected and great relief afforded by the administration of a drachm and a half of iodide of potassium, with
two grains of sulphate of morphia, in eight ounces of iieppcrraiut-water, in doses of a tablespooufnl every four or five
hours. In the case of an old man, in whom there was much jactitation and tremulousness, I obtained good effects
frtmi twenty or thirty drops of Hoffmann's anodyne three or four times a day. Cotton was Avrapped around the pain-
ful joints, which were then covered with oiled silk. The bowels were kept open by Epsom or Rochelle salt.
Jet. J»s'l Surgeon Alfred MrLi.ER, Fort ndgelei/, Minn.. Jpril 1. 1862. — In six severe cases of acute articular
rheumatism I used gentle frictions of the chlorure of elayl [chloride of ethylene: Dutch liquid] from one-half to one
drachm at a time; in each case there was almost instantaneous relief, and in some a perfect cure from one single
application. The relief produced was very evident and continuous; much needed sleep was obtained and convales-
cence established. I never observed any disagreeable consequences after the use of this remedy. Its effect is such
as to leave no doubt of its value: the remission of the pain is so constant and often so instantaneous that it cannot
be attributed to mere chance.
Xotwithstandiug the frequency of the rheumatic cachexia, as doubtfullj^ evidenced by
the statistics, ophthahnia was so seldom associated with rheumatic manifestations in the
joints that the three cases which follow may be regarded as exceptional rather than as illus-
trating a class of cases of their kind. The sclerotic, however, became frequently involved
in tedious cases of catarrhal conjunctivitis.
Case 39. — Private Isaac S. Carr, Co. B, 152d Pa.: age 24: had acute rheumatism in 1858, since which time he
has been subject to rheumatic pains. He enlisted Oct. 20, 1862. In July, 1863, after exposure to wet and cold, he
bad pain in the head and pain and swelling around the left eye, which -was very red. After treatment at the camp
hospital the pain and swelling subsided but the redness remained. All these symptoms recurred in an aggravated
form in January, 1864 ; vision of the left eye became impaired. The pat lent was furloughed, and on his return was treated
with some benefit, at Wills hospital, for rheumatic iritis. He was received into this hospital from Camp Cadwallader
February 6. At this time his general health appeared good; his left eye was very red; a distinct zone surrounded
the cornea, which presented a small opacity, some slight vascularity and several small points of ulceration ; the iris
was discolored. Photophobia and impairment of vision were associated with these local changes. Gave a table-
spoonful, three times a day, of a mixture containiDg an ounce of Rochelle salt and six drachms of wine of colchicum
Med. Hist., Pt. 111—106
842 ■ EHEUMATIC AFFECTIONS.
in seven .iiul a half oui'.ees of vrater; sulphate of zinc wash; full diet. 13th: Improving. Gave a teaspoouful, six
times a day, of a mixture coutainiugone ounce of oil of turpentine and half an ounce each of sugar and gum acacia
in seven ounces of peppermint-water, and applied turpentine around the eye six times a day. 15th: Less redness:
vision improved. March 5: Kedness subsided; slight impairment of vision. Continued treatment. 11th: Well:
returned to duty. — Titrner's Lane Hosjrital, I'hUadeljihia, Pii.
Case 40. — Private Allen T. Hammond, Co. M, 2d Colo. Cav., was admitted March G. 1804, with conjunctivitis.
His eyes had been perfectly sound until Kov. 12, 1863, when first one and in a few days the other became intlamed
and painful, feeling as if grains of sand were incommoding the ball. He was then at Fort Lyon, Colo., where he was
treated with flaxseed and opium poultices for nine weeks. On admission into this hosiiital a solution of nitrate of
silver was applied ; Ijut it caused so much pain that the jiatient refused its further application. Crave iodide of potas-
sium, acetate of potash and muriate of ammonia, and used a zinc lotion occasionally. May 10: Eyelids granular;
vision imperfect ; iris inflamed. Patient cannot read longer tlian fifteen minutes at a time ; on a dull day he is unable to
recognize an acquaintance at fifty jiaces ; objects at a hundred paces apjiear double. Uave two teaspoonfuls morning
and evening of a solution of two grains of corrosive sublimate and twenty grains of iodide of potassium in three
ounces of water; ai)plied suljihate of copper to the lids every third day; fly-blister below and behind the ears. 31st :
The patient during the past ten days has sutfeied much from conjunctivitis; photophobia has been distressing, but
was allayed by means of a drop of a solution of five grains of morphia in a fluid drachm of glycerine. June 30 : Cornea
injected. The lids to be everted every third day and painted with a solution of twenty grains of nitrate of silver iu
one ounce of water. July 31: Discontinued nitrate of silver and substituted six grains of red precipitate ointment
iu one drachm of simple cerate; to be applied morning and evening. August 7: Uiarrhwa for a few days. Gave
anodynes and astringents. 14th: Diarrhoea persisting; articular rheumatism manifested in the lumbar region and
in right knee. Applied volatile liniment and gave a teaspoonful every fourth hour of a solution of morphia, two grains,
in one ounce of cinnamon water. 21st: Easier; some debility. 31st: Eheumatic ophthalmia recurring; flakesoflymph
doubtfully present in aqueous humor; iris hazy and sluggish; cornea clouded; vessels much injected, especially
those around the upper half of the cornea. Applied equal parts of extract of belladonna and mercurial ointment to
forehead and temples and gave half a drachm of wine of colchicum every six hours ; three compound cathartic pills
every second day; ten grains of Dover's powder at bedtime. Continued morphia in glycerine to the eyes. He was
discharged from service September 16, at which date he was suft'ering from intense photophobia, being unable to keep
his eyes open long enough to see anything, even if the condition of the aqueous humor and cornea had permitted him
to see. — Kansas CUij Hospital, Mo.
Case 41. — Serg't Turner Locks, Co. F, ILstli 111.; age 31; was admitted Aug. 26, 1863, having been suffering
with sore eyes for six weeks. They were red, painful and .sensitive to light. The patient's health was otherwise
very good. Elixir of calisaya was given and a colly rium of acetate of zinc. September 4: Lids granular but eyes
less painful and sensitive. Nitrate of silver solution substituted for the zinc: elixir continued. The silver caused
much irritation and was discontinued in favor of sulphate of copper. October 27: After the application of blisters
to the temporal and mastoid regions the eyes improved considerably. Nitrate of silver was again tried, but stopped
on account of the irritation it caused. He had pain in the hips and legs at night ; for this morphia was administered.
November 2; The pain in the right hip assumed a rheumatic character and was associated with some fever. Iodide
of potassium was given and the elixir omitted. 7th : The silver solution was again tried on account of a purulent dis-
charge from the eyes. Quinine was given along with the iodide. 9th: Severe pain in the temporal region. A col-
lyrium of extract of belladonna and morphia was prescribed. 11th: Severe circumscribed pain with increased
inflammation and a mueo-purulent discharge from the right eye. The bowels were freely opened by a mercurial purge.
16th: Pulse 90; bowels constipated; a small gray spot on the right cornea; some chemosisaud an occasional paroxysm
of severe pain. 19th: A gray spot on the left cornea; severe pain extending to the back of the head. Quinine and
suli>Iiate of iron, laxatives and low diet were prescribed. 28th: Inflammation and pain lessened; left cornea almost
completely clouded with gray exudation. The patient had a severe chill this morning. Cantharidal collodion was
applied around the eyes and quinine was given in five-grain doses every four hours; extra diet. December 1: The
chills are suppressed, but there is fever, with delirium at night; pulse 90, small; tongue cleaning; some thirst; a
slight erysipelatous redness about the nose. Iodine was applied to the face, and ten drops of the tincture of muriate
of iron with quinine in two-grain doses every three hours were administered. The patient was kept in a dark
room and continued on extra diet. 2d: The erysipelatous swelling has extended to the forehead; bowels oi)en; eyes
less congested; left cornea opaque, right clouded at one sjiot; delirium in the evening. Treatment contmued, with
morphia, nourishing food and stimulants; valerian and ammonia were also employed. 3d: Mind clear; profuse
epistaxis during the night; erysipelatous swelling subsided; tongue brown and dry in the centre: pulse feeble and
intermittent. The muriate of iron and quinine, with extra diet, were continued. 16th : He has slowly improved ;
the circumorbital pain has abated considerably and the opacity is diminished. Jan. 1, 1864: He has continued to
improve and is able to walk about; appetite good; bowels regular; the sight of the left eye is very imperfect.
Quinine and good diet were continued. April 1: Ho has been furloughed for twenty days and has continued to
improve. The left cornea is almost wholly obscured, the right but slightly. He can discern objects close by, but at
a distance can with difficulty distinguish a person. lie was discharged from the service May 6, 1864.— Jc(. Ass't
Suryeon F. K. Suilcy, Hospital, Qtiinci/, IU.
The inflammatory re.sults of exposure to cokl and wet were exceptionally localized iu
other parts of the body:^In 42 there was a recurring periostitis of the tibia, and in 43 and
44 suppuration in the vicinity of the hip-joint.
KHKUMATIC AFFECTIOKS. 843
Case 12 rihate L. liiauiiiger, Co. II, ISTtli Pa.; ago 22: was ailmitted Dec. 2, 1802, having already passed
tliiee iiioiitbs ii> the Kiuley ho-spital, Washington, D. C, with ilicumatism. lie was weak and ana inic. and com-
idaiued of pains which liecanie aggravated in damp cold weather. Five grains of iodide of potassium three times a
day. with generous diet and porter. 2uth: A well-marked attack of periostitis of the tibia. To rub mercurial oint-
ment over thoatVected part. Jan. 2, 18(53: No iodide of potassium in the surgery; a teaspoonful of Huxhain"s lincturo
thrice daily. 15th: Increase of pain with slight fever. Twenty grains of acetate of potash three times a day. 18th :
The acetate having afteeted the bowels is discontinued. 20th : A teaspoonful of cod-liver oil three times a day, and
to have, iu addition to the regular house-diet, two pints of milk and two eggs daily. 21st: A slight friction sound
over the cardiac region, but no increase of fever; the patient too much reduced to admit of dejjleting measures. No
change in the treatment. February G: Iodide of potassium again prescribed. 7th: Periostitis of iho malleolus. To
be rubbed with mercurial ointment. 12th: Not quite so well. One-twelfth of a grain of corrosive sublimate to bo
added to each dose of the iodide. ICtli . A severe attack of periostitis of the tibia. Treatment af. before. March 14 :
Somewhat improved in general health, but to-day both legs and ankles are afteeted with periostitis. 18th: Placed
by the discharge board in the Invalid detachment. April 21: Transferred to the guard. May 8: The attacks of
periostitis are always slight and do not last more than twoor three days: they are characterized by redness and jiain
upon pressure over the afteeted bone; very slight roughness is perceived by passing the finger over the tibia. I
occasionally see the man. who appears now to have regained his health. He denies all specific taints, and there is no
evidence that the aft'ectiou is of syphilitic origin. — Sutterlee Hospital, riiUadelphia, I'a.
Cask 43. — Private William Payne, Co. H, 9th Ind.; age 42 ; enlisted February, 1862, previous to which time he
had never been sick. He did duty until September, when he was attacked with rheumatism after exposure to cold
and wet. The disease manifested itself in the right hip-joint: In October a swelling extended from a little below
the right external abdominal ring to the right anterior inferior iliac spine: this was lanced, bringing away about
four ounces of pus, while he was at Howling Green, Ky., about the middle of November; after which about a table-
spoouful of matter came away daily. When admitted to this hospital, November 28, he could not walk without a
cane: he had pain in the light hip-joint when he rested on that leg. Gave ten grains each of powdered guaiacum
and carbonate of ammonia every three hours, and applied a compress. 2;Uh: Much pain during the night. Applied
a liniment of two drachms each of oil of c.ajeput and laudanum, half an ounce of turpentine and one ounce of volatile
liniment: also a saturated solution of alum. December 1: Swelling somewhat diminished. Injected the cavity with
ten drops of solution of chloriuated soda in one ounce of distilled water. This caused considerable jiain : but the injec-
tion was repeated with a weaker solution on the following day without discomfort. Wooden compresses were applied
on each side of the sinus. 7th: Swelling diminishing; discharge of pns lessened. Discontinued guaiacum and
ammonia: continued the injection, alum lotion and compresses. 10th: The injection caused a cold feeling extending
nearly to the hip-joint. 13th : The sinus is almost closed towards the ilium, but a hard and painful tumor has devel-
oped near the external abdominal ring. 15th : Applied nitrate of silver to the tumor; discontinued the wooden com-
presses and injections and applied a light cloth compress. 16th: Tumor enlarging. 17th: Inflamnuitiou extending
from the pul)es to the ilium. 22d: Tumor painful, roller-like in shape, with the original opening in the middle: dis-
charge pretty constant : high fever at night. December 29: Died. — TTint End Hospihil, Cincinnati, Vhio.
Cask 44. — Private Caswell M. Donica, Co. E, 57th 111.: age 22; having been exposed for several hours in the
rain on April IS. 1862, was attacked with severe pain in his right hip, the whole of the gluteal region becoming
swollen, tense and tender : soiue fever accompanied the local inllanmiation. He was treated with poultices and iodide
of potassium until the middle of June, when an incision was made over the sacro-iliac symphysis and about two
qnarts of pus evacuated. Treatment by poultices was continued, with wine aud generous diet. In September, when
lie was discharged, the abscess had healed, but the parts remained tender and painful aud the patient was unable
to bear his weight on the limb: his appetite was good and he was gaining iu flesh. An examination of his chest
showed a moderate dulness over the lower half of the right side: mucous rales on the left side, with dulness and
feeble respiratory murmur below and harsh inspiration with prolonged expiration at the apex. — Hospital, Quincy, III.
The unsatisfactorv results of treatment in chronic rlieumatism may be gathered from
the cases and extracts that have been submitted, and particularly from the large number of
patients discharged as unfit for service after prolonged periods of treatment in various hos-
pitals. Among the internal remedies used were iodide of potassium, colcliicum, guaiacum,
sarsaparilla. Fowler's solution, quinine and iron with or without nux vomica, cod-liver oil,
acetate and nitrate of potash, tartrate of soda and potasli, citric acid, nitric acid, etc. Dover's
powder at bedtime, or morphia, in conjunction with the basis or principal ingredient of the
anti-rheumatic prescription, was frequently used to allay the distress of the patient. In many
cases most of these remedies were tried at one time or another without avail. In case 30,
a patient who had been submitted to more or less treatment from Xovember, 1861, to May,
1863, was admitted into the Satterlee hospital, Philadelphia, Pa., and during the year that
elapsed until his discharge in April, 1864, he was subjected to iodide of potassium, cod-liver
oil, tincture of aconite. Fowler's solution, wine of colchicum and other remedies, with vigor-
844 CO>'GESTION ASD INFLAMMATION
ous local treatnneiit, but without the production of any permanent benefit. Nevertheless the
repute of many of these remedies may be sustained by pointing to individual cases. Recov-
erv took place under the administration of the acetate of potash in case 14; of guaiacum in
16; of Rochelle salt in 18 and 26; of quinine and iron in 27; of iodide of potassium with
colchicum and guaiacum in 19. with sarsaparilla in 17, and alone in 15 and 20-24. Iodide
of potassium, indeed, appears to have the weight of testimony in its favor; but there is an
important per contra to this statement: In 18, 29, 30 and 33 it was valueless; and there
were but few of the 12,653 white and colored soldiers that were discharged on account of
disability from rheumatism who had not been subjected to its influence prior to their dis-
charge. No doubt the admission of these men into hospital was in many instances followed,
as in case 28, by a certain amount of improvement to which medical care and comforts cer-
tainly contributed, but their recovery was not effected. Local treatment by wet and dry cup-
ping, warm applications, carded cotton and oiled silk, occasional cold douches and counter-
irritation by iodine, various stimulating liniments and blisters, was ecpially uncertain in its
results, although often seeming to afford temporary relief.
The experience of Confederate surgeons was of a similarly discouraging character, as
shown by the following extract from the records of the Chimborazo hospital :
A large number of chronic rheumatics in this hospital receive no treatment. Of those treated nearly all are
siihjected to colchicum, \yhich has very rarely proved beneficial, either because not adapted to the case or because of
bad quality; in doses of twenty drops, three times a day, it has seldom purged. Iodide of potassium is given iu
nearly every case treated, and with very fair success. Remedies indigenous to the South, and cheap, are seldom pre-
scribed, and guaiacum has been used with great reserve for want of alcohol, which the pharmacy has not supplied.
Galvanism is neglected.
The febrile condition in cases of acute rheumatism was frequently treated by quinine,
especially in malarious localities. Saline purges, as Epsom or Rochelle salt, with opiates to
allay pain, were also in frequent use. Often, indeed, Dover's powder formed the basis of
the method of treatment. Colchicum was generally employed. The acetate of ammonia or
potash, and the nitrate of potash* with sweet spirit of nitre, were likewise frequently pre-
scribed. The swollen joints were wrapped in carded cotton or flaxseed poultices, or kept
soaked in alkaline lotions with or without previous cupping. Tincture of iodine was the only
local irritant employed during the acute stage. Pain in the prsecordial region suggested the
use of opiates and cups, followed by blisters in the event of effusion. Generally, on the sub-
sidence of fever, iodide of potassium was prescribed, with cinchona or other tonics and anodvne
or rubefacient liniments to the painful or stiffened joints.
IV._OTHER DISEASES ATTRIBUTED TO EXPOSURE.
I.— CONGESTION AND INFLAMMATION OP THE SPINAL MEMBRANES.
Among the cases of disease due apparently to exposure to cold and wet were many in
which the spinal cord or its membranes became affected. Surgeon Alexander B. Mott,
■ U. S. Vols., in charge of the Army hospital, Lexington Ave., oSTew York City, says in his report
for November, 186^2:
■* Surgeon P. A. O'Coxxell, 28th Mass. Vols., — Boston MefUcal and SurQico.lJoiymal^\o\. LXVI, 1SC2, p. 32, — iu referring to the use of nitrate of potash
saysthut:—" Persons have been admitted to the hospital witli flushed face, hot skin, rapid and full pulse, the feet, ankles and knees swollen and painful,
and a few days sufficed to fit them for duty.'' The two cases, Xos. 1 and 2, submitted iu the text from the case-book of Dr. O'Consell's regiment, appear
to sustain this statement.
OF THK SPINAL MEMBRANES. 8-45
A disease much noticed at the present time by that part of the profession connected with the army has been
variously named general neuraljiia, myalgia, or, from its chief situation, intercostal neuralgia. It occurs mainly in
soldiers exposed to the malarial emanations of southern marshes, existing intercurrent with typho-malarial fever, or,
in some cases, preceding it or even following its attack; it has also been seen to follow intermittent fevers, but in
many cases exists alone. Its prominent characters are the following: Coming on gradually, showing itself first in a
portion of the spiue, gradually extending around the chest and down the extremities, though in some cases fixed iu
a particular situation, as iu the lower liowels. Ilypera'Sthesia is a prominent characteristic, the patient fearing the
approach of the surgeon lest ho be touched carelessly. The body is bent to an angle, aud any effort to assume
the uiiright posture is attended with so much pain and distress that the patient will not make the attempt: gait
straddling and careful. There has yet been no fatalca.scat this hospital, so that the local lesion has not been studied.
The nutrition remains good and the functions, when not affected by jirevious illness, are well performed.
Surgeon J. E. Sanborn, 27tli Iowa, writing from Jac-kson, Tenn., March 31, 1863, also
refers to this spinal affection :
a singular affection has nuiuifested itself in this regiment, taking the form of a severe spinal irritation and,
possibly, spinal meningitis. There is pain iu the hiuibar region, occasionally sharp but usually dull and aching: at
limes the feeling is described as a sense of weakness, with inability to stand or sit straight aud ii didiculty in l.viug
down except in certain positions. There is tenderness on pressure upon the spinal processes or just upon either side
of theiu. The first few cases of this disorder 1 suspected to be feigned, but the iirevalenco of the afi'ection and the
character of uuiny of the subjects soon indicated that iu many eases at least it was .a serious reality. Some cases were
at first thuught to be the resnlt of an affection of the kidneys brought ou by lying on the wet ground, an idea sug-
gested by the fact that they were accoiupauied by dark or very red urine. Iu other cases it was observed that this
affection either followed or accoiupanied chronic diarrha-a. In the matter of treatment almost every reasonable mode
has been employed: Constitutionally, quinine and similar antiiieriodics ou the miasmatic presumption; then com-
binations of iodine aud other alteratives, with tonics in cases of possible rheumatic diathesis. Locally, stimulating
liniments, blisters, cupping, both wet and dry, croton oil, and other forms of external irritation aud pustulation, all
of which have been aliuost invariably unsuccessful. A number, having limped about with canes to support their
bending spines for souu' time, have finally been discharged. The temptation is so strong to feigu such a disease that
special care has to be taken to watch the cases and treat them vigorously.
Sometimes the attack was so sudden that the case, as in 1, 4 and 8 of tlie following
series, was reported as one of paralysis; or as inflammation of the spinal cord or its mem-
branes, if associated at its inception with febrile movement and tenderness over some part
of tlie spiue, as in cases 2 and 5; again, the disease was reported as a chronic myelitis when
the spinal tenderness, as in case 6, was not associated with a symptomatic pyrexia. "Whether
the inflammatory action in these cases was modified by a rheumatic diathesis is uncertain ;
but in its lighter grades, when characterized merely by pain and stiffness, or impairment of
muscular power in the limbs, it was generally reported as chronic rheumatism.
According to the records most of the cases of paralysis resulted from exposure in cold
and wet weather. In some instances there was a liistory of injury to the spine, but the
proximate or immediate cause in several of these, as in 3 and 10, was evidently the subse-
quent exposure to the vicissitudes and inclemencies of the weather. The injury, however,
may have determined the localization of the inflammatory results of the exposure. The
acceptance of this view would give a substantial support to Dr. Klapp's explanation of the
frequency of rheumatic manifestations in the lower part of the spinal canal among soldiers
on active service.* Over-exertion and heavy burdens on the loins would predispose liy
repetition as sui-ely as a more pronounced injury inflicted but once.
The number of white soldiers re^Dorted as taken sick with paralysis amounted to 2,837,
the deaths to 231 and the discharges to 2,838. The anomaly expressed by these numbers
is chiefly due to the fact that among the discharges mentioned were many cases that had
made their appearance on the sick-report as inflammations of the spinal cord. Others, reported
originally as chronic rheumatism, were discharged on account of an aggravation of the spinal
affection manifested by paralysis and muscular tremors, and paralytic sequelte of such dis-
eases as the continued fevers also contributed to the total of those discharged.
• See note *, page 833, siipra.
846 CONGESTION AND INFLAMMATION
Perfect recovery, implying ability to perform military service, was unusual in tliese
cases of spinal affection. In cases 1 and 2 recovery was complete: j^early two years after
his paralytic seizure the patient in the first case was captured by the enemy, and died after-
wards in prison of diarrhoea and starvation; in the second the soldier served with his com-
mand until it was mustered out. In 3 the patient, although returned to duty with his regi-
ment, continued more or less disabled, and was in hospital on account of general debility
when mustered out at the close of the war. Usualh^ indeed, the attack was the beginning of
a permanent disability from loss of j^ower in the affected limbs and tremors which, in some
instances, 8-11, were recorded as paralysis agitans. In the fatal case, 13, the liistory does
not exclude injury as the proximate cause; but in 16, also fatal, there was no traumatism.
In case 12 the patient attributed his paralysis to injury from the wind of a shell which
had passed close to his spine. Surgeon D. L. Huntington, U. S. Army, in speaking of
alleged injury from iviiidage, states* that — "it is now conceded by modern surgeons tliat
without the actual contact of the projectile injuries cannot occur; on the other hand, it is
admitted that slight Contact from the grazing or brushing of a projectile, or the rolling motion
of a cannon-ball over the surface of the body, may, by the weight and momentum, aided by
the elasticity of the skin, effect most serious results while little or no external evidence of
such contact is left." In this, and similar cases in which tliere was no external evidence of
contact, it is suggested that an explanation of the internal injury may be found in the sudden
and violent spasm of the voluntary muscles, which is usually the involuntary result of the
near passage of a large and dangerous missile. Muscular action has ruptured internal organs .
and fractured bones; it is therefore readily conceivable that the spine may have suffered an
iniury although there was no actual contact with the passing shell.
Case 1. — Private John C. Henninjr, Co. F, 16tli Iowa, being engaged, Aug. 7, 1862, in working in the fortifica-
tions, was somewhat suddenly seized with loss of jiower in the lower extremities. He was assisted to his quarters and
rapidly became worse, till on the next day he was completely paralytic in both arms and legs. This condition con-
tinued for two days. Treatment consisted simply in the application of a sinapism along the spine, continued a suffi-
cient length of time to destroy the cuticle. On the third day lie was much improved and has now so far convalesced
as to be able to walk about the camp. The functions of the bladder and bowels were not interfered with, notwith-
standing the extent of the paralysis. The paralysed limbs were neither swollen nor aftected in the slightest by
pain. — Surgeon Frederick Lloyd, 16th Iowa, tiear BoUrur, Tenn. [The reports of the Adjutant-General of Iowa show that
CorpT John C. Henning, Co. F, 16th Iowa, was captured at Atlanta, July 22, 1864, and died at Millen, Ga., Oct. 22,
1864, of chronic diarrhcea and starvation.]
C.vsE 2. — ^Private Franklin Cooker, Co. A, 138th Pa.: age 20; was struck, Jan. 24, 1864, in the lumbar region
and knocked down by the limb of a tree. He was stilf and sore for a few days after tliis, but continued to do duty
until one morning, after a wet night on picket, _iiis legs became paralysed and painful. He also had a sharp pain
in the -back and the feeling as if a cord were bound tightly around his hips; there was no loss of tactile sensation.
He was admitted May 11, having been under treatment in the Emory hospital, Washington, D. C, since February 2.
On admission he tried to walk with crutches; there was muscular hypera-sthesia, mostly on the left side ; tactile sen-
sibility was imiJaired on the inside of the thighs, around the knees and on the outside of the feet, and this impair-
ment was greater on the right than on the left side; there was tenderness on pressure over the vertebra from the
first dorsal to the last. Galvanism and tonics were employed, Furloughed August 20; returned September 8. Fur-
loughed November 3; returned on the 24th. Returned to duty on the 26th. — Turner's Lane Rospital, Philadelphia, Fa.
[This man served with his command until it was mustered out, June 23, 1865.]
Case 3. — Private AVilliam White, Co. I, 188th Pa.; age 23; was admitted from Hampton hospital to De Camp
hospital, David's Island, N. Y. Harbor, June 10, 1864, whence he was furloughed on the 20th, On August 23 he was
received into Haddington hospital, Philadelphia, and on Sei)tember 2 was transferred to this hospital: Sensation
and motion in right leg impaired: inguinal glands slightly enlarged; tonic contraction of right extensor femoris, with
jerking of foot and leg on attempting to extend the leg on the thigh. He was first aftected iu January, while exposed
to wet weather, during Kilpatrick's raid. The onset was gradual and was in part attributed to the weight of the
cartridge-box in marching, as there had been pain in the lumbar and sacral regions prior to the interference with
sensation and motion. Pain was sometimes felt in the left groin, but there was no paralysis on this side. Diag-
nosis: Meningeal inflammation of the lower part of the cord. Dry cups were applied over the lower part of the
* Page 707 of the Thiid Part of the Surgical Volume of this work.
OF THK SPINAL MEMP.RA>"ES. 847
spine daily: twenty fjrains of liromido and five grains of iodide of jiotassiuni wcio given tliree times daily, llo
leeoveied and was retnrned to duty Octolier 2l'. — Tiinur'n Lone Hospital, rhiladcJphia, Pa. [In(iuiry into the snbsc-
cjnent history of this man shows him treated for neuralgia, Jan. 12, 18t», to January 30, in the field hos|)ital at Point
of Rocks, Army of the James. Ho was returned to duty on the latter date. On May 21 he was received into liosjiital
at Fort Monroe, Va., on account of general debility, and was mustered out July 5. It is of interest to noti' that ho
was regarded as a malingerer when at Hampton hospital in May, 18G4.]
Case 4. — Private Thomas H. Reid, Co. I, MTlh Pa.; age 44; became paralysed while at Camp Crossman, Pliila-
delphia. and was sent to South street hospital March 2.S, 18G4. He was transferred to this hosjiital May 5 and fnr-
loughed July 20; but he became worse and was admitted to Clay hospital, I.ouisville, Ky., on the 28th. He improved,
and on August 8 went to his regiment in front of Atlanta, but as he was unable to do field duty he was i>laced on the
sick-list for a few days. After this he assisted in the hospital, and then acted as hospital steward of liafy K, 13th
N'. Y. On the 31st ho was transferred to the Artillery Brigade, 20tli Corps, Army of the Cumberland. His health
was variable — not so good in bad weather. While going on furlough early in January, 18G5, he was much exposed
to cold and wet weather on the stennuT from Hilton Head. Ho again became aSected with paralysis and, on arriv-
ing at Philadelphia, was sent to Uroad and Pine streets hospital, thence, January 21, to this hospital: General health
not much impaired: total loss of sensation in right foot, partial throughout remainder of right lower extremity;
partial loss of motion in same limb; muscular sensibility and irritability not much impaired; left lower extremity
but slightly affected; dnll pain in the lumbar region. Gave one-sixtieth of a grain of sulphate of atropia three
times a day; applied four wet cups to spine: dry tups to bo used daily. February 1; Stopped atropia: gave a tea-
spoonful three times a day of a solution of liromido of potassium in six ounces of syruji and water. 4tli : Applied lly-
blister six by eight inches. 15th: Sensation improving in left foot. Rejieated fly-blister: continued the bromiile.
May 1 ; Transferred to Invalid Corps because of partial paralysis of right leg. — Tunier's Lane EoKpital, I'hilndelpliiii, I'a.
Case 5.— Private Daniel E. Russell, Co. E, ITfltli X. Y.; age 24; enlisted in September, 18GI ; admitted Xovcm-
ber 30. He stated that about the middle of October, after exposure to excessive fatigue and cold, he was attacked
with violent fever and was unconscious for ten or twelve days. On regaining consciousness he had lost the u.se of his
legs. When admitted he was in fair condition excepting the paralysis; there was tenderness on pressure along the
entire spine. His condition remained unchanged during December: the innervation of the lower extremities did not
improve: the skin was without sensation; there was no pain or uneasiness other than an occasional pricking and
numb sensation in the thigh. During January, 1865, he complained of frequent headache and much jiain in the
groins and testicles, darting np the back; the appetite f\iiled and the muscles of the lower extremities became soft
and atrophied. In February the left arm and forearm became numb and stiti', but this afterwards in a measure disap-
peared. The patient gradually became ana'uiic. Counter-irritation was applied along the spine, stimulating friction
to the limbs and jiassive motion to the. joints; purgatives and alteratives were given, iodide of irou particularly: nux
vomica was also used, but cautiously, as it appeared to aggravate the spinal ox<;itemcut and pain ; anodynes and wine
were employed. He was discharged from service March 7. — Third Division Hospital, Jhxantlria, I'd.
Casic (i. — Private David Van Klceck, Co. M, 17th Pa. Cav.; age 33; was much exposed in the'winter of 18G2
while scouting and picketing. He felt occasional pains in the lumbar region, shooting down into the legs, and had
soreness of the muscles and sensitiveness of the skin. These attacks increased in severity and frequency until July,
1863. when, having been wet by rain while overheated, his lower limbs became paralysed. He was admitted as a case
of chronic rheunuvtism Sept. 11, 1864, from the Mower hospital, Philadelphia, Pa., where he had been under treat-
ment from Oct. 29, 18G3. Four months after his arrival at the Mower hospital he was able to walk a short distance
with a shullling gait. In March, 1864, he caught cold and had a relapse which confined him to the ward for three
months. On admission to this- — Turner's Lane — hospital he had pain in the back, tenderness over the lower lumbar
vertebne and a feeling of constriction around the body at the iliac crests; his legs were numb aud weak, but lu' was
able to walk slowly and unsteadily with the aid of a cane; he was unable to stand erect. Electro-nmgnetic irrita-
bility was impaired mostly in the tiiighs. A]iplied dry cnpsto the lumbar region. Furloughed November 3; returned
on the 24th. Discharged Feb. 17, 1865, because of iiartial paralysis. — Turners Lane Hospital , Philadelphia, i'a.
Case 7. — Private Thomas Do wdall, Co. C, 142d X. Y.; age 40; was admitted March 27, 1863, having been sufler-
ing for two nmnths from partial paraplegia consequent upon chronic myelitis of the lumbar portion of the spinal cord,
the result of exposure to cold and dampness. He had been treated in camp and in the Fairfax Seminary hospital.
He could not move about without the aid of crutches. His bowels were obstinately constipated and purgatives
only gave temporary relief. Iodide of potassium was fairly tried, but no benefit was derived from its administration.
Helladonna plaster was applied to the loins. A furlough of thirty days was granted and extended three times. Ho
was discharged without improvement October 28. — Central Park Hospital, Xew Torlc Citij.
Case 8. — Private John Molineaux, Co. F, 22d Pa. Cav.; age 50; became paralysed in ,Iune, 18G4, wliile sleeping
in the rain at night after a hard day's march. For two nujuths after this he was unable to stand; he used his arms,
however, the next day to pull himself np; he could feed himself, but could not cut his food. Admitted .July 3 to
hospital at Frederick, Md.,— transferred August 9 to Camden street hospital, Baltinjore, and Septemlier 27 to Had-
dington hospital, Philadelphia. Admitted on the 30th to this hospital: Diminished sensibility of right side of face
and of left arm and leg; no wasting or muscular contraction. Furloughed Xovember 3; returned 21st. Discharged
because of paralysis agitans Feb. 8, 1865.— r«nio'« Lane Hospital, Philadelphia, Pa.
Case 9.— Corp'l Abraham S. Butler, Co. I, 22d Pa. Cav.: age 24 ; was wounded in the calf of the left leg Oct. 6,
1863, but this left no subsequent impairment of sensation or motion. While on picket at Bolivar Heights, Va., Jan.
1, 18t>l, he was attacked with chills and was contined to bed for several days. He was admitted into this hospital
S4S CO>XtESTIOX axp ixflammatiox
Octulier 13, Imviiij: tliiriiis the iuterveiiiug months been nuder treatment in several hospitals. He comiilaiued of
constant dull headache, and was subject to choreic movements of the upper extremities which were aijjiravated by
exposure to cold; he had an aching and numbness throutrhout the body, and tenderness on pressure over the vertebral
spines from the tenth dorsal downward; his appetite was poor and he was att'ected with constipation and dysuria.
Ho Avas treated with dry cups and bromide of potassium. He was furlousihed in Feliruaiy and discharged April 15,
because of paralysis agitans and incipient phthisis. — Turner's Lane Sospitul, Philadelphia, Pa.
Cask 10.— Private Edward W. Gold, Co. F, 90th Pa. Vols.; age 33: enlisted July, 1863. In Xovember following
he was hurt by a mule in the small of the back, and passed blood per rectum freely for two days after the injury: but
at the end of two weeks he was returned to duty. Soon after this he woke one night chilled and wet by a leak in
the roof of his quarters. He was contiued to bed for several days with loss of power but not of sensation in his legs.
Gradually power returned and he became able to walk with aid. lu February, 1864, he had an abscess in his right
hand, during the progress of which the arm became swollen, and after the closure of the wound made for the dis-
charge of matter the lingers continued flexed. At this time his legs again became weak, and ho was sent to Lincoln
hospital, Washington. He was exposed to cold in the cars for eleven hours and to a heavy rain-shower during his
conveyance in an ambulance to the hospital. For some time after admission his condition did not iminove, but later
he began to recover power over his legs. He was transferred to Satterleo hospital, Philadelphia, on Jlay 3. — diag-
nosis: nervous deV)ility, and on the 31st to Turner's Lane. The records of the latter hospital report the patient on
July 0 as having frequent pains in the small of his back and cramps below the knees, chiefly at night : sensation was
not materially altered, but the legs and arms were tremulous and powerless, the right arm lieiug in addition consid-
erably atrophied. On August 3 it was stated that the patient was able to walk for the tirst time since falling into this
paralytic condition. Ou November 21 he was discharged because of paralysis agitans and paraplegia.
Cask 11.— Serg't James T. Taylor, Co. H, 99th Pa.; age 36: enlisted July 1, 1861, and did duty until a few days
alter the battle of Chancellorsville, in May, 1863, when he was found lying in his tent with his lower limbs paralysed.
A dark spot, seemingly a contusion, extended from the left knee half way up the thigh. He was treated in regimen-
tal hospital, afterwards in the division hospital at Potomac Creek, Va.: from this he w as transferred to Fairfax Sem-
inary, Alexandria. Va., where, on his arrival, June 14. his case was regarded as one of chronic rheumatism. He was
furloughed July 16, and shortly after his return was transferred, September 23, to Mower hospital, Philadelphia,
where he was regarded as suffering from nervous debility. Quinine with extracts of valerian and hyoseyamus was
prescribed, and on October 1 he was again furloughed. Ou his return he was placed on light duty, and on March 1,
1.>*C4, was sent to his regiment: but on April 21 he re-appeared as a patient at the Lincoln hospital, Washington. —
diagnosis: paralysis agitans. Ho was transferred to South street hospital, Philadelphia. May o, — diagnosis: chorea:
and ou July 25 was discharged because of expiration of service and tremor after paralysis.
Case 12. — Private J. .1. Sherman, Co. I, lOoth Pa., became affected with chills, nausea and vomiting at the si^ge
of Yorktown, but did duty till after the battle of Fair Oaks, when he was sent to hosi)ital suffering from paralysis of
the lower extremities, the right upper extremity becoming shortly afterwards affected. He attributed his paralysis
to the wind of a shell w hich passed near his spine, tearing his clothing but leaving no mark on the skin. He was
taken to Long Island College hospital in June. 1862. where he became aphonic, and for a time lost control of the
sphincters. He was admitted into this hospital Jan. 23, 1863: Loss of motion and sensation in lower extremities;
could move the toes, and after much effort bend and raise the knees: slight power over the movements of the fingers
of the right hand bnt none over those of the other parts of the limb : left upper extremity unaffected ; spoke in a fine
whisper with little effort: moderate tenderness over the lumbar vertebr,a> and between the shoulders; pulse feeble
but of normal rate; heart -sonnds natural; no pulmonic symptoms: appetite poor, but no emaciation: countenance
natural ; had control of abdominal muscles: no erections or seminal emissions after inception of paralysis: no response
to irritation to soles of feet. He had been rejieatedly blistered and variously medicated. Gave citrate of iron and
quinine: porter: good diet. Frictions were applied to the general surface, and the patient was made to sit up part
of the day and to exercise the muscles. He was discharged September 23, on account of paralysis. — Ladies' Some
Hospital, Xcir York Citi).
Case 13. — Private John C. Fleming, Co. I, 6th Vt,, was admitted Sept. 10, 1863, at 10 a. m. At daylight he had
been found lying on the road near a dramshop. Motion and sensation were lost below the level of the umbilicus,
but the circulation was good: the abdomen was slightly tense, and there was a slight ridge across the back over the
twelfth dorsal vertebr.T?, but no abrasion, discoloration or other mark of injury; there were no head symptoms.
The patient spoke naturally but seemed anxious; he complained of tenderness over the epigastrium, pain in the
back and nausea; he stated that he had drunk freely of brandy ou the previous day and had been seized with a
sudden faintness on emerging from the dramshop, after whicli he had no recollection of anything until picked up in
the morning. He insisted that he had not been drunk. Ipecacuanha was given and the patient vomited freely; the
catheter was introduced and five pints of pale urine removed. This gave relief and the sense of feeling returned,
but the paralysis of motion continued. A stimulating embrocation was applied to the spine without benefit. Attempts
to move the patient occasioned excessive pain. At 9 r. M. there was much tympanites and the pain along the spine
persisted. The catheter was used, and an ounce of oil given. He rested fairly during the night, but was no better
next morning : the tympanites had increased and become painful. An enema of soap with warm water failed to give
relief: three drops of croton-oil were then administered; the catheter brought away high-colored uriue. At noon the
patient was anxious; had pain in his head and could not bear the weight of the bedclotliing on his abdomen: his
bowels had not been moved. A strong turpentine stupe was applied to the abdomen, followed shortly by an enema
of oil of turpentine, a tablespoonful in a pint of warm water. In a little while very copious stools were passed with
OF THE SPINAL MEMBRAXES. 849
almost iostaDt relief. At 3 p. m. he asked for food for tbe first time. There was bat little pain ; the bladder was still
paralysed. Forty drops of sweet spirit of nitre were given. On the 12th he was mnch easier: the urine drawn off
was natural in appearance; sensation in the lower extremities was normal, but the motor paralysis continued; there
was no pain along the spine except when he was moved. He was transferred to hospital, liurlington, Vt., being car-
ried en roult on a mattress. He died October 2. — lUyimenlal Sonjiilal, 6/A ft., Kingilon, X T.
Cases 14, 1.5 and 16. — In making this quarterly report I have to note three cases which will be regarded with
nnnsnal interest. One of these died: the other two recovered. All belonged to the 42d Ohio. On Dec. 11, 1861,
privates Levi I). Smith, Co. 0, age IH: Jas. O. Hum|ihrey, Co. H, age 20, and J. H. .Schneider, Co. IS, age 17, were
admitted into i>ost hospital in the following condition : They all had opisthotonos, affecting the muscles of the back
and loins : but those of the neck and face were not affected. The eyes were quite dry and red, the pupils fully dilated
and nnaffected by light. They took no notice of things around them, seeming to be in a deep sleep. Respiration
was increased in frequency but was otherwise natural. The pulse was quick and frequent, from 112 to 128 per minnte.
The heat of the heail and body was atjout natnral ; feet cool though not cold. A blister, three by eight inches, was
applied to the neck and back, with sinapisms to the feet and legs, and the nurse was instructed to give each a little
brandy and water from time to time. From the regimental surgeon and the comr.idcs of the men the following his-
tory was received: They were all put on guard at 10 o'clock on the morning of the 12th, and stood the usual time
except on the last relief on the morning of the 1.3th, when they were neglected and allowed to stand from 8 to 12
o'clock. When they were relieved from guard they complained of pain in the bowels and head, for which their sur-
geon gave to each a small dose of sulphate of magnesia, to be followed, after the bowels were moved, by five grains
of Dover's powder and one of calomel. Two powders were given to each man, with the direction that if the first
did not quiet them within two hours the second was to be cakcn. The salt operated freely, after which the powders
were taken, each being vomited soon after its administration. In the latter part of the night they slept quite
soundly, their comrades said, and in tbe morning were unconscions. After hearing this account I was at a loss to
know what to do. Thinking that the heart's action should be controlled to relieve the hea<l and Inngs, I ordered
tincture of veratrum viride, two drops e%-ery two hours, until the pulse was reduced to 70 or 80 Ijeats per minute. At
the same time a strong liniment containing turpentine was applied to the back and bowels. The pulse came down,
after the second dose of veratrum, to tetween 60 and 70 beats i»er minute, and the respiration l>ecame natural and
full. Nine hours after they came in one of the patients. Smith, spoke for the first time, complaining that something
was biting his neck and that he wanted to make water. He passed urine freely, which, with the exception of slight
redness, was of healthy appearance. The second, Humiihrey, waked up with a similar request about two hours after
tbe first. The third. Schneider, was examined, but finding no accumulation in the bladder I thought it safe to leave
him until later without using the catheter. At midnight he became conscious, making the same request as the other
two, and jiassing water freely. On the morning of the 1.5lh they were all conscious, suffering intense pain all over,
sometimes complaining of pain in the back, sometimes in the head and bowels. They were very restless, throwing
themselves from side to side on the beds, turning over on their faces and sometimes resting on their hands and knees,
hut were prevented from resting on their backs by opisthotonic spasms. A i»rofuse secretion from the eyes, nose and
mouth commenced on the first night, and was of so acrid a character as to cause redness and vesication of the nose,
lips and other parts of the face, and also the hands when wet with it. To relieve their safTering I put them on byos-
cyamns, but receiving no benefit from it, I ordered morphine in small doses, fre^jnently repealed, until they rested
<-.isT, when the time Ijet ween the doses was extended. On the evening of the second day quinia, brandy and beef-tea
were added to tlieir treatment. This was continued for four days, during which they all apparently improved. Two
of the cases were returned to duty three weeks after their admission. The third, .Schneider, whose symptoms through-
out were of considerable severity, died on Peceml>er 2.5. His sufferings resembled those that follow violent and con-
tinned muscular action. — Honpital Hexords, Camp Chaiie, Ohio, JUarch 31, 1862. [This rej>ort is unsigned ; .Surgeon L. C.
Buowy, 85th Ohio Vols., appears, from other parts of the record, to have been in charge at the time.]
n.— OPHTHALMIA.
Inflammations of tbe eye were reported prior to June .30, 1862, under the Leadings
Op/d/udmia and Iritis; subsequent to that date the term Conjunctivitis was substituted for
the former. During the five and one-sixth years 8,904 cases of ophthalmia and 6-5,739
of conjunctivitis were reported among the white troops, making a total of 74,643 cases,
included among which were probably many cases of sclerotic and corneal inflammations,
a3 1,463 cases — 1.96 per cent, of the whole number, or 1 out of every 51 cases — were dis-
charged as unfit for military service; the average annual sick-rate was 33.4 cases per thou-
sand men. These inflammations of the eye were somewhat less frequent among the colored
troops, the whole number having amounted to 5,153 cases, or to an average annual rate of
28.1 per thousand. This exceptional infrequency of disease among the colored troops is
explained by two considerations: Ophthalmia was not occasioned in a notable degree by the
ordinary exposures to cold and wet incident to camp life and active service, but was the
Med. Hist., Pt. Ill— 107
850 OPHTHALMIA.
result of special causative conditions existing consjjicuously in certain localities. Moreover,
these localities were held by a larger proportion of the white than of the black troops. Oph-
thalmia prevailed to a much greater extent among the troops serving on the Gulf Coast than
among those operating against Riclimond. During the year ending June 30, 1865, 1,198
cases of conjunctivitis were reported among the 80,982 white troops constituting the Army
of the Potomac, while 2,158 cases are said to have occurred among the 45,629 white soldiers
serving in the Department of the Gulf. The prevalence in the latter command was generallv
attributed to sun-glare and sandy particles in the atmosphere of stations on the coast line.
Colored troops operated in this department, but the majority of tho.se that contributed to the
statistics held the line of the Mississippi river and were protected from the exposure.? to whicli
ophthalmia was attributed.
During the four years, July 1, 1861, to June 30, 1865, the average annual rate of prev-
alence of ophthalmia among white troops was, in the Arm}' of the Potomac 17.5 per
thousand of strength, in the Department of the Gulf 37.0, in the Department of 'Sew Mexico
47.5, and in the Department of the Northwest 85.0 — the rate for the whole army having
been, as already stated, 33.4 per thousand. From these rates something may be learned of
the localities specially affected. The Army of the Potomac suffered lightly; the other com-
mands mentioned had rates considerably higher than the average.
Perhaps the same causes operated in all these localities, but were more intense in some
than in others. In Virginia the prominent causes were, in summer, the sun-glare, heat, and
especially the clouds of dust that in dry weather enveloped the marching columns; and in
winter, draughts in imperfectly constructed huts and foul air in those more effectually chinked,
with tlie acrid smoke of the wood-fire, which, in many huts, was a constant constituent of
the atmosphere, and the snow-glare when the soldier was exposed on duty. But tlie attacks
were usually light, and subsided after a short seclusion in hospital from the harmful influences,
unless the case was complicated by some constitutional morbid proclivity.
On the Gulf and Southern portion of our Atlantic seaboard the glare of the sun on the
white sand of the coral formations, and particularly the dust raised from their surface by
the wind, were considered the chief causes of the prevalence of ophthalmia among the troops
stationed along these lines. Surgeon B. K. Towle, 30th Mass., writing from Ship Island,
Miss., in April, 1862, and alluding to the deep shifting sand of -the island, says:
The glare of the sun on the white sand does not seem to induce ophthalmia, as I supposed it would. Indeed,
I think the most of the injury to the eyes from the sand is mechanical — as, when the wind blows, one's eyes, if exposed,
are literally filled with it."
Axs't Surgeon Cyrus Powers, 15th X. T., Fort Pickens, Flu., Jan. 17, 1862. t— The island— Santa Rosa— is nearly
or quite forty miles long (itsjvestern extremity being about forty miles southeast of Mobile > and is entirely comi)osed
of intensely white sand, appearing at a little distance as if covered with salt or snow. When the sun shines the
reflected light from the intensely w hite surface is almost intolerable, giving rise to a peculiar and obstinate ophthalmia,
resulting, in some instances, in total blindness. Its onset is sudden and is characterized by great intolerance to
light and deep-seated pain, with but little external inflammation. Four men of our regiment are already under treat-
ment, although, in fact, treatment seems to have but little control over the disease. Exclusiou of light and cold-water
compresses to the eyes and temples, with low diet, seem to be somewhat beneficial. Several soldiers of the Xew
York Sixth, who came here last May, have been sent home nearly or quite blind.
Suryeon W. W. Brown. 7lh X. B., St. Atigufttine, Fla., May 1, 1863. — The white substauce of which these islands
are formed is very disagreeable and injurious to the eyes. The sand forming the surface does not contain a particle
of silex; it is entirely the debris of the coral formation. Several cases of amaurosis, complete and partial, occurred
among oxir men while at Fort Jeli'erson ; also many cases of ophthalmia more or less severe. As the latitude of the
fort is about 24° north, the sun is nearly vertical at the summer solstice, and the variation not very great during
the year. This renders the reflection from so white a substance intensely disagreeable and painful to the eyes.
• Boslon Medical and Surgical Jmintat, Vol. LX VI, 1862, p. 300. t See Journal last cited, page 30.
OPHTHALMIA. 851
Siogton H. IIOVET, iGth X. Y., Ti/htc Iiltinil, (la., Dec. 31, 1861. — Our prevailini; (li.sea.sc.s were fevers, tlisea.sesof
the digestive ami re.spiratory sy!item,rlioninati.sina!ul |)Uli';.;mi)ii, also severe cases ot'ophlhaliiiia.of wliicli the greater
part occurred at Hilton Hiad, where the lieulth ofthe troops was the worst. The days were hot, the lushts wet and
foggy, the ground sandy and of such a (luality that the dust covered and penetrated everything. To this agency
I ascribe principally the cases of bronchitis and ophthalmia.
Ophthalmia was also frequently developed on the sage-brush mesas of the Western
Territories, where it was attributed to sinulur causes.
Jus'l Surgeon J. C. C. Do\v?iiSG,U. S. A., Fori rnio)i,X. Mex., March 31, 18t)3.— Opiithalniia is occasionally troulile-
sonie: the high winds which often prevail are loaded with dust and fine sand, and are highly irritating to the con-
junctival nuicous niembraue. Repeated attacks often result in pernumeut thickening of the conjunctiva.
Jas't Surgeon Charles C. Furi.ey, 2d Cal. Cav., Fort Churchill, Xev., Dec. 31, 1862. — Ophthalmia, generally more
or less common, may he considered duo to the alkalinity ofthe water used by the men for their ablutions and to tho
coMuuinuted particles of dust which are ever flying through the air.
Tn the northwest the snow-glare takes the place of that from sandy or arid levels.
Ass't t^urgeon W. H. Gardner, U. S. A., has given an account of the iiernicious effects of
ivflected light on the eyes as observed by him on these bleak prairie regions.'''
The disease is most common in the early part of spring, when the snow is beginning to melt, for then the water
formed liy the melting snow fills up the irr?gularities of the snowy surface and makes a more perfect mirror. The
grade of the disease accords with the amount of the exposure and the length of time the irritation is kept up, and
may occur as an ephemeral conjunctivitis, subsiiliug in a few hours after the removal of the cause: or as a violent
panophthalmitis, destroying the eye at once or leaving a condition which secondarily does so. A troop of Minnesota
cavalry marched in tho spring of 186G from Kort Abercrombie, Dak., to Fort Snelling, to be mustered out of service.
When theirdestination v.as reached there were not ten men in tho troo]) — which was full — who were not more or less
snow-blind. In most ofthe cases tho ati'ection was a mild conjunctivitis; but in several there was ulceration of the
cornea and in others panophthalmitis, which doubtless permanently impaired tho eyesight. Whether mild or severe,
the dise.ise was always exceedingly painful and always prone to cause the destruction of the eye. The cheniosed
conjunctiva iuterfeies with tho nutrition of the cornea and tends to its tilceratiou. This may heal in time, leaving
an opaque spot to mark its site, or prolapse of the iris may occur through the jierforated cornea. If the irritation of
the retina he of long contiiumnce all the tissues of the eye may become involved at once, causing loss of sight. Dr.
G.iKDSKi! points out that the lires of men travelling on the plains in the winter time depend ou the organ of vision
lieing intact. The records of the posts in the northwest show some lives lost every winter by men l)ecoming snow-
blind, losing their way and i>erishing in the snow. He advises prevention by the use of goggles, as practised by the
Indians, and suggests a hard-rubber eye-cover with a small oval opening in the axis of vision.
The persistence of ophthalmia in individual cases occasionally depended on a rheumatic
or syphilitic taint. Its j^revalence or persistence in a command was sometimes ascribed to
influences affecting the constitution. These v/ere generally malarial. Surgeon John W.
Trader, 1st Mo. Cav., cured his worst cases in a short time after resorting to quinincf
Indeed, this remedy was frequently tried when local treatraeut proved inefficient. Medical
Inspector F. H. Hamilton attributed the eye inflammations tliat prevailed in two Ohio
regiments to the existence of the scorbutic taint.
Surgeon A. W. McCl.fRE, ith Iowa Cav., near Helena, Arl:, Oet.l, 1862. — We have had a large number of cases
of ophthalmia, many of which have been troublesome to treat in camp. All, however, have terminated favorably
except one case, in which there is left a consideralile corneal opacity. Our treatment has been mainly quinine, oiiium,
calomel, and the local application of an infusion of opium with acetate of lead or sulphate of zinc.
^[edi^lll Inspector V. H. Hamilton, U. S. A., Xu-thriUc, Tinn., June 1, 1863. — There was but little sickness among
the men of the ITlst ami 83d Ohio at Dover, near Fort Donelson, and no well defined case of scurvy; but there were
about sixty cases of ophthalmia. This disease proved very obstinate and continued to spread notwithstanding the
isolation of the cases and the adoption of other prophylactic means. I ascribed it to a want of vegetable food.
The following cases are suljmitted from the records:
Case 1. — Conjuncliritis. — Private Robert Constance, Co. H, 2d Colo. Cav., was admitted .\ng. 8, 1864, with acute
conjunctivitis. He had taken four compound cathartic pills and applied mild red precipitate ointment without benefit.
Wet cups were used on each temple at once, and repeated in the evening, with warm-water dressings to the eyes. An
active cathartic was given. The soldier was returned to duty on the 28th. — Kansas City Hospital, Mo.
Case 2. — Conjuncticilis with superftcial ulceration of the cornea. — Private Jacob Ecker, Co. A, 47th Pa.; age 40;
*.imrricnn Joiinml of Ihf Medit>il Stieitcff, Vol. LXI, 1871. p. 334.
t lit- ipiyo llin-o cmiiis of ^nlplinti- t.f '{uiuiiK- anil oiK'-fourtli uf a grain of sulphate of morphia, or one grain of opium, every tiiree hours. Local
tnatmelit was restrictnl to thi- u>e of a <-..llyriinn of chloride of *i<Klinm or aretate of lead. — tit. Imu'm Mt;tt. and Siirij. Jour., Vol. Ill, 18G6, p. 120.
852 OPHTHALMIA.
■n-as nniiiitted to ward L of this hospital Xov. 24. 1863. He had been for some months affected with conjunctivitis.
There was sliglit pain in the eye and a feeling of pressure: at times, also, there was a pricking and burning sensa-
tion and a roughness as if sand was under the upper lid ; there Avas likewise a feeling of stiffness owing to heaviness
of the lids. Each sclerotic was covered with an irregular light-scarlet vascular network which was freely movable;
the semilunar membrane was loose and much swollen ; the conjunctival and Meibomian secretions much increased.
The I'eneral health of the i)atient was good. An eye-wash of sixteen grains of lapis diviuus,* thirty drops of lauda-
num, four drops of solution of acetate of lead and four ounces of distilled water was applied. 27th : The follicular secre-
tion is gray and tilameutous. 28th : The circumference of the cornea is dim. 2ilth : Epiphora and some photophobia.
30th: The follicular secretion hardens into scabs during sleep and excoriates the edges of the lids. For the eye-wash
was substituted an ointment of four grains of alcoholized lapis divinus, fifteen drops of wine of opium, one drachm
of lard and half a drachm of camphor — a piece the size of two pinheads was put into each eye morning and evening.
December 1: Some dimness of sight, and chromopsia in consequence of slimy deposits forming thin layers on the
cornea. 2d: The patient becomes worse every evening ; this is supposed to be owing to exposure to artificial light.
He becomes worse also after hearty meals. 3d : Some small superficial abrasions on each cornea. 4th : The left cornea
shows a facet, the result of a relaxation, and a softening eliminating process in the corneal epithelium. 6th : The
patient is improving rapidly. The cornea became clear and the discbarge cea.sed liy the 13th. He was returned to
duty on the 22d. — Suttcylcc Hospital, Philadelphia, Pa.
Case 3. — Conjunctivilis with tdccratioii of the cornea, jirof use discharge and photophohia.- — Private AVilliam Plant,
Co. C, 47th Pa.; age 37; while on duty with his regiment at Key West. Fla., in March, 1863, was attacked with inflam-
mation of the left eye. This subsided partially after two days ; but four days later the right eye became affected. The
disease persisting, the patient was furloughed August t1. On his return, November 20, he was sent to hospital at Har-
risburg, Pa.; thence to York, Pa., December 10, and thence to this hospital March 2, 1864: Much debilitated; catarrhal
ophthalmia; ulceration of cornea ; excessive purulent discharge ; photophobia. Atropine drops; a diluted ointment
of red oxide of mercury to the lids; a solution of borax as a collyrium ; a teaspoonful every two hours of a solution
of one drachm of muriate of ammonia in two ounces each of water and syrup. He improved slowly: the discharge
and iihotophobia gradually diminished. He was transferred to Harrisburg, September 7. for muster out on the expira-
tion of his term of service. — Sattcrlee Hospital, I'hiladelphia, Pa.
Case 4. — Conjunctiritis icith opacity of the cornea; unsuccessful operation for artificial pupil. — Private Charles Hend-
ricks, Co. B, 16th Jlich.; age 44: caught a severe cold in March. 1864, while on duty with his regimeut at Grant Station,
Va. He was admitted from Lincoln hospital, Washington, D. C, April 12. with Ijoth corne:e ulcerated, excessive puru-
lent discharge and intense photophobia. Borax wash and atropine drops were used, with cod-liver oil internally.
July 1: Conjunctivitis much diminished. 15th: Right cornea tilled with lymph; left similarly affected except at its
margin. August 1: Infiamniat ion nearly subsided; corneas somewhat clearer; patient can see motion of hand between
him and the window, but cannot count the fingers. December 1 : An operation for an artificial pupil was successfully
performed on the upper and outer aspect of the left eye ; the new pupil was perfectly clear, but the vitreous humor
and choroid were so deranged that the jiatient was unable to count the fingers. All treatment was discontinued Feb. 1,
1865, and on March 2 the soldier received his discharge papers on account of total loss of sight from catarrhal ophthal-
mia.— Satierlec Ho.y)ilal, PhiU(delphia, Pa.
Case 5. — Flceration of the cornea ; jterforation ; albugo. — Private Thomas Burgess, Co. K, 183d Pa.; age 18; was
admitted Sept. 27, 1864, from Summit Hou.se. Philadelphia, where he had been under treatment for a gunshot wound
of the great toe. His right eye was Inflamed and the cornea ulcerated. A fly blister was applied behind the ear, a
saline purge was given, atropine solution dropped into the eye and borax and laudanum used as an eye-wash; a
green shade was w^orn and a screen placed around the patient's bed; foot-bath of salt and vinegar; extra diet. On
October 1 the cornea became perforated, but after this improvement was rapid. Cod-liver oil and porter were used.
In January, 181U. the eye appeared well but for the albugo; it was, however, sensitive and irritable. All treatment
was stopped on Ajiril G, and the soldier was placed on fatigue duty. He was discharged May 16, under General
Orders, A. G. O., dated May 3, 1S65.— Sattcrlee Hospital, Philadeljihia, Pti.
Case 6. — Conjunctiritis nith subsequent gonorrhnal infection, ending in loss of sight. — Private Harrison Sovocool,
Co. F, lOSlth N. Y.; age 21 ; was admitted Jlay 5. 1864, from Campbell hosjiital. Washington. D. C, with an inllannna-
tion of the eyelids. A collyrium of alum was used three times a day, and an ointment of oxide of mercury applied to
the edges of the lids at bedtime. He improved and was furloughed June 2. He returned on the 24th with gonor-
xhcea, and the eyes, especially the left, considerably inflamed. A purgative of Epsom salt was given, eight leeches
were applied to the temple, a green shade was used over the eyes and a screen around the jiatient's bed; foot-baths;
low diet. Two nurses were specially detailed to sjionge the eyes with warm water and alum solution and to ensure
cleanliness. The discharge continued profuse; the corneal surfaces became clouded and eroded. On July 5 nitrate
of silver solution was dropped into the eyes every three hours ; calomel was given. By the 10th there was much
improvement, the gonorrhtva meanwhile having been cured. A camphorated solution of sulphate of copper was used
as an eye-wash ; tartar emetic ointment was applied to the nape of the neck. On the 15th there was a severe relapse;
the anterior chamliers became filled with purulent matter, the corner infiltrated, the irides discolored and the dis-
charge from the eyes almost unmanageable. A dozen Eurojiean leeches were applied around the orbits, and all local
treatment was stopped except the instillation of atropine and frictions to the forehead with an ointment of the white
precipitate of mercury. Blisters were applied behind the ears on the 20th, but there was not much improvement
until the 27th. He was able to walk about on August 5, when he was taking quinine and iron and using borax washes
♦Sulphate of copper, alum and nitmte of potash, heated to watery fusion with camphor, and subsequeutlj- congealed.
OPHTHALMIA.
853
and diluted citrine ointment. He was discharged Xovember 29 because of nearly total blindness.— Satterlee Honji'lal,
Philadelphia, Pa.
C.VSE 7. — Conjiinclinliti irilh perforation of the cornea and prolapse of the trig. — Private William TrunibOTer.Co. G,
112tli Pa.; age 19: became alH-cted in Fcbniarj-. 18GI, with pain, swelling, loss of vision and pnnileut di.scliarge from
the riglit eye. He was admitted Ai)ril 11 to Turner's Lane. Philadelphia: General health good; right eye much
swollen; profuse watery and purulent discharge; prominent chemosis; cornea slightly opa<iue: .pain; loss of vision.
Scarified conjunctiva after clearing away the discharges; applied nitrate of silver to the eyea; fly-blister to the tem-
ple; gave four compound cathartic pills. 18th: Less chemosis. Applied nitrate of silver in solution twice a day.
20th: Slight ulceration of cornea: chemosis increased. Scarified conjuncti\-a. 21st: Ulceration and opacity increased;
swelling and discharge subsiding. Gave porter and sulphate of qninia ; repeated fly-blister. 25th: Chemosis relieved
and discharge much abated. 2Gth: Transferred to this hospital. The cornea was ulcerated, the membrane of Des-
cenu-t ruptured, the iris prolapsed, and there was a constant oozing of the a<iueous humor; the patient complained of
severe pain in the affected side of the head. Atropine was used; the prolapsus was touched every second day with
lapis mitigatus and the eye cleaned occasionally with a borax wash; full diet was prescribed. May 6: Much better.
A]iplied an ointment of white oxide of mercury to the lids; gave two grains each of sulphate of iron and quinine
three times a day. 0th: Prolapsed iris inflamed. 20th: Stopped previous treatment but continued quinine an<l iron.
June 1: Prolapsus much reduced in size. 9th: Corneal opening closed by plastic lymph. 13th: On light duty in
ward. July 8: General health good. Feb. 6, 186.5: Discharged from service beeaufc of total loss of vision of right
eye and partial loss of left. — Satterlee Hoipital, Philadelphia, Pa.
C.KSK 8. — CAionic o»;i/Hno/iri(i(i.— Private Francis M. Slagle, Co. H, 2d lU. An y, « :i> admitted .June 9, 1863, from
St. Louis, Mo. He stated that he had been unable to do duty on account of his eyes since September, 1862. The
principal symptoms were congestion and jdiotophobia. Solution of nitrate of silver was used, with quinine, iron,
cod-liver oil and full diet. As his condition did not improve he was discharged Feb. 3, 1864. — Hospital, Qiiimnj, III.
C.\SE 9.— Chronic oon/iitic^iri/i*.— Private Cyrus Wright, Co. E, 83d Ul.; age 42; was attacked with ophthalmia
■ at Fort Donelson, Tenn., in May, 1863, and has done no duty since then. On admission, September 18, his eyes were
painful and the lids granular, but his general health was good. Alteratives and tonics were employed, and a nutri-
tious diet with various local applications, but without benefit. He was discharged Feb. 25, IS&l.—IIonpital, Quiucy, III.
Case 10. — T'/ironic coii_/««f^iri/i«.— Private Anthony McGowan, Co. F, 12th V. R. Corps; admitted Aug. 23, 1861,
with conjunctivitis of more than a year's duration. The conjunctival vessels were greatly enlarged, the left cornea
opaque and much thickened and vision nearly destroyed; the right eye similarly though not so badly aifccted ; both
very sensitive to light and constantly filled with tears and mucus. Applied weak solutions of nitrate of silver, cold
water, morphine, belladonna. The last allayed the pain somewhat, but only for a time. Cupping and blistering
produced temporary benefit. Constipation required the frequent use of cathartics. Discharged from service Sep-
tember 27. — Third Dicinion Hospital, Alexandria, Va.
Case Xl.— Chronic cfliy«nc/iri/i>.— Capt. Horace Scott, 3d Ky. Cav.; age 26: was admitted from Officers' hospital,
Nashville, Xov. 22, 1864, having had conjunctivitis for fifteen months, although doing duty except during the last
eleven days. The lids were granular, their margins thickened and the ocular conjunctiva much inflamed. Improve-
ment followed the use of iodine around the orbit and an eye-wash of chloride of sodium. He was returned to duty
Jan. 17, 1865. — Officers' Honpital, Loaiisville. Ky.
m.— SUNSTROKE.
Sunstroke is charged by the Monthly Reports with having occasioned 6,617 cases of
eickness among the white troop.s during the five and one-sixth years; this is equal to an
average annual rate of 3 per thousand of strength. Four per cent, of the cases were fatal,
the deaths having numbered 261. Among the colored troops, 583 cases with 58 deaths
were reported. The average annual rate was, as among the white troops, 3 per thousand;
but 10 per cent, of the cases ended fatally. Had there been similar exposures on tlie part
of the white and colored troops the statistics would have indicated an equal susceptibility to
the causes of sunstroke, but the numerical records give no information concerning the con-
ditions associated with their facts. There appears to have been no recorded instance of the
same march made by white and colored commands under the same dangerous conditions
quoad sunstroke. Hence the inferences from the statistics are not precise. But the evidence
establishes the liability of the colored man to suffer from the causes of sunstroke, and his
greater tendency to death when prostrated by this as by most other serious maladies.
The causes of sunstroke operated chiefly during the months of ^lay, June, July and
August. These months were credited with 92 per cent, of the whole number of cases, the
854
SUNSTROKE.
proportion of each in the order named having been, respectively, 17.2, 21.4, 31.4 and 22.0
per cent, of the totah But these results depended less upon the temperature of the months
than upon other circumstances. The temperature of September, during the years of the war,
was considerably higher than that of May and nearly as high as that of June, yet its pro-
portion of cases of sunstroke was small. The tempei'ature of August was somewhat higher
than that of July, but its proportion of cases was much smaller.*
Some of our armies suflfered more from sunstroke than others. The Army of the Poto-
mac was specially subject: In June, 1863, although constituting only 18.2 per cent, of tlie
strength of the commands that rendered the reports, it furnished 58 per cent, of the cases;
in May, 1864, when its ranks contained 18.0 per cent, of the strength of our armies, it fur-
nished 54 per cent, of the cases; in June of the same year, with 16.0 per cent, of the strength,
it yielded 38 per cent, of the cases, and in August, with only 9.9 per cent, of the strength,
it gave a little over one-third, 33.4 per cent, of the cases. In contrast with this the troops
operating in the Department of the Cumberland and Tennessee had these percentages reversed :
In June, 1863, they furnished only 17.5 per cent, of the cases while constituting 43 per cent,
of the military strength; in May, 1864, they reported 14.9 per cent, of the cases from 33.3
per cent, of the strength, and in August 11.6 from 39.1 per cent.
Sunstroke seldom visited our camps; it seized on its victims while on the march or
engaged in laborious field work. Occasionally nine-tenths of the monthly aggregate of cases
that occurred in a command were the result of one day's long or forced march. Fatigue
was as much an element in the causation of these cases as exposure to the sun. In fact,
the majority of the cases reported as sunstroke were tlie result of heat, over-exertion and
an insufficient water-supply. They were a combination of exhaustion with its syncopic
tendency, and of an abnormal quality of the blood, manifesting itself by a tendency to stasis,
particularly in the lungs or brain. Clinically this was shown by the syncopic character of the
attack and the non-suppression of the heat-reducing function of the skin, as manifested by
the moisture which bedewed its surface. Recovery in these cases was speedy and complete
when the conditions were favorable. The removal of the belts and burdens of the soldier,
rest in the recumbent position, protection from the heat and stimulants and water as recjuired,
generally sufficed to re-establish his natural powers.
ISTevertheless, in most of these cases of exhaustion there existed to some extent a super-
heating of the blood which rendered them proportionately dangerous. In hot weather the
extra heat develo^jed within the system by the toilsome efforts of a hurried march requires
to be dissipated to preserve the normal temperature of the body. Harm will ensue if any
cause disturl^ the equilibrium between the production and dissipation of the animal heat.
Nature preserves the normal, when the tendency is to an increase, by an increased activity
of cutaneous and pulmonary exhalation. Any interference with these cooling processes
induces a superheating of the system, which, on reaching a certain degree, becomes mani-
* The statements in the tost may be verified by referring to the following mean of temperattivo observations taken at 3 p. m. during the months
and years stated, calculated from the annual volumes of the Astronomical and Meteorological Observations of the Naval Observtitory^ Washington, D. C:
April.
May.
Juno.
July.
August.
Sept.
1861
62. 63
.')6. 67
54. 92
57. 2S
63.73
70.96
71.01
74.11
75.58
71.93
82.57
75.31
77.35
80.54
82,69
S3. S3
79. 95
80.97
87. 62
82.96
83.64
84.01
87. M
85.93
82.40
79. ,50
78.24 '
75.14
74. nil
S3. 52
1S62
1S63
1.S64 - "
1865
Moan__
59.05
72.72
70.69
83.07
84.72
78.08
suxstf.okp:. 855
fested by urgent symptoms, as a tlionnic lover or sunstroke. Free play for the lungs and a
light body-covering are necessary to the perfect operation of the heat-dissipating processes.
Unfortunately the load carried by the soldier during the marches of the civil war not only
interfered with pulmonary expansion, but so covered the surface of his body as to prevent
its participation in the process of evaporation. His blanket, rolled into a long cylinder, was
slung from one shoulder to the opposite hip; his canteen and haversack were similarl}- sus-
pended by straps from the opposite shoulder, while a waist-belt kept the cartridge-box in
position on his loins and the bayonet-scabbard by his side. Not a cooling evaporation, but
a profuse loss of water in bulk from the system \\'as the result of exercise under this heavy
accoutrement, even though the air might be greedy of moisture. While perspiring profusely
on a hot march the laboring foot soldier instinctively bared his breast to the atmosphere
and exposed his arms to increase the small extent of evaporating surfiice. Many medical
observers have noted the prevalence of sunstroke in a warm moist atmosphere, which inter-
feres with evaporation from the surface and permits a loss of water from the system without
a commensurate dissipation of heat. But even in a dry atmosphere the accoutrements of
our troops prevented evaporation by keeping their body-covering in close contact with the
skin. Again, the equilibrium between the production and dissipation of heat may be
destroyed by a want of water in the system. When the water-supply at the command of
the soldier was adequate, the superheating of the blood was so delayed that before it reached
a dangerous point a temporary halt for rest, or perhaps the close of the day's march, enabled
the system of a threatened subject to recover its normal condition and energies; but in the
absence of a constant supply to replace that lost by excessive perspiration the skin speedilj'
became dry. Promptly on the cessation of the cooling influence of evaporation from the
surface the temperature of the bodj' rose, and when the point was reached at which normal
action ceased, the individual became sunstruck. The following extract from a paper by the
writer describes the onset in a case of this kind:*
The mau who is to become the suhject of a coup dc soldi, most likely a raw Irish or Germ.an recruit, at first
perspires very freely, as indeed do his veteran comrades, whUe toiliug along under the weight of arms, knapsack,
lilanket and rations. The back of his head feels painfully hot, notwithstanding he may have draped it with a silk
handkerchief, reversed his cap or tilled its crown with leaves as an infallible protection against the scorching rays.
His heart beats violently and his mind is unpleasantly cognizant of its action. He breathes rapidly, open-mouthed,
for there is a slight feeling of weight in his breast, which the hot air he inhales, rendered hotter still by the dense
clouds of dust with which it is laden, does not seem to have body enough to uplift. Thirst torments him also, while
a crowd of lesser evils contribute to the sum of his discomfort. His eyes smart from the influx of the streams of
perspiration, which neither the eyebrows nor the greased margins of the eyelids suffice to turn aside ; while the optic
nervous masses and the brain as a whole ache with the glare of the sun's retleciion. He is very miserable, so much
so that his niiud is filled with nothing but impressions of his own morbid sensations.
These symptoms grow rapidly more distressing. He halts for a moment, and, notwithstanding the remon-
strances of his comrades, takes a long draught of the warm water his canteen contains. He feels the better for it
and pnslies on with renewed vigor, but by and by relapses into his former state.
Your old soldier, when in this condition, drops out of the column, throws his gun and knapsack on the ground
and stretches himself at full length in the shade of some tree, where he lies alternately fanning himself and sipping
his stock of water. By the time he has finished his canteen he is quite recovered and, as ho has no desire to be chal-
lenged by the Division Provost Guard, ho immediately buckles to the road, rejoining his coniniand most likely at its
next resting place. But your raw material does not attempt this, feeling as he does from homo if separated from his
regiment, and alone in the world when beyond the limits of his brigade. He staggers onward, a vague feeling of
some imi>cnding calamity oppressing his mind. His heart becomes lessened in power, it flutters rather than beats.
The perspiration disappears from his skin, but his thirst increases; he makes frequent but futile efforts to sjiit away
the viscid phlegm that sticks to his lips. The aching in his head becomes pain, the oppression in his chest agony.
A tremor seizes his limbs, a feeling of sinking takes possession of his heart and his mind swims into unconsciousness
as he falls — sunstruck.
He is insensible. At first, perhaps, he may be able to articulate an indistinct answer to inquiries concerning
• On Suattnlx <u U ocaimd in the Arm) ofOa PoUmac — Amrr. Jam. ofOit Med. Bdttuxt, XLIX, 1865, p. 843.
§56 SUNSTROKE.
his name or regiment if asked iu a loud, sharp tone, hut this does not last long; he hecomes totally unconseious in a
very short time. The pupils may he dilated or contracted. His pulse is quick, compressihle and small withal; it
even intermits occasionally. His hreathing is hurried, short, shallow and interrupted now and again hy a long-drawn
sin'h. His skin is hot and dry and his lips livid. He clutches nervously (and this is a measure as well of his insensi-
bility as of his pra'cordial distress) at his chest with a force oftentimes sufficient, if the surface be exposed, to lacerate
the skin. If no one be present to have recourse, either knowingly or unwittingly, to the means calculated to obviate
the abnormal condition and promote a speedy return to consciousness and ease the man will assuredly die, unless,
indeed, nature should interfere, as she sometimes docs, and by the bursting of a thunderstorm effect a cure. The
power of deglutition becomes lost as his insensibility deepens. His pulse flickers faintly until, with a sigh, broken
perhaps hy the de.ath-rattle iu his throat, he expires.
But very frequently to these symptoms is superadded one which gives the disease to the onlooker a very fear-
ful aspect. I refer to the occurrence of tetanic convulsions. The intermissions last for two or three minutes or longer,
the paroxysms from ten to thirty seconds. As the fit comes on the breathing becomes more rapid and shallow, the
limbs writhe and the nervous twitchings of the fingers, as they tear at the prspcordia, are very marked. Violent
muscular contractions speedily ensue, stretching the body out perfectly straight, or, more couuuonly, with the head
thrown back and the abdomen raised from the more powerful action of the extensor muscles. This condition con-
tinues but a few seconds iu all its intensity; the sp.asm then relaxes and seems about to disappear, when, after
one or two hesitating twitches, the muscles again start into rigid iirominence. This may be repeated several times
before the fit comes to a conclusion. While the body is thus bent in rigid spasm the breathing is susi)ended and the
lividity of the lips increases. The termination of the fit is marked by a long sighing expiration, which is less notice-
able the nearer the case approaches its fatal end. Death, when it does occur in these cases, usually takes place during
the continuance of a convulsive seizure.
The symptoms of the uttack appear to depend on loss of water from the blood liej'ond
the limit consistent with functional activities, and on the increased heat consequent on the
suppression of evaporation. This indicates, as measures of prevention, free supplies of water
and rest to lessen the production of heat and to afford opportunity to relieve the body from
its impediments to cooling ev^aporation. Cold affusion or immersion in water fulfills the
indications for treatment.* The first case in which water was used by tlie writer as the
remedial agent was one of many that occurred, Sept. 1 2, 1863, near Rappahannock station, Va.
I was riding forward to overtake my command, from which I had been separated for an hour or two by some
duty, and when I was about half a mile from the tail of the column I found a man in the sun, by the roadside, in con-
vulsions, with a small circle of men belonging to the provost guard around him. He was comatose; his skin was
hot and dry; his lips livid; his left pupil dilated somewhat, and his pulse, from its smallness, softness and rapidity,
could not be counted. The convulsions were frequent and so violent that I expected that each succeeding jiaroxysm
would terminate life. He had been in this condition for about ten minutes — the fits, according to the statements of
the men around, having during that time been steadily increasing in frequency, intensity and duration. A medical
officer had seen him immediately after he had been struck down. He could not be said to have treated him, having
simply attempted to pour whiskey into his stomach, failing in which he had galloped off to order an ambulance to the
spot, leaving instructions that cold cloths should be kept to the patient's head. A man had gone in search of water
but had not returned.
I had the patient carried to a hou.se situated about a hundred yards from the road. I laid him down in its
shade, and having obtained water placed a few drops iu his mouth; but no attempt was made to swallow, and some
* Douching with cold water has been frequently employed by British medical officers in India and the East. J. R. Taylor, Deputy Inspector of
Hospitals, gives a gratifying account of his success, — LfiHct/, II, 1858, p. 22G : "During the active operations at Martaban and Rangoon, iu April, 1852,
numerous cases of the acute eflfects of high and continued tropical tempeniture came under my care. In every instance the soldier was immediately
stripped of all but his trousers, and bheesties then couimenced pouring a stream of water, first on the patient's head, then over his throat, chest and epi-
gastrium, and subsequently along the spine. This cold affusion was continued till decided signs of restoration showed themselves. In these cases,
accompanied with sickness of tlie stom.ich, effervescing draughts, sometimes with compound spirit of sulphuric ether, were found very grateful and
reviving, and, in anticipation of this, a large supply of prepared effervesc-ing powders had been included in the light surgical equipment for the field.
The cases of insensibility, sometimes lasting from one to three hours, and in some instances attended with one or more epileptic fits or couvulsions, were
apparently very threatening and strongly suggestive of the necessity for more active treatment ; but former experience of the little or very dubious
advantage, if not positive mischief, from loss of blood in such cases, together with the fact of the circumstances under which these cases occurred, having
been calculated to produce a condition of impoverishment of blood and of exhaustion, were considerations which haply withheld me from all treatment but
stripping and cold affusion in the shade. This simple treatment was successful, not one case terminating fatally. The other medical officers on the
ground who followed this plan of treatment expressed their gratification at the result." W. C. McLe.\n, of the Army Medical School, Netley, England,
gives the following instructions in his article on S>ni»lri^€, in Reiniold's Siiste7n of Medicine, Vol. II, London, 1S68, p. 153 : " At the earliest possible moment
let the sufierer he carried to the nearest shade, stripped and assiduously douched with cold water over head, neck and chest. If this be effectually and
quickly done, the powerful impression on the cutaneous nerves will soon re-establish respiration, at first hy gasps and catches, soon iu a more regular and
tranquil mjinner. It will also reduce the heat of the skin. It may require to be done again and again ; in hospital it may be necessai-y to envelope the
patient in a wet sheet and to ply the fan or punkah over him vigorously until the skin is reduced to a more natural temjjerature." In the United States,
Arsns Flint has used this method of treatment with advantage at Bellevue hospital. New York City: see his Ti-eatise on the Principles and Pittctice of Medi-
cine, Philadelphia, 1884, p. 689. LooMis also gives it his approval ; "In most cases the cold-waler treatment is the best. The patient should be taken to
the nearest pump, stream or water-tank and immersed for a considerable time, or a stream of cold water should be poured over the head, neck and back.
Between the baths dry cups may be applied, and during the baths stimulants may be given if the pulse demands thetn." ' —Practical Medicine, New Tork>
1884, p. 1055.
SUNSTROKE. 857
trickling into the larynx, a convulsion more severe than any hitherto aft'ecting him was inilnceil. Tlierciiiion 1 mat tod
his hair with water and poured it freely over his body, thorouj;hly saturating the woolen shirt ho wore. • * •
I'resently I thought his spasms recurred less frequently and diminished in intensity; his pulse certainly altered for
the better and his breathing seemed to improve, notwithstanding that his hand tore at his chest with greater violence.
As I continued sprinkling water over him a few drops fell upon his lips: his tongue instantly iirotruded itself and
gathered them up. 1 dropjied some intentionally ui>ou them with a like result. He was improving. At the end
of the next paroxysm, which was a slight one, I raised his head and he drank greedily, u[>lifting his eyelids as I
placed him back upon his jiillow, but no gleam of intelligence was yet apparent in his look. In ten minutes more,
having drauk several times during that interval, and objected by a motion of his head when I held a cup conlaiulng
whiskey to his lips, he was recovered, ^"ery much exhausted he was, it is true, but his pulse and breathing were
regular anil his sensibility and consciousness had returned, and although occasionally his fingers would tw itch as
they had jircviously done when a convulsion was about to seize him, such movements were not now foUoweil by tlio
general spasms. To prevent any evil ett'ects that might arise from the continued application of the water to his body
I directed his wet underclothing to be removed, tho surface rubbed dry and a clean shirt, which his knapsack fur-
nished, to bo put on him. His' canteen was then filled with water and his blanket wrapped around him before ho
was transferred to the ambulance.
But suiistruck cases tlid not always have so favorable an issue uiKler this plan of treat-
niir'iit: for, if Juring the unconsciousness and convulsions of the primary attack the patho-
genic conditions led to an injur}^ of the brain, apoplectic cOma, with speedy death or a pro-
longed illness, was the consequence. Headache, nausea, vomiting, faintness, quickly followed
by unconsciousness and convulsions, characterized these cases; but until the development of
the comatose state there was always a hope of prompt recovery. When coma supervened
treatment consisted of cold to the head, cups and active purgation. General bleeding was
seldom attempted, and perhaps fortunately so, as British military experience does not
countenance its use.* There is usually so much associated exhaustion in the cases of sun-
struck soldiers, even when seemingly in the main apoplectic, that the patient is liable to die
from syncope during the operation. Happily, however, the comatose state was developed
only in a few deadly cases. The experience of civil life gives a fifty per cent, rate of fatal-
ity to sunstroke; but this high rate depends upon individual peculiarities: The cases occur
chiefly in those who have reached that stage of life when the conditions favorable to the
supervention of apoplexy and paralysis are fully matured, while our soldiers were young
men with all their tissues sound and free from the degenerations of advancing years.
Nor was the recovery of consciousness always followed by immediate convalescence.
In some cases more or less febrile action was associated with local inflammatory processes
of the brain, spinal cord, lungs or other organs. Untoward sequels were, however, of more
frequent occurrence when the incidence of the morbific influences was mainly in the brain.
The following cases have been collected from .the records :
Case 1.— Private William H. Ashwill, Co. G, 8th Ind.; age 22; was admitted July 25, 18G3. He had been struck
on the head, April 1, by a piece of timber. The wound soon healed and he appeared to have recovered, but on Jlay
17. while standing in the sun at the battle of Magnolia Hills, he fell, fainting, and with severe headache. Some hours
afterward he was picked up and carried to the field hospital. He was returned to duty November 9. — iMwson Hos-
pital, St. Loiiin, ilo. [His name does not again appear on the registers of sick; he was mustered out June 11, 1865.]
Case 2.— Private Daniel U. Dunn, Co. E, Gth N. Y. Heavy Art'y; age 30; became giddy and unconscious May
7, 18GI, during the operations in the Wilderness, Va. When seized he was lying in the intrcnchments under fire,
tinder a hot sun at noon. (The troops had just fallen back; they were heated and the earthworks were damp.)
Before his seizure he felt exhausted and sore all over. His unconsciousness lasted five days. He had no feeling in
his legs, nor could he move them. .Sensation returned about the middle of June, while he was at the Mansion House
hospital, Alexandria, Va.; the power of nmtion returned later in the month. On the 2"th ho was transferred to the
Cuyler hospital, Philadelphia: Diagnosis — paralysis of the lower limbs. On July 18 he was transferred to this hos-
pital. Spinal tenderness extended from the first lumbar vertebra to the third dorsal. Furlonghcd Scptemlier 1;
returned on the 2L'd. Furlonghed November 4; returned on the 20th. Returned to duty March 3, 1805. — Turner's
Lane Honpitul. rhiltt<Ulj>hii(, I'u. [This man's name does not again appear on the registers.]
Ca.se 3. — .Serg't John Kiely, 3d Pa. Cav.; age 23; was admitted Feb. 2, 1803. He had been much fatigued and
exhansted Sept. 17, 1802, at the battle of Antietam; a few days afterward, while on duty, he became insensible and
* See last note.
Med. Hist., Pt. 1X1—108
858 SUNSTROKE.
fell from Uis horse. He was sent to Mount Vernon hospital, where he remainetl a mou'h, when he was returned to
his ren-iment. After a few days, being unfit for duty, he was sent to a New York hospital, where he remained six
weeks and was aijain forwarded to his regiment ; hut his former symptoms returning while cii route, he was sent to
this hospital. Diagnosis — Sunstroke: Some emaciation; nervous excitability; dizziness on exertion ; skin jiale, cool
and moist; perspires occasionally at night and readily on exertion; lips bloodless; slight cough with weakened
respiratory murmur: tongue clean and moist; appetite capricious; constipation; urine normal; sleeps badly. His
condition improved under the use of purgatives and compound tincture of cinchona. On the 9th iodide of potas-
sium was prescribed in infusion of quassia. On the 16th, while taking this mixture, he had convulsions at night,
and on the 19th dizziness and impairment of vision. Iodide of zinc in two-grain doses, with one-third of a grain of
extract of belladonna, was given three times a day. On the 24th he had a convulsion which lasted for a few minutes ;
there was unusual rigidity; the hands were clinched and eyes shut, but there was no distortion or stertor. On March 4
the zinc was omitted. He was returned to duty on the 23d.- — Salterlee Hospital, Philade1j)hin, Pa. [This man finished
his term of service without further recorded sickness, and was mustered out Aug. 24, 1864.]
Case 4. — Corp'l James A. Finn, Co. G, 28th Mass.; age 18; had intermittent fever in April, 1862, at Charleston,
S. 0. About June 1, 1863, after exposure to wet, sleeping in wet clothes, and fatigue, he had a chill and fever, fol-
lowed by headache and unconsciousness on exposure to the Sim ; these symptoms, with extreme weakness and wake-
fulness, continued for five days, during which his pulse was feeble and slow. He was admitted to Mount Pleasant
hospital, Washington, on the 14th, and on the 19th was transferred to this hospital. He had lost eighteen pounds in
weight since his illness began ; pulse 120; heart-sounds unusually clear and sharp. Gave fifteen drops of tincture
of digitalis three times a day in mild chamomile tea. An eruption of scattered and sligbtlj- elevated papules appeared
on the surface of the body on the 23d; he had headache, pain in the back and loins, hot and dry skin and fre(iuent
pulse — 128. Gave neutral mixture and sweet spirit of nitre. The eruption faded and the febrile action subsided
next day; skin cool; pulse 60. Reduced digitalis to ten drops. This remedy was continued in varying doses until
July 20, during which time the pulse varied from 110 to 132 when the patient was standing and from 58 to 96 when
recumbeut. Citrate of iron and quinine was used until August 5, when the recurrence of a chill, followed by fever,
Jed to the substitution of sulphate of quinine in two- and afterwards four-grain doses three times daily; but as this
did not control the aguish paroxysms, Fowler's solution, in doses of five drops, was given on September 2. During
the three weeks which followed he had two chills. Ou October 2 he was sitting up, but he slept badly and had some
fever, headache and copious perspirations without chills; appetite deficient; countenance dejected; pulse 134 when
erect, small and quick; bowels regular; urination frequent and copious; no enlargement of spleen. Improvement
was very gradual. Quinine and i)rotocarbonate of iron were iirescribed ou November 21, and on December 4 all medi-
cine was discontinued and the patient placed on full instead of milk and extra diet. He was returned to duty Jan.
21, 1864. — Sattcrlee Hospital, Philadelphia, Pa. [This man was killed May 5, 1864, in the Wilderness, Va. ]
Case o. — Lieut. A. M. Goltry, 34th Iowa; age 33; fell exhausted at 3 p. M., July 13, 1864, a fiercely hot day for
a fatiguing march. After an hour or two he so far recovered as to be able to get into camp, suffering, however,
from a violent headache, which did not leave him during the remainder of the sunmier. The lower and back part
of the head was chiefly aftected; he sufiercd also with chills and fever for sevor.al weeks. He received leave of
absence in September, and while at home improved rapidly, gaining twenty-five pounds of body-weight in thirty
days. After August 24 he had partial paralysis. He had been on duty at Port Hudson in the Ked River expedition,
and afterward at Morganza, and subjected therefore to the malarial influences of the Louisiana swamps. He had
taken quinine and iron for nearly three months. From camp he was sent, October 8, to St. James' hospital. New
Orleans, whence he was transferred ou the 18th to this hospital. He grew rajiidly worse after admission, becoming
unable to sit up for any length of time or to feed or dress himself. The sartorius, <iuadriceps extensor and the muscles
of the legs and feet were paralysed; the upper extremities were partially affected, the deltoid and coraco-brachialis
of each side being specially involved; there was also a loss of power over the muscles of the larynx, by which his
speech was affected, and over those of the pharynx, causing difficult deglutition. The extremities, especially the
lower ones, were cold, mottled, and so destitute of sensation that, as he stated, he could not tell where his legs were
lying ; a general numbness with prickling sensations affected them. On attempting to sit up he had uneasy feelings
along the cervical vertebne with flexion of the neck and head ; pressure on the first dorsal vertebra made him flinch ;
he had also weakness and insensibility in the lumbar region; pulse 75; digestion good. Gave one grain of the alco-
holic extract of nux vomica every four hours ; sponged the surface of the body with dilute tincture of cayenne ; applied
a 2- by 6-inch blister to the nape of the neck. Diet, — boiled milk, beef-tea, gruel. 31st; increase of numbness and
paralysis of the extremities ; secretion from pharynx and adjacent mucous membranes at night abundant, disturbing
rest; dysphagia lessened; jjulseSl; skin moist ; some dyspniea; no evacuation of bowels for thirty-six hours. Gave
hlue-pill and Seidlitz powder. November 1 : Better ; restless at night ; mucous secretion free but somewhat diminished ;
dysphagia lessened; can sit up better and is more hopeful ; pulse 96, a little corded; dyspnoea; pain in small of back ;
appetite fair; skin in good condition. Friction and sponging with tejiid water; nux vomica continued. 2d; Rested
well; extremities warm; can move about better; skin moist; pulse 84; tongue furred: persisting pain in the back:
dyspncea lessened. 3d: Rested well; extremities warm ; skin moist; pulse 82; tongue clean ; appetite fair; a little
tormina; continued dyspncea; some involuntary motion of fingers and toes ; can shut the fingers with ditficulty, but
cannot straighten them. Gave nux vomica every five hours, alternating with one drachm of fluid extract of valerian ;
continued sponging. 5th: Rested well, but has a dull pain in right forearm and hand ; motion improving; pulse 84;
skin moist. 6th: Not so well; pulse 96 and weaker ; did not rest well; tongue a little furred. 7th: Pulse 90; rested
hetter; tongue clean ; secretions of mouth and fauces free. 8th: Pulse 90; some trembling sensations in extremities
and other jiarts: motion improving; iio dysphagia; a little restless during the night; pain in back part of head.
SUSSTROKE. 859
Oraittfil mix vomica. 9tli: Pulse G8; no trombliu'; srusation. lOtli: Eested well, Uiit hail some oolioUy vain ami
cpijtastrif oppivssiou at night; iinlseW: tonjine furred. Kesunied nux vomica. During the lltli and 12tli the
syuiptomsc-ontinnedfavorahlcand the treatment was continued. i;ith: Heceived leave of absence. 27th: Discharged
for disaliility. — Xulchcz Hospitnl, ili«i.
Cask 6.— Private David Michener, Co. G, 127th 111.: age 38; was admitted July 'J, 18G4. lie stated that he had
heeu sunstruck in battle at Resaca, CJa., May 21, and had remained nncouscious four days. He was debilitated: eyes
laniruid: lips tremulous: tongue coated : apjietite poor. As no improvement was apparent after continued treatment
by iron, iiuiuine and a liberal diet, he was discharged October (!, 18lil. — Uo«j>ital, Qiiinci/, J II.
Cask 7. — Private Nicholas C. Drake, Co. K, 12tth X. Y., was sunstruck in September, 18r>2. while crossing the
long bridge from Washington to Virginia, and a few days afterwards was attacked with pneumonia. He was admitted
November 13. complaining chielly of headache and wakefulness. Applied cold water to the bead and a blister. 1 by
I inches, to the neck: gave a grain of calomel three times a day. A larger tly-blistcr, 5 by 8 inches, was applied to
the neck on the 25th, about which time also a mixture of tolu, squill and morphia was given. He was rejiorted as
-imewhat better on the 29th, when small doses of iodide of potassium were prescribed; but ou December 5 the per-
-istence of headache was noted and there was tenderness along thespine. On the 11th the patient was able to be up,
1 lit the headache continued and there was pain in the chest. A blister, 3 by 10 inches, was applied to the back ; but
:i> he became restless at night and complained of increased pain in the head, a mixture of acetate and nitrate of potash
with veratrum viride was prescribed on the 1.5tli. He was discharged Jan. 2'.', 18(53, on account of general debility. —
SatUrUf Hospital, I'hiladiljiliia, I'a.
Cask 8. — Private Thomas Clearwater, Co. E, 124th X. Y., was sunstruck in September, 1862, while on the march,
and was treated in hospital in Washington until admitted to this hospital, Xovcmber 13. He complained ofheadache
■itVeetiug the forehead and vertex: bowels regular: appetite impaired : tongue coated: pulse, while asleep 84, while
^iwake 108 : tonsils swollen and very red. Cold was ai)plied to the head, tincture of iron administered and a solution
i>f nitrate of silver used on the iudaiued tonsils. In a few days the throat aftectiou was subdued, but the headache
coutinued. On December 5 the patient was able to be up but felt dizzy. A seton was placed in the neck ou the 26th.
He was discharged April 21, 1863, on account of sunstroke and valvular disease. — Satlerhe Hospital, Philadclxthia, Pa.
Cask 9.— Private Patrick Denver, Co. K, 97th X. Y.: age 54; was sunstruck Aug. 23, 1861. Facial paralysis
followed, with impairment of sight and hearing on the right side, and a few days later he became unable to pick up
anything of weight with his right hand, but sensation was not atfected. He was treated in the hospital of the Third
Division, Fifth Army Corps, in Douglas hosjiital, Washington, and in Satteilco hospital, Philadelphia, whence, on
October 13, he w as transferred to this hospital. C)n admission his condition was as already stated. Electro-magnetic
irritability and sensibility were impaired in the right arm and shoulder and lost in the facial ma.scles except those of
mastication: no loss of taste on the right side of the tongue; no arching of the velum palati. Diagnosis: Probable
eft'usion into the fourth ventricle. Gave a teaspoonful three times a day of a solution of one grain of strychnia in
one drachm of diluted nitric acid and two ounces and a half of water. He was discharged Jan. 21, 18G5, on account
of the paralysis, — Tinners Lane Hospital, I'liHudclpliia , Pa.
Case 10.— Private David Plunkett, Co. E, 52d Pa.; age 18; fell, sunstruck, on review at Hilton Head, S. C,
May 26, 1864, During the night he had several convulsions, each lasting about twenty minutes. Eight days after-
ward the right arm and leg became paralysed and numb, Ou Jan. 1. 1865, he was sent to De Camp hospital, David's
Island, X, Y, Harbor, and on March 14 was transferred to this hospital : General health good ; right side paralysed and
atrophied. Galvanism was applied daily. On May 10 he was transferred to the McClellan hospital, Philadelphia
[whence he was discharged June 30, because of hemiplegia]. — Tio-ner's Lane HospUaJ, Philadelphia, Pa.
Case 11.— Private Peter Joyce, Co. H, 77th 111.: age 23; was admitted Xov. 21, 1862. He had been sunstruck
iu July and under trcattncnt at Covington, Ky., for five weeks; two weeks after his return to duty he was seized
with rigors, which necessitated his readmittance into hospital, where he had fever with wild delirium and intense
headache. The fever subsided, but the pain recurred daily about 5 r. M., although gradually decreasing in intensity;
the bowels were regular. On admission to this hospital he was weak and much emaciated: he had numbness in some
of his members and was subject to vertigo when he attempted to walk; tongue clean: eyes clear: appetite good and
bowels regular. On the 24th he was scarcely able to walk: periodic headache continued to affect him. Qninino in
two-grain doses was ordered ; but next day it was reported that he could not retain the medicine. He had diarrhrea,
and although his appetite was good he sometimes vomited after eating: pulse soft and small: tongue clean; head-
ache recurring. The bowels were unmoved ou I he 26th audcontinued torpid during the27tli and 28th, the tongue jnean-
while liecoming furred and the headache acute upon movement, and accouii)anied with vertigo, instead of dull and
heavy as it had been heretofore. Two compound cathartic pills were given, which were followed by two stools.
Iodide of iron w!is given on the 29th, but, the relaxation of the bowels continuing, on December 1 the iron was omitted
and chalk and opium administered. The diarrhea persisted, the stools ou the 4th being mucous and bloody and
accompanied with some tenesmus, but the headache had meanwhile ceased. Pills of acetate of lead and opium were
given, with 8iuai>isms to- the abdomen. Ry the 6th fever had l)een added to the symptoms; the stools were more
frequent and the tenesmus aggravated and accompained with abdominal pain. Opiate enemata were employed with
warm fomentations to the abdomen; but these measures failing to procure relief, and strangury h.iving occurred,
pills of lead, blue mass, ipecacuanha and opium were given, and seven wet cups were applied to the tract of the colon,
with subsequent warm fomentations. The blood drawn was dark and thick and did not exceed a tablespoonfnl in
quantity. On the 7tli he had one mucous and bloody stool every hour, fever and much abdominal tenderness. On
the 8th there was tympanites but less tenderness: nausea was developed, with vomiting of gelatinous matter dark
860 SUNSTROKE.
lead-blue in color. On the Otb, the symiitoms being uuclianged except by the increasing exhaustion of the patient,
lead and opium injections were used, with tiaxseed poultices to the abdomen, all other medication being discontinued.
On the 10th the bloody stools continued; the abdomen -was very tender; there was fever with delirium and periodic
headache, .and pain in the urethra during urination ; pulse 100 and full. One-third of a grain of powdered ipecacuanha
was ordered to be t.aken every three hours, with enemata of starch and laudanum after painful stools. During the
following night six stools were passed, some of which were feculent; the fever continued but the delirium ceased.
On the 11th, during the day there were eight stools, three of which contained much blood and mucus; the fever
and painful urination continued. Five grains each of mercury with chalk and Dover's powder were given every
three hours with one-sixth of a grain of jiowdered ipecacuanha. On the 12th the stools were neither so frequent nor
so bloody and the urination was free. The i)atient rested well during the following night, and next day the abdomen
was but slightly tender ; the appetite was improved and the bowels moved but twice, the stools being thin and
feculent. A slight aggravation of the symptoms occurred on the llth and 15th, the strangury returning, but without
abdominal tenderness and without blood in the stools, which were greenish and mucous. Bicarbonate of soda was
added to small doses of ipecacuanha and Dover's powder and given every three hours. The record to recovery is as
follows: 16th: Eight stools at night, green and mucous; much emaciated; less fever; someepistaxis. Gave chicken
soup. 17th: Nine stools at night ; pulse feeble and thready; abdomen sore; tympanites over ascending and descend-
ing colon, dulness over transverse colon ; pain during urination. Gave of opium one grain, ipecacuanha one-fifth
grain, bicarbonate of soda two grains, every three hours. 18th: Eesting better; drowsiness; stools less frequent;
fever at night. 19th: Five stools; micturition free ; fever at night ; periodic headache ; abdominal tenderness; appe-
tite better; pulse 85 and feeble ; slept much. 20th: Three stools; epistaxis. Applied sinapisms to abdomen, follow-ed
by warm fomentations. 21st: Five stools, more feculent. 22d: Three stools. 23d: Five stools. 24th: Improving
and gaining strength. Feb. 2, 1863, returned to duty. — West End Uospital, rhiladeJphia , Pa.
Post-mortem observations are exceedingly meagre.
Case 1. — Private Martin Schirm, Co. G, 11th N. Y. Heavy Art'y; age 33 ; admitted June 1.5, 1864, with sunstroke.
Died 22d: rost-mortem examination: There was much congestion of the brain with effusion into the ventricles; the
brain-substance was but little softened.— T/iicrf Dicision Hosxntal, Alexandria, Ta.
Case 2. — Frivato Edward P. McKee, Co. H, 98th Pa.; age 43; admitted from Fiuley hospital, D. C, May 19,
1865 suifering from the eft'ects of sunstroke. The patient was very weak ; his mental powers w-ere obtuse and he
spoke but little; he had incontinence of urine, torpid bowels and abdominal pain. On the 20th a blister was applied
to the lumbar region and small doses of tincture of cantharides administered, for which,in a few days nitro-muriatie
acid was substituted. On the 29th the mental faculties seemed more obtuse and there was some congestion of the
lungs ; the tongue became dry and dark-colored, sordes collected on the teeth, the pulse and respiration increased iu
frequency and prostration became extreme. He died on the 30th. Fost-morfem examination : Serum was found beneath
the arachnoid and in the ventricles of the brain; the brain-substance was passively congested. The npper lobe of
the right lung was hepatized, the upper lobe of the left congested. The right ventricle of the heart contained a
filn-inoHS clot which extended into the pulmonary artery; the left contained a quantity of black uncoagulatcd blood.
The spleen was healthy; the gall-bladder distended with black bile; the kidneys fatty; the intestines normal. — .S'«(-
terJee HospHal , Philadelphia, Pa.
Case 3. — Serg't H. B. Graham, Co. C, 127th N. Y., had been exposed to the heat of the sun April 26, 1864, ou
which day he was admitted, unconscious, with dilated pupils and intermittent pulse, about 85, and a red and moist
tongue. Next day he became conscious, but his replies were incoherent; he suffered from froutal headache, but his
tongue and skin were moist. Mustard was applied to the back of the neck, and five drops of Magendie's solution,
ten of Hoft'mann's anodyne and one-fifth of a grain of tartar emetic were given three times daily. On the 28th he felt
better and walked about the ward, but as his conversation was incoherent he was ordered to bed. His bowels were
moved several times during the days which followed, but the brain symptoms remained unchanged until May 2, when
a tendency to coma was manifested. On that day ten drops each of fluid extract of ginger and of laudanum were
given twice ou account of colic. He died comatose on the 5th. Pos(-)HO)'(r»i examination: Stomach congested and
slightly eroded on its anterior wall near the greater curvatur3; similar appearances in the descending colon. Liver
and spleen atrophied; gall bladder nearly empty. — Hospital, Morris Island, S. C.
CHAPTER X.— 0^ CERTAIN LOCAL DISEASES.
I.— CARDIAC DISEASES.
Organic affections. — x\ccording to the reported statistics organic disease of the heart
was rare among our soldiers. Only 3,778 cases were registered as having been taken on
sick-report among the white troops during the five and one-sixth years, and no doubt in
many of these the disability existed before enlistment. But if the records of discharges on
certificate of disability be examined it will be found that no less than 10,636 men were lost
CARDIAC DISEASES. , 861
to the service on account of lieart disease. The difference between tliese numbers may be
regarded as expressing in a general way some of the results of the 1-45,551 cases of acute
rheumatism that were reported.
J. ^r. Da Costa has shown that of thirty cases of organic heart disease, taken indis-
criuiinatelv from his note-books, one-half were attributable to rheumatism, six antedated
tlie enlistment of the men, four were sequent to pneumonia, one to measles and two to the
fatigue of hard marching, while in two no connection with antecedent disease or other
probable cause was manifested.* This writer considered that pneumonia had no causative
relation to heart disease. He referred the four cases in which a cardiac lesion followed the
pneumonic affection to the predisposing influence of violent exercise, which, in his view, had
as much to do with the development of endocardial inflammation as any exposure to which
the men were subjected. But the pronounced pericardial lesions in cases 70-96 of the
post-mortem records of pneumoniaf suggest the possibility of the dependence of endocardial
lesions on the influences that determine the progress of pneumonic fever. In the cases
mentioned the condition of the endocardium was seldom stated, the attention of the observers
having apparently been absorbed by the fibrinous clots adhering to the valves and inter-
digitating with the fleshy columns; nevertheless it occasionally appears on the record: In
77 the endocardium was said to have been unaltered; but in 82, 93 and 95 it was materially
changed from the healthy condition.
The following notes on cardiac disease were filed by Act. Ass't Surgeon F. K. Bailey:
From October, 1862, to June 9, 1864, there were 631 admissions into my division at Quincy, lU., and among
tliem were forty-two cases of cardiac disease. Some of these were severe and involved the valves. Tliere were also
many cases of other diseases which were found to be complicated with cardiac symptoms. So mauy labored under
some attectiou of the chest iu which dyspntva and orthopnea were prominent symptoms, that it was necessary to
provide extra pillows in order that the head and shoulders might be elevated. Indeed a great number reciuired to
Have the shoulders elevated who merely labored under the seiiuehe of diarrho-a and other abdominal affections.
Enlargement of the liver or spleen, or eflused fluid iu the peritoneal cavity, caused an upward pressure on the dia-
phragm, which, being deprived of its tonicity, could not prevent mechanical pressure on tlie heart and lungs. There
were cases of increased impulse and paljiitation in which no organic lesion was detected: but the forty-two cases
above mentioned were characterized by the physical signs of hypertrophy or other organic morbid condition. That
a similar state of things existed in other hospitals was evident from the fact that early in 1863 an order was issued
advising a close scrutiny to prevent deception in certain cases, among which disease of the heart was included.
I do not know that much can be oSered in regard to treatment. So many were discharged before the complete
organization of a separate corps, in which men unfit for field duty could be made useful, that a full course of treat-
ment was not tested. Many were broken down during the second year of the war by disease and exposure, and much
care and good judgment were required to effect their restoration to health. These cases were new in many of their
features, or at least disease assumed unusual forms as a consequence of the unusual circumstances which conspired
in its causation. Xo case was found in which tonics were not called for. There was an adynamic condition which
demanded supporting treatment. Sulphate of quinine or other preparations of cinchona, iodide of potassium and
chalybeates were the leading therapeutic agents. Sedatives were particularly useful in relieving palpitation and
paroxysmal dyspniva. Hest iu bed, with nutritious and easily digested food and such medicines as were called for by
the .symptoms, gave more or less immediate relief. Comparatively few cases proved fatal, and it is probable that most
of them have partially recovered and are now upon the pension rolls.
Inasmuch as detailed histories of these cases are wanting. I can only give a general idea of their causes. The
anny was hastily made up of all classes of men from the ages of sixteen to sixty. Instead of the rigid scrutiny exer-
cised in recruiting the regular army, there was little regard paid to examining into physical defects which might inca-
pacitate for field service. The men were at once taken several degrees south of their own latitude and exposed to a
hot snn by day and a damp lodging at night. Thus the surface became chilled and internal determinations resulted.
During the summer of 1--61 but little rheumatism was developed. In the following winter and spring the
armies of the Missouri and Tennessee were constantly exposed to cold and dampness. The campaigns of Forts Henry
and Donelson were accomplished under almost continuous storms of sleet and rain. The battlefield of Shiloh and
the dreadful strutisle on the Mississippi at Island No. 10 made cruel inroads upon the health of those who escaped
the bullet. During ilie summer of 1862 there was much suffering from miasmatic disease and affections of the abdom-
inal viscera. Enlargement of the liver and spleen resulted, weakening the vital force and causing an impoverishment
• OlwerT*tioii5 OD the Di^aaesof the Heart noticed among soldiers, particularlv the Organic Diseases, pp. 300 el eeq-J'. s. S<ijnl-irif C"iiinii>^ion Mtfinoirg,
t Supni, page 708 rf Kq.
862 CARDIAC DISEASES.
of the blood. Long-continued debility produced a softening and flabbiness of the muscular tissues, in which the car-
diac walls participated : hypertrophy resulted fiom overaction and dilatation from the softened condition. Peri- and
endocarditis had perhaps already existed from an arthritic history, and scores of men were sent to hospital laboring
under a pathological condition which was easy of diagnosis but uncertain of prognosis and perplexing in treatment.
A plausible theory, explanatory of the causation of some cases of cardiac disease in the army, was suggested by
Surgeon L. D. Kellogg, 17th 111.: A soldier during the day carried his knapsack upon the back at a point immedi-
ately opposite the heart. At night the load was removed and the surface, which for hours had been subjected to
profuse perspiration, was laid next the cold and damp ground. This often recurred to my mind while treating suf-
ferers from thoracic diseases, both cardiac and pulmonic.
Functional disturbances. — Among the affections of the heart a functional ilisturb-
ance known by the name of irritable heart or cardiac muscxdar exhaustion was tlie most
notable product of the war. The unusual characters of this disease rather than its frequency
made it the subject of observation and study.'-' Henry Hartshokne, in speaking from
his experience of the relative frequency of various cardiac affections among soldiers, states
that acute endocarditis and pericarditis were rare; valvular disease and dilatation, witli-
out evidence of true muscular hypertrophy, occurred occasionally; palpitation from sym-
pathy with gastric derangement, nervousness, the abuse of tobacco, etc., was more common
and, as in civil life, often connected with the ansemlc condition; but the largest number of
cases consisted of those to which he applied tlie title cardiac muscular exhaustion as express-
ing tlte pathological characteristic of the affection. Da Costa examined a series of three
hundred cases of this functional disorder. Special facilities were required to enable him to
have so large an experience. In December, 1862, he called attention to this form of cardiac
malady, and arrangements were afterwards made by which cases of this kind were sent to
his wards in the Turner's Lane hospital, Philadelphia. Here he demonstrated the transition
from irritability to hypertrophy. In two hundred cases carefully examined there were
twenty-eight of undoubted hypertrophy, one hundred and thirty-six of functional disorder
and thirty-six of doubtful or mixed character in which irritability was passing into hyper-
trophy; he rarely discovered dilatation of the heart. The functional disorder was at first
regarded as hypertrophy with dilatation. Dr. Thomas T. Smiley, in a communication dated
October 15, 1862, says of cardiac diseases at Hilton Head, S. C.f
Hypertrophy and dilatation of the heart occur frequently, and in some instances aneurism of the aorta. They
have occurred chiefly in very young men or in men of feeble constitution tasked probably beyond their strength.
The history which most of them give of their symptoms is that they came on whilst engaged in practicing the double
quick. L'nder the iutiuence of digitalis, veratria, rest and mild diet, most of them have been partially relieved, but
some have remained for several mouths in hospital, without any prospect of being able to rejoin their regiments.
Irritable heart appears to have been a result of active field service. It is true, cases were
attributed to the drills and double-quick movements of camp, effected under the full burden
of arms and accoutrements, particularly when the individual was debilitated, as from an
attack of diarrhoea, or while convalescing from typhoid fever, but the greater number dated
from some overaction of the heart during a particular battle or campaign. This was early
observed by our medical officers in the field: thus Surgeon A. J. McKelway, 8th N. J.,
referring to the battle of Williamsburg, May 5, 1862, says: —
Disease of the heart appears to have been developed in several cases from overexertion preceding the battle
and excitement and effort during its continuance. In these cases the pulse remained for days at from 110 to 120 beats
per minute. Some fifteen cases, which have since been discharged or sent to hospital, originated at that time.
Overaction of the heart during an engagement was due perhaps as much to nervous
excitement and anticipation of danger as to overexertion. The recruit might control the
* See Address before the Phila. Co. Med. Soc., February, 1863, by Alfred StillS ; also Henry Hartshokne — On Heart Disease in the Army — in the Traos.
of the College of Physicians of Philadelphia.— /Im. Jour. Med. Sciences, XLVIII, 1864, p. 69 ; and J. M. Da CoST.i— Oh Irrilahle Heart— Ibid., LXI, 1871, p. 17.
t Boston Med. and Surg. Jour., LXVII, 1863, p. 272.
CARDIAC DISEASES. 863
movements of his voluntary muscles but not those of the sympathetically accelerated heart.
Even soldiers accustomed to the alarms of battle were not at all times exempt from the
results of mental impressions. The call to action usually dissipated the feelings which gave
rise to this acceleration and substituted a beat of greater force, although perhaps not of les-
sened frequency if the exertion of the occasion was violent or prolonged. Many cases of
irritable heart were received into the general hospitals after the continued exertion, anxieties
and excitement of the seven days' fight from Richmond to Harrison's Landing, Va.
The affected soldier was subject to fits of fluttering cardiac action, accompanied with
pain in the pra3Cordia, shortness of breath and perhaps haemoptysis, dizziness and dimness
of vision; sometimes these were so severe as to occasion insensibility. At first overexer-
tion or mental emotion was required to induce them, but in aggravated cases the slightest
effort sufficed to call them forth. Sometimes even sleep did not protect the patient from an
attack, which seemed to be excited in many cases by lying on the left side. The pain during
a paroxysm of accelerated action was acute, sometimes radiating to the left axilla, arm or
shoulder-blade ; during the intervals there was a feeling of uneasiness, discomfort or dull pain .
The pulse, which was rapid, feeble and compressible when the patient was at rest, became
greatly accelerated by slight movements. Hartshorxe speaks of men possessing the aspect
of average health, with sufficient flesh, fair color and considerable muscular strength', whose
pulse ran up to 120 or 130 on slowly walking a few yards. In the case of Baily, given
below, the irritable pulse rose from 120 to 171 when the patient walked the length of the
ward. The impulse of the heart differed from that in ordinary palpitation by its relative
deficiency in force. The first sound, according to Da Costa, was generally lacking in volume,
feeble or short and valvular. As recovery ensued it gradually recovered its normal charac-
teristics, even although it had been almost extinct when the functional disorder was at its
height. The second sound was generally increased and always very distinct. When irri-
tability gave place to hypertrophy the impulse gathered volume and began to be forcible,
the first sound lengthened and lost its valvular character, the second became less distinct,
the action of the heart less rapid, the pulse fuller; the cardiac pain lessened, but the respira-
tion, although it came to bear a more natural proportion to the still excited action of the
heart, was persistently oppressed; finally, but graduallv, the boundaries of percussion dul-
nfss became markedly extended.
Rest constituted the essential of treatment; tonics and diet the adjuvants. Of the
special remedies employed digitalis gave the best results; in anaemic cases it was usually
combined with iron. Ten drops of the tincture were given three times daily and continued,
with slight intermissions, for weeks and months without evincing any evidence of cumula-
tive effects. In slight cases this remedy lowered and steadied the pulse in about a week,
and gradually led to a permanent improvement. Tn severe cases its action was slower, but
ultimately as decided. In some cases, however, it failed. Aconite was valuable when hyper-
trophy was in progress. It reduced the force of the heart and lessened the tension of the
pulse. Veratrum viride often calmed the cardiac irritability, but its action was not i^er-
manent like that of digitalis. Belladonna was particularly valuable in cases of irregular
action, but in irritability without irregularity or in hypertrophic cases it was seldom of use.
Other remedies tried, such as gelseminum, hyoscyamus, coniuni, cannabis indica, valerian,
ergot, strychnia, etc., while not absolutely valueless, failed to give decide«l results. Bella-
donna applied externally relieved pain ; cups and blisters were useless.
364 CAKDIAC DISEASES.
The progress to recovery was slow — months of rest and treatment in hospital failed in
many cases to do more than improve the condition of the heart. Nevertheless 38 per cent,
of the two hundred cases treated by Dr. Da Costa were returned to duty with their regiments
after having been tested by running and other exercises, and the cure in many of these is
known to have been permanent.
Of 4,901 men discharged for disability at Convalescent Camp, Va., during the early
part of 1863, 2,323 cases, or nearly one-half, were certified on the ground of heart disease:
1,123 are said to have been organic and 1,200 functional. Surgeon Sakford B. Hunt, U.
S. Vols., a member of one of the examining boards, speaks thus of these cases of "functional
disease of the heart:"
The term is a misnomer; yet, as I have already shown, it was employed in 1,200 certilieates of disability. In
all cases the objectionable phrase described a heart far too rapid in its action, the pulse ranging from 120 to 150, fre-
quently attended by dyspncea, vertigo or syncope, but revealing no abnormal sounds eitlier on percussion or ausculta-
tion. The convenience of this collocation of words was perhaps the strongest reason for its employment. It saved
an extended historical notice of each case upon the limited space of the certificates of disability. In reality these
■were cases of disturbance of the function of the heart dependent upon causes foreign to the organ itself. Thus, the
soldier who has been prostrated with Chickahominy diarrhoea, with typhoid or remittent, and whose ganglionic
system had been stupefied and ruined by the specific effect of too much quinine, would have left to him a rapid pulse
after the subsidence of the diarrh(pa or the fever. The eflect was thus put before the cause, and the man was certi-
fied for "functional disease." Again, there were great numbersof cases of the effects of miasm, as shown in enormously
enlarged livers and spleens ^nd a tumid belly. It would have been more accurate to have certified these as they
were, viz: enlargements of the liver and spleen from miasmatic causes, witli disturbed function of the heart from
mechanical pressure of the diaphragm and impaired action of the inferior vena cava. But there was not space or
time for all this. It was enough that the man had been sick for six or eiglit months; that a full year north would
be required to restore him, and that a second season south would make him the easy victim of pernicious intermittent.
He stood there a bad bargain for the government; and in the toil of getting through the task of one hundred exam-
inations daily, to make up one's mind that the man ought to be discharged puts an end to all niceties of diagnosis.
Such is the history of these cases. Without entering into an apology for the action of the different boards in
discharging them I wish to remark that, unless the examining surgeons were incompetent to perform the more ordinary
duties of their profession, it is fair to suppose that they knew what they certified to. So far as organic disease is
concerned, the diagnosis of the mere fact is not difficult. A valvular murmur, a diffused impulse, an enlarged area
of percussion, a friction sound in the pericardium cannot be feigned and are as easily recognized as any other phys-
ical sign. It is only when we come to sub-classify, when we assign the sound to a particular valve,' as none of the
examining board did, that diagnosis becomes nice and difficult. Much has been said about the use of deception in
those cases classed as "functional." I do not defend the use of that term; lint what was the man to feign ? A rapid
pulse, and that only. As a surgeon, I know only one successful method of producing this, that used by fraudulent
mesmeric subjects of quietly straining as if at stool. This could not be pursued in the examining room, and it is
only in very sensitive individuals that the pnlse can be forced above 110 by this trick; moreover the man could not
feign the tumid belly, enlarged liver and spleen, or the cachectic look, which are what "functional disease" means.
While writing this article I have re-examined many of these cases which were sent to quarters, and I found the action
of the heart almost unchanged, though three months have elapsed.
The cases of heart disease seen by Surgeon M. K. Taylok, U. S. Vols.,* in the hospitals
at Keokuk, Iowa, were of a wholly different character from those studied in the Philadelphia
hospitals. As shown by the symptoms, physical signs and post-mortem observations, they
consisted of dilatation and thinning of the walls of the right ventricle, with more or less incom-
petency of the tricuspid valve. ' Sudden death occasionally occurred in these cases. The
cavity of the right ventricle was fully twice the size of the left, and its walls, in some places
scarcely more than three-quarters of a line in thickness, presented sometimes a bluisli appear-
ance on their pericardial surface. Nine-tenths of those affected had suffered from some
impediment to the free circulation of the blood at no very remote period. Sometimes the
obstruction depended on consolidation of the lung-tissue, as in pneumonia, or on compression,
as in pleurisy, but in by far the larger number of cases it resulted from inflammatory con-
•
* Hemarks on Heart DUeu^e 06 ohten-ed in the ^[iUtarti ServUe from 1861 io 1865, mcliisue, by M. K. Taylor, — Tiamactioiis Ainerican Metlical AsBociation^
XTIII, 1807, p. 139.
CARDIAC DISEASKS. 865
ditioiis following measles. Scurvy and malarial poisoning were regarded as predisposing
causes. The afiection in other instances was ascribed to sudden and undue burdens imposed
on the heart by rapid marching or the overwhelming fatigues and excitements of battle.
Many of the patients stated explicitly that the first evidence they had of any cardiac ailment
was immediatelv after such excitements. Treatment was based on the history of the disease
and the existing condition of the patient : Exercise and diet were so regulated as to restore
the tone of tlie muscular structures ; iron and bitter tonics were employed with moderate alco-
holic stimulation after meals. Many recovered a fair degree of health who. without medical
supervision, would probably have died prematurely. Dr. Taylor considered tiiat in these
fovorablc cases the muscular tissue of the heart became so far invigorated as to permit of
the contraction of the ventricular cavity to its normal size.
Da Gosta's article on irritable heart is illustrated by many interesting cases. The fol-
lowing, from unpublished records, indicate the general characters of this functional disorder:
C.vSF. 1.— Private As.a L. Rickcr, Co. C, 32d Mass.: age 21; was admitted Aug. 10, 1862. He was in the seven
days' figlit in Juno l)ol"oiv Kiolimond, during which lie coutraeted lever, probaI)ly typhoid, from which ho was recov-
ering wlien brought here. Convalescence has been retarded by palpitations which are independent of any appreci-
able organic lesion. Ten drops each of the tinctures of digitalis and iron were given three times daily, with generous
diet. Ho improved somewhat, but prolonged or violent exertion caused a recurrence of the palpitations. On Jan.
20, 18G3, there was a slight bloating of the face, which led nie to suspect some disease of the kiilney: the urine, how-
ever, proved to be normal. On February !• Dr. D.v Costa examined the patient, coinciding in the diagnosis and
approving the treatment pursued. An application for his discharge was denied, and in March he was transferred to
another ward for duty as a clerk. — Satlerhe UosplUil, r!iila(ld2)hia, Pa.
C.\SE 2.— Private Oscar Schreiber, Co. M, 4th N. J. Cav.; age 25; suftered from cardiac troul)le before entering
the army. In March, 1863, he had pain in the pra-cordia. He was admitted May 7 with irritable heart: No abnor-
mal sounds over chest: cardiac pain, increased on motion; impulse of heart frequent: appearance good; tongue
slightly coated. Iodine was at first used and a stimulant liniment afterward. He spat blood on the 19th. Sulphuric
acid was given. He was returned to duty June l."i. — Sattcrlee Hosjiitul, ritihuMphiu, I'u.
C.iSE o.— Private James B. Bruce, Co. M, 8th \. Y. Cav.; age 38; was admitted Dec. 18, 1862. He says ho suf-
fered from bilious fever for a month previous to his entrance; evidently he had beeu the subject of some severe
illness which had much reduced bis strength and given rise to palpitation of the heart. The percussion sound was
somewhat less clear and the vesicular murnuir less distinct than normally; the apex of the heart was displaced
downwards and inwards, giving rise to pulsation in the epigastrium ; no murmur was discovered. From an extended
cardiac dulness and feeble condition of the pulse I considered the heart slightly dilated. Some years ago this man
had a severe attack of pleurisy, during which dislocation of the heart and adhesion of the two surfaces of the pleura
may have taken place, giving rise to the conditions above noted. The tinctures of iron and digitalis were admin-
istered, but little benefit was derived. He was discharged the service Feb. 28, 1863.— SaUei-lee IlospitaJ, I'hila., Pa.
C.vsK 4.— Private Elias Schmidt, Co. A, 4th Jlich. Cav.: age 23; was taken in April, 1862, with pain in the left
side and shortness of breath: since then he has been unable to do duty. He was admitted March 10, 1863, with dull
pain in the pra^cordia and dyspncea; pulse feeble and frcciuent; appetite good: bowels regular. Alteratives and
Strychnia were given and wet cups applied over the heart. He was returned to duty July 2'.— Hospital, Qiiiiicij, III.
C.vsE .5.— Private Michael McGonegal, Co. I, 15th Pa. Cav.; age 23; was taken with palpitation of the heart in
December, 1862, and has done no duty since that time. He was received March 10, 1863. Auscultation revealed no
organic di.sease. He improved under the use of strychnia internally and iodine externally, with nutritious diet and
a careful avoidance of stimulants. He was returned to duty August W.— Hospital, Qaincij, III.
CvSE 6.— Private A. C. Smith, Co. K, !)5th Ohio; age 29; was attacked with palpitation of the heart Aug. 1,
1862, attributed to over-exertion in marching. He was received March 10, 1863. Exerci.se or overloading the stomach
lirought on dizziness and jialpitation : no organic disease was discovered. He was treated with strychnia and cin-
chona, with epispastics to the spine and iodine to the pra^cordia. His condition was much improved when, in May,
he was transferred to Camp Chase, Ohio. — noi>pitul, Qtiincy, III.
C.VSE ".—Private James Curley, Co. K, 2d N. H.; age 24; admitted from the tield April 6,1864, with hypertroi)hy
of the heart. He w.as unable to take exercise without sutl'ering from palpitation and dyspncea; pulse full and reg-
ular; appetite good: bowels costive. Gave liuid extract of valerian, and at times, when the palpitation was exces-
sive, small doses of digitalis: occasionally an aperient. He was discharged August 1. — Ilospitul, Point Lookout, Md.
C.VSE 8.— Private William Bailey, 6th X. Y. Cav.: age 29: enlisted Aug. 1. 1862, and was sent to Cam]. Conva-
lescent, near Alexandria, Va. Here he took cold by sleeping on the ground with iusufHcient covering, and was so ill
as to be for a time umler treatment in one of the general hospitals. In October, having joined a portion of his regi-
ment which was then in Washington, he was severely jolted in trying to mount an unruly horse. The injury seemed
to him to be somewhere in the abdominal walls. About a month afterward he was sent to I'hiladelpliia to this lies-
Med. Hist., Pt. Ill— 109
866 CARDIAC DISEASES.
jiital. Ou admission, November 12, he Tvas a good deal debilitated; pulse rapid: tongue coated; expression of pain
on liis face: great tenderness -with marked tympanites of the abdomen, and diarrhoea recurriag every few days; appe-
tite fair. He was treated with tonics, cod-liver oil, anodynes and nourishing diet. In January, 1863, he was put on
digitalis as his pulse continued to range above 130. On February 20, when he was ordered to be discharged, his
abdominal symptoms had left him and he was in good condition otherwise, except that his pulse remained over 120,
rising to 174 when he walked to the end of the ward and back. I was unable to define accurately the source of the
mischief in this case. The patient had not, according to his own account, had a distinctly malarious fever, nor had
he while under my care a fully developed peritonitis. His heart was in no respect abnormal except in its irritability,
which did not seem to arise from the state of the blood,-nor was there any evidence oL disease in any other organ. —
Act Ass't Siirycoii Jvhn B. Pachard, Salterh-e Hospital, Philadelphia, Pa.
Ii)i0PATHi.c Peeicakditis. — Most of the recorded cases of pericarditis liave already
been submitted as incidental complications of general diseases or the specific manifestations
of a blood-poison on the serous lining of the sac* There remain, however, a few cases in
which the general disease is not defined. Whether these were truly cases of idiopathic peri-
carditis is uncertain.
Case 1.— Private Martin O'Brien, Co. E, i3d X. V., was admitted Aug. 10, 1862, with intermittent fever. He
died September 9. Post-mprtem examination: Body large and of vigorous appearance; age about 55. The tracheal
and bronchial mucous membranes were inflamed and the bronchial glands enlarged, one opposite each sternoclavicu-
lar articulation containing a purulent accumulation. The pleune and lungs were healthy. The pericardium was
injected, roughened and bathed with pus ; tlie right ventricle contaiued a white clot. The liver and spleen were nor-
mal. Tlie kidneys were small, rather lobulated and of a pinkish-cream color on the surface mottled with purple: the
cortical substance was fatty, but the microscope revealed much less oil among its cells than was anticipated from the
color. The ileum was inflamed and eroded in patches, but its glands were healthy. The c:ecum was inflamed and the
mucous membrane of the sigmoid flexure and rectum was much corrugated, the summit of the rug^ being deeply
injected; the solitary glands were natural. — Act. Ass't Surgeon J. Lcidi/, Satterlec Hospital, Philadelphia, Pa.
C.\SE 2. — Private Eli Joslyn, unassigned recruit; admitted April 24,1865. Diagnosis — typhoid fever. Died
May 2. Po.s(-»io)-(emexamiuatiou : Eight lung firmly adherent ; left normal. Pericardium containing twenty ounces
of purulent serum. Abdominal viscera healthy. — Depot Field Hospital, Sixth Army Cor2>s.
Case 3. — Private Isaac Givens, Co. K, 101st Ind.; age 42 ; admitted Nov. 28, 1864, suffering from cough, dyspna?a
and pain in the pnecordia ; he was quite feeble, anaemic and aphonic. For two months, during which he was treated
with anodynes, antispasmodics, expectorants and stimulants, no marked change occurred, but on Feb. 12, 1865, a
double uiurnnir was heard with the heart-sounds, and the patient's discharge from the service was ordered. On the
16th he had a chill, followed by severe lancinating pain in the left side, with great dyspncea, cough and expectora-
tion of viscid, glairy mucus. Next day there was dulness over a large part of left side of the chest. Five grains of
Dover's powder with.three grains of quinia were given every four hours and one ounce of whiskey every two hours.
On the 18th the area of dulness was increased, the heart-sounds were obscured and coarse rales were heard over the
greater part of the chest; sputa tenacious. Profuse sweating occurred during the night of the 19th. A blister was
applied over the heart. On the 20tli half a grain each of calomel and opium was given every three hours. The patient
felt somewhat better until the 24th, when the dyspnoea agaui became urgent ami the sputa tenacious, threatening
sutibcation. Carbonate of ammonia aud whiskey were administered. He died on the 26th. Post-mortem examina-
tion : The brain was not examined. The pericardium, which adhered externally to the pleura aud other surrounding
parts, contained eighty ounces of purulent serum ; the surface of the heart was much thickened aud corrugated by
an appareutl}- organized exudation ; the walls were softened, friable and fatty; the cavities on both sides contained
fibrinous clots; the mitral and aortic valves were thickened. The lungs were much congested, the trachea filled with
muco-pus aud the vocal chords thickened and altered. A calcareous tubercle the size of a hickory nut was found in
the posterior mediastinum. The liver was soft, friable and fatty; the spleen congested and softened; the kidneys
together weighed tweuty-two ounces but appeared healthy; the other organs were normal. — Hospital, Madison, Ind.
Case4.— Private Arnold Willet, Co. D, 96th 111.: age 28; admitted Oct. 17, 1863. Died 28th. PosZ-worteH exam-
ination: Body moderately emaciated; legs somewhat a'dematous. The brain was not examined. The heart was
coated with lymph and tlie pericardium largely distended with serum ; the mitral valves were enlarged and indurated.
The apex of the right lung was solidified. The liver was congested ; the spleen flabby: the left kidney dark-colored ;
the bladder much distended. The colon was attached by recent adhesions and the coils of the small intestine were
interadherent. The mucous coat of the stomach was softened aud of a yellowish color ; the small intestine was of a
soiled yellow color; the colon dark-green; the mesenteric glands enlarged. — Hospital Xo. 1, Xashrille, Tenn.
Case 5.— Private Henry W. Todd, Co. H, 20th Conn.; admitted April 17, 1863. He was debilitated and com-
plained of pain in the left side of the chest, extending down the left arm; his sleep was dreamful and unrefreshing.
He died August 24. Post-mortem examination : The heart was coated and the pericardium lined with large quantities
of tough lymph; the tissues around the base of the heart were agglutinated, — [Specimen 655, Med. Sec, Army Med-
ical Museum]. — .ic*. Ass't Surgeon L. D. Wilcoxson, Knight Hospital, yew Haven, Conn.
Case 6.— Private Samuel Chealley, Co. H, 5th Iowa Cav., was admitted Dec. 8, 1862, with gonorrhoja. Four
See stipra, pp. 14S, 428, IGo, 504, 010, "59, 7C8, 7S1, 505 aud 810.
rAKDIAO DISEASES. 867
(I;iys before death he complained of a severe pain in I ho pr;eoordia, which he said had trouhled Iiini frequently for
some months. The heart was carefully examined, Imt, excepting a little irreRularity and obscurity of the sounds,
nothin;; abnormal could bo discovered. The patient continued to jjo about until the morning of the 18th, when, after
an ordinary breakfast, he lay down on his bed and was found dead shortly afterwards. I'osl-mortcm examination:
The brain was not examined. The pericardium was filled with turbid yellow serum and shreds of lymph; its lining
membrane was much injected, andnjion the surface of the heart were spots of old organized fibrin. There were some
pleuritic adhesions and some bands over the spleen ; otherwise the various origans were healthy. — Surgion B. Dairucli,
C >'. Foh., Hospilat, JItiitoii Jiiinackx. ilo.
Case 7.— John W. Shelton, Co. C, 27th Miss.; age 35; admitted April 27, 1864, complaining of dyspnoea and
pain in the cardiac region. The pulse was full, quick and hard, and there was dulness with friction sounds over the
heart. He died twelve liours after admission, i'osf-mor/cni examination : Heart partially adherent to pericardium;
sac containing effused liquid: walls of heart thickened: mitral orifice slightly contracted. — Act. Ass't Suriiion .V. K.
Uhnxon, Rock Islaitd Honjiita}, lU.
Case 8.— Private .lohn \V. Manson. Co. H, llSltlf Pa.: age 22: received May II, 1805, from Filbert street hos-
pital. He was much debilitated and had pain and oppression in the cardiac region. Ho died on the 1.5th. [This
man was admitted .June 23, 18(>3, into McClellan hospital, Philadelphia, where he remained under treatment for
chronic bronchitis until .\pril 12, 18G5, when he was transferred to Filbert street.] rost-iiiortcm examination: The
lungs were nnich congested. The pericardium contained about a quart of serum; the heart was enlarged and its sur-
face roughened ; the left cavities contained a dark clot and the right cavities a yellow fibrinous clot. The kidneys
were congested. The other organs were normal. — Sattcrlce Hospital, rhiladelphia, Fa.
RuPTURR OF THE Heart. — jSTotwithstancling the excitation to which the inuscular sub-
stance of tlie heart was subject in the exhausting exercises of the field, — notwitlistanding,
also, the irritable condition just described, the flaccidity and degeneration .so common after
attacks of typhoid and other adynamic fevers, and the dilatation, believed liy Taylor to be
consequent on pulmonary obstructions, — rupture of the heart must be considered as phenom-
enal. The following is the onlv recorded case:
Private William Sands, Co. A, 147th Pa., was admitted May 7, 1863, with a tiesh-wound of the tliigli, received
at Chancellorsville on the 3d. The patient seemed in good condition and complained of nothing apart from his wound.
On the nmruing of the 15tli, Dr.,A. P.Williams having been called to see him, found him so near death by asphyxia that
no opportunity was afforded to examine the chest during life. At the evening visit on the previous day the patient
had some fever and complained of restlessness, for which an opiate was administered. About midnight his mind
wandered somewhat, but not more than might bo attributed to the opiate. After this the nurse on duty noticed that
his breathing was short and somewhat labored; but as he was ([uiet and made no complaint the attending surgeon
was not called, rost-mortem examination: The ball, which had impinged on the fenmr without fracturing it, was
removed from the wound, which showed nothing unusual. On elevating the sternum the thoracic cavity was found
filled with black blood. The lungs adhered to the walls of the thorax and the diaphragm; the pericardium to the
pleura and the diaphragm: these adhesions were firm and extensive. The heart, enveloped in its pericardium, was
carefully removed : the pericardium was firmly adherent to the heart. An opening nearly half an inch in length was
found exteniling through the anterior wall of the right ventricle and its adherent pericardium. On strip])ingoft" the
pericardium the heart, which was of large size, appeared paler than natural, having evidently undergone fatty degen-
eration ; the opening in the wall of the ventricle was in the direction of the muscular fibres and was rendered valvular
by the intrusion of one of the fleshy columns. Every point in the ca.se shows that the cause of death was rupture of
the heart not following any violent exertion. The nurse's statement that he noticed the short breath of the patient.
Borne hours before death, and his asphyxiated appearance when Dr. Willi.\ms saw him, indicate that death was.
oansed by the gradual eflusiou of blood compressing the lungs. The man probably lived four or five hours after th&
rupture of the heart, the colnnina carnea at the base of the opening preventing an immediately fatal hemorrhage..
The opening in the pericardium and heart could scarcely have been made by the knife of the dissector without inflicting
injury on the lleshy colunni at the base of the opening, which, it will be observed, was uncut; nor would the chest
have been suddenly tilled with blood by a poM-mortcm cut in the right ventricle, in which was found a large soft clot. —
J»»"( Surgeon Alixamkr Ingram, I'. 6'. A., St. Alogsim Hospital, WaKhington, D. C."
There occurred in army practice many sudden deaths which were attributed to the failure
ot a relaxed or degenerated heart or to the development of fibrinous concretions within its\
• Rapture of the heart, aa shown by Richard Quais in liis article On FaUij Dueme of the Heart, — SZedu^-Cliimrgicnl TrnoMctinnn, London, 1850, p.
'M, — is A not unfrequfnt ti-miinatioii of fatty or other dogenerHtion of it8 Duiscniar strncture ; in a scries of S3 cases of fatty heart, deatti occiin-c<n)y rup- .
Inre in 28. Of 10 caj^-s coIIiH-te<l l>y B.iylk, 14 wen? in tfie left ventricle, 3 in the right, 1 at the apex and 1 in the septum. — CtjdnpeAia of Pntctknl Medicine,
n, 1M,\ p. 410. In 52 casw by GlvOE, the left ventricle was the seal in 37, the riRlit in 8, both in 2, the right auricle in 2 and the left in Z.—.Atltv> ihr rallml,
AmU. i Die ZrTTeiMniH<j iU-* Jlrrzeiix. p. 2>, Jena, 1S43. The rupture is usually suddenly elTocted and death is correspondingly sudden in its advent, the action
of the heart U-ing i>ver|NiwenMl by the accumulation of bhuMl in the jiericardiuni. Sonietinies, however, death is delayed for many hours : 'WAl.snE gives -.
a case in which life conlinueil for thirty hours after the manifestation of the first symptoms of the lesion, which was situated close to the apex of the right
Tentricle and so small as lianlly to give jia.'Vage to an ordiuar>- itiu. —ItiM-oees of the UeaH ami Great Vesfeh, London, 1S73, p. 414. Fli.nt has known death j
4obe delayed for six hour>4 after the occurrence of symptoms indicating rupture, life having been prolonged by the temporary closure of the iM-rforatioDj
bymeana of a clot. — Praetieo^f ^fe<lieiuc, 1S84, p. 3o8. .\ceording to Walsue V.ie fissur:; is usually in the Hue of the main faiiciculi of the cardiac fibres^
868 CARDIAC DISEASES.
cavities; but in the following case, reported by Dr. Leidy, neither of these conditions appears
to have been present :
I'l iv;itf Edward Jlibliavd, Co. I, 211th N. Y., was admitted Aug. 10, 1862, vritii disease of tlie heart. He fell dead
suddenlvon the 15tli, while staiidiDg listeuing to apreacheron the hospital grounds. Pos/-mo)-(e»i examination: Body
vigorous : age about 40. There was about one gill of liquid in the pericardium, hut no evidence of disease of the heart.
The luuirs also were healthy, nor could any lesion be detected in the abdominal viscera. Except a more than usually
bloodless condition of the pia mater, the brain was likewise healthy in appearance. Of what did this man die ? Was
it merely an emotion?
A.VEURISM. — Smiley referred tlie occurrence of aneurism of the aorta to the overtask-
ino- of x'ouno- or enfeebled men beyond their powers of endurance. The accuracy of this
observation cannot be verified by the data at command; but it seems highly probable that
the violent cardiac action, frequently incident to active service, was the cause of sudden
death in these aneurismal cases. A few instances of rupture appear on the records:
Case 1.— Private Patrick Fletcher, Co. H, 4th U. S. Cav.; age 42; died suddenly while in camp, Dec. 9, 1863.
He had not been at surgeon's call daring his service of over ten months in this regiment, but a comrade stated that
he would occasionally place his hand to his side, complain of pain, and remark that he would die of disease of the
heart. He had previously served five years in the 3d Art'y and five years in the 2d Inf. On the day before his death
he marched with his regiment a distance of twenty-five miles. It rained all day and was very cold, nearly freezing.
He, like every one else, had to sleep on the ground in wet clothes. Next morning a march of five miles was made and
the regiment went into camp. Fletcher, while assisting to pitch a tent, fell down and, gasping once or twice, died.
rost-mortem examination: Neck swollen as though the bloodvessels were engorged. The pericardium was smooth and
healthy, but was enormously distended with twenty-six ounces of blood-clot and serum. The heart was of natural
size, but the Walls of the left ventricle were thicker while those of the right appeared somewhat thinner than usual ;
the endocardium and valves were healthy. In the aorta, about an inch and a half above the valves, was an aperture
a quarter of an inch in diameter, opening into an aneurism the size of an egg, the walls of which adhered firmly to
the superior cava and pericardium and were as thick as those of the aorta itself except at a point where rupture had
taken place into the pericardial sac, — [Specimen 965, Med. Sec, Army Medical Museum], The left i)leura was adhe-
rent and the lung engorged with venous blood ; the right lung was healthy , although much compressed by the liver,
which was so engorged as to reach the lower border of the third rib. The spleen was enlarged ; the kidneys healthy. —
Act. Ass' t Surgeon Thomas Bowen, ith V. S. Cav.
C.\SE 2. — Private William Cunningham, Co. A, 1st Md.; age 22; while on guard, June 27, 1865, fell to the
ground insensible and expired in a few minutes. It was reported that for some time before his death he suffered
much from mental depression. Post-mortem examination: There was great venous congestion of the brain and lungs,
with distention of the large vessels of the neck. The pericardium was distended with blood w liicli had escaped from
a small aneurism of the aorta situated just above the semilunar valves; the sac of the aneurism comnumicated also
with the pulmonary artery. ISjiecinieii 558, Med. Sec, Army Medical Museum.] — Suryeon Aaron Ansell,lst Md.
Case S.^Private William Robinson, Co. C, 5th Pa. Reserves, was admitted Feb. 19, 1863, with a dislocated
ankle. He died suddenly, March 26. Fost-mortcm examination: Body well nourished. The braiu and lungs were
healthy. The pericardium was much distended by six ounces of reddish serum and a clot, nine ounces and a half in.
■weight, completely surrounding the heart ; the right auricle was thinned towards its appendix ; the lining membrane
of the left auricle was pale and roughly areolated: the cardiac valves were healthy: The aorta was congested and
atheronuitous, as were tlie great vessels arising from its arch. On the posterior surface of the aorta, about two
inches from the semilunar valves, was an aneurismal tumor with a cavity as large as a black walnut, communicating
by a minute valvular opening with the pericardium. — Lincoln Hosintat, Washinyion, I). C.
Case 4. — Private Charles Willmau, Co. G, 1st Mo. Art'y; age 32; was admitted Oct. 27, 1863, with aneurism ol
•Dhe abdominal aorta, for which he had been under treatment for four or five months in Nashville. On admission he
■ complained of .severe pain, with constant throbbing in the epigastric region. An oval tumor, not so large as a hen's
■ egg, was felt pulsating immediately below the ensiform cartilage, where a bellows murmur was heard. A soft bellows
murmur was also heard over the apex of the heart, growing louder towards the base and the root of the left lung.
There was bronchial respiration with pectoriloquy at a circumscribed spot below the clavicle; the patient had also
■ some cough. Milk diet was prescribed, with morphia to relieve pain. During November the epigastric pain con-
tinued severe and extended through to the back. The patient was compelled to remain constantly in a recumbent
position, feeling easiest when lying with his head bent down between his knees. He sometimes recjuired as much as
.two ajid a half grains of morphia in twenty -four hours to relieve the pain. On December 6 he was seized with sud-
«len and severe convulsions, accompanied with great pallor and loss of consciousness. He continued in this condition
until death on the morning of the 7th. Post-mortem examination : The left lung was bound by old adhesions; its apex
contained a cavity and a number of tubercles. The aorta presented two aneurismal dilatations, — [Specimen 502, Med.
Sec, Army Medical Museum], — one, about the size of an orange, at the arch, involving the great vessels, the other,
of larger size, iu the abdomen surrounded by much clotted blood which had escaped from a rupture in its coats. The
bodies of the last dorsal and first lumbar vertebra; were extensively eroded by the pressure of this sac, — Surgeon Alex-
ander T. Watson, r. S. Vols., Claij Hospital, Loiiisi-iUc, Eg.
HAEMOPTYSIS. 869
CAtiE 5.— I'liviito Georgo Blake, Co. C, 7th Conn.; ii^o 29: was ailmittea from Hilton Head, S. C., .luno 2!i,
1863. with a pnl.satinj,' tumor, apparently abont three inches in iliamcter, Jnst above anil to the left of the iimbiliens;
an aneurisnial bruit was heard over it. The patient first noticed the swelling after an extra elfort in lifting heavy
boxes some nuiuths before. He had not much pain, but was feeble, sleepless and without appetite. Treatnu'nl con-
sisted in the use of tonics, stimulants and nourishing diet, with occasional opiates. Death took place suddenly,
August 7. Posl-moittm examination: The cavity of the abdomen was tilled with blood from the ruptured aneurism.
ISpeciiiuH 545, Jled. Sec., Army Medical Museum.]— Jc/. J»»7 Siirgton 1). L. Duijgett, limtjht Uoxpitul, y\iv liui-ni. Conn.
- On the other liaiid, it may be questioned whether tlie feebleness of the circuhuion
iiuluceil by debilitating camp diseases, as chronic diarrhrea, did not, under certain circum-
stances, lavor the progress of conservative changes in the aneurismal sac. In the following
case the walls were extensively thickened by deposits of lamellated fibrin, and in a case
reiiorted by J. L. Oliver as having occurred in liis ward at 'SlWl Creek hospital. Fort Mon-
roe, Va., a solidified aneurismal tumor was found on the aortic arch of a man who died of
an e.\;hausting diarrhoea.'-'
C.\SE 6.— Private James McFarland, Co. A, 22d 111.: age 24: was admittc.l Juno 22, IXiV.i. much emaciated Irom
diarrhu^a of some months' duration. A pulsating tumor was oli.served in the umbilical region iunuediately in the track
of the aorta, but on careful examination it was found to be susceptilile of lateral displacement to a ccuisiderable extent :
towards the right it could be pushed over into the lumbar region. The patient becinue exhausted by the diarrlnen,
and died July 1. roit-mortcm examination: The small intestine was extensively ulcerated. The superior nie-sen-
terie artery was dilated into a spherical aueurismal tunu>r the size of a small orange. ISpecimen 503, Med. Sec., Army
Medical Musetim.] — Act. Ass't Suriieo". B. F. Grant, Hospital Xo. 1, HntijxvUhjKij.
II.— MORBID CONDITIONS ATTRIBUTED TO THE WEIGHT OF THE ACCOUTREMENTS.
HAEMOPTYSIS was so prominent a symptom in some cases of consumption that it was
occasionally made their diagnostic title on tlie hospital case-books. Tiiere occurred, how-
ever, certain cases of hemorrhage from the lungs in which tubercular disease was absent or
not manifested by its usual signs: In cases of irritable heart, the expectoration was some-
times tinged with blood during and after a paroxysm of accelerated cardiac action and
oppressed breathing. In other instances haemoptysis was apparently connected with injurv
from various causes, as from contusion by blows or falls, strains in lifting, etc. In many
cases the soldier, and frequently the medical officer, attributed the heemoptysis to exercise
under the weight of the knapsack and pressure of the belts: and. among cavalrymen, hard
riding was sometimes sufftrested as a cause.
Alfred Stillk of Philadelphia, in a special report dated March 1, 1863, gives a brief
account of seven cases of haemoptysis apparently unconnected with pulmonary consumption.
The records of the Quincy hospital, Illinois, furnish two cases; but in one of these, Carnaby,
the subsequent history of the individual shows him. discharged from service March 12, 1865,
because of phthisis pulmonalis, and in the other, Moss, the terms of the record cast a doubt
on the character of the case, inasmuch as hajmoptysis was occasionally selected by the malin-
gerer as the ailment by whiqh to lengthen his stay in hospital or secure his discharge from
the service. The cases are as follows:
Case 1. — Private Alpheus Fuller, Co. G, 16th Me., a tall and muscular man, entered tlie ward Sept. 27, 1862>
He stated that in lifting a heavy log he strained himself and was attacked with ])ain in the left side and ha-uuiptysis.
The blood at first was abundant and of a dark color, but gradually diminished in (luantity and was mixed with
mucus and saliva. The chest presented signs of chronic pleurisy of the left side, confined to the lateral and inferior
* Tlic patu-nt wiis extremely emaciated aud liis countenance distrcsseil and haggaril. He had a quick, irritable nud weak i.ulse and consiUeniljlc .
Jifflcultj- in (jn'atliinj;, the uostrils dilatiuj; widely during inspiration. He liad contracted diarrhoea during the Peninsular Camiiaign. Itis general
ippeanince. eniacialiou. cough and nuicous expectoration led to a suspicion of phthisic, hut auscultation dipcovered none of the iihysicul signs of that di»'ase.
Astringents anwiyiies and !slinnilant.s » ere administered on account of the exhausting diarrlioa. but although they se( nied t" give temporary relief the
lenient sank gradually and died about feu days after his admission, rofl-imrlem examination revealed a highly congested ileum anil unusually healthy
lungs. .\ hanl heniisphirical tumor, about three inches in diameter, was discovered on the |H«terior a»i)ect of the arch of the norta, compressing the
trachea. Ufwn cutting into this tumor it was found to be a largeancurism the cavity of which had been filled by layereof Ijinph, the layers distinct and
arrangid like the coats of an onion. The calibre of the artery remained of its original size. See Tram. Meil.Soc. Pamti/lramu, 1SC4, p. 430.
870 HEMOPTYSIS.
rcions, and ^vas the seat of coustaut paiu or a sense of constriction. His general healtli had improved, Imt the con-
dition of tlie side and the h;pmoptTsis were unchanged at the time of his di.scharge, Feb. 4, 1863.
Case 2. — Private David Cunniugliam, Co. C, 12th U. S. Inf., entered Nov. 8, 1862, convalescing from intermit-
tent and typhoid fevers. About the commencement of the latter disease he had au attack of hiemoptysis after stoop-
iwr and straining. For some weeks past he lias expectorated more or less blood every day, in the morning mixed with
mucus and in the afternoon clear. He is also becoming shorter of breath and losing flesli and strength. He was dis-
charged Feb. 10, 1863, having had repeated hiemoptysis, with progressive loss of flesh, but without any defiuite phy-
sical signs of pulmonary tubercle. [From the case-book we find that the quantity of blood brought up by this patient
was about half an ounce daily, and that the respiratory murmur lacked clearness on both sides.]
C.^SE 3. — Private John AVeidness, Co. I, 1st N. Y., entered Nov. 13, 1862, suffering from chronic diarrhoea and
chronic pleurisy of the riglit side. On the 23d he had h.fmoptysis, was much emaciated and coughed and expecto-
rated mucus; but under cod-liver oil and astringents, with good diet, his flesh and strength gradually improved,
although from time to time he brought up blood. Feb. 28, 1863: Tlie signs of chronic pleurisy persist: the diarrhoea
is much reduced, the cough diminished and no pliysical sign of tubercle can be detected. His general nutrition is
good. [The physical signs as recorded iu the case-book, under date December 28, are dulness, greater on the right
side than on the left, mostly below; respiration feeble: no bronchial respiration or rlionehus; liver depressed: costal
cartilages prominent at epigastrium.]
Ca.se 4. — Private Hiram Morse, Co. C, 23d N. Y., entered Dec. 18, 1862, having had haemoptysis for .several
months, which he attributed to the weight of the knapsack and cartridge-box. He was rather thin but not cachectic.
His general health improved. At the present time he presents no physical signs of tubercle except a slightly dimin-
ished respiration at the apex of the right lung. He alleges that lie continues to spit lilood, but in small fiuantities.
[The case-book shows that this man was returned to duty March 7, 1863.]
C'a.se 5. — Private Aberuetha Grundyke, Co. G, 1.5th N. J., entered Dec. 18, 1862, complaining of pain in the right
.side, which is dilated and dull on percussion in its lower half. He has had no active symptom but haemoptysis, for
which no special cause is assigned except the weight of the knapsack and cartridge-box. The quantity of blood
expectorated is small, but it is frequently discharged. His general appearance and flesh have decidedly improved.
[The case-book, December 31, records the signs as: Right side developed fully an inch more than left at level of nip-
ple, below which there is dulness and diminished respiratory murmur but no rhonchns. March li"), 1863: Recom-
mended for discharge on account of chronic pleurisy and hiemoptysis.]
Case 6. — Private George McAually, Co. E, 1.5.5th Pa., entered Dec. 12, 1862. In June he was injured by his
horse falling upon him, after which he became subject to hremoptysis, and was subsequently attacked with typhoid
fever. Since his entrance he has suftered from palpitation of the heart, general debility, nervous trembling and con-
stant pain in the left side beyond the heart, at which point there are signs of chronic pleurisy: but the chest presents
no physical signs of heart disease or of phthisis. He was discharged Feb. 26, 1863. [The case-book does not mention
the fall of the horse, but attributes the chest troirble to the sabre-belt and hard riding.]
Case 7. — Private Peter McGowan, Co. H, 6th U. S. Inf.; age 39; entered Dec. 18, 1862. At Antietam, Septem-
ber 17, he received a shell contusion on the left side, since which time he has had repeated hiemoptysis. On Feb. 9,
1863, while scrubbing the floor he threw up almost half a gill of dark blood. At this time the lower part of the left
side was sensitive on percussion but not dull, and respiration was everywhere pure. On the 10th the haemoptysis
recurred, but he has been free from it since then. Meanwhile he has had several attacks of gastric pain, with furred
tongue, anorexia, iujected eyes and frequent pulse — such symptoms, indeed, as would be produced by a debauch, but
he has been under observation and has not quitted the ward. [He was returned to duty March 23.]
Case 8. — Serg't William A. Carnaby, Co. I, 52d 111.; age 25; was admitted Sept. 24, 1864, from furlough. He
had been taken with au affection of the lungs in ttlaj, and began to spit up blood about June 1 ; he had also suffered
from diarrhoea for twelve months. On admission there was some cough with emaciation and debility, but he had not
expectorated blood for four weeks. Exertion caused shortness of breath and soreness iu the right lung. He improved
under cod-liver oil, stimulants and full diet, and was returned to duty December 7. — UospituJ, Quincij, III.
Case 9. — Private Joseph H. Moss, Co. F, 103d 111., was admitted Nov. 29, 1864, with lur^moptysis. He left his
regiment on July 1.5, 1864, on account of i^aiu in the breast, and has done no duty since that time. He complained of
nothing else, but showed blood in the spittoon on several occasions. He seemed perfectly well and was jiut on duty
in the kitchen, where he proved quite efficient. He was returned to duty Feb. 20, 1865. — Hospital, Quincy, III.
Harm to the soldier by the weiglit of the knapsack was in general effected during drills
and parades at tlie recruiting and other stationary camps rather tlian in the field. When
unusual exertions were anticipated in a proposed campaign knapsacks became of secondary
importance. They were stored during the period of active service and returned to the men
at its conclusion, or, if no official provision was made for their disposal, they were thrown
away without concern as to their recovery. Veteran troops, as a rule, dispensed witli their
use. A change of underclothing was carried in the blanket, which was rolled into a cylin-
der and slung across the body from the shoulder to the opposite hip, where its free ends were
tied together by a string. In fact, when the march or service became exhausting, the soldier's
HERXIA. 871
impedimenta were carried at will. The harm accruing was the result of exertiou under a
given burden, and in no way pertained to an obligatory method of supporting it.
The figure on the right side of the plate focing page 870 shows the regulation position
of the knapsack, blanket, canteen, haversack, cartridge-box and bayonet-scabbard on the
person of the soldier when outfitted for service; the figure on the left, the arrangement of the
straps and belts by which these articles were supported; the central figure, the veteran in
light niarchiug order, with his blanket dis2>osed en baJidoliei-.*
Hekxia. — The cartridge-box, resting on the loins and held in place bv a belt fastened
lightly around the waist, was the subject of a more extensive accusation than the various
weights sustained by the dioulders and thorax of the soldier. Hernia, which caused 65.9
per thousand of the discharges for disability ,f was occasioned or aggravated by exertion under
the 2>ressure of this waist-belt.
Medical Inspcclor E. P. A'oLLr.M. U. S. A., Jug. 21, fSG'J. — Several cases of hernia had occurred in this refriiiieut
[1st Va.]. caused, in the opinion of the surgeons, by the pressure of the belt on tlie abdomen in marching and other
hiWrious efforts. This seems reasonable, as the weight of ammunition carried is now four pounds.
SMrgeon H.- P. Stroxg, lllh Wh., Sulphur Springs, Mo., Dec. 31, 1861. — I have had recently two cases of inguinal
hernia, apparently caused by the weight of the cartridge-box upon the waist-belt.
Brigade Surgeon Thomas H. B.^CHE. I". S. V., Ship Inland, Miss., April, 1862. — Hernia is very common. I have
noticed it frequently elsewhere than at this post. The primary canse may be a tendency to the disease, but I think
the great weight of the cart ridge-box. with forty rounds of Minie ball cartridges, the chief cause. The belts are buckled
tightly, instead of hanging easily on the hip-bones. They hold by their tightness and diminish the diameter of the
aWomrn at the waist. When the men run and pant violently, each contraction of the diaphragm forces the intes-
tines downward and imperceptibly enlarges the internal abdominal rings, making them ready to catch the gut.
Surgeon Orphecs Everts, 20//i Jnd., PoolesviVe, Md., Oct. 24, 1862. — Rupture disabled a large number on the
various marches. It was attributed to the heavy weight of ammnnition upon their belts aud to the handling of
heavy logs in constructing temporary breastworks. From Fair Oaks to Harrison's Landing General Kearny ordered
the men to carry one hundred aud fifty rounds of ammunition. Some of them did so.
Surgeon E. GiuswoLii. 112(7i P<i.. Fort Saratoga. TTashington, D. C, June 5, 1862. — The artillery drill is laborious
and the infantry drill fatiguing. Several cases of hernia have been produced by heaving at the guns.
Surgeon L. CJ. Meyer, 2oth Ohio, HuitonariUe, JTest Va., Jan. 3, 1862. — Carrjing the logs by hand caused new
cases of hernia, and aggravated and brought to my notice old ones not known to me before.
Surgeon D.win Meisritt, both Pa., Beaufort, S. C, May, 1863. — Hernia has been common during the past two
years. The cause, in the opinion of the men, was the double-quick brigade drills instituted by General Viele: but
as the men used the shoulder-straps aud wore the belt loosely, the double-quick drill could hardly have been the prev-
alent cause. Some of those affected referred the accident to lifting heavy logs whilst at work on the stockade-fort
at Hilton Head: others said they had been ruptured by falling. One. now a nurse in regimental hospital, became
ruptured, according to his own statement, at the battle of Poeotaligo by jumping over a ditch. But we are inclined
to believe that many were ruptured before they came into the service, and subsequently, finding the hardships of
military duty to be disagreeable, presented themselves as ruptured and eligible for discharge. In regard to the exam-
ination of the recruits for this regiment, the writer is of opinion that many men were admitted to service whom he
would certainly have rejected had he enjoyed the privilege of selecting the men whom he was afterwards to treat
during their military career.
Strangulation of the hernia was an uncommon occurrence, for of 24,353 cases of rupture
• A btianj of infaDtrr officers, Nov. 24, 1874, recommended the adoption of a clothing-hag, wliich, with the haversack, vms to Ik* slung from a liack-
ftA ABd shonlder-brare.-s. constituting a kind of yoke for their support. It wa^ claimed that the back-pad gave additional liearing surface for tlie weight
carried and that iu shajie enabled the shoulder.«tnips to be riveted in such a manner as to sejiarate them on the back and shoulders, while tlie method of
conne<-ting the fn>nt enils of the shoulder-sti^ips secured a b*-aring on each. Tlie braces adjusted themselves to fit any size or form of shoulders and
enabled a Iciul to l>e carried vrithont compressing the waist or chest, l«earing down on the hijis or dragging the shoulders liackward. The lags were to hv
worn on the porterior aspect of each side, well up under the armit. Tliis, the Pabiier Lnw Sjfslem, was approved aud the new equipments were issued, but —
"from Captain 31ichaelis' report — it apiicars that in Indian aunpaigniug the carrying-braces werv regarded as a failure, and were therefore not used.
He says : "The men are always in light marching ordeV and never under any circumstances use the carrying-brace.* .\nd further: *I saw two comj^anies
of the nth Infantry, under the command of Lt. Col. Chambers, a member of the lK^t\l which adopted the carTying-biscesyst "m, which had been supjilied
with the new model, under cin-umsLinces which re.^uired them to make forced marches, and yet not a single soldier wore the brace. * « « When
General Terry's colnmn marclie<l frt-m Fort .\. Lincoln I h.ad fifty sets of the new equipments on band for issue ; I could not induce the infantry officers
to five them a trial during the cam]aign — the mere sight of a man in harness, as they expressed it, was sufficient to condemn the .sy>tem for field serv-
•**.*" — <^- Sotn 67, WMhiMglrm. Job. 1, 1877. The clothing-bag has since l<een miidified — Ord. Koie$ 170, March 4, ISS'2 — into a knapsack carried high on
the lack by straps which jnss from its upper margin over the shoulder aud under the aruipit to its lower comers — in fact a rt-luni to the knaiisack of the
period of the civil war. But thui. practically, is not in use. Our soldiers in their Indian campaigns, as formerly during the marches aud battles of the
rebellion, sling their blankets cw boHdoiia- ajxd do without a knapsack or clothing-bag. t See atpm, page 27.
872 HERNIA.
reported among the white troops during the five and one-sixth years, onl\- 39 liad a fatal
termination. The records of two of these cases have been preserved:
Case 1. Ser"-'t Lorenzo McBride, Co. A, 1-lth Veteran Reserves; age 35; ■nas admitted at 10 r. M. March 8,
1805. with symptoms of strangulation of the bowels. Vomiting was freqnent ; the pulse quick and feelde; the coun-
tenance anxious and expressive of great suffering. He died thirty-six hours after admission. Post-mortem examina-
tion : The stomach and a large portion of the great omentnm were found in the thoracic cavity, the protrusion having
been effected through the esophageal opening in the diaphragm, — [Specimen 522, Med. Sec, Army Jledieal Museum].
The protruded parts were gorged with blood. — Act. Ass't Surgeon Isaac J. MoxleijjAayur Hospital, Washington, D. C.
C.vsE 2. — Private Jno. A. Robbins, Co. 1, 143d Pa., was admitted Oct. 27, 1863, on account of functional disease
of the heart. He wore a truss, but gave up its use in January, 1864, saying that his hernia no longer trouljled him.
He became iutoxicated on the lltli, and late on the evening of the following day complained of the hernial tumor.
He lay in bed with his knees drawn up, lint had no sjiecial pain. The hernia was of moderate size but irreducible
by the taxis under ether. A second eftbrt was made to reduce before resorting to operative proceedings. On the
morning of the 13th Dr. A. D. Hall opened the sac and found a mass of healthy omentum, a trifling ett'usiou and
about thirteen inches of uuadherent intestine of a ruby color. While incising the internal ring on the tip of the
finger the bowel became wounded by riding against the knife, and although the wouud penetrated only to the mus-
cular coat it bled so freely that a ligature was put on it before the intestine was returned. At one stage of the oper-
ation the ether produced alarming symptoms, the face becoming livid and the respiration gasping and almost ceasing.
Ammonia to the nostrils, artificial respiration and galvanism to the cervical spine and pra-cordia were resorted to,
and the patient rallied slowly. At 2 p. M. he was free from pain and quite comfortable, his countenance tranquil and
pulse 112. An opiate was given to induce sleep. At 2 a. m. of the 14th he expressed himself to the nurse as feeling
very easy, but half an hour afterwards was seized with a convulsion, labored respiration and coma, which ended in
death at 5 A. M. Post-mortem examination: The membranes of the brain were much congested and the veins of the
sulci engorged; the lateral ventricles contained yellow serum and the choroid plexus in each was congested. The
right lung and the posterior part of the left lung were deeply congested. The pelvis was filled with bloody serum;
the returned portion of the intestine was of a deep-red color, with patches of fresh lymph near its mesenteric attach-
ment and adhesion of its coils; the ligature which had been placed on the wound of the intestine had come away aud
there was a recent clot on its surface; the omentum was inllamed and the peritoneum around the internal inguinal
opening marked by deep ecchymoses. — Hospital, 16ih and Filbert streets, Philadelphia, Pa.
In a third case the present writer operated but failed to save the patient:
AVhile inspecting the field hospitals of the Second Army Corps at Burkesville, Va., Ajiril 16, 1865, he discovered
a case of strangulated scrotal hernia which had been treated for several days by Epsom salt, croton oil, etc., as one
of obstinate constipation by an inexperienced and careless ward physician. Chloroform was immediately adminis-
tered and cautious efforts made at reduction by Surgeon Charles Page, U. S. A., Medical Director of the Corps, and
others, but, these failing, the sac was laid open aud the loop of intestine liberated and returned to its place. The
patient died a few days afterwards of peritoneal inflanuuatiou.
Lumbar P.\i]srs, etc. — Pains in tlie abdominal walls, in the loins and lower extremities,
by some referred to rheumatism, were by others ascribed to congestion of the membranes of
the spinal cord, induced, in part at least, by the weight of the cartridge-box.*
Ass't Surgeon DwiGHT M. Lee, 22^/ X T. Car., Harper's Ferry, Va., Aug. 31, 1862.— I wish to advert particularly
to the injurious effect of the body-belt worn by many of our regiments. The weight of forty to eighty rounfls of
annnunition in addition to a heavy side-arm, supported entirely upon the hips and loins, is, I am confident, most per-
nicious. As we made no long marches I failed to trace any case of hernia to its agency, but there was constant com-
plaint among the men of paiu and weakness in the back, of soreness and tenderness in the bowels, and in some cases
evidence of renal congestion. I was obliged to keep many men, otherwise fit for duty, on the sick-list, to avoid
imposing on intestines already enfeebled aud irritated, a pressure which I feared might provoke severe inflammation.
Ass t Surgeon Lee speaks of renal congestion in connection with tlie weight suspended
from the cartridge-belt; but in none of the recorded cases of disease of the kidney is the
attack referred to this as its cause. In fact, the only case of injury attriljuted to the belt,
outside of those already mentioned, is the following:
Private George H. Tarbox, Co. E, 18th Conn.; age 25; was attacked with diarrlirea after a fatiguing r.,arch,
June 30, 1864, near Gauley Bridge, Va. He remained with his compauy, and after ten days of exposure, fatigue and
no treatment, reached Slartinsburg, where the diarrhu'a became complicated with paiu and swelling in the upper
part of the abdomen. These he attributed to his buckled belt, the weight he was carrying aud the exhaustion of the
march. He was admitted July 27: Tongue very red; pulse frequent; diarrhrea; extreme tenderness and swelling
with fluctuation over abdomen: skin hot; countenance anxious. He was treated with small doses of blue-pill and
Dover's powder, castor oil aud afterward turpentine emulsion, opium and milk diet. On August 7 small doses of
tincture of aconite were given, and next day balsam of copaiba and spirit of nitre. On the 10th the swelling was cir-
* See snt)ra. pa^e 833.
CONSTIPATIOX, HEADACHE AND XEUKALGIA. R7!>
cnmscriliod ami tender. Tincture of iuiliue was nrplied and Rocliellc salt administered. Xext day caloniol, iiieiac-
iianlia and oi>ium were given, and on the 15th the iodine was reapplied. He had a severe chill on the IKtli, after which
the fever subsided somewhat, the tenderness became lessened and the patient felt better and was able to walk about,
but his tongue continued red and aphthous and his face and feet (edematous. Opiates were jriven at night and the
iodine reapplied until the 28th, when he was seized with violent pain in the bowels and died ne.\t morning. Xo
autopsy. — Jlospital. CiimberUiiKl, Mil.
m.— CONSTIPATION. HEADACHE AND NEURALGIA.
Constipation was the most frequent ol tlie diseases of tlie digestive orgaii.s and headache
of tlie diseases of the nervous system, witli neuralgia following closely in order of frequency.
There were reported among the white troops 145,960 cases of constipation, equivalent to
111 average annual rate of 65.5 cases per thousand of strength; 66,826 cases of headache,
equalling an annual rate of 30, and 58,774 of neuralgia, equalling a rate of 26.4. Death
in these cases was an accident explicable on the assumption of errors of diagnosis or the unre-
corded supervention of some fatal disease. Twenty -three of the constipated patients died,
one of the cephalalgic and eighteen of the neuralgic. Among the colored troops tlie cases of
constipation numbered 17,204, or 93.8 annually per thousand men ; of headache 14,732, or
80.3 annually, and of neuralgia 6.018, or 32.8 annually. Six deaths were reported under
the heading of constipation, one under headache and five under neuralgia.
Constipation was relatively of more frequent occurrence during the earlier months of
the war. This may be ascribed to the change in the food and habits of the men consequent
on their enrolment for service. During the progress of the first winter, as the volunteer
troops became accustomed to their new mode of life, the disordered condition became less
frequent; but subsequently, with the occurrence of the warm weather of the second sunmier,
the number of cases increased to its maximum. This increase was in part due to the advent
of new troops and in part to a seasonal influence, which was distinctly manifested during
the summer months of 1864, '65 and '66. In 1863 the seasonal influence was marked less
by a defined accession in May, June and July than by a suspension of that decline in the
rates which should have followed the gradual accommodation of the troops to their new
manner of life. The rates of prevalence among the colored troops presented analogous
characters — irregular and sudden elevations during the first year corresponding with acces-
-ions to the strength of the command, and seasonal variations giving a maximum in July
and a minimum in the winter months.
An intimate correspondence may be observed by comparing the lines of prevalence
A constipation with those of diarrhoea and dysentery. Dr. Woodward recognized that the
summer rates of constipation were larger than those of the winter months, and that the
monthly fluctuations in so far harmonized with those of diarrhoea and dysentery, this con-
stituting in his view the only similarity in the curves of these functionally dissimilar affec-
tions. In reality, however, there is no notable variation in the curves of prevalence of
diarrhoea and dysentery that is not found in those of constipation. Of course the variations
in the latter disorder were small as corajDared with those of the more prevalent diarrhoeas;
but in both instances they preserved similar proportions to the totality of frequency. From
this may be inferred a similarity in certain of the causative conditions. The increased
prevalence of constipation in the summer may be attributed to the irregularity introduced
into the personal habits of the men during this the season of active campaigning. Even
the calls of nature were often deferred on the march or other toilsome service until a more
convenient opportunity, which, when presented, not unfrequently found nature irresponsive.
Med. Hist.. Ft. Ill— 110
874 CONSTIPATION, HEADACHE AND NEURALGIA.
Certainly many of the cases thus originating cuhiiinated in a subsequent diarrhoea, wliich
was reported, altliougli the preliminary condition of constipation remained unnoted.
To this intimate connection between constipation and diarrhoea may be referred the
statistical differences which led Dr. Woodward to doubt the intimacy of the connection.
He found that it was precisely where diarrhoea and dysentery were least frequent that con-
stipation was most prevalent, the average annual rate of the latter being 132 in the region
of the Pacific, 70 in the region of the Atlantic and 60 in the Central region, whereas the
fluxes were least frequent in the Pacific and most common in the Central region.* But
the failure of seasonal influences to sustain an argument based on the antagonistic quality
•of the regional influences should have suggested a closer investigation of the conditions attend-
ing these dissimilar results. Manifestly the high rate in the Pacific region becomes the sub-
ject of inquiry. This region was garrisoned by an average strength of about 10,000 men,
or less than one-fortieth of the troops from which the medical statistics of the war were
gathered. Moreover, this small proportion of the total force was exposed to few of the
hardships and onerous duties to which their comrades on the eastern side of the continent
were subjected. Their duties differed but little from those of the regular troops garrisoning
the same stations in time of peace. Under these conditions there came up for report minor
ailments wliich would have passed unnoted during the stirring events of an active campaign.
Constipation became thus more frequently re|)orted, although not of necessity more frequent
ki its occurrence, while diarrhoeas were less prevalent, in part at least, because of the increased
attention paid to the preliminary condition of constijoatiou.
But while indicating the connection between torpidity of the bowels and diarrhoeal
conditions as of importance from the stand-jioints of the sanitary officer and the clinician,
the many other causes of diarrhoea and dysentery so admirably discussed by Dr. AVoodward
are by no means undervalued.
Headache. — Traced on the same diagram as the lines of constipation are those of
headache among the white and the colored troops. The parallelism of these lines "is strik-
ing, and suggests that the army might have been preserved from much of its sickness reported
under the term headache had the causes of constipation been better known and more
effectually shunned.
Neuralgia. — The fluctuations in the prevalence of neuralgia were slight and irregular.
The causes of this morbid condition appear to have been constantly in operation and with
but little variation in their intensity. No influence of season or region was manifested;
the affection was as common in Avinter as in summer,— in the Army of the Potomac as in the
■Department of North Carolina. The want of connection between the occurrence of cases
reported under the title neuralgia and the passage of the great autumnal wave of the malarial
diseases has already been mentioned.f In fact, neuralgia seems to have been due to con-
ditions in which the individual rather than his surroundings constituted the prime factor.
IV.— JAUNDICE.
Jaundice occurred frequently in the progress of the malarial and other fevers as the
result of morbid changes affecting the liver or the blood. The yellow coloration in these
cases was mostly an incident or symptom of the well-defined primary disease. There were,
however, a large number of hepatic or haematic disorders in which the alteration of color cou-
*See Second Medical Volume, p. 632. t See wijira, page 82.
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JAUNDICE. 875
stitutoil so prominent a symptom that the disease was recorded under the heading of jaundice.
Xo loss than 71,691 cases of this kind were reported among the wliile troops. Generally
the cases were sporadic, but sometimes a series occurred in a command constituting a local
cpidemrc, whicli was frequently associated with an outbreak of continued fever, sometimes
preceding the appearance of the fever and sometimes following its subsidence. Fortv-seven
cases were noted in the report of the 27th Conn, for the quarter ending March 31, 1863.
Concerninor these the regimental case-book has the followin(<: remarks :
The tlisoase was characterized as follows: Usually some little excitement of tlio pulse; Iicadaeho: liackaclie:
nausea ami fRMjuent vomiting: as a rule eostivencss, thoufjh at times diarrluva, precedeil or succeeded the invasion:
l>ain. apt to he of some duration, in the Inmhar re-jion and in the epigastrium — generally the right hypoeliondrium was
also tender, hut the (irincipal distress was in the epigastric region; in one or two cases the left side of the chest was
complained of: in perhaps one-i'ighth of the cases the right side of the thorax and shoulder seemed to be the seat of
pain: at times the tenderness extended across from one hypochondriac region to the other. The nausea increased to
vomiting, which generally ceased, when not modified hy treatment, during the first wecl, ■ Constipation, when present,
was apt to persist during the continuance of the attack, excepting when obviated hy cathartics. The appetite wa.s
from the first almost absent, and its return was tho most reliable sign of convalescence. The stools, when uninfluenced
by cathartics, wore light in color and deficient in bile. The urine was dark but not scanty; at times it caused a little
irritation in its passage. The pain in tho lumbar region seemed referrible in many cases to tho kidneys; it generally
subsided when the urine became clearer. The eyes in some assumed a yellowish-green and muddy appearance. Con-
valescence was often imperfect, — iu one case, after the pjitient had become strong enough to go on duty , typhoid fever
supervened and proved fatal. Headache was often quite severe in the first stages of the disease, and was aggravated
by the constipated condition. Debility was manifested early, and in some cases contincd the patient to I>ed. After
the liist throe days the pulse generally dropped to the ordinary rate, and in marked cases fell even as low as 1.'), this
condition remaining to the end of the sickness. The skin showed the yellow-green tint. Emaciation was proportioned
to the loss of appetite and gastric derangement: food usually caused great distress until rejected by vomiting. The
tongue in some cases became brown, dry and even glazed or cracked. No case of the disease terminated fatally.
Trc;itment consisted at first of small doses of blue-pill: but this seemed to be iiiefiicient or injurious, at times
increasing the epigastric heaviness and pain. A scruple each of calomel and ipecacuanha, given in one dose as early
as possible in tho attack, acting thoroughly upward and downward, allayed the nausea and vomiting for the next
forty-eight hours and often permanently. Although the patients usually complained of the emetic action, they were
almost invariably changed for the better; the headache ceased or was much mitigated, the lumbar pain became
easier, the skin moister, the pnlse slower; in fact the change was evident and decided. Jalap or rhubarb, with ipe-
cacuanha and capsicum, were ordinarily resorted to when constipation recurred; if these fiiiled to act, as they occa-
sionally did, sulphate of magnesia proved all-powerful. During convalescence qninine, iron and serpentaria were
used with light food. In one case of extreme depression — pul.se 45 to 50, tongue dry and brown, afterwards glazed,
mind somewhat confused and fiice dusky — -a five-grain do.s<- of quinine in half an ounce of whiskey was given three
times a day for several days. The disease supervened in one instance upon an attack of dysentery. In several cases
the yellow color of the eyes, epigastric and lumbar pain, etc., have been singularly mixed with fever of a remittent
or typhoid character, the jaundice subsiding after the use of an emetic and purge and the fever going on.
A few other extracts are herewith submitted :
Surgeon R. W. Hazi.ett, '2d TT. Va., AFoiint Summit, Mil., April 1, 1862. — We report sixty-fonr cases of jaundice as
having occurred during the past three months, a number sufficient to justify us in calling it an epidemic. The cases
were mild and readily yielded to treatment.
Surgeon Harvey E. Browx, "iOth X. T., Camp Farnum, Md., March 31, 1862. — During the past month many cases
of icterus have been reported. Nearly all were slight; few were so sick as to require excuse from duty. The disease
yielded rc.idily to treatment. A mercurial purge was followed by a teaspoonful of fiuid extract of bueliu every hour:
when there was restlessness, morphia was given at night. This seldom failed to remove the jaundice in from two to
four days. When it failed, small doses of calomel, opium and ipecarnanha were given with good effect. It was unques-
tionably miasmatic in its origin.
Surgeon T. Hll.DKETll, 3d Me., IVhite's Ford, Md., Oct. 25, 1862. — On Sept. 7, 1861, the regiment was encamped
near Alexandria, Va., on high, well-drained ground. The tents were comfortable, the camp well policed, ami the
rations sufficient in quantity and of good quality; nevertheless we had a large number sick with fever, diarrhcea and
jaundice. About one hundred cases had well-marked symptoms of icterus. The men were nearly all homesick, which
apparently predispo.sed them to be attacked, as those not homesick and consequently more cheerful were generally
exempt from the disease. The insanitary causes were believed to consist of change of climate, exposure and home-
sickness. Many dated their disease from exposures at the battle of Bull Kun.
Aan'l Surgeon W. W. Gkanger, 3d Mo. Cur., Holla, Mo., Xor. 2, 1861. — Of icterus there were nine cases, seven of
which yielded readily to light alterative treatment in connection with proper regulation of the bowels and tonic bit-
ters or infusion of wild-cherry bark. Mercurials in the beginning and iodide of potassium in the later stages were
the alteratives used. One of the two remaining cases was comiilicated with remittent, the other with intermittent
fever. Quinine in liberal doses formed the treatment of these until thev were subdued.
876 JAUNDICE.
Siirijcou W. H. Grimes, 13(7i Koimas, Sjn-intjjidd, Mo., Feb. 2, 18fi3.— Untler the head of diseases of the digestive
orgaus are reported quite a luimber of cases of jaundice. I feel satisfied that these do not include half the cases that
occurred. Indeed, from its freciuent appearance among both officers and men, the disease resembled an epidemic. A
few cases appeared after the battle of Cave Hill, Xovember 28, as Avell among some rebel prisoners as among our owu
men, but the greatest number occurred after the tight at Prairie Grove. Whether the predisposing causes of this dis-
ease were to be found in the condition of the atmosphere, the habits of the soldiers, or were to be sought for in the
emotions of the mind, is uncertain. The cases were mild and easily controlled, none fatal. They were treated with
blue mass, sulphate of magnesia and decoction of wild-cherry bark.
In the absence of records bearing on the subject it is inrpossible to define the iiatiiology
of these cases of jaundice. Many were probably due to tlie temporary occhision of the bile-
duct bv gastro-duodenal inflammation ; others, particularly those with epidemic relations, to
an action of the malarial influence similar to that which in its intensity gives rise to the
hfematuric variety of malarial fever; and others again to various organic changes in the gland-
ular structure. The following; are submitted as illustrations:
Case 1. — Private Aaron Clements, Co. H, 1st N. Y. Cav.: age 27; was admitted Sept. 3, 1864, in feeble condi-
tion, pale and emaciated, his health having been much impaired by fasting, fatigue and diarrhtea during Hunter's
raid to Lyuchburg, Va. On October 1 he became jaundiced, but had no fever and but little pain. He died on the
7th. Post-mortem examination: The mucous membrane of the stomach was intiamed in patches near the pylorus.
The duodenum contained a large quantity of nuico-purulent matter: its mucous membrane and that of the jejunum
were thickened and pale and their ruga' almost obliterated. The gall-bladder was about half full of dark-colored
bile, but there was none in the intestine. The liver, ileum and colon were healthy. — Ciimhcrliind Hospital, ild.
C.\SE 2.— Private William Hanks, Co. E, 13th East Tenn. Cav., was admitted Feb. 0, 1864. The surface of the
body was deeply jaundiced and there was some tenderness over the hepatic region : he had also acute diarrhwa. The
pulmonic difticulty, which was no doubt the immediate cause of death, was not well characterized by symptoms
during life, there having been neither cough nor dyspncea. I'ost-mortcm examination: Body moderately emaciated.
The membranes of tlie brain were of a greenish-yellow color. The right lung weighed thirty-three ounces, its lower
lobe being hepatized; the left lung eleven ounces; the i)leural cavities were greenish-yellow in color. The pericar-
dium was distended with three ounces and a half of serum ; the heart was enlarged, soft and flabby. The peritoneum
was of a pale-yellow color. The stomach was coated internally with greenish slime; the small intestine distended
■with flatus; the large intestine thickened in its lower portion but not ulcerated. The liver, seventy-seven ounces,
was soft, friable and greenish-yellow in color; the gall-ducts were free from obstruction and the gall-bladder con-
tained bile of a deeper color and greater specific gravity than usual; the spleen was soft and weighed eleven ounces;
the kidneys also were soft and weighed thirteen ounces: the bladder contained two ounces of dark-colored urine.
The solid viscera were tinged with bile-pigment. — Act. Ass't .Surgi-oii J. E. Marsh, Hoi^pita! Xo. 19, Xaslirilh', Tiiin.
Case 3.— Private George C. Booz, Co. G, 119th Pa.; admitted May 16, 1865, with jaundice. Died 29th. Posi-
morlem examination: The right lung was firmly adherent posteriorly and its upper lobe hepatized. Both ventricles
of the heart contained olive-yellow clots. The liver was oue-fourth of the usual size: the gall-bladder was normal
and contained one ounce of bile. The spleen, stomach and intestines were normal; the bladder was distended with
yellow urine. — Depot Field Hospital, Sixth Armi/ Cor2>s, Armt/ of the Potomac.
The monthly rates of prevalence of jaundice were exceedingly irregular during the first
year of the war, the period of aggregation of the troops, but the spjecial causative influence
is as urdvuown, so far as shown by the records, as the pathological conditions. The high
rate in the Atlantic region in November, 1862, was due to an unusual prevalence of the
causes of the morbid condition in the Middle Department and in that of Washington, which
gave 32 and 24, respectively, as the rates for the month, while the Army of the Potomac
gave 11, the Department of Virginia 7, of tlie South 5, of North Carolina 4 and of the East
3 per thousand men. After this the disease became comparatively infrequent, but manifested
a tendency to recur in the autumnal months. A similar seasonal increase was observed
among the colored troops.
It was well recognized that jaundice was of more frequent occurrence in malarious than
in non-malarious localities, although this is by no means demonstrated by a comjDarison of
the statistics of the .two diseases. A careful survev of the ratios of prevalence in the various
departments fails to manifest a correspondence between jaundice and the malarial influence.
Thus, during the year ending June 30, 1863, tlie Army of the Potomac, the Department of
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INFLAMMATION OF TlIK LIVER. 877
"West A^irginia, the Middle Department and the Department of Wasliington, none of whicli
had an average annual rate of malarial fever exceeding 400 per thousand of strcngtli/-'
reported respectively 53, 55, 71 and 92 cases of jaundice in every 1,000 men, while the
malarious Department of North Carolina returned only a rate of 45. The probable explana-
tion of this lies in the fact that the jaundice of notably malarious localities was so frequentl}'
associated with well-defined malarial disease that few cases remained for entry undrr the
symptomatic heading.
i^or do the statistics show any close relation between jaundice and inflammatory con-
ditions of the liver. The annual rate per thousand of strengtli during the five years ending
June 30, 1866, were, in the order of their occurrence, for jaundice 39, 52, 14, 30 and 26, and
for inflammation of the liver 12, 13, 6, 7 and 6. It is probable that when jaundice was recog-
nized as associated with hepatic disease it ceased to appear on the records as jaundice.
The frequency of liver complications in diarrhoea and dysentery, malarial and other
fevers, has already been noted ; but besides these there occurred among the wliite troops
11,120 cases which were recorded as acute inflammation of the livkr. Mo.st of the 243
fatal cases probahlv terminated in suppuration. A few of these have been jM'cserved:
C.\SE 1. — Private JaeoTi S. Bis.son, Co. H, Ist U. S. Veteran.s: age 4.t; was ailiuittcil Nov. 'J, DSliri, liavinj^ been
seized two week.s before admission witli cliill.s, wliicli reclined on two snoces.sive days and were preceded l>y languor
and loss of" appetite. He was anxions and prostrated: his \ oice faltered : his tongue was dry and slightly brown but
its tip and edges were red; his pulse was 81 and weak and his respiration 34 per minute; his bowels were tympanitic
and constipated, and there was great tenderness in the right iliac fossa; he had a stitch in his right side, with an
exaggerated vesicular murmur in the upper ijortion 'of the right chest and a distinct gurgling of liquid, coincident
with expiration, in the lower portion. Acetate of ammonia and Dover's powder wore prescribed, w ith whiskey and
beef-tea, a blister to the side and an enema of soapsuds. Diarrhoea, thin and slimy in character, occurred on the
4th; he complained also of cough, with slightly blood-stained expectoration, and of some gastric jiain. Warm fomen-
tations were applied and pills of lead and opium prescribed. At 7 r. .M. the patient had a rattling in his throat
from accumulated nnicus which he was unable to bring up. He died shortly after 8 p. .M. I'ost-mortcm examination:
The lungs were small and dark from deposited pigment: they contained no tubercular matter; the lower lohe of the
right lung adhered so firmly to the diaphragm that the latter was ruptured in the effort to detach it. The bronchial
glands were tilled with dark pigment. The heart and pericardium were normal. The liver was so greatly enlarged
that the diaphragm was pushed up to the third rib: an abscess containing forty ounces of thick flaky jms was found
in its right lobe, — ISpccimeii 009, Med. Sec, Army Medical Museum]. The spleen was small and soft; the supr.-ireiial
capsules normal; the kidneys slightly congested. The intestines were inflamed in several places and Peyers glands
enlarged, but there was no ulceration. — Midical Ctnlet Harry C. Morrison, Jlospital, Fort Mclhiirji, Md.
Ca.sk 2. — Private William H. Andrews, Co. H, OSth N. V.; age 41; was admitted from Annapolis, Md., Oct. 1.3,
1864, with phthisis and dysentery. He died November 28. I'ont-mortem examination: Body extremely emaciated.
The lungs were somewhat congested but contained no tubercle; there were some calcareous concretions around the
root of the right lung. The lower lobe of this lung was fused to the diaphragm and liver and formed the npjier
wall of an abscess which extended into the liver and occupied the whole of the upper part of its right lobe; the inte-
rior of the abscess, which was irregular and ragged, was filled with unhealthy pus. The surface of the liver was
covered with small abscesses, some of which contained healthy pus. The gall-bladder was occluded by a gall-stone
about the size of a hickory nut. The mesenteric glands contained tubercular matter. The spleen was rather hard
and congested. The other organs were normal. — Act. Ass't Suri/con B. B. Miles, Jarvis HospituJ, Baltimore, Md.
C.VSK 3. — Private Benjamin Burns, Co. E, 13th West Va.; age 32; was admitted April 4, 1805, having been suf-
fering for about four weeks from pain in the right infraniammary region and a troublesome cough; he was much
emaciated; his pulse quick and weak, tongue moist and bowels constipated. He became Jaundiced on the 15th, had
a severe chill on the 25th and a second on the following day, lasting about twelve hours. He died on the 28tli. Posl-
morlim examination: .Surface Jaundiced. One-third of the lower lobe of the right lung was hepatized and adherent;
the remainder of the right lung, the left lung and heart w-ere normal. The right lobe of the liver adhered to the
diaphragm and was hollowed out into a large abscess containing two quarts of pus: the remainder of the liver was
highly congested, enlarged and softened. The spleen was enlarged and congested; the colon much contracted; the
kidneys enlarged, softened and infiltrated with pus. The peritoneal cavity contained thirty-two ounces of licjuid. —
Cumherland Ilonpitul, Md.
Cask 4. — Private Louis Ritt, Co. K. lT8th N. Y.; age .50; admitted Nov. 25, 1865. This man had been four years
iu the United States, more than two of which were spent in the service, but he had formerly been a resident of Kio
Janeiro: his habits were intemperate. He was very weak and ainemic, yellowish and waxy in appearance, with pale
*See mpra. Tabic XXXIII, page 98.
878 INFLAMMATION OF THE LIVEK.
gums, flabliy. dry and harsh skiu, and swollen, pendulous abdomen. He had a frequent, short and dry cough. Ten-
derness in the hepatic region was increased liy cough, deep breathing, digital pressure and lying on the right side.
Hepatic dulness extended upwards to the mamma, but not much in a downward direction. There was no anasarca,
but the patient complained of general abdominal fulness in addition to a sense of weight in the liver: he had ano-
rexia, great thirst, gaseons eructations and constipation, his bowels on admission having been unmoved for eight
days. A mercurial purge produced two very copious feculent brown stools, after which he felt easier, having less
thirst, pain and distention, but a sharp pain continued to accompany a full inspiration or cough. Qiiinia. in two-
grain doses, -was ordered three times a day for two days, with nourishing diet, such as oyster-soup, eggs and beef-
steak. Half an ounce of castor oil on the 2Tth produced several greenish stools of a penetrating odor, and on the
following day the patient was able to lie on the right side, the pain and cough having decreased considerably. At
this time the abdomen, though less hard, continued distended, and although there was no thirst the appetite was poor
and the mind depressed. Citrate of iron and quinine was prescribed, with castor oil oi Seidlitz powder every second
day, and milk-punch, sherry wine, ale or porter as desired. Hiccough became troublesome about December 2, and his
sleep was light and insufficient. During the next ten days he lost strength and became unable to get up without
help. On the 12th he complained several times of feeling chilly; his cheeks and eyelids were a'deniatous and his
tongue dry. He had lost all appetite and was very somnolent. From the right hypochondrium a large tumor could
be seen extending downwards an inch below the level of the navel: it was tender, rather soft, knobby and not dis-
tinctly limited; the integuments over it were oedematous. The urine was free from albumen ; the stools consisted of
small clay-eolored lumps, mixed sometimes with a little blood and a few drops of puriform liquid. Xext day, the
13th, the tumor extended into the liypogastrium and was the seat of a dull aching pain. Death occurred on the 14th.
Fosi-mortem examination two hours after death: Body congested in the dependent parts and offensive in odor; integu-
ments of abdomen a>dematous and fatty; extremities emaciated. Two gallons of pus mixed with blood were removed
from the peritoneal cavity; the opposed peritoneal surfaces were adherent, and the mesentery, intestines and omentum
interadherent by layers of organized lymph. The liver adhered in part to the diaphragm, but when these adhe-
sions were broken down a large sac containing pus was discovered between them, by which the diaphragm was
elevated as high as the nipple. The left lobe was enlarged, rather soft and yellowish ; its cut surface, which greased
the blade of the knife, was of a yellowish color, with numerous dark points of blood oozing from the divided vessels.
The right lobe, which was soft and friable, was coated with dark-colored exudations. Towards the right edge of
this lobe was an unopened orango-shaped abscess, four and three-eighths inches in diameter, iilled with thick pus.
A second abscess, separated from the first by a thin partition, communicated with the peritoneal cavity by an opening
the size of a half-dollar, near the middle of the convex surface: the cavity of this abscess measured four and five-
eighths by five and three-quarters inches, and was lined with a thick pyogenic membrane; it contained pus similar
in character to that found in the abdominal cavity. The suppurative destruction affected at least three-fourths of
the substance of the right lobe of the liver, — [Specimen 742. Med. Sec. Army Medical Museum]. The spleen was smaller
than usual and shrunken; its coat was wrinkled and its edges somewhat indented. — Surgeon SutnueJ KneeJand, C. S.
Vols., nosj>itul, Mohile, Ala.
Case 5. — Major John Leo, 18.5th N. Y.; age 33: was admitted Nov. 18, 18G4, with what was at first called remit-
tent fever. The stomach was extremely irritable; the liver slightly enlarged but not tender. On the fifth day after
admission a swelling appeared over the left lobe of the liver; it was not painful and it subsided next day, when
large quantities of an ofl'ensive green liquid were vomited and copious stools were passed of slimy, bloody matter
with purulent admixture. At no time during the progress of the case was there any soreness in the abdomen. Gas-
tric irritability continued to the last, a teaspoouful of beef-essence sufficing to induce vomiting. Death occurred on
Decembers. Post-mortem examination : The right lung was adherent, but otherwise the thoracic organs were healthy.
The stomach was filled with a green liquid similar to that vomited during life. The right lobe of the liver was
slightly enlarged but its tissues appeared healthy; the left lobe was natural in size and color but strongly adherent
to the transverse colon, stomach and omentum. An abscess-cavity, walled in bj- these adhesions, was found on the
under side of the liver near the transverse fissure; it communicated with the colon by two apertures, — \_S2)ecimen 453,
Med. Sec, Army Medical Museum]. The omentum was red and thickened: the intestines contained viscid pus. —
Surgeon TT. L. Fajron, 32(7 Mass., Depot Hospitaty btlx Army Corps.
C.iSE 6. — AVilliani Lewis; civilian; colored; age 28; was admitted May 19, 1864, with pneumonia. On August
13, when the record first shows his condition, he was suffering from ascites, which caused a sense of fulness in the
abdomen but gave no pain ; he had also some a-dema of the feet and legs. His appetite was good, but he was unable
to walk much, though he occasionally went out for air. Diuretics were tried for several day.s, but failed to give
relief. Mercurials seemed for a time to do good, bnt the benefit was not permanent and the patient gradually failed.
He was seized on October 4 with intense abdominal pain, which by midnight became excruciating. In the absence
of a trochar an incision large enough to introduce a female catheter was made just below the umbilicus, and twenty
pints of liquid were drawn oft'with temporary relief to the patient. He died early next morning, rost-mortim exam-
ination: The liver was nmch enlarged, grayish-yellow in color, and contained several small abscesses filled with thin
yellow liquid : the spleen was large and soft and presented in its upper portion a cavity filled with pus. The mes-
enteric glands were enlarged. — Act. Ass't Surgeon W. K. Fletcher, L'Oarerture Hospital, Alexandria, Va.
Case 7. — Corp'l Gideon McCall, Co. C, 31st Colored Troops; age 36; was admitted Aug. 9, 1864, with gunshot
wounds of the left hand, side and hip. The jiatient was a mulatto of good character and steady habits. Shortly
after his enlistment, in January, 1864, he was attacked with a diarrha-a of dark-colored stools, which continued with
occasional intermissions until the date of his admission for gunshot injury. His wounds healed kindly and his
IDIOPATHIC PER1T0>"ITI:?. 879
■
bowels, altliough sometimes loose, were easily coutrolled. Aliout Sejitember 20 the intestinal discharges l)eeamo
frcqticut ami thin and seemed to contain decomposed blood ; bnt nndcr treatment he improved rapidly and appeared
to be in a fair way to recovery. This fit vorable condition lasted only three or four days. Troublesome hiccough super-
vened and the patient began to sink into a typhoid condition, lie died October 8. Poat-morUm examination : The
liver contained thirteen large abscesses, — [Spvcinun 117, Med. Sec, Army iledical Museum]. The large and small
intestines were examined with care, bnt no ulceration was discovered nor was there any evidence that bony tissue was
involved in tlie gunshot injury. — Surgeon K. BcitUci/, V. S. Vols, L'Oiiicrtiirc IIos2)ilal, Ahxttndiia, T'a.
C.vSK 8. — Musician .Joseph Price, llth V. S. Inf.; ago 10: was admitted April 3, 18tvl. While in Washington,
awaiting transportation to his regiment in Virginia, he was much exposed to the weather, having to sleep in the
snow. He was sick when he joined his regiment, March 24, having iinotidian chills, colliquative diarrho-a, insomnia,
great thirst and extreme teiulcrness of the chest and abdomen. On admission etiervescing draughts, quinine, tur-
pentine emulsion, with morphia at night and turpentine stupes, were i)rescribed. Kgguog was added to the treat-
ment on the Dth, and on the following day, as tho diarrhoea persisted, an enema of one grain of nitrate of silver iu
cue ounce of mucilage was administered. Ou tho 7th his mind became partially disturbed, and soon afterwards the
discharges were passed involuntarily. He died ou tho llth. roxl-mortcm examination: The pericardium contained
eight ounces of straw-colored liijnid. Tho lungs were healthy excepting .a slight pleurisy on the right side. The
diaphragm adhered at all points to the upper surface of the liyer, wliich was very largo and heavy and filled with
numerous abscesses, — [Speciimii 2itr>, Med. Sec, Army Medical MiuscumJ. The cavity of the abdomen was greatly dis-
tended with liquid, but the stomach, intestines, spleen, pancreas, kidneys and bladder were healthy. — Asu'l Surgeon
E. />()''. Bnneman, V. S. J., Uonpiluh 1*' Dirixioii, 5th Jrnii/ Corjjs.
v.— IDIOPATHIC PERITONITIS,
In previous chapters of this work peritonitis has been found associated with malarial
and typhoid fevers either as a result of the systemic poisoning or of the extension of inflam-
matory processes from the mucous membrane of the intestine or the solid abdominal vis-
cera.'-' Peritoneal inflammation occurred also in the progress of tubercular disease,f and was
a frequent and fatal complication of diarrhoea and dysentery. J But in some instances it
was regarded as an idioj^athic disease: 1,294 such cases, 530 of which proved fatal, were
reported among the white troops. Idiopathic peritonitis must, however, have been a rare
affection, for on examining the recorded cases of death from peritoneal inflammation hat
remain to be submitted it is found that perforation from dysenteric or other ulcers, injnrvto
a hernial protrusion or the probable presence of malarial or typhoid fever, accounts in certain
instances for the invasion of the peritoneum by the diseased action; in a few cases only the
record fails to demonstrate the causation of the jieritoneal inflammation.
Case 1. — Private Randolph Gideon, Co. C, 2d Tenn.; age 35: a paroled prisoner; was admiited May 2, 1863,
having been taken sick while en route from Kichnu)nd, Va., to his home. He had severe and persistent vomiting,
ejecting a watery tluid mixed with bile and portions of undigested food. He was more or less comatose from the first,
but sometimes answered. questions rationally. There was no epigastric or hepatic tenderness, and no evidence of
pain except on the 12th. w hen he complaiiu-d of his right hip. His tongue was dry, thirst excessive, urine copious
and passed invohmtarily, and his bowels, although constipated, were readily moved by eucmata. Oxalate of cerium,
creasote. bismuth, nu)rphia and chloroform with counter-irritants were emitloyed, without success, to check the vom-
iting. Only raw eggs and small quantities of milk were retained. Xourishiug enemata were frequently administered.
He died on the 14th, rost-mortcm examination: Body moderately emaciated. The brain was not examined. The
thoracic viscera were healthy. The liver was rather larger than normal, but healthy. Tho stomach was normal in
size and contained some watery fluid; its mucous membriine was reddened and its pyloric orifice contracted. At the
commencement of the duodenum there was a firm well-marked constriction, reducing its calibre to less than half an
inch iu diameter. Around this portion of the intestine were deposits of coagulable lymph, and immediately below,
ou the posterior aspect of the gut, was a perforatiou with thickened and introverted edges. The gall-bladder was
distended. The kidneys were normal. — .Isn't Surgeon Cliarks I!. White, U. S. A., I'lttuburgh JJospituI, I'd.
Case 2. — Private .John II. Colbert, Co. II,32d Wis.; age 31: admitted May 1.5, 18G5, exceedingly exhausted from
the continuance of a violent diarrhfea with bloody stools. Died 23d. roxt-mortnn examination: There was a large
perforation iu the duodeuum through which the intestinal contents had escaped. The whole of the canal was much
inflamed and its mucous membrane eroded. — Third Division Hospital, Alexandria, Va.
Case 3. — Charles Smith, teamster, was admitted Aug. 8, 18G3. His health had been gooil until early on the
ilay preceding his admission, when he had been seized with jiaiu in the stomach and bowels, but not of so severe a
character as to prevent his engaging iu his usual occupations. Towards noon the pain became greater and he was
compelled to stop work. He took a dose of sulphate of maguesia, which produoeil a free watery evacuation and gave
• Se« mpra, pages 134, 277, 425 and 450. t See mpra, piigc 827. t Part II, pp. 314, 388, 453, 437 aud 540.
880 IDIOPATHIC PERITONITIS.
*
considerable relief, but during the night he again became worse. On admission the abdomen was much distended
and tender. He died on the 16th. Fost-nioHcin examination: The abdominal cavity contained a large quantity of
purulent nuitter and coagulated lymph. The lower part of the large intestine was almost gangrenous. — Union Bos-
intiil. Mtnqihis, Tenn.
Case 4. — Private Kelso Bicking, Co. E, ITSth Pa.; admitted July (>, 18fi3. Peritonitis. Died 11th. Post-mortem
examination: Body not emaciated: thighs, shoulders and back purple. The peritoneal cavity contained a quantity
of serum mixed with pus and lymi)h. The mesentery was much thickened and congested, and the coils of the intes-
tine were glued together and to contiguous organs by thick lymph: on breaking up the adhesions several large per-
forations were found. All the coats of the intestines were disorganized and in a putrid condition. — Act. Ass't Surgeon
Lloyd Dorset), Sarewood Hospital, Washington, D. C.
Case 5. — Private S. T. Morse, Co. B, 38th Wis.; admitted July 24, 18G4, with chronic diarrhoea. Died September 4.
Post-mortem examination: Body much emaciated. The lungs were bound down by old adhesions. The abdominal
cavity contained twelve pints of bloody purulent serum. The intestines were coated with greenish-yellow lymph
and glued together so that they could not Ije separated without rupture. The liver had a similar coating; tlie gall-
bladder was distended: the spleen was soft and measured seven inches by four and a half; tlie kidneys and supra-
renal capsules were healthy. — Act. Ass't Surgeon J. H. Price, Fairfa.r Seminary Hospital, Va.
Case 6. — Private William H. Simons, Co. H, 88th Pa.; age 17; was admitted July 20, 1864, with an inguinal
hernia on the right side. He was on duty as a nurse until Jan, 14, 1865, when he had a slight chill with pain in the
head and loins, lassitude, anorexia, a moist, yellow, furred tongue, dry and hot skin and slightly quickened pulse;
his bowels were regular and there was no abdominal tenderness. On the 19tU nausea and restlessness were developed,
and the abdomen became tympanitic and tender on the right side. Vomiting followed next day, and delirium and
death on the 22d. Post-mortem examination : The right ventricle of the heart was dilated, the left contracted. There
was some stasis of blood in the upper lobes of the lungs, lobular pneumonia in the lower lobes and recent adhesions
on the right side. The .abdominal viscera were interadherent by yellow lymph. The liver was yellow and granular;
the spleen soft; the ileum distended with air, injected of a rosy hue and presenting, at about eight inches from the
ileocifcal valve, a loop with adherent sides and slightly darkened surface. The internal abdominal ring was open
and tlie hernial sac empty and uuiuflamed. — Lincoln Hos2>ilol, Washington, Ll. C.
Case 7. — First Lieut. Jloses H. Luber, Independent Company, 20th Pa. Cav., was admitted moribund Oct. 3,
1863, and died in two hours. He bad sufl'ered from excruciating pain in the right iliac region, with tenderness but
no tympanites of the abdomen, rosi-moWcm examination : The vermiform appendix was ulcerated and perforated
and the peritoneum inflamed; the ileociecal valve was extensively ulcerated. — Officers' Hospital, Phila(lelj>hia, Pa.
Case 8. ^Private Frank AVade, Co. F, 2d 111. Cav.: age 17; was admitted May 8, 186-5. in an emaciated con-
dition from a continuance of fever and diarrhoea. Under the influence of quinia, turpentine, Dover's powder and
diffusible stiuuilants, he improved until the 25th, when he suftered a relapse, and died June 4. Post-mortem examina-
tion : The lower lobes of the lungs were congested. The large and small intestines were inflamed and adhered together
and to the walls of the abdomen l)y bauds of fibriu. — Slough Hospital, Alexandria, Va.
C.\SE 9.— Abel W. Roberts, Co. E, 8th Miss.; admitted Dec. 17, 1864. Typlio-malarial fever. Died 20th. Post-
mortem examination: Body jaundiced but not emaciated. The lungs were healthy although the pleura was slightly
inflamed. The pericardium contained four ounces of dark-yellow serum. The liver was engorged. There was peri-
tonitis with slight effusion in the abdominal cavity: the omentum was thickened and adherent to the intestines. —
Act. Ass't Surgeon J. 21. Wilhenvax, Hospital, Rock Island, III.
Case 10.— Private Samuel Davidson, Co. E, 62d Pa.; admitted June 9, 1862.. Died July 8, at 4.10 o'clock, appar-
ently without pain. The case, as indicated by the attending physician, J. M. D.v CoST.\, was one of cirrhosis in a
person who probably had been intemperate, — enlarged spleen from malarial influence, pleuro-pneumonia and finally
acute iieritouitis. Post-mortem examination ; The brain was not examined. The heart was natural in sizeandstructurc.
The left lung was healthy except that it contained a few small tubercles about the size of hemp seed, scattered through
the parenchyma near the surface, especially in the upper lobe : the pulmonary pleura also presented a few small pat dies,
from one-eighth to one-half inch in diameter, of grayish translucent pseudoniembrane; the corresponding costal ami
phrenic pleara> were healthy. The right pleural cavity was distended with a coft'ee-colored serous liquid : the lung
was collapsed and reduced to a mass little larger than the fist, dark-pui'iilish in color and on section spongy and
comparatively dry, but containing no air ; its three lobes were compactly joined, the original separation being seen
in section as thick opaque white lines; the pulmonary pleura was thickened, white and covered with yellowish trans-
lucent iiseudomembrane, which also adhered to the phrenic and pericardiac plenne : the corresponding costal pleura
was white, opaque and somewhat thickened but not covered with pseudomembrane. The abdomen was distended
\yith several gallons of a coffee-colored serous liquid. The peritoneum was everywhere covered with pseudomem-
brane of recent formation and nearly uniform thickness, — that investing the abdominal parietes and the great omen-,
turn was rather translucent yellow- with vascular spots, while that on the intestines was brownish-red with spots of
yellow. Excepting the liver, stomach and spleen, the viscera were not agglutinated. The pseudomembrane, which
readily stripped from its attachments, was between the sixth and the fourth of a line in thickness. Detached, it
appeared yellowish with vascular spots. In structure it consisted of a filuo-grauular stratum containing a multitude
of granular corpuscles about the size of pus-corpuscles. Yellow spots on the membrane consisted of accumulations
(purulent foci) of similar corpuscles. The liver was moderately enlarged, brownish-yellow, decideilly granular — ( in an
earlystage of cirrhosis). The gall-bladder, twice the ordinary bulk, was distended with bile containing an abundant
granular intermixture. The spleen was much enlarged, eight inches long, six broad and three and a half thick; its
IDIOPATHIC PERITONITIS. 881
section luesontcil a lirij^lit eir.reiit ji'lly cdlor ami oiilinary cousistence, with a (Unser stnictuie of li;,'liter color peiie-
tratiu"' irregularly from a lim to an inch and a half from the surface into the interior. The stomach was con-
tracted and einjity. its nuiC4)ns membrane healthy. The small intestine was contracted; the mucous membrane,
including the agminated and solitary glands, healthy. The pancreas was of the usual size and color, but remarkably
hard and crisp. Tlie suprarenal bodies were natural : I he kidneys smaller than usual, but healthy. — -Ic*. Aas't Surgeon
J. Lekhj, SattirliT Ilospiliil, rhihi(hlj>liici. /'«.
C.vsE 11.— Louis Weder. Co. I, 1st X. Y. Cav., was admitted March 28, ISOI. having been aftccfod for six weeks
with synovitis of the right knee, the cause of which was unknown. Tincture of iodine was applied daily. On April
3 he had a violent headache, with pain in the back and bowels, some vomiting and diarrluea, complete anorexia,
and jaundiced eyes and skin. t'am]dior and opium pills were given, with hop fomentations to the abdomen. Next
dny drowsiness and fever were added to the symptoms; the pain in the abdomen was aggravated, the pulse small and
freriiient. During the night of the 4th he had fourteen stools and vomited a greenish liquid once or twice. At .5 A. >I.
of the oth the pulse was 110, very small, weak and soft, respiration IL', expression anxious. The pain in the abdomen
continued; the vomiting, temjiorarily checked by creasote and morphine, recurred at times with increasing prostra-
tion until death occurred, on the morning of the 6th. ront-mortem examination: Body not emaciated; skin tawny;
conjunctiva- yellow : mouth and nostrils giving issue to a yellow liquid. The knee-joint contained about two ounces
of synovia and a few tlakes of lymph; the membrane lining the cartilages of the patella and femur was roughened; the
subserous areolar tissue on the ligamentuui pateihe and other soft parts of the joint was exceedingly vascular. The
abdomen was distended with several quarts of serum and lymph, — there was a large quantity of lymph in the pelvis
and also above the liver, and the intestines were glued together, but no perforation or other indication of the origin
of the peritonitis was discovered. The stomach and intestines were distended with liquid. The liver was fatty;
part of the right and left^obes w.as hob-nailed, showing on section a surface mottled with red, yellow and gray, and
knotty to the touch. Heart and lungs healthy. — Asx't Surgeon J. II. Enrtkolf, U. S. Vols., Jloijiitid, Frederic!,-, l/rf.
CvSE 12.— Private L. X). Lockwood, Co. U, 22d N. Y. Cav.; ag(! 17: admitted April 28. 18()1. Pied May 6.
riist-morlcm examination: Urain, lungs and heart healthy. The stomach was much congested at its cardiac extrem-
ity. The intestines were aniemic. The peritoneum contained a half-pint of creamy pus. The liver was soft and
tlabby; the spleen anaMuie; the kidneys flabby, their pyramids congested. — Lincoln Hos^iital, ll'ashington, 1). C.
Cask 13— Private Louis Roberts, Co. A, 32d Ala.; age 21; admitted Oct. 29, 1864. Debility and diarrhcca.
Died 31st. lie was insensible when admitted. I'ont-mnrtrm examination: The pericardium contained six ounces of
clear serum : the surface of the heart was corrugated and its substance softened ; the right ventricle iilled with a white
clot, which extended along the pulmonary artery until its divisions were no larger than a pin. The ouunitum was
enlarged and the abdominal viscera adhered to each other and to the diaphragm. The liver was much softened; the
gall-bladder contracted to about a ([uarter of an inch in diameter. — Hocl Island Hosinlal, lU.
Case 14. — Private John A. Smith, Co. K. 6th \. J.; ago 17: was admitted July 13, 1863, with a gunshot wound
of the fingers of the right hand. On July 17 the middle tiuger, with the head of the corresponding metacarjial bone,
was amputated, and by .Sejitembcr 3 the wound had nearly healed: but the patient appeared feeble and nervous. On
Kovember24 he complained of headache: his skin was hot and dry and his liowels constipated. Blue-pill was given,
followed by Epsom salt. On the 27th he had sore throat, to which nitrate of silver was applied. He vomited twice
on the 29th and exhibited great nervous excitement. Small doses of sulphate of morphia were given. Next day he
had continual vomiting, epigastric pain and tenderness, great pallor, hot and dry skin, rapid and almost thread-like
pnlse, dry and coated tongue. He died on the 31st. rost-morUm examination: The pleura covering the lower lobe
of the left lung was acutely inflamed. The lungs and heart were normal. The peritoneal cavity contained two and
a half quarts of seropurulent liquid. The large and small intestines were of a bright-red color and agglutinated by
fibrinous deposits; the parietal peritoneum also was much inflamed. The liver was somewhat enlarged and engorged
with bile; the spleen was three times the normal size: the stomach and kidneys normal. — Act. Asx't Surgeon I'. J/.
Girriii, Satterke UospHnl, Philadeljihia, Pu.
Case 15. — CorpT John Angermeier, Co. D, 99th, Pa., admitted Sept. 14, 1862, with debility. Peritoneal inflam-
mation supervened, and he died December 1. rost-nwrtem examination: The peritoneum, visceral and parietal, was
inflamed and thickened by exudation. — Third Division Hospital, Ahxandriu, la.
Case 16. — Private James Robinson, Co. G, 126th Ohio, was admitted during the night of Sept. 5, 1863, in a state
of collapse from idiopathic peritonitis. Death occurred next morning, roxl-mortvni examination: The intestines
were covered on their serous surface with a layer of recent lymjih: the peritoneal cavity contained half a pint of
senim. — Act. Ass't Surgeon S. Smith, Central Park JJuspital, .Viic Tori: Citi/.
VI.— DISEASES OF THE KIDNEYS.
It is evident from the records tliat these diseases were infrequent during the war.
Death from lesions of the urinary and genital organs appears from Table IV'^' to have been
as frequent among the male population of the military age in the United States as among
the troo2>s, and somewhat more frequent among our regular soldiers since the war than
• •SMDra, page IG.
Med. Hist., Pt. Ill— IH
882 DISEASES OF THE KIDNEYS.
among the volunteer troops of tlie war period. The kidneys were often implicated in the
cono-ested and inflammatory conditions consequent on specific febrile invasion, but idiopathic
disease was unusual. Most of the reported cases were aggregated under the heading Tafiam-
mation of the Kidneys: 154 deaths occurred in a total of 9,464 cases among the white
troops, but neither the clinical nor the post-mortem characters of these cases were recorded.
The few instances of fatal organic disease found in the Case-books and Medical Descriptive
Lists are such as niight have appeared in the wards of a civil hospital. Exposure to cold
and the other hardships of a campaign are suggested as the determining causes in some of
these cases, but neither the weiglit of the cartridge-box nor the pressure of the belt is
arraigned in connection with them.
Case 1.— Private Jobu E. AVood, Co. I, 10th N. Y. Heavy Arty; age 21; -svas admitted Dec. 24, 1864, with
marked oedema of the legs and some puffiness of the face, especially aliout the eyes, which had apijeared four weeks
Ijefore his admission, after exposure to cold by lying on the damp ground. The swelling began on the day following
the exjiosure and gradually increased. ' He had a cough and a syphilitic eruption on the skin; his urine was albu-
minous. He was treated with diuretics, diaphoretics, iron and other tonics. On Feb. 4, 1865, Rochelle salt, in a
daily dose of one ounce, was prescribed. On the 11th he was much worse, being somewhat comatose, the pulse fre-
quent and feeble, the urine scanty and dark-colored, showing under the microscope red-blood corpuscles and many
cysts filled with oil-globules. Tincture of digitalis in ten-drop doses w-as given every three Lours. On the 13th
the pulse was stronger and the mind clear, but the anasarca had become general and there was considerable ascites.
Bromine was ordered on the 18th for a bed-sore which had ajipeared. The stools became involuntary on the 22d and
the breathing difficult on the 26th. He died March 1. rost-iiiorlem examination : All the tissues were infiltrated with
.serum : the abdominal cavity contained sixteen pints. The right kidney weighed ten ounces, the left eleven ounces.
l.S2>e<.imiit 530, Jled. Sec, Army Medical Museum. When received at the museum the kidneys were of a tawny-yellow
color, mottled on the surface; the epithelium of the tubuli contained large numbers of oil-drops, and the connective
tissue of the matrix many new elements.] — Act. Jss't Surgeon D. L. Haiyht, Douijlus Hospital, Wdshinf/tOH, D. C.
C.^^SE 2. — Private John E. Colter, Co. C, 59th Ga.; age 47 ; was admitted April 22, 1865, with general dropsy.
The patient said that he had been in good health to within a few weeks, and ascribed his dropsy to exposure, cold
and other hardships of the campaign. Cathartics and diuretics were prescribed. He died two days after admission,
rather suddenly and without premonition, while eating his dinner. Post-mortem examination : On opening the thorax
an enormous (juantity of watery serum escaped. The lungs were pale, dry and emphysematous. The pericardium
was filled with water; the heart was considerably hypertrophied but there was no valvular disease. The liver was
much enlarged and harder than usual; the gall-bladder large and filled with deep-greenish, almost dark, bile; the-
spleen double its normal size and highly congested. The kidneys were inflamed and altered in structure. The stom-
ach and intestines appeared healthy. — Act. Ass'l Siiryeoii A. Kesshr, ll'cst's Biiilcliiit/s llospitid, Baltimore, ild.
Case 3. — Private John Shirly, Co. K, 29th Colored Troops, became affected with oedema and ascites in August,
1865. Died November 9. Post-mortem examination: The right lung w-as congested and (.edematous, and the pleural
sac containeil a quart of slightly discolored serum ; the left lung was normal. The aortic valves were thin and per-
mitted regurgitation. The peritoneal cavity containeil three quarts of clear serum. The liver was enlarged and
somewhat fatty. The kidneys were small, fatty, and so soft that they broke easily under pressure; there was no dis-
tinction between the cortical and pyramidal structures. — Act. Ass't Surijeon H. BaphueJ, Post Hospita}, Brownsrille, Texas.
Case 4. — Private George Rice, Co. E, loth N. Y. Cav.; age 50 ; intemperate ; was admitted November 21, 1864,
with anasarca, the thorax, abolomen, face, hands anil lower extremities being involved: he had a hard, tlry, hacking
cough and urgent dyspnoea; his bowels were constipated. He was treated by a diuretic mixture of squill, buclm,
copaiba and spirit of nitre, with an occasional dose of Epsom salt, cream of tartar and jalap; the action of the latter
on the l)owels was always followed by marked but temporary relief to the dyspniea. His •strength gradually failed,
and he died Jan. 3, 1865. A few days before oleatli he expectorated some blood-clots. Post-mortem examination : The
pleural sacs contained three pints of liquiol. The lungs were mottled gray and bluish-black by venous congestion;
from the anterior surface of the middle lobe of the right lung projected a tumor, which on section showed coagulated
blood ramifying into the adjacent bronchial tube. The heart was normal. The stomach was congested and thickened,
its rugi-e obliterated. The liver was cirrhosed and the gall-bladder distended with bile. The right kidney was lobu-
lated and had a hydatid tumor the size of a filbert imbedded in its lower extremity; its cortex was almost obliterated
and its pelvis loaded with fat which extended by many diverging lines to the surface. The right kidney was soft
and friable and presented some fatty deposits in its pelvis. — Cumberland Hospital, JJd.
Case 5. — Edward P. Matthers; age 24 ; assistant druggist on board hospital transport, died July 31, 1862. Post-
mortem examination: The apices of both lungs were iiartially attached by old adhesions; that of the right lung exhib-
ited a contracted and condensed portion cf pulmonary tissue, apparently the cicatrix of an old ulceration. The heart
was slightly hypertrophied and the mitral valve atheromatous. The abdomen contained several gallons of serous
liquid. The liver was cream-colored, enlarged and fatty. The kidneys were affected with fatty ilegeneration which
involved the whole of the cortical substance. — Act. Ass't Surgeon J. Leidy, Satterlte Hospital, Philadelphia, Pa.
DISEASES OF THE KIDXEYS. 883
Case 6. — Piivato William II. Williams, Co. D, llOth Pa., was ailiiiittoil Xov. 30, 186-1, with luiiiliar paiii-s and
gastric irritability. He was much emaciati'd : i>iilso full ami intermittent. Hi. lie was treatcJ with anodynes, astrin-
gents, tonics, stimulants, and concentrated food liy the mouth and rectum, hut without improvement. Died Decem-
ber 18. I'ost-morlnii examination: Plenra' adherent on both sides; lungs {edematous, in jiart collapsed; pericardium
containing four ounces of straw-colored serum: auricles of heart hyi>ertrophied; aortic valves thickened by ossifio
deposits; liver disorganized, fatty; spleen healthy: peritoneum containing eighteen ounces of straw-colored serum;
intestines congested and iutlamed but not ulcerated; left kidney enlarged, weighing sixteen ounces, granular; right
kidney in similar condition but not so large; bladder containing six ounces of pale albuminous urine. — Third Division
//ii«j)i7(W, Alcxioidfia, J'a.
Case 7. — Private Benjamin Miller, Co. K, oOth Colored Troops: age 20: admit ted Dec. 7, 1864, with dropsy. Died
Jan. 22, 1865. This man did light duty for some time about the wards, but on January 1 the u'denni of the lower
extremities began to increase, and in a few days the swelling had become general ; ho had also several chills, each
followed by fever, roxl-moitcm examination: The abdominal cavity was tilled with scrum and the kidneys were
large, fatty and gianular. — Act. Ass't Surgeon II', Biaho^i, L'Ounrlun' Hospital, Alexundria, Va.
Case 8.— Private Alfred .Stewart, substitute; age 27; admitted Oct. 21, 1864. Died Slst, from ura>niia. I'ost-
mortcm examination: The pia mater was slightly congested; the brain healthy. The viscera were normal except that
the lungs showed some old adhesions, and the kidneys were small, dark-colored externally and congested internally,
the left presenting also an abscess the size of a walnut. — Second Division UospituI, Alexandriu, Va.
Case 0. — Private Daniel Wood, .'ith Me. Batt'y- -ige 31; was admitted Aug. 27, 1861, having had alliuniinuriii
for about a mouth. His appetite was good: his feet and legs were (edematous,' and he had pain in the pr^i'cordia and
loins, with some headache and dyspniea : pulse 90; respiration 32: urine albuminous, acid, passed freijuently and in
large quantity, — as, for instance, on the 29th, five and a half pints in seven hours. He was furloughed on the 30th
and returned September 22 in bad condition: Tongue red at the tip and edges, dark and dry in the centre; much
thirst : no appetite ; he had slept none for two nights while on his journey. The anasarca had become general, causing
cough and so much dyspniea that he had to be propped up in bed to sleep ; there was also some mental hebetude. He
had a dull pain in the loins and had passed but little urine during the previous week, — acid, dark-colored, sp. gr.
1011, highly albuminous and rich in tube-easts and blood-corpuscles. Dry cups were applied to the back and a mix-
ture containing digitalis, calnmba, opium, spirit of nitre and camphor was given three times daily, with Dover's
powder at night. Two days later it became needful to puncture the scrotum. On the 28th coma and convulsions
supervened, whereupon cream of tartar was substituted for the mixture. With a somewhat increased discharge of
urine the tendency to coma became less uuuked, but dyspniea continued, necessitating the sitting posture night and
day and causing great exhaustion and incoherent muttering. Coma recurred on December 20: pulse 64, weak and
fluttering: breathing laborious; extremities cold; face clammy: urine scanty; stools involnntary and associated with
prolapse. The stonuich became extremely irritable at this time and continued so until de;itli, on the 31st. Post-mor-
tem examination: Trunk and ujiper extremities much enuiciated ; legs and scrotum (edematous. The brain was
healthy; its ventricles free from effusion. The pleural cavities were nearly tilled with serum; the lungs compressed
but otherwise normal. The heart, pale and tlabl>y, contained no clots. A large fiuautity of liquid was found in the
peritoneal cavity. The liver was firm, pale and waxy; the spleen small and firm; the pancreas normal. The kid-
neys were enlarged, — the left weighed ten ounces and was waxy, its cortex pale and its medulla dark-colored: the
right weighed ten ounces and a half. The stomach and small intestine were normal; the colon thickened and soft-
ened: the rectum congested, thickened and softened. — Hospital, Annapolis Junction, ild.
Case 10.— Ashley R. Jackett, Co. K, 5th Mich. Cav., was admitted June 26, 1863. No history could be obtained
previous to the occurrence of the anasarca, which appeared shortly before his admission. The urine, high-colored,
acrid and albuminous, contained tubular casts, renal epithelium, an abundance of lat-globules, a few blood-disks and
crystals of uric acid. Treatment consisted of cups over the loins, warm fomentations and diaphoretics: later the
hot-bath Avas used, with acetate and bitartrate of potash, the latter of which afforded some relief. The feet were
scarified. The diet was nutritious, fats being avoided. Erysipelas set in July 23. Death on August 3 was preceded
bycoma. i'o«/-»io>7e»i examination: Body much emaciated; hydrothorax, ascites and general anasarca present. The
heart weighed eleven ounces and a half. The lungs were healthy. The kidneys weighed eight ounces and each pre-
sented the appearance of Bright 's disease. — Act. Aaa't Stirgeon Xorman S. Barnes, First Division Hospital, Alexandria, Va.
Case 11. — Corp'l George Montague, Co. K, 19.5th Ohio: age 29; was admitted Dec. 8, 1865, with acute rheuma-
tisiu. He had been treated at regimental hospital for eight days and had been intoxicated for two weeks previous
to the attack. On admission the left thigh, knee-joint, leg. ankle and foot were much swollen and very painful, and
the left elbow and wrist tender and painful ; the tongue was dry and dark-brown, the stomach irritable, the abdomen
tympanitic, the stools freiiuent, light-colored and watery, the pulse 100 and weak, the skin dry and the mental facul.
ties dull. Colchicum, morphine and efi'ervescing draughts were prescribed. Next day, as the patient had passed no
nrine since admission, the catheter was employed, but only a tablespoonful of ropy liquid was obtained. Small and
repeated doses of calomel, opium and ipecacuanha were prescribed, and subsequently dry cups to the loins, with
buchu and spirit of nitre, and barley-water as a drink. Xo urine was passed, and the patient died comatose on the
11th. Po8t-mor(fm examination: Body not emaciated; complexion sallow. The brain was congested, and a small clot
was found in the fissure of Sylvius, near the island of Keil. There were old adhesions on the posterior aspect and
»1)€X of the right lung; its middle lobe was in part hepatized and presented old cicatrices on its anterior surface. The
heart was large but otherwise normal. The liver was fawn-colored and enlarged: the spleen very large and firm.
The kidneys were large, fawn-colored and mottled on the surface with streaks and spots of congestion ; the epithelium
884 NOSTALGIA.
of the tubuli Tvas granular aud contained free oil-droi)S, — [SjMciwifH 766, Med. Sec., Army Medical Museum]. The
bladder was empty and firmly contracted. The descending colon \vas contracted and contained several small blood-
clots, but there was no ulceration.— Sdi-iyeoH E. Benilcy, U. S. Vols., Slough Hospital, Alexandria, Va.
Case 12. — Private John Tyler, Co. I, 1st Reg"t Invalid Corps, on duty in the hospital kitchen, was taken sud-
denly with convulsions Jan. 11, 1804. He had no pain in the abdomen and had been complaining but little prior to
this attack. He died next day. I'ost-mortem examination : The lungs were engorged with blood, which llowed freely
upon section. The heart contained a large white clot. Two pints of pus were found in the peritoneal cavity. The
liver was covered with lymph and softened but not granular: the spleen was macerated and softened, pale-blue exter-
nally and grayish-blue internally: the pancreas was healthy. The intestines were healthy except within three feet
of the anus, where the mucous membrane was congested and covered with whitish tenacious mucus. The kidneys
were purplish-red, large and flabby, the sections mottled and greatly congested; the suprarenal capsules were pale
and friable but of natural size. — Ass't Surgeon Harrison Allen, V. S. A., Lincoln Hospital, TTashington, D, C.
Case 13. — Private John Donnelly, Co. B, 1st Mass. Heavy Art'y, was admitted Nor. 22, 1865, with anasarca,
increasing dyspnoea, drowsiness aud convulsions occurring at hourly or half-hourly intervals, during which he passed
small quantities of albuminous urine. Coma supervened, and he died next morning, rost-mortcm examination : The
l)ia mater was moderately injected, especially at the base of the brain; the sac of the arachnoid contained a small
quantity of limpid serum : one spot of ecchy niosis was found on the upper and back part of the right hemisphere ; the
corpora striata were speckled on their ventricular aspect with minute ecchymoses: the floor of the fourth ventricle
showed lines of marked congestion aud blood-spots. The lungs were a-dematous, the right weighing thirty-four aiul
the left thirty ounces. The spleeu weighed sixteen ounces but was otherwise normal. Both kidneys had a pale
cortex which tore readily in the direction of the tubules aud was of low specific gravity; the right kidney contained a
small cyst in its lower part. The fundus of the stomach was reddened. The mucous membrane of the large intestine
was darkly discolored throughout. — Ass't Surgeon Geo. M. McGill, U. S. A., Xational Hospital, Baltimore, Md.
Case 14. — Private Louis Kail, Co. D, 119th N. Y., was admitted Oct. 15, 1863, with ascites and rheumatism.
The joints were tender and the abdomen rotund, but the patient was able to walk about the hospital. Colchicum and
sweet spirit of nitre, aud afterwards jalap and cream of tartar, with iodine locally, were used. For a time there was
some improvement, but on December 8 he became wildly delirious, requiring restraint by the straight-jacket. Active
purgation by calomel and rhul>arb. and afterwards by castor oil and crotou oil, was employed. This induced pros-
tration, aud on the night of the 11th he slept for a few hours. When awake he talked constantly, laughing vacantly
and using desperate oaths. On the 16th he kept blowing through his teeth as if to cast something from his mustache,
alternating this with wild screams or muttering delirium: his pulse was almost imperceptible and his skin covered
with cold perspiration. He died on the morning of the 18th. Post-nwrleiii examination: The vertex and sulci of the
cerebrum were bathed in sero-puruleut matter and the ventricles filled with bloody serum. The lungs were healthy.
The heart was fatty and somewhat dilated; the muscular walls were reduced to half their normal thickness. The
liver was hypertrophied and indurated: a cyst the size of a buckshot and containing biliary matter was found on
its surface. The calices and pelvis of the right kidney were filled with exuded fibrin and albumen — traces of which
were also present in the left kidney. — Act. Ass't Surgton TV. A. (rordon. Hospital, Louisville, Kg.
CHAPTER XL— OJf CERTAIN DISEASES XOT HERETOFORE DISCUSSED.
I.— NOSTALGIA.
A temporary feeling of depression frequently pervaded our camps on account of dis-
comfort, hardships and exposures, especially when these were recognized or assumed by our
volunteer soldiers to be of a preventable or uncalled for nature. During its continuance the
happiness and comforts of home arose to mind, coupled with the desire to again experience
them. This natural result of existino; discomfort constituted the onlv nostalo-ic influence to
which our troops as a rule were subject. While it lasted it was dangerous to their efficiency;
but even the rumor of an intended movement generally sufficed to ruffle the mental surface
on which the home attractions were depicted, blur the outlines of these and arouse the men
to their wonted activity and energies. Occasionally, owing to peculiarity of temperament or
to domestic troubles or afflictions, the home feeling became develo]ied to a morbid degree and
was reported as nostalgia. This must therefore be regarded as a camp disease of the wor
period, although it cannot be said to have been of frequent occurrence, as only 5,213 cases
were reported among the white troops, or 2.34 cases annually per tliousand of strength. In
NOSTALCilA. 885
the second year of the war, when the average number of men in the field was nearly double
that of the first year, the rate of prevalence rose to 3.3 per thousand. Epilej^y, indeed, so
far as frequency is concerned, has more claim than nosta]o;ia to be called a disease of our war
camps, for 9,029 cases were reported, or 4 annually in every tliousand of strength.
Baktholow has given an excellent summary of tlie points connected with this morbid
condition. ■•' The primal cause was undoubtedly absence fro'm home in new and strange sur-
roundings, particularly when these were of a depressing character. The j^atients were derived
from two classes of soldiers, — young men of feeble will, highly developed imaginative facul-
ties and strong sexual desires, and married men for the first time absent from their families.
The monotony of winter camps favored its evolution — active campaigning repressed it. Cases
rarely occurred in regiments provided with mental and physical occupation. Intellio-ent
officers prevented a morbid depression of spirits by directing the work of their men in chan-
nels leading to comfort and health, in improving the condition of their camps, giving variety
to military exercises and instituting open-air sports and pastimes. In nostalgic cases some
derangement of the health, as a rule, preceded the mental phenomena. Ass't Surgeon J.
Theodore Calhoun, U. S. Army, generally found nostalgia associated with some other mor-
bid condition, — as a cause still abiding or a result.f In either instance the complication was
of a serious character, as the mental depression seemed to destroy the recuperative jiower.
Ill the following case the nostalgic influence seems to have determined the fatal result :
Private Ezra Biiigmaii, Co. G, IGlst. Ohio; age 30; was admitted M.ay 18, ISGl, convalescing from rheumatism,
much drjiressod in spirits and exceedingly homesick. On July 7 his pulse was weak, cough slight, expectoration
tough and stringy, skin dry and harsh, tongue white; liectic fever, dysphagia and much prostration were followed
by liiccough. and death July 21. Post-morkm examination; The lungs were emphysematous anteriorly and much
engorged with venous blood posteriorly. The heart was small and fatty; the liver enlarged, friable and fatty; the
other organs were not examined. — Cumberland Hospital, 21(1.
References to nostalgia are infrequent in the reports of our medical oificers;
Surgeon JI.U)lsox Eeese, llSth III., March, 1863.— During this month nostalgia affected a large number of the
men, nor were they perhaps less free from it the previous mouth. The state of the weather, their uncomfortable sit-
natiun, the vast amount of sickness throughout the whole army and the numerous deaths — all combined to depress
their spirits. They were but lately from home and its comforts, and their present condition was in striking contrast
to their former one. The men who were principally afl'ected with this disease were those wlio were somewhat ailing
liut were able to go about. They had physical sulfering, but not enough to keep their thoughts from dwelling on
home. 5Ien who were severely sick and suffering from bodily pain were generally but little ali'ectcd with this trouble.
In one case the disease amounted to mania.
Siiryco)! John L. Taylor, 3(1 Mo. Car. — In civil life every man was necessarily engaged in some business that
gave more or less employment — enough for the sanitary condition of the mind and body. Many had been habituated
to physical labor, with only such exercise of the mind as was uecessaiy to accomplish the work on hand. For them
to acquire a more extended field of mental labor is impossible; their habits of thought are formed. It is therefore
needless to try a system of book-study with them. They must bo taught practically the obligations aud duties that
become necessary for them to learn. They must be taught the manual of arms by the force of practice. They must
learn the science of tactics by repeated drill. Daily military exercise should bo enforced. This combines physical
exercise with the same amount of mental labor that has been their custom through life. The homesick patient shows
a want of resolution and activity in all his undertakings; he is serious, sad and timid, apprehending on the slightest
grounds the most serious results — great personal danger, and even death itself. This condition is soon followed by
emaciation, languor aud listlessuess.
How shall we treat these patients ? To send them home would encourage others to indulge in the hope of getting
away. They begin to contemplate a leave of absence. Their minds are then permitted to entertain the causes that
have ]iroduced the disease in others, and they become, as it were, imperceptibly entrapped. To ward off this condi-
tion the soldier must act before the vital and nervous powers become depressed.
During the first twelve months of the organization of this regiment we had twenty -three home-sick patients,
and in five of these there was some mental alienation, especially manifested by their insistance that a return to their
homes was indispensable to the recovery of their health. In many instances the symptoms of hypochondriasis were
present: Disordered digestion; increased sensibility; palpitations; illusions; a succession of morbid feelings which
appeared to simulate the greater part of disease; panics; exaggerated uneasiness of various kinds, chieflv in what
• Sw jMse 21, r. S. B.mUanj CcmmiaUm JImoin, Xew Tori:, IS'i". f JfeJical ami Sitrrjical Rrporter, XT, )>lliladelpllin, 1804, p. 130.
886 KOSTALGIA.
regards the health, which they strenuously conteiideil was seriously iujured and could not he restored short of heing
at home. There was a stubborn iudolence in these jiatients — an aversion to anything like even ordinary exercise.
They were generally found lying in bed or sitting around the tents, making a great deal to do about their sutterings
and the ills that were awaiting them. Kind and symi)athizing words — amusements — seemed to invite a more deplora-
ble condition. We became satisfied that an altogether difiereut policy must be carried out. Ko ordinary means could
arouse them from their mental and physical inactivity — they seemed to be callous to moral sensibility.
The patients were now required to exercise to the extent of their physical ability. This was enjoined as a duty.
At the same time a system was inaugurated to impress them that their disease was a moral turpitude; that soldiers
of courage, patriotism and sense should be superior to the influences that brought about their condition, and that to
speak of home as insejiarably connected with their recovery, and all that constituted happiness, was petty and degen-
erating. The purpose in view was made known to the nurses, and every opportunity was taken to inflame the feel-
ings of their patients by imi)ressing them with the idea that their disease was looked upon with contempt — that
gonorrhcea and syphilis were not more detestable. This course excited resentment, — passions were aroused, a new
life was instilled and the patients rapidly recovered. Within two years not a single case of nostalgia has occurred,
which may l>e attrilmted to the fact that idleness is unknown in the regiment, while the odium attached to the dis-
ease has jilayed a part in causing the men to overcome the influences which tend to its production.
In the absence of detaileil reports on this subject by others, the writer feels waii-anted
in submitting the results of his own experience.'-'
The fatigues of a march and the excitements of an active campaign stimulate the nervous energies to a high
point. Ou the inauguration of a permanent camp, the labor necessary to secure shelter and comparative comfort
fully occupies mind and body. But after a time, unless a healthy safety-valve be provided for the nervous force
which has heretofore been expended in the superintendence of muscular action and in vital resistance to exposures,
the soldier becomes fretted by the tameness of his camp-life. Tobacco is smoked during this period of listlessness and
inactivity, nominally to jiass the time, but in reality for its sedative influence on the unemployed nervous system
until the circulation becomes jioisoued and loss of apjietite, impaired digestion and prostration of nerve-power are
the results — the last heing manifested by languor,- tremulousness, palpitations and obscure cardiac pains. If alco-
holic liquors can be obtained they are much resorted to at these times, and excesses tell on the nei-vous system by
depressent action. A'icious dealings with the generative functions have, in individual cases, furnished the temporary
excitement and produced that subsequent collapse of the vital powers which has figured on the registers as '' nos-
talgia." Gambling is the favorite excitement of many, and prolonged sessions are held in cramped positions and foul
atmospheres, implying loss of sleeii and disorder of assimilation.
Excitement is ci'aved — something to do to pass tlie dull hours. Drills and parades are better than nothing, as
furnishing occupation and exercise; but they are distasteful to the men as devoid of excitement and savoring of
unnecessary work.
Company commanders should cater to the tendencies of the leading spirits of the command. There are always
certain men who can carry the crowd with them, either into foot- and base-ball clubs and other outdoor sports or to
minstrel troupes and semi-theatrical entertainments, which furnish amusement to all, either as actors or audience.
These men should be encouraged as the most valuable for the time being in the camp. Horse-racing affords an inter-
est to all ; and target-practice — not the formal so many rounds per man of duty-firing — but competitive shooting by
teams from the difiereut regiments. Pedestrianism ought to be cultivated among infantry troops, and prize-matches
arranged for favorable days.
In large commands men can be jiicked out with special talents as vocalists, prestigiators, gymnasts, etc., and
these should be organized as an army company and encouraged by ofiicial recognition and assistance in catering for
the amusement of the troops. Everything of this kind would be hailed with enthusiasm.
A camp kept well amused will be a healthy one — free at least from all nostalgic influences — and the object to
be gained, as promotive of efficiency, is worthy of special eftort. In large commands an officer should be detailed as
Superintendent of Public Amusements, who should be manager of theatrical performances, races, competitive shoot-
ing and prize competitions of all sorts. If active and enterprising, he would save many from the sick-list and tide
the command over the tedium of winter-quarters with undiminished nerve-force.
II.— ARMY ITCH.
During the period covered by the statistics there were reported among the white troops
32,080 cases of itch and 35,667 of skin disease; among the colored troops 3,156 of itch
and 3,279 of skiu disease. The average annual rates calculated from the sum of these
numbers are 30 per thousand of strength among the white and 35 among the colored troops.
The disease popularly termed army itch constituted an unknown proportion of these cases.
The reports on file in the Surgeon General's Office give no information concerning this
disease. In the absence of official records personal testimonv may be of interest:
* See Vol. XIX, Zieiiissen^s Cyclopedia, Aiueficu)i EiL, New York, 1879, p. 117.
AKMY ITCH. 887
The ■(vriter served in the field with the Second Army Corps, Army of the Potomac, from the autumn of 1802 until
the disbandment, and had special facilities for observing the medical history of that command ; yet he saw only an
occasional case of scabies, and but few cases which, not being scabies, were of such a character as to warrant their
designation by the i>opular title of that parasitic disease. Many men suftered from prickly heat, especially during
their tii'st summer in the south. In some cases the papules became torn and inflamed in eftbrts to allay the intoler-
able itching, and in others an eczematiius condition was developed, due perhaps to some peculiarity of the eonstitu-
tioual state. Lichen was frequently aggravated by the unaccustomed contact of coarse-fibred clothing, anil when,
as was not unfreciueutly the case during an active campaign, a ciunpany or regiment became infested with the inili-
ciiliis corjMris, the combined sources of irritation produced a disease of the skin which sometimes incapacitated the
soldier from service, associated as it' was with great suffering, mental disquietude and loss of rest.
These constituted the only pruriginous conditions which, in the experience of the writer,
prevailed among our soldiers in the field. Nevertheless, a number or articles appeared in
the medical journals, after the close of the war, depicting army or camp itch as a contagious
disease, epidemic among our troops, disseminated by them extensivel}' among the civil pop-
ulation in the vicinity of their camps and lines of march, and conveyed to their homes in
the north on their return to civil life. Some claimed the disease to be a new importation
from southern territorv; others insisted on its existence in the northern states prior to the
outbreak of the rebellion. Some western practitioners recognized in it an old acquaintance
known by the names of prairie dig, luestern itch or Ilissouri mange. Certain writers con-
sidered the disease in all cases to have been neither more nor less than scabies, and announced
its amenability to the specific treatment for that affection. Others believed it to be allied
to prurigo, differing, however, from that disease by the possession of infectious characters,
or akin to scabies, but dependent on a parasite to which the exposed rather than the pro-
tected aspect of the limbs afforded a congenial settlement. It was claimed that the disease
did not attack the commissures of the fingers or the flexures of the joints as in scabies, but
the arms, chest, abdomen and lower extremities. Those who sustained its parasitic nature
generally found sulphur washes or ointments efficient in its treatment; while those who con-
sidered it akin to prurigo as generally failed in curing their patients by means of sulphur.
According to the descriptions given the disease began as a lichen or prurigo with the
development of papules which itched intolerably. Scratching caused the surface to be dotted
with dark points of dried blood. Afterwards the affected j^arts assumed an eczeraatous or
even an impetiginous character as the result of neglect and violence, and in certain stages of
the disease a thin, yellowish, acrid liquid exuded from the inflamed parts.
It is interesting to note that those medical ofiicers wlio had the best field of observa-
tion in the northern as in the soutliern armies distinguished between scabies and the disease
to which they applied the name camp itch. S. J. Radcliffe of Washington, D. C, who
had been on duty at Annapolis, Md., during the war, regarded the disease as vesicular, and
contagious from the highly excoriating qualities of the exuded liquid ; he discovered no para-
site in the inflamed parts. Jxo. H. Claiboene, who had been in charge of the Confederate
hospitals at Petersburg, Va., found the disease registered by medical officers as itch or camp
itch to have been rarely scabies, but an affection akin to lichen or jjrurigo, which sometimes
became vesicular or pustular when aggravated by the many unpropitious influences to which
the soldier on active service was exposed.
It would seem, therefore, that our medical ofiicers confounded under the term army itch
two series of cases — the one scabies, and the other a non-parasitic inflammation of the skin
originating in a coraplexus of local irritant and unhealthy constitutional conditions. The
former appears to have prevailed among the civil population and the troops in contact with
them, the latter among the soldiers engaged on the actual theatre of war.
888 ARMY ITCH.
Scabies has no claim to the title of army itch. It was well known before the war in
Maryland, Pennsylvania and many of the Southern and Western States. The troops became
infected by contagion from civil life. Crowding in camp and want of facilities for personal
cleanliness in some instances diffused the disease. The soldiers exposed to the torment of
this civic infection suffered enough without having to bear the odium of its development.
If the name of camp itch is to be retained by medical men it sliould be restricteil to the non-
parasitic cases of pruriginous skin diseases.
The following abstracts of papers on army itch are submitted:
George M. Sternberg, Ass't Surgeon, U. S. Army,* declares the only difference between this disease and
scabies as seen iu civil practice to be one of degree. Soldiers neglect to apply for treatment until they are completely
covered with the eruption, which is so lacerated by the patient's nails and masked by complications that it
would be difficult to recognize the disease if the case were an isolated one. "It is not surprising," he says, "that
the disease should cover a larger extent of the surface and appear on the outside of the limbs as well as iu the tlex-
iires of the joints, when we consider the crowded manner in which soldiers live in their tents or barracks and the
carelessness that exists among them iu regard to personal cleanliness. The soldier catches the disease by sleeping
with a comrade who is covered with the eruption or iu blankets which are filled with acari and their ova, and the
disease is at once started from many ditfercut centres. The little acarus squats upon a new recruit with every pros-
pect of a long life and a large family, and burrows away, undisturbed by soap or sulphur, until every square barley-
corn of the poor soldier's skin is like a New York tenement house, — full inside and out." During the winter of 18lw-66
he had nearly two hundred cases among the recruits at Jeft'erson Barracks, JIo., and found no ditHculty iu etfectiug
a speedy cure by means of a wash prepared by boiling an ounce each of sulphur and recently-slacked lime in two
quarts of water until the liquid measured three pints. This was filtered for use.
W. S. FORWOOD, Darlington, Md.,t also considers army itch as scabies aggravated by long standing and neglect.
He s.rw a large number of cases in 1864 and 1865, and as scabies prevailed in the same vicinity jirior to the war he
had ample opportunities for comparison. Sulphur ointment invariably cured the disease in his part of Maryland.
D. L. Ph.\res, Newtonia, Miss.,} observed the disease in all its stages and complications among all classes, con-
ditions, ages and occupations, and claims to have demonstrated its cause, the acarus scabiei, in hundreds of cases.
An ointment of two parts of sulphur, one of carbonate of potash and eight of lard, following the use of soft soap in
the warm-bath, cured ninety-nine per cent, of all cases by a single thorough application. He notes that sulphur
itself produces an eruption on the skin of many persons, and that he has seen practitioners keeiiiug up by its use a
cutaneous irritation little less distressing than the original disease, which they supposed they were still treating.
H. B. WiLSOX, Boonsboro', Md..4 refers to the hundreds of thousands of troops from the north and south that
traversed the county of Washington, Md., during the progress of the war, and to tlie consequent infliction of army
itch on its inhabitants to a greater degree than in any other county in the United States. He assumes the disease to
have been parasitic, but sulphur ointment, with sulphur aud cream of tartar internally, failed to cure it. The infal-
lible remedy in his hands consisted of an ointment of four ounces of sulphur, two drachms each of white precipitate
and black sulphuret of mercury and twenty minims of creasote in ten ounces of lard.
,J. E. Jacksox, Fallston, Pa.,|| who was familiar with the disease before the war, conceives that it differs from
the old, common or school itch only iu a want of predilection for the roots of the fingers, the flexures of the joiuts
and the finer jiarts of the skin, and in its failure to respond to the sulphur treatment, which is eft'ective in scabies.
He assumes the presence of a peculiar acarus, which requires for its destruction the free use of soaj) aud warm water,
and the subsequent application of an ointment consisting of two drachms each of white precipitate, nitrate of potash
aud iodide of sulphur, and half an ounce each of carbonate of potash aud oil of bergamot in six ounces of lard.
B. F. Records, Paradise, Mo. ,11 and J. J. Tyree, Waynesville, Mo.,** testify to the existence of the disease in
their State prior to the war, when it was known under such names as Illinois Itch, Missoini Munye, Prairie' Dig and
Bastard Itch. The former was successful iu treating it only when he had recourse to an ointment of two drachms of
sulphur, one drachm of sulphate of copper, half a drachm each of red oxide of mercury aud alcoholic extract of
aconite iu two ounces of lard. The latter objects to the uame of army itch as conveying inaccurate views : refers to
the thin yellowish liquid that exudes from the inflamed patches in certain stages of the disease, and states that
although Fowler's solution internally and red oxide of mercury ointment externally constitute the best remedial
agents, these sometimes require to be continued for many weeks before a cure is eft'ected.
P. J. Faexsworth, lowa.t t also recognized the disease as an old acquaintance known from the time of the earliest _
settlers by the name of Western Itch. He has always regarded it as an undescribed affection allied to prurigo. It ia
very contagious aud is no doubt often associated with scabies; but it does not, like the latter, make its first appear-
ance between the fingers, but on the body and limbs. It associates with nearly every other form of papular and ves-
icular disease; iu some cases eczema results from it, and in other cases pustules. Sulphur ointment fails to cure the
* Medical awl Surgical Heporler, XIV, Philadelphia, Pa., 1866, p. 298. t Meilical and Surgical Reporter, XIV, Philadelphia, Pa., 1806, p. 3T8.
X Ibid., Vol. XVI, 1867, p. 524. g Ihid., Vol. XIV, 1806, p. 136.
I|/(.W.,XV, 1800, p. 104. •[ Ji)W.,XV,lS66, p. 105.
**Ihid., p. 105. tt Iltid., XV, p. 106.
ARMY ITCH. 889
disease, liut a lotion of sluiri) vinegar or of corrosive suliliniate is eliective. I'owler's solution may be reiiuireil on
accouut of complicating disorders.
\V.E.\VniTKiiE.\D,Ass't Surgeon,U.S. Army,* found the disease inUifienoiis in the Southern .States, and especially
(irevaleiit in Missouri, Arkansas and Tennessee. It is contagious, particularly among members of the same family or
eonipauy, or where fre<iuent and close contact takes place, as by the use of the same bed, blankets orarticles of clothing.
It chielly affects the inner aspect of the thighs and forearms and the lower part of the abdomen. ,Soap and water with
compound sulphur ointment or kerosene as local applications controlled the disease in from ten days to two weeks.
K. A. Woop. McKeesport, Pa.,t was familiar with the disease in his section of the country before the war. He
distinguishes it from prurigo by its contagious properties and from scabies by its attack on the outer or more exposed
portions of the body and limbs. It is generally caught by sleeping with or wearing the clothes of an infected person.
It runs through the varied progressions of erythema, lichen, eczema, impetigo and psoriasis, and may even be com-
plicated with boils. Treatment by sulphur was effective in his practice. Like Jackson of Pennsylvania, he assumes
the presence of a parasite similar to, but distinct from, the acarus scabiei.
L. C. lii'TLKR, Essex, Vt.,; traced it invariably to importation from the south by our returned soUliers. It is
highly contagious and is no respecter of persons. He says positively it is not scabies. It seldom, in his opinion never,
in its inception is found in the groins, axilla, armpits or between the fingers, but instead appears on the arms, fore-
arms, chest, abdomen or lower extremities, and in some rare cases upon the scalp. Sometimes it is a fine erupt ion, hardly
discoloring the skin or raised above it ; again it resembles rubeola and gives a-seusatiou of roughness to the surface.
The pruritus is sharp and stinging, causing incessant scratching, by which the i)apnles are torn and a minute blackish
crust formed on their apices, giving the eruption a characteristic appearance. I'nderneath this crust is a minute red
point which fades as a new crop is developed. In many of its characteristics, exclusive of contagion, it resembles
prurigo. It has no vesicle nor pustule, yet sometimes, from the incessant irritation, there is formed a discharging
surlace which may be covered with scabs. IIo refers the disease to an infection in the blood, which re(iuires con-
stitutional as well as local remedies. Uniform success attended perseverance in the use of a mixture of four to eight
grains of arsenito of soda in four tluid ounces of compound syrup of sarsaparilla in doses of a teaspoonfnl morning
and evening, with the occasional exhibition of fluid extract of iris versicolor, leptandrin, pipsissewa or podophyllin,
as may be rctiuired, and the external application of an ointment prepared by blending intimately, with the aid of heat,
one ounce each of the red oxides of mercury and lead and four ounces of Burgundy pitch, all in fine powder, with one
onuce of Venice turpentine and twelve ounces of fresh butter.
T. I?. Smith, Otsego, N. Y.,i regards the disease as of amixed character, combining th(! distinctiveappearancea
of several cutaneous atlections. Many cases fell under his olwervation in which, in his opinion, the coexistence of
lichen, prurigo and scabies was well marked. In these cases alkaline, sulphurous and acid washes had but little effect
except to allay the tormenting pruritus. Mercurial and sulphur ointments, when strong, were harmful. The most
satisfactory remedies in his practice were the diluted citrine and white i)recipitat6 ointmeuta and a solution of half
a drachm of corrosive sublimate in eight ounces of water, with Fowlcr'a solution internally and the removal of the
digestive derangements that arc frequently associated with the disease.
S. J. Kai>ci.ifi"E, Washington, D. C.,l| had many opportunities during the war of examining and treating this
Iiarrassing artection while on duty in the hospital at Annapolis. He considered the disease essentially an eczema.
It spread irregularly over the whole surface of the body, but was found principally on the hands, fingers and elbows,
scattered in distinct red spots and vesicles from the axilla to the wrist, on the nates and particularly in the popliteal
space and about the ankles. The skin was frequently so stiff from crusts and painful from excoriated fissures as,
with the associated itching, to occasion an almost unsupportable nervous irritation. The vesicles contained a Iiighly
excoriating limpid fluid which was capable of extending the diseased action. No parasite was discovered. The dis-
ease was attributed to want of cleanliness and the continued exposure to the rays of the hot sun in poorly-fed men,
ami was therefore perhaps of more fVei|ueut occurrence among our paroled prisom^rs than in the ranks of the army.
Ill its treatment he tried without benefit ointments of sulphur and iodide of sulphui', washes of sulphuret of lime,
corrosive sublimate, the oxides of mercury, muriate of ammonia, chloride of calcium and many other local a])plica-
tious, with Fowler's and Donovan's solutions internally. Ultinuitely he realized that better results followed the use
of unirrit a ting remedies. .Strict attention to cleanliness and the application twice daily of a mixture of olive oil and
glycerine seldom failed to effect a speedy cure.
J. H. Ci-.UBORXE, Surgeon, C. S. A. ,11 reports the disease as seen in the hospitals at Petersburg, Va., to have liecn
papular and akin to lichen or xirurigo. No acarus was iiresent. In the absence of regular medical supplies he found
that a decoction of poke-root used as a wash cured the uncomplicated pa]uilar disease in ten days, and that when the
surface was much indamed by scratching or other sources of irritation a decoction of broom-straw root or of sli])pcry
elm was of value. Mercury and arsenic were administered internally.
S. R.CHAMiiEH.s,Ass't Surgeon, C. S. A.,"* used an ointment composed of lard, sweet gum, resin, olive oil, sulijhur
and an extract of the inner bark of the elder, made by evaporating a strong decoction.
« Jl-tUmI mill Snrgkal i?.jwr(.r, XIV, rinladeli.hia, I'a., I.. -flT. t .V«ili('i( „ml Siirijlcal Bciiorlir, XIV, Pbilndi-lj.llia, Pa., \t. 70.
: lUI., ].. 101. I Ili-l, XIV, p. 124.
' Ihi-h, XVI, |>. 3. 1[ CtitiftiUrale tUiilea Medical am> SurgimI Jmnml, Vol. I, 18C4, p. 39.
•* a>ii/..I,r.ir.- .Sfo/M Mvlicnl mill Sniv/iciiJ Journal, Vol. II, 18C5, p. 11.
Med. Hist., Ft. Ill— 112
890 - POISOXO'O-ALCOHOLISM.
III.-POISONING.
Under tliis heading were reported among the white troops 3,288 cases, of which 97 were
fatal. Some of these, including most of the fatal cases, resulted apparently from opium taken
by mistake or with suicidal intent; but the mass of the cases consisted of a cutaneous inflam-
mation of'the head and face, sometimes of tlie upper extremities, and occasionally of the nates,
scrotum and adjoining parts of the trunk and thighs, which was referred to the agency of the
poison oak, Rhus toxicodendron. This inflammation was attended with much pain, heat and
irritation, and the swelling sometimes, as in erysipelas, obliterated the features. The affected
surface .was of a lurid-red color, covered in aggravated cases with vesicles, the contents of
which became encrusted on drying or oozed as a thin liquid from superficial fissures. There
was usually little constitutional disturbance, but often much suffering from local irritation
and loss of sleep. Generally the inflammation subsided in about a week or ten days with-
out leaving subcutaneous 'suppurations. It was treated by aperients, cooling lotions, ano-
dynes and hypnotics.
The records present only two cases illustrative of poisoning by deadly drugs:
Case 1. — Private Walter Fitzgerald, Co. H., 4th V.E. Corp.s; age 68; was admitted June 14, 1865, -with a rUeu-
niatic affection, from Tvbicli he so far recovered as to be able to evade the guard and keep himself sujiplied with
whiskey. On August 6 he had a slight attack of delirium which confined him to bed for some days, and on the 21st
a more severe recurrence. At 9.40 p. M. of the 22d it was found that one ounce of laudanum had been administered
by mistake : he was insensible, but could be aroused by shaking ; pupils much contracted, pulse 150; respiration 10 ;
skin pale and warm ; hands like a washerwoman's. Eight grains of extract of belladonna were at once given and
the patient was kept aroused by the galvanic battery and friction. At 10.30 the pupils began to dilate ; ijulse 14-1 ;
respiration 10 when in repose, 14 when aroused : the skin seemed regaining its color and the face and hands were
nearly natural. Half an hour later four grains of the extract of belladonna were administered, under the influence
of which the dilatation of the pupils continued and the respiration became more frequent, 17; pulse 144 : but the
drowsiness increased, and the skin became cooler and assumed a blue color. Whiskey and carbonate of ammonia
were given by enema. He lived until 5 r. m. of the next day. Artificial respiration was attempted. Post-moytem
examination : Eigor mortis slight. The membranes of the brain contained three ounces and a half of bloody serum
and the lateral ventricles half an ounce, the choroid plexus of each being enlarged; the cavernous portion of the
right internal carotid contained a long fibrinous clot; the superficial cerebral veins were engorged. The lungs pre-
sented some old adhesions, — the right was congested, the left had a small vomica in its apex and miliary tubercles in
its ujjper lobe. The heart was Uabbj' and contracted; it contained fibrinous clots which extended into the great
vessels ; one of the aortic valves presented a cartilaginoits deposit about the size of a small pea, another showed a
harder deposit, the third was healthy. The oesophagus was red; the stomach normal: the liver enlarged and fatty:
the gall-bladder distended ; the spleen shrunken and tiabby ; the kidneys fatty, — the left of normal size, the right half
the usual size aud nodulated. — Douglas Hospital, Washimjion, D.C .
C.\SE 2. — Private Albert Boggs, Co. U, 1st Pa.; age 17; admitted Aug. 2, 18B3. He had been attacked ou the
previous day with cholera morbus, for which a physician had prescribed sixty drops of laudanum every half hour;
he had taken altogether between one oitnce and one ounce and a half up to the time of his admission. His eyes were
injected and watery, pupils contracted, head hot, face slightly flushed, lips blue, mind confused, pulse small aud fre-
♦juent, about 96. He became comatose and died on the 3d. Cold was applied to the head aud sinapisms to the extrem-
ities. The record of the post-mortem examination gives no other information than that the head, trunk aud upjier
extremities were cyanosed. — Cumberland Hosjntul, Muryhind.
IV.— ALCOHOLISM.
Under this term may be included the statistics of inebriation, delirium tremens and
chronic alcoholism. Among the white troops there were reported during the five and one-
sixth years 5,589 cases of inebriation, of which 110 terminated fatally; 3,744 cases of
delirium tremens with 450 fatal, and 920 cases of chronic alcoholism with 45 fatal. These ^
are equivalent to a rate of 4.6 cases annually per thousand of strength. Obviously troops
stationed in the neighborhood of large cities furnished the greater number of the cases.
The Army of the Potomac during its years of active service, ending June 30, 1863, '64 and
'65, had rates of 1.5, 1.8 and 0.8 respectively, but during the year ending June 30, 1862,
three-fourths of which was spent in the immediate vicinity of AVashington, the rate was 5.3
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VENEREAL DISEASES. 891
cases per thousand men. For obvious reasons, also, tlie rates were higher at the beginning
and end of the war than during its progress. The monthly variations are shown in the
accompanving diagram. The annual rate among the colored troops, .22 per thousand, equiv-
alent to 1 nian annually requiring medical attendance on account of intemperance in every
4,500 men, contra-sts favorably with the returns from the white troops, which indicate 1 case
annually in every 220 men.
But sickness from this cause is mentioned here merely as a matter of record. It ofl^rs
few points of interest statistically, and the recorded cases are such as may be paralleled daily
in the medical experience of civil lil'e.
Preventive measures belong rather to the government and discipline of camps than to
their sanitation — to the military more than to the medical officer.
v.— VENEREAL DISEASES.
Venereal diseases were associated witli intemperance in the conditions which favored
their causation. Hence they were more frequent at the beginning and the close of the war
than during its progress, and among troops stationed in the vicinity of cities than among
those on active service. Elevations of the lines of prevalence during the continuance of the
war correspond with the accession of fresh levies or the return of furloughed veterans.
Among the white troops 73,382 cases of syphilis were reported, and 109,397 cases of gonor-
rhoea and gonorrhoea! orchitis, giving a total of 82 cases of venereal disease annually per
thousand men, as compared with 87.86 in our army before the war and 87.62 from the records
of the ten years immediately following the war period.* Among the colored troops syphilis
had an annual rate of 33.8 cases and gonorrhoeal affections 43.9 cases per thou^^and of strength.
The variations in the monthly rates are shown in the diagram facing page 890. The lines
of svphilis and gonorrhoea run courses parallel to that of their consolidation.
The hospital records present 426 cases of venereal disease, — 53 of gonorrhoea and 373
of svphilis. Of the former 50 were simple cases and 3 complicated with suppurating bubo.
Of the latter 194 developed no constitutional symptoms, — among these, gonorrheal compli-
cations were present in 41 and supurating bubo in 77. It is impossible to determine, fron^
the language of the record, the character of the primary sores in 179 cases which were fol-
lowed by secondary symptoms. The most notable point connected with their history is the
frequency with which sore throat, cutaneous eruptions and other manifestations of the con-
stitutional taint are reported as having followed venereal sores associated with suppuration
of the inguinal glands: 19 such cases are recorded.
Treatment as a rule was first restricted to the local lesions, mercury or iodide of potas-
sium being withheld until the development of secondary symptoms. No reference is made
to scorbutic complications nor to untoward results in constitutions undermined by the hard-
ships of military service. In fact, a similar series of cases might easily have been gathered
during the same period in the wards of our civil hospitals. A few reports on file indicate indi-
vidual views of the method of treating these diseases :
Aaa't Surgeon Robert F. Strattox, ll(/i III. Cai:,June30, 1862.— It was impossible to cure goiionba'a while the
patients were exposed to the rain and had to sleep on the damp ground and live on a salt and stiuiulatiug ration.
Surgeon WlLLi.iM R. Blakeslke, 11.")/7i Pa., Alexandria, Ta., Oct. 20, 1862.— Gouorrhcea was greatly modified and
in most cases completely subdued by injecting a solution of chlorate of potash, one drachm in eight ounces, every
♦See mpra. Table IV, page 16.
892 VENEREAL DISEASES.
hour for twelve successive hours, ami then grailually ceasing its use during the next two or three days by prolonging
the interval between each injection. Dietetic rules were observed, with rest and occasionally a saline laxative.
Siii-gcoii A. F. Pkck. 1st A'. J/. Car., Los Lunas, N. M., Sept., 1862. — Nearly one-third of the cases this month con-
sisted of gonorrhoea, which readily yielded to treatment. With much iutlammatory action iu the first stage, I gen-
erally i>rescribed a saline cathartic, rest, cooling lotions and low diet. After this stage had jias.sedl found balsam of
copaiba, powdered cubebs and magnesia given a.s a bolus, four or five times a day, to be very eft'ectual. At the same
time I used an injection of chloride of zinc, two to four grains to the ounce of water, once or twice a day. When the
system is much reduced tonics are beneficial.
SurrjeoH Is.\.\c F. Galloite, nth Mass., Feb. 20, 1863. — Syiihilis and gonorrhcea prevailed extensively in the
regiment during its stay iu Baltimore. Rapid and complete recovery was secured in all cases treated as follows: —
Gonorrlui'd : Injections of a weak solution of sulphate of zinc, one grain to one ounce of water, every hour or half
hour; light diet. By this treatment the disease was always cut short, no discbarge appearing after the first use of the
injection. SijphiUs: Cauterization of the chancre in the first instance, followed by the continuous ajiplication of
black wash. All cases thus treated recovered without secondary disease.
AssH Surgeon P. W. R.\xdall, 1st Cal., Fort Bragrj, CaL, Jan. 1, 1863. — For gonorrha^a my treatment, which is
successful, consists of a thorough cleansing of the alimentary canal, rest, low diet, the balsam and cubebs internally,
with urethral injections of nitrate of silver, sugar of lead or sulphate of zinc. For syphilis I use mercurial and saline
purges, rest, low diet, iodide of potassium and bichloride of mercury, with caustic to chaucres, warts or vegetations.
Surgeon J. G. Br.\dt, 26(/i il/ass., Nexo Orleans, La., Jnn, 1,1863. — Of the various forms of venereal disease chancre
of the non-indurated variety is the most prevalent. It is accompanied in a majority of cases with bubo. The sores
yield readily to cauterization with acid nitrate of mercury and applications of black wash, the bowels meanwhile
beiug regulated and the patient kept on low diet. But one case of indurated chancre has been observ-ed, and this
was unaccompanied by a bvibo. It was treated with mercurials internally and peruitrate of nnercury to the sore.
Sufficient time has not yet elapsed to determine whether secondary symptoms will be developed. No case of non-
indurated chancre has been followed by constitutional symiitoms. Gonorrha'a is much less frequent than chancre,
and more obstinate under treatment. My practice has been to use injections of sulphate or chloride of ziuc; oeca-
sioually, when there is irritability of the bladder, I employ diuretics. The cases are prone to become chronic. I have
no faitli iu the empirical use of balsams and diuretics, so long considered specifics iu this disease. I consider that,
by their tendency to over-stimulate the kidneys, they do more harm than good.
The reporter last cited, Ajiril 1, 1863. — I have not as yet seen the first case of secondary symptoms, although a suf-
ficient period has elapsed for them to make their appearance. In two or three cases only have I considered it advisable
to employ mercury internally. The remedy was continued until the gums were aft'ectcd, which condition was kept
up for ten or twelve days. Iodide of potassium was then given combined with touics. I do not consider mercurials
essential to the cure of the form of syphilitic ulcer most common in this city.
Shc(/coh David WoosTER,5//i Cal., Sacramento, Cal., ■Jan. 13, 1862. — linoculateevery case of chancre. If the virus
take, I treat locally and liygienically alone; if it fail to produce chancre after the third inoculation, I use protiodide.
The cttres in both series of cases are generally reasonably prompt, oceupyiug from fifteen to rarely sixty days. I have
not yet had secondary developments iu cases the primary accidents of which have been treated at this post.
Surgeon Allem F. Peck, 1st ]<[. M. Ifonnted Vols., Fort Stanton, X. M., Dec. 31, 1862.— rrimary: Cauterize with
nitrate of silver, after which apply black or yellow wash until the sore is healed. Consecutive : If there is no consti-
tutional contraindication I give mercurials, — the protiodide yields better results tlian any other preparation. If the
patient improves I continue the remedy until the sores are healed and the induration dissipated, using at the same
time disinfecting mercurial and astringent washes. If the system is exhausted I give tonics.
Surgeon Ezra Read, 21.s( Lnd., Baltimore, Md., Sept. 5, 1861. — For many years I have pursued the method of treat-
ment by mercurial fumigation, which deposits the mercury upon the surface of the body wlien in a state of perspira-
tion induced by the heated vapor of water surrounding the patient confined iu a close and air-tight bath. This treat-
ment is commended to our consideration because it eradicates the disease in a shorter period of time than is required
by the internal use of mercury; moreover, when thus applied the constitutional eftects of the mercury are under sat-
isfactory control. In primary syphilis, after careful and thorough cauterization of the chaucre, I regard fumigation
as the best method of treating the disease, and as the most reliable means of preventing constitutional manifestations.
In the secondary form I think it the only method by which a perfect cure can be effected.
Ass't Surgeon Wakrex Wehster, U. S. Aryny, Fort Lamed, Kansas, Oct. 1, 1861. — In this connection I desire to
record my unwavering belief in the efficacy of the mercurial treatment in syphilitic complaints. I have had special
opportunities among the Arapahoe and Kiowa Indians, who have been scourged for years with this disease and have
never been subjected to mercurial treatment, of observing the natural course of the diseased action. It has been urged
by many modern authorities that in the individual the virus of syphilis, if left to nature, will wear itself safely out.
These supporters of the non-mercurial treatment assert, somewhat dogmatically, and it appears to me without much
evidence to sustain their position, that mercury and syphilis together form in the system a sort of poisonous compound
which produces the worst and most destructive forms of constitutional syphilis. Now, these Indians of the plains,
who lead a simple and inartificial life, calculated by their habits of exercise and the mildness and salubrity of their
climate to foster a vigorous physical condition, are many of them the victims of the most desperate forms of consti-
tutional syphilis, evidencing itself iu lost noses, vacant palates, and the vilest cutaneous aftections, and this, too,
without having probably taken a particle of quicksilver. The inference is obvious when I state that their disease,.
VE^■EEl!;AL DISEASES.
893
oil being attacked betimes, Las generally kindly yielded to the judicious administration of mercurials. I may add
that a somewhat extensive observation of this unfortunate disease among the natives of this region has confirmed me
in the following beliefs, which have a bearing on its treatment. First: The virus must work in the tissues about
the surface during four or live days before it is sufficiently elaborated to affect the system through the blood. If,
during this time, the sore should slough or we produce this effect by caustic, the poison is destroyed or removed before
it is ripe, and we need nut administer mercury. Second : If the sore has not been destroyed or has not sloughed away,
the poison has been carried by the absorbents to the glands in the groin. These inllame and suppurate, aiul with the
pus the poison is discharged and does not further atVect the system. In such a case we need not, I think, prescribe
mercury. Ibit again, we have the chancre of Hunter andC'armichael, in which the poison, instead of stopping at the
glands and sujipurating there, passes straight into the system at large, and a rash declares that the constitution is
affected. AVhen this chancre has had time to mature without being destroyed by caustic, then we must introduce
the only medicine, mercury, which has the power of efficiently striving with the enemy. ^
Jaa'l Surgeon E. A, Tompkixs, ilk Cat, Fort TamhiU, Oregon, Jpril 1, 1863. — The patient contracted syphilis in
June last, a short time before I arrived at this post. He was relieved by the use of iodide of potassium in syrup
of sarsaparilia. Small doses of corrosive sublimate were also given, and lunar caustic was applied to tlie chancres.
.V continuance of this treatment for three weeks enabled him to return to duty, though not entirely well. Five weeks
later he was readmitted. All the indications of syphilis had disappeared, but ho complained of violent pain in his
head and his bowels were constipated. Twenty-five grains of calomel, followed by a black draught, relieved these
symptoms: but he was forthwith taken with a violent pain of a neuralgic character in his left leg. This pain affected
him at fre<iuent intervals during the day and was nearly constant during tlie night, sometimes varying in its site.
The painful leg was much colder than the other. Ho was treated first with an enteiic, next with stimulating embro-
cations and then with blisters along the course of the affected nerves. After tliis iron and (juinine were administered,
with laxat i ves to guard against constipation. Anodynes were occasionally recinired for the relief of suft'ering. Chloro-
form was used externally, but with only temporary relief. lie remained in the hospital over three mouths, during
which period the affected leg diminished materially in size. At length the pain became less frequent and severe.
The patient is now perceptibly recovering under the persistent use of iron and ([uiiiine, his leg at the same time being
enveloped iu cottozi wadding and daily rubbed with stimulating liniment.
Systematized efforts at prevextiox. — Efforts were made atKashville and Memphis,
Tenii., to suppress or limit the spread of these diseases among the troops, and, according to
the testimony of the officers concerned, the results were highly satisfactory.
It appears from the records that Brigadier General R. S. Granger, in command at Nash-
ville in June, 1863, was "daily and almost hourly beset" by the commanders of regiments
and their surgeons to devise someway to rid the city of the diseased prostitutes infesting it.
The matter was referred to the Provost Marshal, Lieut. Col, George Spalding, 18th Midi.,
who, by means of the police force and provost guard under his command, succeeded in placing
on board a steamer which he had chartered all the women of the city publicly known to be
of vile character. On Julv 8 the boat started for Louisville, Kv., but on arriving; at that
port the city authorities refused to receive the exiles. Cincinnati also closed her doors
against them. A few were taken off at Newport, Ky.. by a writ of habeas corpus, and
these soon found their way back to Nashville. Ultimately, in accordance with orders from
Washington, the boat returned to her starting point, and on August 3 disembarked her pas-
sengers to resume their former modes of life.
Meanwhile, Colonel Spalding, recognizing the failure of his attempt to remove the
women, suggested a system of licensed prostitution, with frequent inspection for the removal
to hospital of those likely to disseminate disease:
1st. That a license be issued to each prostitute, a record of which shall be kept at this office, togetln-r wiili the
number and street of her residence,
2d. That one skilful surgeon be appointed as a IJoard of Examination, whose duty it shall be to examine |)er-
sonally, every week, each licen.sed prostitute, giving certificates of soundness to tliose who are healthy and ordering
into hospital tliose who are in the slightest degree diseased.
3d. That a building suitable for a hospital for the invalids be taken for that purpose, and that a weekly tax of
fifty cents be levied on each prostitute for the purpose of defraying the expenses of said hospital.
4th. That all public women found plying their vocation without license and certificate be at once arrested and
incarcerated in the workhouse for a period of not less than thirty days.
The plan having been approved by General Granger, medical officers were detailed for
894 VENEREAL DISEASES.
iluty in connection therewith, a hospital was established for the treatment of diseased women,
and all prostitutes were required to present their certificates of inspection and procure a
license before a given date, August 20. It is assumed that many diseased courtesans left
the city on the publication of the order rather than be subjected to hospital treatment.
Certain it is, however, that the number at first ref|uiring medical attendance was small, the
daily average of sick not exceeding twelve. But in November, shortly after the passage of
the 11th and 12th Corps through the city, twenty-eight new cases were received. Up to
January, 1864, the whole number examined, licensed and registered was 300, of whom 60
were diseased. On AjDril 30, 1864, the whole number licensed was 352, and the number
of cases treated in hospital 92; but some of these cases were recurrences, as they were rep-
resented by only 64 women. Twelve months after the institution of the system 456 white
Cyprians had been registered, and it is stated, in explanation of the rapid increase in the
number, that many of the better class of prostitutes had been drawn to jSTashville from
northern cities by the comparative protection from venereal disease which its license system
afforded. About this time the supervision was extended to colored prostitutes, 50 of whom
had been registered. Of the whole number of women who reported for examination but four
are said to have opposed the system.
Under these regulations a marked improvement was speedily noticed in the manner
and appearance of the women. When the inspections were first enforced many were exceed-
ingly filthy in their persons and apparel and obscene and coarse in their language, but this
soon gave place to cleanliness and propriety.
The sum suggested by Colonel Spaldixg proved inadecjuate to meet the expenses of the
hospital. The inspection fee was accordingly raised to one dollar, but even' then much dif-
ficulty was found in meeting expenses, as some of the women were unable or declined to pay
for their certification.
The influence of this supervision on the health of the troops in the vicinity of the city
is illustrated by Surgeon W. M. Chambers, U. S. Vols., who had charge ot'Hospital Xo. 15,
which, in February, 1864, w^as converted into a hospital for venereal cases. According to
his statement, up to June 30, 994 cases were admitted, and of this number 13 only had con-
tracted the disease in Nashville. Surgeon R. Fletcher, U. S. Vols., in charge of the Female
Venereal hospital, in a letter dated August 15, spoke of the system in these terms:
It is not to be supposed Ibat a system hastily devised, established for the first time on tliis continent, and cer-
tain to encounter all the obstacles that vicioias interests or pious ignorance could put forth, should be other than
imperfect. We have here no Parisian " Bureau des Moeurs," with its vigilant police, its careful scrutiny of the mode
of conduct of houses of prostitution, and its general care of the public Tveltare both morally and in its sanitary con-
sideration. This much, however, is to be claimed, that after the attempt to reduce disease by the forcible expulsion
of the jirostitutes had, as it always has, utterly failed, the more philosophic plan of recognizing and controlling au
ineradicable evil has met with undoubted success.
Among the difficulties to be overcome was the opposition of the public women. This has so effectually disap-
peared that I believe they are now earnest advocates of a system which protects their health and delivers them from
the extortion of quacks and charlatans. They gladly exhibit to their visitors the " certificate" when it is asked for,
a demand, I am informed, not unfrequently made. The majority of the patients in the hospital are not sent from the
inspection room, but consist of women who, suspecting their malady, have voluntarily come for examination and
treatment.
That a vast amount of venereal disease still exists in this army is incontestable, but from careful inquiries made
of the men, when opportunity served, and from the reports of surgeons of regiments, the origin of the evil has been
but to a small extent traceable to this city. When a soldier of the post forces is infected it is not uncommon for his
captain to reiwrt the case, with the name of the suspected woman, who is immediately arrested and examined.
About a year after the inception of preventive measures at Nashville, Tenn., L. L. CoxE,
an inspector or agent of the U. S. Sanitary Commission, submitted to General C. C. Wash-
VENEREAL DISEASES. 895
biirne, commLinding the DepartiueiiL ot" West Tennessee, a. series of rules and regulations for
the government of prostitutes residing .in the city of Memphis. These were of a more
. elaborate and detailed character than those on which the Nashville system was based. The
action taken by General Washburne does not appear on the record; but it seems that the
regulation of the evil was under consideration in Memphis itself at the time, as on August
2, about three weeks subsequent to the date of Dr. Coxe's communication, the provisional
council of the city adopted a resolution authorizing the mayor, in connection with the mili-
tary authorities, to make and enforce necessary and proper rules to control and mitigate the
evils of prostitution within the limits of the city. In pursuance of this resolution Lieut.
Colonel T. H. Hakkis, Assistant Adjutant Genei-al, 16th Army Corps, on duty as mayor of the
city, sent Dr. CoxE to Nashville to investigate the operation of the system in force at that
station. A favorable report was submitted on August 26, and on the same day the Com-
manding General of the Department directed Colonel Harris to make the necessary arrange-
ments on behalf of the military authority. This officer, now rcpreseniing both the military
and civil authorities of the city, communicated his purpose to the Adjutant General's Office,
Washington, .1). C, August 31. His views were approved by Assistant Surgeon General
R. C. ^^'ooD and Surgeon General Barxes, and he was authorized to call upon Surgeon
B. J. D. Irwin, U. S. Armv, Superintendent of Hospitals, for the detail of two medical officers
to make the weekly examinations. Meanwhile arrangements had been made for the recep-
tion of diseased women into the city hospital, and on September 30 the system was insti-
tuted by the opening of a registry office and the promulgation of the following order among
the women concerned :
Private ] City Meiulai. 1.\.si'ection Detartment,
Circular.) Mayor's Office, Memphis, Texx., Septemher 30, 18G4.
All women of the towii, iu the city of Mciiiiihis and vieiuity, whether living in boarding-honses, singly or as
kept mistresses, are notified that they must hereafter be registered and take out weekly certificates.
Women who can show that they are living privately with a responsible citizen of good character will be
exempted from the weekly medical inspection by calling weekly, between 2 and 5 o'clock r. M., at the Mayor's olSce,
and paying the regular hospital fee. No woman residing iu a boarding-house will be registered as a kept woman.
All other than such kept women, whether practicing prostitution regularly or occasionally, are ordered to call
on the City Medical Inspectors at the private oltice, second story over the confectionery store on corner of Main and
Union streets, entrance through the store, or at Xo. 21 Union street, on any afternoon between two ami four o'clock
before the 10th of October, and receive a medical certificate, for which two dollars and fifty cents will be charged.
Or women can receive the medical certificate at their homes by reiiuesting the Medical Inspector to visit them,
and paying one dollar extra for the visit. .\ imte directed to lock-box 201, post-office, giving the street and number,
will be attended to.
On receiving the medical certificate a ticket of registry must be called for i)ersonally at the JIayor's ofiice, for
which ten dollars will be charged.
The money received goes to the support of the private female wards in the new City Hospital, on the corner of
Exchange Street and Front Row, into which registered women are admitted at any time for any disease upon show-
ing their weekly certificate, are aft'orded all the privacy and comfort of a home, and nursed by an experienced matrou
and female nurses, free from any cost or charge whatever.
'•Street walking,'' soliciting, stopping or talking with men on the streets; buggy or horseback riding for
pleasure through the city in daylight : wearing a showy, fiasli or immodest dress iu public ; any language or conduct
iu public which attracts attention; visiting the public squares, the Xew Memphis theatre, or other resort of ladies,
are prohibited and forbidden.
Good conduct will ensure relief from detective or police visits, exposure or loss, and a violation of the orders
will inevitably incur punishment.
Any woman of the town, public or private, found in the city or vicinity after the 10th day of October, 1864,
without her certificate of registry and medical exemption certificate, will be arrested by the police and punishedr
This circular is intended for the information of the women only, and must not be shown or given to men.
By order of the Mayor : JOHN B. GRAY,
CUy Medical Insp. Dep't.
The result is shown in the following report of Provisional Mayor, Mr. Channing
Richards, rendered Feb. 11, 1865, a short time before the system , was discontinued. As
S9Q VENEREAL DISEASES.
this officer evidently disliked his connection with licensed prostitution, and endeavored
to relieve the civil authority from all responsibility in its inauguration, his testimonv to it^
successful operation is all the more valuable:
III accordance ■with orders of Feb. 9, 1865, I have the honor to siilmiit the following rejiort, as called for. iu
relation to the City Jledioal Inspection Department:
Thefiiilure of all efforts made by the military authorities to suppress the vice of iirostitution in the city induced
the said authorities to introduce a system of registration. On the 31st of August, 1S64, the Commanding Oiiicer of the
District of AVest Tennessee, by Special Order Xo. 129, Ex. IV, entrusted the matter to the control of Lieut. Colonel
H.^HRis, the acting mayor of the city, who was instructed to make the necessary arrangements.
The first requisite was proper hospital accommodations, and as the city was then preparing a new hospital,
arrangements were made for the reception of diseased women into that institution.
The registry was opened on September 30, since which time one hundred and thirty-four public women have
been registered, of whom one hundred and ten are now in the city, to wit: 14 housekeepers, 4 kept mistresses and 92
boarders. The inmates of all public houses and all other white cyprians known to the department are registered.
It is impossible to say how many have evaded the orders and eluded detection, but there is no reason to suppose that
there is any considerable number.
The total receipts of the department to Feb. 1, 1865, are $6,428.65: expenses during the same time, $2,535.16:
the balance of $3,893.49 has been passed to the credit of the hospital fund.
The city physician is charged witli the medical inspection of the women, for which he receives no compensa-
tion in addition to his salary from the city as city physician. The salaries iiaid to the employes of the department
are as follows: Pi-r n!o:itli.
Eegistrar _ _ $200 00
Detective 115 00
Hospital Assistant _ 50 00
Assistant Plivsician ) t iTf * i- ii -^ i 'x i i. i i (65 On
tr ..,;» .1 Ar.,;.. ., !■ 1° addition to pav from the citv as hospital steward, matron - ;. X,
ji(»spital jMation, ) ^ • ' ^ ' ( !.:> 0(i
Total ...1 $445 00
The fees charged for examination are as follows:
For examination at inspection room $2 50
For examination at residence 3 50
\o portion of these fees is paid to the examining physicians, nor do said physicians receive any ''special fees"
or extra compensation of any kind for any services connected with the department.
The total number of admissions of diseased women into hospital t<i date through this agency is 34 : the number
now there is 10. It is imjio-ssible to give the expenses of the hospital department, because the women are treated in
the city hospital with the city patients. That hospital was fitted ux> by direction of the Commanding General at an
exjjense of aboitt $50,000 — the recejition of these women was contemplated iu the directions. The niouthly expenses
are about $2,500. If a hospital were fitted up for the special accommodation of the women the expenses would be
scarcely less than half that amount.
In conclusion, I desire to say that I have considered myself as acting for the military autliorities in this mat-
ter, and that the city government as such has never been connected with it : neither myself nor others belonging to
the department have any desire to retain that connection longer than is entirely satisfactory to the military authori-
ties. The matter was originally entrusted to the mayor of the city because the city was prepared with the necessary
means of enforcing the orders; but if the United States Sledical Department is now able to provide for the women
found diseased, and desires to assume their examination and treatment, such an arrangement would to no one be more
satisfactory than to the city 2)hysician and myself, for I need scarcely say that any connection with such a depart-
ment is extremely unpleasant. 15ut I shall certainly regret the abandonment of the system, for the result of my own
observation has been decidedly favorable to it. During my connection with the Provost Marshal Department in this
city I was cognizant of the elibrts to suppress this vice and their utter failure. In contrasting the jiresent system 1
6ee many advantages to recommend it, for while it does not eucourage vice it prevents to a considerable extent its
worst consequences.
For the successful operation of the system the credit is entirely due to Mr. J. C. He.^zlett, who is charged
with the registration, and to Dr. A. Gkegg, the city physician, who conducts the medical examination and treatment
of the women. For the system itself credit is due to Lieut. Colonel H.\rkis. who was acting mayor at its inception.
CHAPTER XII.— ON THE GEXERAL HOSPITALS.
At the outbreak of the civil war this country knew nothing practically of large military
hospitals; indeed, most of our volunteer medical officers knew nothing of military hospitals,
small or large. The troops were raised by regiments. The Regulations provided hospital-
tent accommodation in proportion to the number of men on the regimental rolls. Perhaps
THE GKNEKAL HOSPITALS. 897
the first military hospital which many of our officers entered was that of their own newly
outfitted regiment. These small tent-wards appeared at first sight to have nothing in com-
mon with the large civil hospitals, which, for the sake of economy, had one tier of wards
piled over another in a solid and permanent structure: but subsequent experience speedilv
showed that an aggregation of regimental hospitals might be consolidated into a single estab-
lishment for a larger body of troops, as a division or corps, with much advantage to the sick
and wounded of the command; and that a hospital thus constituted, if detached from its
regimental connections, would necessarily be a large general hospital.
At first, when the sick accumulated in a regimental hospital beyond the capacity of
the regulation canvas shelter, a neighboring house was usually converted into a hospital;
and in like manner, when those of many regiments accumulated at some depot, a church,
factory or other large building was extemporized into a brigade or general hospital.
The first military hospitals were opened in Wasliington, D. C. The E street Infirmary
and the Union Hotel both received patients in May, 1861; the former, a city hospital, was
destroyed by accidental fire in November; the latter, in the Georgetown district, near the
bridge over Kock Creek, was abandoned when better facilities became available, — in 'Slay.
1862, its patients, medical staff and material outfit were removed to the recently established
Cliff burne hospital;* nevertheless, at a later period of the war, when the number of sick
and wounded in the city required all its available shelter, the Union Hotel was for a time
reopened. Among the buildings temporarily appropriated for hospital purposes were the
Trinity churches of both Washington and Georgetown, the Dumbarton street hospital and
Water's warehouse, the Georgetown College, Caspari's Hotel, Island Hall, Odd Fellows Hall,
Grace Church, the Church of the Epiphany, Eyland Chapel, Union Chapel, the Baptist church
on E near 6tli, the Unitarian on 6th and D, and the Ascension hospital, comprising the Church
of the Ascension, the Presbyterian church on 9th near H and the 8th street Methodist church.
Besides these, temporary hospitals were established in the Capitol and Patent Office, in Saint
Elizabeths Insane Asylum and in many private residences.
In Alexandria, Va., hospitals were organized in abandoned dwellings, warehouses,
churches, seminaries, etc., the whole constituting the three divisions of the General hos-
pital of that place. The building first occupied was the old Hallowell House on Washing-
ton street, opened about the time of the battle of Bull Kun, July 1, 1861. Afterwards
many others were added, as the new Hallowell house, a private residence : the Tebb's house,
previously known as the Bell Haven Institute, a female seminary; the Fairfax street hos-
pital, also a seminary; the King street hospital, three private dwellings; the Fowle and
Johnson houses on Prince street; two residences on Wolfe street; the Methodist church on
Washington street and the Grosvenor house on the same street near the corporation limits.
The Fairfax Theological Seminary, near the city, was used as a brigade hospital by the troops
of Kearny's Division during the autumn of 1861 and the winter following; after the army
moved this establishment assumed the character of a general hospital on account of certain
sick men that were left behind in it.
In Maryland, Baltimore contained one or two notable instances of extemporized hos-
pital accommodation, as the National Hotel and Wests warehouses. The buildings of the
Naval Academy at Annapolis and those on the grounds of the Agricultural Society of Fred-
erick Co. were early converted to hospital uses.
* See in/ra, page 910.
Med. Hist., Pt. Ill— 113
898 * THE GENERAL HOSPITALS.
The Christian street hosi^ital, Philadelphia, opened in June, 1861, continued for severa,!
months to be the only general hospital in that city. Not until the Army of the Potomac
was preparing to move on the campaign of 1862 were increased accommodations required.
On the breaking up of the brigade and regimental hospitals of that army and the removal
northward of their inmates, a number of buildings were hastily transformed into hospitals,
all of which were at first considered wards of the Military hospital at Philadelphia, with
headquarters in the Broad and Cherry street building, — the position of this ward on the
railroad making it as it were the entrance to the general hospital. The Christian street build-
ing was previously a commissioners' hall. Broad and Cherry a railroad depot, Fifth and But-
ton wood a coach factory, Twenty-fourth and South street a silk factory. Sixteenth and Fil-
bert an old arsenal. In a few months the Philadelphia hospital was reorganized and each of
the establishments, hitherto its wards, became separate general hospitals.
North of Philadelphia there were but few extemporized hospitals. Factory buildings
were occupied in Newark, N. J. A three-story cabinet factory contained most of the hos-
pital beds in Elmira, N. Y. Contracts were made at Rochester and Buffalo with the civil
hospitals at 50 to 75 cents daily per bed. The Mason hospital in Boston, Mass., was a pri-
vate residence, given up rent-free by its owner; this was the only general hospital estab-
lished in Boston during the war, and for the greater part of the war period the only govern-
ment hospital in the state of Massachusetts.
The hospital in the Hygeia Hotel, Fort Monroe, Va., was for some time the only estab-
lishment of the kind south of the Department of Washington ; at a later date the Chesapeake
Female Seminary was converted into the Chesapeake hospital. At Portsmouth, Va., the
Marine hospital was used, and the Balfour hospital consisted of two hotels, a car factory,
two churches, three public halls and twenty hospital tents.
Many general hospitals connected with the western armies were extemporized. In
Cincinnati, Ohio, the hospital on Third street, which was the first one opened, had pre-
viously been an orphan asylum, and the West End hospital a school-house. The Marine
hospital of that city is said to have been well adapted for the comfort and cure of the sick.
The hospital at Mound City, 111., was constructed from a block of new tenements. Hospital
No. 1, Quincy, 111., had been a furniture warehouse, and No. 2 a carriage factory. At Lex-
ington, Ky., the University buildings were impressed into service. In Louisville the impro-
vised hospitals were at first known by number only, thus: No. 1 was a warehouse opposite
the depot of the Louisville and Nashville railroad; No. 2, a machine-shop corner 8th and
Green streets; No. 3, a seminary; No. 4, a plough factory; No. 5, a block of stores; No. 6,
a private residence, etc. The buildings converted to hospital use in Nashville, Tenn., were
also known by number. Some of them, as the Howard High School and a gun-factory building,
constituting Hospital No. 1 , are said to have answered their purpose admirably. At Memphis,
Tenn., large buildings constructed for mercantile purposes became converted into the Wash-
ington, Webster, Gayoso and other general hospitals; the Overton Hotel also was used. At
Helena, Ark., the residence of the Confederate General Hindman became a hospital. St.
John's College, Little Rock, formed the basis of a Confederate hospital, which was afterwards
continued as a U. B. establishment. The Good Samaritan and the Marine hospitals of St.
Louis, Mo., having been built for hospital use, may be considered as instances of the highest
grade of adaptability to the necessities of the period. In New Orleans, La., several hotels,
as the St. James and the St. Louis, and the University and other buildings, were used. The
THE GENEEAL HOSPITALS. 899
general hospitals for the colored troops and contrabands were established in sheds, originally
cotton-presses; these, when walled in and ventilated by louvered tnrrets, are said to have
made excellent wards.
The records contain many elaborate plans of these extemporized liospitals, but no good
purpose would be accomplished by presenting them at this time. A few will serve to show
the general character of the whole. The descriptive outlines submitted below have been
compiled from the regular and special reports of medical inspectors and surgeons in charge,
save in a few instances specially noted, in whicli a particular report has been quoted or
summarized.
The Seminary Hospital, Georgeto\vx, D. ('., was oik-uciI July 23, 1861. It consisted of a tlireo-story luick
ImiUling with a baseiiu'iit, coniei- of Washington anil (Jay streets, formerly occxipieil as a young ladies' seminary. It
faced the west, ITS feet on Washington street, with a wing, 50 feet, on (iay street, and a second wing extending back
11) feet from the centre of the main l)uilding. Exclusive of the basement it contained 15 rooms, of which 32 wore ill
use as wanls, — the remaining 13 having Ix'cn occupied as offices, dispensary, reception-room and the private rooms of
officers, cadets and female nurses; tlio kitchen, mess-room, laundry, store-rooms, etc., were in the basement. The
dimensions of the wards varied considerably; generally they were small, containing only three or four bods ; two were
comparatively large, containing twenty beds each. The average air-space was 596 foot to each of 147 beds, or 713 to
each of 123 beds. During the warm months, with the doors and windows open and ventilation free and uninterrupted,
as many as I'Jt) patients w ere cared for in this hospital at one time ; but Ass't Surgeon J. K. Smith, U. S. Army, reilueed
the number of beds to 123 during the winter on account of the ab.sence of satisfactory nujans for renewing the air.
The ceilings were low, — in fourteen rooms the height was less than eight feet ; in only one room did it reach eleven
feet. Gas and hot and cold water were distributed throughout the building. Many of the rooms were at first with-
out means of warmth. Notwithstanding its disadvantages this hospital was regarded favorably by the medical officers
connected with it. as it was quietly situated and had jwrticoes and a largo well-shaded yard in its rear for the use of
convalescents. For the plan of this liospital see ne.xt page.
The National Hospital, Bai.timohk, 'ili>.— Extract from a report of Roheuts Baktiiolow, Aioi't Siiri/coii, V. S.
Armij. — Notwithstanding the dissimilarity in uses, there is much similarity in the needs of a large hospital and a hotel.
In both the business of cooking, eating, sleeping are important concerns, and the manner of doing those with the
greatest regard to the personal well-being of the inmates involves all the manifold relations of sanitary science.
The National Hotel was organized for hospital purposes by Ass't Surgeon W. A. Hammond, U. S. A., in Septemlier,
1><61. The prominent reason probably for the sele<-tion of this building was the convenience of the situation, liein"
in the inunediate vicinity of the Baltimore and Ohio Kailroad depot and within six hundred yards of the harbor.
The relation of the cit.v to the great lines of communication with our armies in the field then and subsei|uentlv vin-
dicates the wisdom of the selection. Some sanitarians have objected to this locality on account of its lowuess and
vicinity to tide-water. A hospital for the reception of sick and wounded patients obviously should be as near rail
and water transportation as possible; and such olijections sliould be held secondary to this necessity. Besides tlie
hotel a large piano factory and eleven,dwelling-houses, situated on both sides of Camden street, have been hired for
hospital purposes. The National contains the appointments usual in a modern hotel. It is five stories high and
contains tifteeu wards, various offices, kitchens, store rooms, laundry and bake-house, as follows: A large hall on the
first lloor communicates with the office, dispensary, water-closets, lavatory and dining-room; a broad circular stair-
way passes from this hall through the centre to the top of the house, and has opening into it the corridors between
the wards. The wards open from opposite sides into the corridors and consist chiefly of suites of rooms. The front
or rear of the.so rooms have large windows opening externally above the elevation of surrounding houses. The base-
ment contains liijuor and commissary store-rooms, coal-cellars, furnace, bake-house and pastry-room. In this part of
the hotel building the defects of the situation appear. From the lowness of the ground and defective drainage or
original imperfectious in the water-pipes permitting leakage, water constantly rises in this basement and a deep
well and ]inuip have been always necessary to prevent overflow. The expensive attempts to remedy this evil have
had but partial success, and the flow of water requires the more or less frequent use of the pump. The dwelling-
liouses are all on the same general plan, having hall, parlor, dining-room and kitchen upon the flrst floor, and rooms
of various sizes in the u]iper stories. The piano factory is live stories in height aud has a large and snuill ward on
each lloor. The large wards contain twenty beds each aud the small ones eight, allowing to eachpatient 800 cubic
feet of air. For convenience of administration the houses on the north side of Camden street are connected with the
hotel and on the south side with the piano factory. All the buildings ajre of brick aud, excepting live wards of the
factory, have plastered ceilings. Many of the wards in the dwelling-houses have papered walls, but the principal
wards in the hotel are hard-finished.
Natural currents of air have been wholly relied upon to ventilate the hospital. All the wards in the hotel
having ample window-space, and nearly all open grates, there is nothing to be desired as to artificial arrangements.
Moreover, the passages between the wards being connected with the central hall and stairway, and having win-
dows at one extremity and transom-windows over the doors of the suites of rooms, an upward current of air from
without inward is constantly passing to the ventilator in the roof in addition to the local currents in each room.
To prevent interference with this system of currents a block of wood large enough to secure an inch of space is
11
900
THE GENERAL HOSPITALS.
BASEMENT.
SECOND AND THIRD FLOORS.
Semi.N'art HospiT.VL, GEORGETOWN, B. C. — Scale ^. — Basement : 1, Dining-room ; 2, Kitchen ; 3, 3, 3, Closets for stores, pantries, etc. ; 4, Store-room :
5, Wash-room ; 6, 6, G, 6, Rooms for attendants ; V, Extra-diet kitchen and 8, its pantry and store-room ; 0, Sitting-room ; 10, Convalescents' room ; 11,
Porcli ; 12, Passages. First JJoor: 1, 1, Otfices ; 2, 2, Officers' quarters ; 3, Bath-room and water-closet ; 4, Officers' mess-room ; 5, Linen-room ; 6, Store-
room ; 7, Female nnrse ; 8, Attendants; 9, Dispensary; 10, Passages; 11, Steward's room; 12, Ward No. 1; 13, Porch. iSerond and third floors i 1, Pas-
sages ; 2, '\VaterH:loset and bath-room ; 3, Porch ; 4, Kitchen for cooking delicacies by gas. The various other apartments were used as wards.
attached to the top of each -n-iiidow and the transoms are removed from the doors. Soldiers are not regardful of
the necessity for fresh air and sunshine, and the opportunity of shutting out botli must he denied theiu. A large
furnace in the cellar sufBccs to heat the entrance-hall, dispensary, dining-room and stairway; hut as the air supply-
ing the pipes is obtained from the cellar, the furnace is not a desirable addition to the means of ventilation. The
wards of the piano factory have large windows at either extremity-, and hence are abundantly supplied witli air and
sunshine. The dwelling-houses were not built with reference to these points. To produce as favorable a sanitary
condition as possible the windows of the houses are kept open by blocks of wood, as in the hotel, and wood fires
maintained in open fireplaces. The elevation of the hotel and piano factory being considerably greater than the
Burronudiug houses, the supply of air and SHnshine is not hindered from any quarter.
Water is obtained from the street mains and is distributed in lead pipes. In the hotel there are four bath-
rooms supplied with hot and cold water, a bath-room and lavatory in each of the dwelling-houses and a bath-room
and lavatory connected with each of the large wards in the piano factory. On the first floor of the hotel, adjoining
-the main hall, there is a lavatory containing six porcelain bowls, each supplied with hot and cold water, a urinal
having an uninterrupted water-supply, and in the same apartment six water-closets either self-acting or operating
"by a knob, containing porcelain bowls and traps. On each floor above there is a single water-closet similarly arranged
.und supplied. The discharges from these water-closets are conveyed through iron pipes to the main sink in the rear
of the hospital, where the solid liortions are deposited, the fluids jiassing through an earthen pipe from this sink into
THE GENERAL HOSPITALS. 901
.1 street-sewer. The water-closets in the piano factory have cast-irou bowls, ami the water is let on at the will of
the operator — both ohjectionalilo arraiifreiiients. The water-closets ill the principal ilwclling-houscs are attached to
the hath-roonis anil are in all respect.s like those in the hotel; but in several the latrines are primitive in style, eon-
sistir.j: of wooden seats and a receiving barrel sunk iu the ground. Gas-pipes extend throughout the hospital.
lu the hotel there are two kitchens, aumall ono for the lady superintendent of the female nurses, where the
delicacies for the sick are cooked, and the principal kitchen. The former is furnished with an ordinary cooking-stove
and the latter with a range having sntlicient capacity to cook for three hundred men; the piano factory kitchen has
a rang© of the same capacity, and each dwelling-house has either a range or a cooking-stove. All of these kitchens
contain the necessary appliances, hot and cold water, waslvrooms, closets and cooking utensils.
The laundry has twelve fixed tuljs with hot and cold water laid on, a large copper boiler for boiling clothes,
and w.a.'ihing-machines. The ironing-room is in the basement next to the bake-house: the range for heating the
irons contains the water-back for the laundry.
The bake-house has an excellent oven for baking 200 one-pound loaves, and is supplied with the necessary mix-
ing-boxes, trays, malt-tubs, baking-pans, baker's scales, bread-tables and shelves.
There are store-rooms for subsistence supplies, liquors, medical stores, unissued clothing, soiled clothes, knap-
sacks, unclaimed arms and accoutrements and the etlects of deceased soldiers.
Compared with the limited ward-space, the complexity of the hospital arrangements is very great and the
administration of the hospital proportionately dilHcult. Allowing to each patient 800 cubic feet of space, the whole
number of beds is 700. The average daily number of patients is not probably more than 150, conseiiuently the allow-
ance of atmosphere is ordinarily much greater than that indicated above. Assuming 1,200 as the minimum and 1,800
as the inasiinum allowance of cubic feet of atmosphere to be given to each patient in permanent hospitals, the Cam-
den street hospital, if full, would bo too much crowded. Medical Inspector rERLEY, U. S. Army, has mentioned a
deficiency of air-space as one of the objectionable features of this hospital.
The sudden importance given to sanitary science in its application to the construction and arrangement of our
military hospitals has had the etiect of developing various crude, undigested and indigestible opinions. The maximum
allowance of air-space may not prevent the occurrence of hospital gangrene, pya-mia and erysipelas, as the history of
some of the new civil hospitals in Europe, built with especial regard to hygienic rules, will show. The 1,800 cubic
feet of air allowed a patient may be foul air, and hurtful simply because stagnant. Sufficient space between the beds
and a constant renewal of the air are more important elements than the number of cubic feet per bed. With respect
to these two elements this establishment is not greatly deficient.
The patients in this hospital being distributed iu small wards over a great extent of buildings, the medical and
administrative service requires a force of physicians, wardniasters and attendants greater than a pavilion hospital of
the same capacity. * * * It is not easy to transport a patient, ill or badly wounded, up five stories of stairway.
It was therefore one of the earliest cares of Dr. Hammond to have constructed an admirable arrangement for elevat-
ing patients — a large dumb-waiter. When the piano factory was converted into a hospital the same mechanical con-
trivance was adopted. Not only are these elevators useful in transferring patients, but they are constantly employed
for niiinifold purposes in the daily economy of the hospital service, for carrying up food and clothing and for sending
down the dead, soiled clothes, utensils, etc.
West's Brii.mN'GS, Baltimore, Mn., consisted of a block of six warehouses each having three stories and an
attic. The brick walls had no interior finish, but as they were thirty-four inches thick moisture was seldom observed
to penetrate them. These houses were each 24 feet vide, but their depth varied from 107 to 121 feet. The ceilings
were too low for the area of the rooms, being 11 feet high on the first floor, 9 feet 6 inches on the second and i) feet 2
inches on the third floor. The first floor was unsuitable for ward use. — it was flagged, and deficient in light and venti-
lation: it contained the ofliees, kitchens, bakery, diniug-rooni, laundry, store-rooms, guards' quarters and a few small
rooms for employes.
The twelve rooms on the second and third stories were used as wards. Their dimensions corresponded with
those of the several buildings: they contained from 32 to 39 beds each, giving a hospital capacity of 400 beds with
800 cubic feet of air per bed. The wards of each floor communicated freely with each other by doorways in the jiarty
walls. The four exterior wards, two on each floor, had good light and ventilation by 10 windows each, 4 along the
length of each ward and 3 at each end; but the eight interior wards, four on each story, were lighted and ventilated
only by the end windows. The wards were reached by interior stairways having no direct communication with the
external air. To improve the ventUation wooden shafts were extended from the ceilings of the various wards to the
ridge of the roof, but no current was established through them, as they were too narrow aud turned twice almost at
right angles in their course. The wards were unequally heated by coal-stoves. There were four bath-rooms and water-
closets, two on each floor, or one to every three wards, but as each closet contained only ono seat a majority of the
patients had to make use of the sinks in the yard. The water-closets were fitted with urinals, but as these were
untrapped they emitted an ammoniacal vapor. The attics were used as store- and knapsack-rooms and as quarters
for nurses. The oflicerof theday hadaroom on the flagged first floor, but no other oflicer had quarters in the building.
The Oli> Hali.owell House, Alex.ojdria, Va., formerly known as "Hallowell's School,'" on the west side of
Washington street, between Queen and Cameron streets, was an old and irregular brick building composed of a main
l>ortion and three additions. The ground-floor of the main building was used as a dining-room for nurses, store-
room, pantry aud kitchen : the oflice and two rooms for employes were on the first floor ; the second story contained
eleven beds for patients in three wards ; the third thirteen beds in three wards, and the attic eleven beds in three
wards. The one-story addition on the north side ran parallel with the main buUding and contained nineteen beds
in a space 50 X 17 feet : this ward was well lighted and ventilated by two windows at each end and three movable
902
THE GENERAL HOSPITALS.
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THE GENERAL HOSPITALS.
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rl skylights (3 X 7) iu
1 tlic sontli side, erect*
, j parallel ■with the lat
' diiiiufi-room and w:
OLD HALLOWELL DOCBE.
fVrf Flfxjr. — 1, Hall ; % Office; 3, Stcwartl's office; 4, Surgeon in
charge; 5, Steward's bed-room; 6, Eeading-room ; 7, Clerk's office; 6,
LineD>room; 0, Hall; 10, DLjpensary ; 11, Sleeping-room for clerts; 12.
skylights (3 X 7) iu the ceiling. The two-8tory addition on
erected 16 feet from the main Imildinj:. also ran
latter. It contained on the ground floor a
rasli-rooiu for convalescents, a store-room
and a dead-room; the two wards of the second story were fit-
ted with 39 beds, and iu the garret above them knapsacks,
arms, etc., ■n'ere stored. Ou the west side of this addition a
round wooden stnicture, once an observatory, was used as a
store-room. Of t-hc two rooms over the arch, connecting the
first lioorof the main building with the addition on the south,
one served as a dispensary, the other as a bed-room for the
ciioks. The two-story addition on the west side contained ou
the ground floor an extensive laundry and an ice-house; the
second story a clerk's oflice, a reading-room and a store-room
for bedding and hospital clothing. The yard to the west and
south of the hospital covered an area of 25,336 square feet.
It was pleasantly shaded by large trees, and had a gymna-
sium and wooden seats for the convalescents. The sinks were
at the west end of the lot, 132 feet from the house.
Hospital, Xkwark. X. 3.,cotnleninil from a report of Med-
ical IiiKpcctor Geo. H. Lv.max, V. S. Armij, Augunt, WA. — The
hospital buildings are five iu number, two near Centre street
and three about a quarter of a mile distant, near Market
St reet. The Centre street establishment is compressed between
the New Jersey railroad, which passes along its front and
only about ten feet distant on one side, and the Passaic
river on the other: from the latter it is separated only
by the width of the wharf. The main building next the rail-
la, Wanls— 39 be<l«; 14, Porch. The eecond and third ptori<« and attic of way is of brick, 131 X 71, four stories high, with a basement,
main huilding contained email rooms for patients and aftendsnte. eleven feet in height, two-thirds under ground. JSeliind this
building is a narrow street or right of way which 6ex)arates it from the second building. This is an irregular struct-
ure, forming wards from 100 to 1.30 feet long and from 31 to 35 feet wide. Wooden bridges above the street connect the
second and third stories of the two buildings, and outside staircases have been built from the ui)per stories to the
ground for escape in case of fire. The Market street building, also on the line of the railroad, is of wood, three stories
high, and with a deep basement which gets light from the sides and rear, the ground sloping rapidly from the front.
The building is 100 x 50; in its rear a long, roughly built shed, 1.00 X 24 X 30, has been adapted for use as a ward : a
third building, a long narrow shed 126 X 6, is divided into a store-room, knapsack and lumber-room.
The accommodation for officers is very limited, most of them living in the town. In the Centre street buildings
the cooks and nurses sleep in the wards ; in the Market street branch the cooks have separate and comfortable quar-
ters. Patients obtain an average of 64 superficial and 696 cubic feet. There are thirteen wards occupied by 1,033
l<edB. The largest wards, 126 x 68, are too wide for good ventilation without a central shaft. The ofiices, scattered
conveniently about the hospital, are sufficient in size and nuuiber. The mess-hall at Center street, in the basement
of the main building, 12« x 63 x 10, is very imperfectly lighted, being mostly tinder ground : a kitchen space, 73 X IT, is
separated from the mess-hall by a wooden screen. The basement has a stone floor, ■with an ojien drain on one side
tenninating outside in the sewer. The kitchen at ilarket street, 56 X 19 X 16. occupies one end of the large well-
lighted basement, the remainder, 59 X 47 X 16, being used as a mess-hall.
The buildings are warmed by stoves and well lighted by windows on all sides, having been erected originally
for factory purposes. Ventilation is good enough in summer, but unsuitable for winter, — the windows and doors are
relied on. Patients near the walls are subjected to currents of cold air. and the central wards are imperfectly purified.
Proper ventilating-shafts have J>een repeatedly recommended. The lavatories and baths are ample on each story and
well snp]ilied with water. At the Centre street buildings one-inch iron pipes are laid from the engine-room to the
bath-tubs; when the tubs are filled with water steam is turned on, affording a warm-bath in a few minutes.
The outside sinks project over tide-water in the river. Water-closets of the hopjier pattern are jnovided for
each ward. .Some oftho.se at Centre street have too much odor, attributali]i». I b.ivi- .ilw.ivs MijiiioRed, to the condi-
tion of the sewerage beneath.
1 do not think the location a desirable one on account of the noise from liie constant j.a'^sage of trains, the abso-
lute want of space for exercise-grounds and the constant clii.-ibing from story to story: its only advantage is the
easy access by rail and water. The construction and general arrangements are devoid of method; ventilation is
imperfect: the wanls are too large for any feasible plan of perfect ventilation, and the mess-hall at Centre street is
gloomy and unpleasant. However, as the hospital has been fitted up at considerable expense and is much needed, I
have always recommended that it should be continued.
Broad axb Cherby Streets Hospital, PaiLAi>ELPHiA. — The building was originally a railroad depot. It con-
tained 5S0 beds for patients and 40 lor attendants. The first floor was fitted up for 78 patients, the second for 2.34,
904
THE GEXEKAL HOSPITALS.
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THE GENERAL HOSPITALS.
905
the third for 268. The air-space measared 577,608 feet, giving an average of 931 feet to each occupant. The ventila-
tion was considered good. Inflow was l>y the doors and windows, outflow by a large shaft teruiiuatiug in a louvered
turret. The building was heated by stoves. The plans on the opposite page show the details of its arrangement.
Hospital, Mound City, III., condensed from a report of Surgeon E. C. Franklin, V. S. VoU. — This hospital was
established in September, 1861. It is situated on the west bank of the Ohio, about six miles above Cairo, on the first
high ground above the mouth of the river and two miles below the grand chain, a bar which at low water seriously
interferes with navigation. It comprises a block of twelve brick houses, three stories high, 265 feet front, 75 feet in
depth and with wings extending 95 feet to the rear. These buildings, intended for business purposes, were unfinished
when first taken possession of by the Government ; the expenditure of much money and labor was necessarily required
to put them in proper condition. Communications throughout the second and third stories were opened, making a
continuous passage from one extremity of the building to the other. I'iazzas 12 feet wide were constructed along
the whole length of the building in the rear, one for each story, to aftord a protection and pleasant promenade to the
patients. All the business of the wards is conducted in the rear of the building by means of these piazzas. They
lead to the privies, which are removed sufficiently to X'revent any unpleasant odor gaining access to the wards. The
stairways leading to the several wards were enclosed and doors placed at each landing. In every alternate ward
the stairways were closed as unnecessary, and the others were rebuilt with a less abrupt rise as more suitable for
hospital purposes. Partitions were constructed for business purposes as the wants of the hospital indicated, and
many additions made and alterations planned for the comfort of patients and economy of administration. An eleva-
tor for carrying sick and wounded patients from the ground floor to either story was one of the important improve-
ments introduced. The first floor is occupied by the dispensary, offices, kitchens, dining-room, chapel, store-room,
attendants' sleeping-room, etc., and by three wards. The second story has ten wards and the third story twelve.
All these wards are of like dimensions, 75 X 22 feet, except the two end wards of the second story, which are 44 feet
wide, and one ward in the third, which is 65 feet long. Most of these wards are lighted only from the ends, having
dead walls on both sides. They are warmed by coal-stoves and lighted at night by coal-oil lamps. Sewers were
constructed from the main privy-vault to the river, and branch sewers from the side privies to the main. Water is
supplied by steam-power to every part of the building, and bath-room facilities have been provided.
The pest-ward, situated about 3<X' feet from the general hospital, is a frame building containing 80 beds. It
is used for erysipelas, rubeola and other epidemic diseases. The small-pox ward is a floating hospital, comfortably
arranged for 30 patients. It is moored on the Kentucky shore directly opposite the general hospital. Attached to
it is a quarantine for such persons as may have been exposed to the contagion of sniall-pox.
The convalescent barrack, a large and well-ventilated frame building, about one-third of a iniK- from the hos-
pital, famishes accommodation for 300 men.
The Good Sajiarit.vn Hospital, St. Lotus, Mo. — This building was erected in 1859, for hosintai piuiioses, by an
association of homoeopathists. It was a three-story building with lofty ceilings, a basement and attic, and was fitted
up to contain 150 patients with the necessary attendants and employirs. The basement walls were of stone; the
remainder of the building of brick. All the doors had hinged transom-lights. The windows, 8 feet x 3 feet 3 inches,
werehungwith sash-weights forregulatingthe ventilation. The floors were laid with yellow pine, oiled with linseed
oil. Each story had a fine wide corridor in the rear of the building, connected with the others by flights of stairs.
These, with a yard containing some shade-trees, gave facilities for exercise. In the rear of the lot there was a two-
story brick building, with a veranda on each floor, a brick stable and a temporary wood-house. Water for cooking
and drinking was derived from a well ; for washing, from two cisterns in the yard; for bathing, from a tank under
the roof in the attic. For the plan of its construction see the accompanying figures.
m
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ATTIC.
Med. Hist.. Pt. Ill— 114
GOOD EAUARITAN HOePITAX, ST. LOOS, MO.
See next page for explauatioD.
nB6T, BBCOJSV AXD TBISD FlOOBfi.
906
THE GENERAL HOSPITALS.
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13
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SECTION
BASEMENT PLAN
GOOD SAMAHITAN HOSPITAL, ST. LOriSj MO.
Scale 3J5. — Bnsemeut: 1, Bakery; 2, Atteudants ; 3, Guard-room ; 4, Baggage-room ; 5, Hall ; G, Mess-room ; 7, Kitcheu ; 8, Dining-room ; 0, Pead-
room ; 10, .\tteudants ; 11, Store-room ; 12, Cisterns ; 1.3, Wood-shed ; a, b, c, d. Detached building at rear of lot ; a, b, c, Rooms for patients ; d. Torch ;
e, Privy; f, g, h, Stables. Fint .iJoor— Scale jj, ; see page 905,— height of ceiling 15 feet : 1, Entrance ; 2, Hall ; 3, Store-room ; 4, Ward, 17 feet 4
inches X IG ft. 8 in.— four beds ; 6, Ward, 17 ft. 4 in. X 24 ft. 4 in. — nine beds ; C, 7, Nnrses' rooms ; 8, OfBcers' dining-room ; 9, OfBce ; 10, Oflicers' quar-
ters ; 11, Ward, 17 ft. 4 in. X 10 ft. 8 in.— six beds ; 12, Bath-room ; 13, Water-closet ; 14, Porch, gecoiid .(ioor- height of ceiling 14 feet : 3, 4, Ward, 17 ft. 4
in. X 34 ft.— twelve beds ; 6, Ward, 17 ft. 4 in. X 24 ft. 4 in.— nine beds ; G, Kurses' room ; 7, 8, 9, Wards, each 17 ft. 4 in. X 8 f t.— th rce beds ; 10, Surgeon's
room; 11, Ward, 17 ft. 4 in. X IG ft. 8 in.— six beds; 12, Bath-room ; 13, Water-closet ; 14, Portico ; Hall-room between 9 and 10 is dispensary. Thirdftoor—
lieigUt of ceiling 13 feet: G, Steward's room ; 10, 11, Wards, each 17 ft. 4 in. X IG ft. 8 in.— six beds. Hall-room between 9 and 10 is a ward, 17 ft. 4 in.
X 8 ft.— three beds. Attic — avemgeheight of ceiling7feet; l.Ward, 8G ft. G in X 25 ft. — thirty-two beds; 2, Nurses' room; 3,Wash-room; 4, 5, Nurses' rooms.
THE GENERAL HOSPITALS.
907
The Marine Hospital, St. Louis, Mo., was con vorteil into a niiliiary lios]>ital in .\pril, 18(>2. Ii i'aocd the south-
west antl was five stories hisfh, including the basement and attic. It was llaiiked hy four towers and had verandas
on three stories, front and rear, coninianding a line view of the river and the surrounding country. The basement,
onehaU' under ground, contained the engiue-rooiu, store-room, lamp-room, wash-room and dead-room. The engine
was used for warming the house and pumping water into the tanks in the attic. The tirst lloor contained the office,
pliarmacy, convalescent diuing-rooni and kitchen, quarters, bath-rooms, steward's and nurses' rooms, kitchen and
dining-room for attaches, sick-ward and water-closets. The second and third Hoors each contained four large double
rooms and one small room occupied as wards. In the attic were the liaggage and tank-rooms and two rooms of uine
beds each, usually occupied by nurses and convalescents. The details may be seen in the acconi]ianying plans.
1 S 2
PLAN UF FLOORS — j^j.
PLAN OF ATTIC — j^g
FRONT ELEVATION — ^,5.
THE 3IABINE HOSPITAL, ST. LOCIS, MO.
nm/oor: 1, Portico; 2, Hall; 3, 4, Dining-rooms; 5, Offico ; 6. Kitclien; ",S, Quarters; 9, 10, .Surgical wards, seven beds in cacli ; 11, Portico; 12,
Dining-room ; 13, KitcLeii ; 14, Nurses' room ; 15, Steward's room ; Ifl. Ifi, ir,, 10, Halls, a water-closet off the end of each ; 17, Pharmacy; 18, Bath-room.
S<n>iiil.(loor— generally similar to first floor: 3, 4, .''., G, 7, 8, 9, in. Wards of seven beds each; 12, Kitchen; 13, 14, l.i, Nurses' rooms; 17, Linen-room; 18,
Ward of four beds. ThirJ rf.x.r— generally similar to second ; 17, Ward of four beds ; 18, Medical cadets. AUic : 1,2, Wards, nine beds each ; 3, Hall.
90S THE GENERAL HOSPITALS.
Mason Hospital, Boston, Mass. — A 30 x 50, four-story brick residence, accommodating 60 patients, — 20 on the
tirst tloor, 16 eacb on the second and third floors and 8 on the fourth or attic floor. Hall-rooms were used for the
steward, clerks and nurses: the cooks and other employes were quartered outside the building. The basement con-
tained the dispensary, kitchens, store-rooms, etc., the laundry being in an L behind. This hospital had all the
advantages of a city mansion, a good site and quiet neighborhood, lavatories, baths, water-closets, and an excellent
system of ventilation and heating by furnace-warmed air, supplemented when necessary by open fireplaces. Medical
inspectors regretted only that there was not more of it.
Frequently, wlien the ground in the vicinity of a building taken for hospital purposes
was of a suitable character, the demand for increased accommodation was sujaplied by hos-
pital tents pitched so as to form a series of elongated pavilions. Thus the Stone Hospital
on Meridian Hill, Wa.shington, D. C, consisted of an old mansion and its outhouses, which
afforded offices and quarters for the medical staff and their subordinates, with facilities for
cooking and laundry work and beds for about 74 patients ; but the capacity of the estab-
lishment was increased to 170 beds by the presence of 16 of the regulation hospital tents,
each fitted for six patients. The Douglas Hospital in the same city, opened in January,
1862, comprised three contiguous mansions and an aggregation of tent-wards. The spacious
rooms, lofty ceilings and many conveniences of the Douglas buildings are said to have made
this hospital one of the best in Washington of those not specially constructed for the shelter
of the sick. At a later period the tent-wards were replaced by two long wooden pavilions.
But before the need for special military hospitals in our large cities had received a prac-
tical recognition, the movements of large bodies of troops in West Virginia, and the want of
adaptable buildings in that part of the country, led Ass't Surgeon W. A. Hammond, U. S.
Army, to urge upon Ass't Surgeon J. Letterman, U. 8'. Army, then Medical Director of the
Department, the advisability of constructing ridge-ventilated wooden sheds for hospital pur-
poses. The first of these, built at Parkersburg, Va., under the supervision of Ass't Surgeon
E. S. Dunster, U. S. Army, measured 130 X 25 X 14 feet to the eaves, and was divided
by transverse partitions into four wards of twenty beds each. 'Speaking of a similar building
at Grafton, Va., Ass't Surgeon Lewis M. Eastman, in a report dated April 1, 1862, says:
It is very difficult, in ordinary buildings used as hospitals, to secure ventilation without exposing the inmates
to injurious draughts of air. This difficulty is avoided in the building now being constructed in accordance with
the orders of Ass't Surgeon Letterm.4.n, U- S. Army, by means of " ridge ventilation,'' which keeps the air constantly
pure without exposing anyone to unpleasant or dangerous draughts.
Shortly afterwards similarly ventilated buildings were constructed at New I'lirk, Va.,
Gallipolis, Ohio, and Clarysville, Md. The figure which follows represents a side view of
one of seven erected at the last-named point, concerning which Surgeon George H. Oliver,
U. S. Vols., reported Oct. 1, 1862:
These buildings, though well adapted for use in warm weather, do not afford sufficient protection from the cold
of winter for sick and wounded men. The declivity of the ground causes them to stand high ; the sides are of rough
upright boards with crevices not battened to their full height; and the ridge ventilators having no sash or shutter
to close, the cold wind and snow ponctrnte to an extent unbearable by the patients.
UUUQJULil.JJ-jLluJJ
O O O 3 J J 'J '^j -^ '^ . JJ ^ «^ _
SIDE VIEW OF ONE OF THE LLMIVSVILLE PAVILIONS.
The inauguration of the Peninsular campaign in the spring of 1862 filled the hospitals
of Washington with the sick men of the moving army; but this same military undertaking
occasioned the vacation of a number of barrack buildings, particularly near Washington
THE GENERAL HOSPITALS. 909
ftml Baltimore, by calling into the field the troops that had hitherto occupied i\u:iu. Advan-
tage was taken of this to relieve the overcrowded condition of the hospitals already in exist-
ence by hastily fitting up the vacated shelters for hospital purposes. These establishments
were intended merely as makeshifts, but the demand for hospital accommodation continued
so steadily in advance of the supply that many of these retained their status of general hos-
pitals to the end of the war.
In few, if any instances, did the buildings constructed as quarters for troops give sat-
iofaction as hospital wards. Sometimes even the site was undesirable. Generally the grounds
'were found to be in bad sanitary condition. Much refuse and filth had to be cari-ied away.
Frequently the surface had to be drained and shallow basins brought to the general level by
deposits of gravel. The water-sup] ily and the disposal of excreta and other refuse came up
for consideration, as these barracks were seldom so far within the limits of a city as to have
full participation in the municipal conveniences. Suitable arrangements had to be provided
for kitchen and laundry work, and store-rooms of a more or less special character were required.
But the essential change involved the adaptation of the former company dormitories for
use as hospital wards. These dormitories were generally long, low and narrow one-story
frame buildings, roughly constructed, imperfectly lighted, frequently with windows only on
one side, unventilated save by the doors, windows and unauthorized crevices, and fitted up
with single or double bunks in two or three tiers. In many instances the rooms were too
narrow for a line of beds along each wall, the ceilings too low to give adequate air-space,
and the board fioors so imperfectly joined that foul exhalations rose through the seams from
the unventilated soil. Generally these quarters were set directly on the ground, and not
unfrequently the earth had been banked up against the lower part of the outer aspect of the
walls to prevent the inflow of cold air through chinks in the flooring. In some of the bar-
racks the buildings were two stories in height, with marked defects in the ventilation of the
lower rooms added to all the objectionable features of the one-story buildings.
To adapt these to hospital purposes the earth was cleared away from the walls and pro-
vision, if possible, made for some air-movement beneath the buildings. The floors were
repaired; additional windows were inserted. The ridge was laid open for ventilation in sum-
mer and louvered exits were provided for winter use, with inlet openings near the stoves. Ven-
tilating apertures were made in the walls, and the unauthorized crevices closed by laths and
plaster in the interior and weather-boarding on the exterior. The lower rooms of two-story
barracks were connected with the ridge by ventilating shafts, but these were insufficient, in
the absence of some more active method of inducing a current than aspiration witliout and
an increased temperature within. It does not appear that the heat of the flues was utilized
in any of these instances.
Besides these defects in the barrack buiklings, their arrangement or relative position on
the camp-ground was seldom the most appropriate for an aggregation of hospital pavilions.
They were either so detached as to greatly augment the difficulties of administration, or so
massed around a central point as to interfere with their ventilation. Thus at Camp Den-
NISON, Ohio, where the pavilions were arranged in a single line with wide spacing between
adjacent buildings, the ward on the right of the line was separated from that on the left by
a distance of nearly a mile. At Patterson Park and McKim's, Baltimore, Md., and the
Campbell Hospital, Washington, D. C, they were placed lengthwise along the sides of a
hollow square or oblong, an arrangement which interfered materially with the ventilation of
910 THE GENERAL HOSPITALS.
the leeward sides. The plan of the Carver Hospital, Washington, D. C, was perhapS
the best of any in this respect. The buildings formed the sides of a rectangular figure; but
as their gables abutted on the enclosure the latter was open to perflation through the inter-
spaces between adjacent pavilions. The following are submitted as illustrations of barracks
converted to hospital purposes:
Cliffhurne Hospital, Washington, D. C. — Extract from a report of Ass' t Surgeon J. S. Billings, U. S. Army. — The
))arracks had been previously occupied by the 5th U. S. Cavalry. I fouud the buildings and grounds iu an extremely
tiltby and dilapidated condition, — no drainage whatever; no sinks, no water within half a mile. Five buildings, the
old barracks, were first fitted up, additional doors and windows being inserted and the system of ridge ventilation
adopted. Apertures were also cut in the sides of the liuildings near the floor, and every part well whitewashed inside
and out. A thorough system of drainage was instituted and three wells dug and fitted with large wooden pumps.
These, however, are insufficient, and one team is in constant use l)ringing water from a distance. A new building
for kitchen and mes.s-rooui was built, 200 feet in length and 15 iu width, and Ball's patent range placed therein, capable,
as found by experience, of cooking easily for 1,000 persons. Wooden privies were constructed, eighteen in number,
and so light as to be readily removed to new trenches when necessary. Fifteen hundred loads of offal were cleared
from the grounds and vicinity of the buildings, and 800 loads of gravel advantageously disposed in various situations.
One hundred and five hospital tents were pitched, framed and floored, and two additional buildings fitted up, making
the number of beds in the hospital one thousand. A bath- and wash-room 50 feet iu length was also built, and four
tubs are in constant use. Three washing-machines are used in the wash-room — and both hot and cold water freely
supplied. An apothecary shop, store-room, clothing-rooms, knapsack-room, dead-house, guard-house, stable, etc., were
also fitted up. Fifteen .Sisters of Charity are employed as nurses ; they prepare all extra articles of diet. Of their
services and conduct lean speak only in terms of the highest praise.
Camp Dennison, Ohio, was situated sixteen miles from Cincinnati, on a plateau between the Little Miami river
on the east and south and a crescentic range of hills on the north and west. About 1-50 acres of level or gently rolling
ground were fenced in. One-half of this enclosure presented green sward, shade-trees, plots of flowers, water-jets,
, plank and gravel walks and graded and gravelled roadways and drives; the remainder was cultivated as a hospital
garden and yielded an .abundance of fresh vegetables. The buildings, like all those originally constructed as quarters
for troops, were too small and narrow for hospital use; their floors were not sufficiently raised from the surface, and
fault was found by medical inspectors with the lighting and ventilation; the smaller barrack-rooms had windows
on one side only. The arrangement of the buildings rendered the administrative duties extremely difficult. The
pavilions used as wards, dining-rooms, etc., were in Hue, their long axes parallel, with an avenue40 feet wide between
adjacent buildings. Their number was such that the line was about a mile long. There were fifty pavilions each
120 X 25 X 11 feet, and seventeen each GO* X 15A X 11 feet. To adapt these for hospital use they were lathed, plastered
and furnished with ridge-ventilation and air-inlets at the floor-level by the side of the stoves. Of the fifty pavilions
five constituted a division of the hospital : but only four of these were used as wards, the fifth having done duty as
the dining-room of the division and as store-rooms, etc., pertaining to it. Of the seventeen smaller pavilions six were
occupied as quarters for the Veteran Reserve Corps on duty at the hospital, one Ijy the band, nine by convalescents
and one as a dining-room. By the side of each of the fifty pavilions was a set of quarters each 21 x 14 X 10 feet, for
attendants ; and in rear of each was a building 21 X Hi X 10 feet, originally the kitchens of the company quarters. A
similar building was found iu rear of nine of the seventeen smaller pavilions. In each division of the hospital only
two of these rear buildings were used as kitchens — one for the general, the other for the special diet of the division
to which they belonged ; the others were applied to use as store-rooms, work-shops, etc. To the right and about eight
rods in front of the line of hospital pavilions was a two-story building, formerly a granary or barn, which, having been
comfortably fitted up. constituted one of the divisions of the hospital. It afforded three wards on the ground floor
22x25x9feet,21x29x9feet,and90x27x9feet,andtwowardsonthesecondfloor53x27x 7 feet and 59 X 26 x 7 feet;
a wing to this main building accommodated the medical officer of the division, the attendants, cooks, etc., and gave
ample room for the kitchen and dining-room. About a hundred hospital teuts pitched in pavilion wards added to the
capacity of the hospital. Besides these buildings, which formed the ward shelters, a number of others were found in
connection with them or constructed subsequently to the adaptation of the barracks for hospital purposes. These
were used as quarters for medical officers and attaches of headquarters, subsistence and other store-rooms, knapsack-
rooms, dead-house, stables, etc. One, situated near the centre of the line of pavilions, was used as a chapel, library
and reading-room. A steam laundry was established in one corner of the grounds. The water-supply was taken from
a mill-race derived from the Little Miami river. A steam-pump, driven by an engine of twenty horse-power, raised
the water about eighty feet to a well-protected reservoir 43 feet in diameter and 15 feet in depth, from which it was
distributed to the various buildings. Its quality was not satisfactory, as the drainage of the whole camp passed into
the stream ahore the point from which it was taken. Hot and cold water was supplied to each Avard. At one end of
each of the large pavilions were two rooms, one on eiich side of the doorway. These were well fitted up as bat h-roonis
and water-closets. The sewerage system was in good order. Deep vaults, six or eight rods in rear of the quarters for
officers and attendants, were used as sinks by convalescents and others.
McKim's MAjsfSiON, Baltimore, Md.— The barracks at this mansion, in the northern suburbs of the city, were
originally intended as temporary shelter for troops. They consisted of three long two-story buildings of rough
boards, with no interior finish. One was 150 feet long, another 175 feet and the third 200 feet. All were 22 feet wide,
THE GENERAL HOSPITALS.
911
with a lioii;ht nf 7 feet 10 inches in the first-floor rooms and of 7 feet to the phito and 17 feet to the ridge in those of
the second floor. They were built clo.<e to the ground, the hitter iu some parts having been dug out to remove irregu-
larities. Tlie floors were coarsely joined, leaving iiuerstices that permitted small fragments of refuse matter t<i drop
from the ui)per to the lower wards or from the hitter to the uuventilated soil V>eueath. Louvered turrets were pro-
vided for the ventilation of the upper rooms. Small wooden flues, 8 to 12 inches square, passing from the lirst-floor
rooms to the ri<lge. failed to induce the intended air-movement. These buildings formed three sides of a parallelo-
gram, the remaining side of which was filled in with tent-wards. Stoves were used to warm the wards. Water was
derived from the city supply, but it was so scanty that only two bath-tubs were iu use and no water-closets.
END E L E VATION
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The biiilaing^ excei»t that marked 2, are two-storied wooden barracks. 1, 1, 1, Wards in both stories ; 2, Administration building (tlic mansion
house); 3, Kitchen on the flr*t floor, cooks' qnarters on l!io second ; 4, Laundry and lirj-ing-room ou the first floor, quarters of female attendants on tbo
^■■con'l ; 5, Dining-room on the first fluor, ward on the second ; 0, Guard-house ; 7, Sinks.
A
912
THE GENERAL HOSPITALS.
Patteksox Park Hospital, Baltimore, Md. — The barracks at Patterson Park were converted to hospital use
in April, 1862. They consisted of four long two-story buildings arranged in the form of a hollow square. Each was
200 X 22 feet, the lower rooms 7i feet high, the upper 12 feet ; a two-story veranda ran along the sides facing the enclo-
sure. In other respects the buildings were similar to those at the JIcKiin mansion. They aftbrded space for seven-
teen wards, eight on the lower floor and nine on the upper, each about 50 feet long, enclosing a total of 184,800 cubic
feet, or an air-space of 434 feet to each of the 426 beds at one time contained in them. Further details are shown
on the ground plan submitted below.
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The Campbell Hospital, Washington, D. C, on the northern outskirt of the city, near the terminus of Seventh
street, consisted of long, low, narrow buildings of rough boards, originally used as barracks for cavalry. Six of these
enclosed an oblong space having two buildings on each long side and one on each short side of the enclosure. In its
centre was a seventh building with its long axis parallel to that of the oblong; these were all used as waj'ds. Project-
ing perpendicularly from the two buildings, forming one of the long sides, were five buildings, that in the centrs being
used as a diniug-room and kitchen and the others as wards. Projecting similarly from one of the short sides was the
THE GENERAL HOSPITALS.
913
baildin;; used fur administration purposes. Tbere were tbne eleven barrack-wards having an aggregate capacity of
81X liun<lre<l beds. Ridge ventilation was introduced when the barracks were turned over to the Medical Department.
Ten t«-nt-w.irds of fifty Ijeds each were subsequently added. The arrangement of the buildings constituting this hos-
pital may be readily appreciated by a reference to the plan submitted. This establishment was Ijetter supplied with
water than the other converted barracks in the vicinity of Washington, — Potomac river water was distributed to the
wards. Waste-water was carried off by drains to the sewers. £ven>' alternate ward had a water-closet and bath-
room, and the sinks for convalescents were kept clean by a running stream.
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1. 1. 1. 1, Wmnis; 2, Admiiustzaticm Imilding; 3;, Dioin^-ioom ; 4. 5. Kitrheua : C, Store-bcnue : ".Stable; 8. Co«]-faoose; 9, Elupad£-rooiD ; lOftcd
D' >or«e«" nuMTUn; 12. Gumnl ; 13, 13, Segro qnanrns; 14, Deut-bofise; IS, IS, IS, Sinb; 10, Corered trsr.
The Carvek Hospital, W.4SIIISGtox. D. C, was situated on Meridian Hill, about two miles north of Penn-
s^vauia avenne. Its area comprised fifteen acres, having an average height alx)ve the Potomac of 128 feet and a
gradual descent in all directions. MouxT Ple.isaxt Hospital was on the northeast, a1>out an eighth of a mile dis-
tant: Columbian College Hospital adjoined it on the south: in other directions the neighboring surface was
unoccupied. The buildings were arranged in a parallelogram, measuring about 1,.500 feet from east to west and 1,000
feet from north to south. The wards, 43 in number, were separated from each other by a distance of 40 feet : they
were 80 x 16, with a height of 8 feet at the side and lOi at the ridge, having a capacity of 11.^40 cubic feet and con-
taining usually about 18 beds. These buildings were constructed of battene<l planks, with felt roofs but no ceiling:
they were whitewashed inside and out. Each had five windows and as many doors. They were ventilated along
the ridge, and h3<i a Ion vered air-shaft for winter use, with openings for inflow within the jackets of the stoves, and
ventilating slides 12 inches s<juare on the sides and ends of each building at the floor-level. The floors were raised
about ten inches from the ground. The arrangement of these wards is depicted on page 914.
At a later date a building 100 x 40 feet and two stories high was erected in the centre of the parallelogram as
quarters for medical officers and stewards, dispensary, store-rooms, etc. The kitchens were reduced in nnmlier to
four. — two for convalescents, one for special diet and one for stewards and female narses. A large number of tent-
Med, Hist., Pt. 111—11.5
914
THE GENKEAL HOSPITALS.
wards added to the capacity of the hospital ; tlieso were well elevated from the ground Ijy plauk flooring. Water
was pumped from wells on the Mouut Pleasant grounds and distriliuted to the kitchens from a tank near the admin-
istration building; Ijiit the ward supply continued to lie delivered by a water-cart, and dry -box sinks were in use to
the end. Waste-water was conveyed by pipe-drains to a neighboring gully.
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1 he E.MORY HospiT.\r., Wasuixgtox, D. C, was situated near the Eastern Branch, on the plain east of the
Capitol. The buildings, originally constructed for a cavalry barracks, had all the objectionable features of those in
THE QEXEKAL HOSPITALS.
915
usf at the lAiivER IlosriTAi., Inn in an aggravated degrcp. Thoy were too low and too narrow, liiiilt directly on
tlie ground, with the earth hanked np against their walls as higli as the floors. Large interstices hetween the coarse
broad ilooring-lioards )ierniitted unwholesome exlialatious from the confined soil beneath to rise constantly into the
wards. The water-supply was pumped from wells into a eenlral tank. The wards, 12 in number and each shaped
like an L. were arranged in two rows, live in one and seven in ihr otlier. The details of their arrangement are shown
on the accomi)anying plan :
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Emoey Hospital, Washixotox, D. C. — .Scale m'sj : 1, General office ; 2, Clmpel ; 3, Barracks ; 4, 4, 4, Wanis ; .'), Dining-room ; fi, Kitchen ; 7 Cooks'
quarters: 8, Surgcon-in-cliargo ; 9, Officers' quarters ; 10, Dispensary ; 11, Linen-room ; 12, Laundry; W.U, Store-lioiiscs ; 15, Dead-house : 10,St,nbleB; 17
18, Launilresses' quarters; Hi, a), Qiuirtere f<jr attemlants; 21, 21, 21, 21,%inkB; 22, Guard; 23, Side elevation of ward.
The hospital at Hilton Plead, S. C, was one of the few buildings which, although con-
structed for hospital purpose.s, were modelled after the barrack system. A single narrow
barrack building, more than 1,200 feet long, formed the sides of an enclosed quadrangle,,
the interior of which was reached by a sally-port on two opposite sides and some narrow hall- or-
passage-ways at points corresponding with the division of the building into wards, etc. Ass't
Surgeon J. E. Semple, U. S. Army, expressed satisfaction with this arrangement as facili-
tating administration, but it is evident that in so doing he compared it only with the .same'
area of continuous ward-room extending lengthwise away from a medical headquarters. As;
\
916
THE GENERAL HOSPITALS.
the situation of this building exposed it fully to the sea breeze, its inmates probably suffered
little inconvenience or harm from the unbroken line of its outer wall.
The Hospital at Hilton Head, S. C, was ori^anized March 1, 1862, in an old bnildiu;; that had been used for
hospital purposes by the rebels prior to the capture of this point bj' theU. S. forces. But aliout the end of the month
the patients were removed tu a new building which had been speciallj- erected as a general hospital. This was situ-
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Hilton Head Hospital, S.C. — 1, 1, 1, 1, Wards; 2, Dining-room ; 3, 3, 3, 3, Pass.ages ; 4, OflRce : 5, Private room ; r., Dispensary ; 7, Reading-room ;
8, Oporating-room ; 9 and 10, Snrgeons' rooms; 11, Kitchen; 12, Store-roora; 13, Batliing- and clotliing-room ; 11, 14, Gateways. Tlic building is sur-
rounded inside and out liy a vi-randa indicated Iiy the faint line.
ated on the seashore on a sandy loam, formerly a cotton field. On the southwest, northwest and northeast, at a dis-
tance of about half a mile, there were large swamps with rankly growing weeds, palmetto palms, etc. A good deal
of labor was expended in removing the more objectionable features of these malarial surroundings. The building,
under a continuous roof, formed the four sides of a hollow stxuare, constituting an enclosed yard. Each side was 325
feet in length. The centre of the northern and southern sides was broken by a sally-port or carriage-way, v.'hich
THE GENERAL HOSPITALS.
917
(lividfil each side into two lai'KO rooms usimI as waiils. 'I'lio west side was divideil liy transverse [lassase-ways into a
central room, usi'd as a dinin;; loom.and two lateral wards. The eastern or seaward side contained one ward, but its
lar^'cr portion was sejiarated into small rooms as olliccs .-uid store-rooms. The floors were raised about three feet from
the proiiiid, and a wide veranda alVorded shelter aloni; the exterior as well as the interior face of the building. The
wards are said to have been well ventilated. In the cent re of the <iuadran<;le was a building 100 X '.iO feet, containing
the kitchen, a store-room and a general bath-room furnished with three tubs ; a part of this was partitioned off as a
knapsack or elothing-rooui. A house outside the quadrangle was used as oflicers' <iuarters. The laundry and dead-
honsc were also ontsido the hospital area. Water was obtained from numerous wclla within the enclosure. The
siuks on the boacU wore cleaned by the tide twice a day. The ground plan is shown on the opposite page.
Early in tlie winter of 1861-'62 the U. S. Sanitar)^ Commission urged upon llio Gov-
ornment the importance of building hospitals on the pavilion principle, instead of collecting
tlie sick and wounded in hotels and other rented buildings which were generally ill-adapted
for iiospital purposes. In accordance with this suggestion the Judiciary Square and ]\Iount
Pi.KAsA.XT hospitals were commenced at Washington, D. C, in tlie course of the winter, and
tinished for occupation in April, 1SG2. The description of one applies to both.
The hospital was raised on cedar ]U)sts
aliout three feet from the ground, the underly-
ing space l>eing closed in but ventilated by many
apertures. An administration building of two
stories was divided along its middle on both
Hoors by a central corridor ten feet wide. On
the tirst floor were eight rooms, four on each
side of the corridor, used as offices, disi)ensary,
store-rooms and i|uarters of medical oflicers,
with small store-closets on one side and a stair-
way, with w ater-clo.set and bath-room under
it, on the other. The second story, similarly
divided, accommodated stewards, wardmasters,
clerks and laundresses, etc.
The corridor of the ground floor of the
ailministration building extended rearward
throughout the whole length of the hospital,
preseninga width often feet, and comnmnica-
ting on each side with the bath-rooms, water-
closets and isolation wards of each of the pavil-
ions. This corridor, with tiie line of small rooms
on either side of it, being covered by one roof,
constituted an elongated cent ral building32feet
wide,on each side of which, and at right angles
to it, were five pavilion-wards each 84 X 2K, and
12 feet to the eaves. These were separated from
each other by a space cijual to their own width,
and the attached eml of the ward on one sidoof
the corridor faced the interspace on the other
side. The details of the wards and the rooms
attached to them on their corridor ends are seen
on the next following page. The passage-way
from the corridor to the wards had doors on one
side leading into a scullery, sink, bath-room and
nurse's room, and on the other into a nurse's
room and a small ward of four beds intended
originally for convalescents, but generally used
as an isolation room for special cases not requir-
ing absolute removal from the hospital. The
water-closet, 8, on the adjoining figure, as may
be surmised from the jiosition of its doorway,
does not belong to the ward depicted, but to
that on the other side of the corridor from
itself. The water-closet of each ward was across
the corridor from the doorway of the ward to
which it belonged; its relation to the ward and
corridor may }>c seen on tlie general plan.
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THE CtEXEEAL hospitals.
The central corridor with its small wards, sculleries, sinks. 1>ath-rooms and water-closets, and the main or
paviliou wards with their nurses' rooms, were all sheltered hy a continuous roof; and as the partition walls of the
various subdivisions under it were only eight or ten feet high, tlierc was a f:eo ooniniuriication overhead between all
5 i
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THE GENERAL HOSPITALS.
919
parts (if the buildiiii;. Twenty lioils are lepreseiiteil in one of tlic main wanls. lint the nnnilx
sideialily increaseiL At .Iudiciauy Sijf.vRK the capacity of the liosjiital was any;nionte(l by c;
anil at JUiuxT Pi.K.vfiAXT provision was made for 1,()2() 2
patients by piteliin^'i" tent-pavilions, each eoiisistingof ^
three hospital-tents placed end on to each other. These
canvas pavilions were arranged in parallel rows with
widi' intervening avenues.
r was afterwards con-
iinvas for 160 patients,
From the central corridor between the administra-
tion bnildini; and the entrance to the lirst or nearest ward
was a i>assaj;e leading to the kitchen and lanndry: the
gnard-honse. dead-honse and stables were in detached
bnildings.
riie Judiciary Sijuake iiospital was connected
witli the city water-nniius and sewerage system. At
Mor.NT Pleasant water was pumped from wells by a
steam-engine to an elevated wooden tank, whence it was
distriliuted to the wards and kitchen. The sewer-pipe
of the hospital ran underneath and parallel with the
main corridor, receiving the laterals from the successive
baths, sinks and closets, and discharging into a neigh-
boring pond.
Surgeon CiiAin.F.s Pack, V. S. Army, reported as
follows concerning the. I UDlil AH YSiifAiu: hospital: Tho
hospital is built with wings extending at right angles
from each side of a corriilor and separated from each other
by a distance eijual to their own w idtli.each ward being
opposite tho vacant space on the other side of the cor-
ridor. In the corridor are built bath-rooms, privies, scuK
leries and water-sinks so arranged that each ward is
connected with its own conveniences. Tho floor of the
building is raised about three feet from the ground and
supi)ortcd on piles, enclosed, but allowed a free cirenla-
tion of air under the house l>y means of numerous doors.
The wards are well supplied -nith windows, having two
sets, one from the lloor six feet up, with double sash, and
one under the eaves, three feet square, moving on a cen-
tral pivot. The eaves are twelve feet from the floor.
The building is not ccileil or plastered. At the ridgo of
the roof ventilators are jjlaccd ten feet apart. The build-
ing is well suited for a hospital in many respects. The
arrangement of the wards is convenient for assigning the
diflerent assistants and attendants to their duties. It is
easily kept clean and there is but little noise in the house.
The absence of stairways reuder.s.it easy forthe patients
and attendants to get about, and the abundance of win-
dows for admitting light and air are all great advan-
tages. The disadvantages are the situation of the privies
and the <ommunication through the corridor over the
partitions of the air of the different wards. The parti-
tions extend only eight feet from the floor and the eaves
of the house are twelve feet, leaving a space four feet
deep iierfectly open and communicating throughout the
whole hospital excepting the kitchen and administration
building. These defects might have been obviated liy
placing the privies at the free eiuls of the wards and ex-
tending the jiartitions to the roof, but in the latter ease
some of the wards would get tlie breeze and others lie
under the lee.
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these hospitals it will be seen that several
grievous mistakes were made. In the original plan the water-closets were
ends of the wards, but, from motives of economy on the part of those charged
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920 THE GENERAL HOSPITALS.
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tion, they were ranged along the sides of the central corridor that a single sewer-pipe might
suffice for both sets of closets. In addition to this, the partitions which separated the water-
closets from the rest of the house were incomplete, rising no higher than those between the
wards and the central corridor. Offensive emanations from these places soon became a
matter of serious consideration. The evil was remedied to a certain extent in both hospitals
by extending the partitions of the water-closets to the roof and supplying them with special
ventilating shafts. Concerning this alteration at the Mount Pleasant hospital Medical
Cadet Elliott Coues, U. S. Army, reported as follows:
The ten wards, Tvith their accompanj-ing rooms, are not entirely separated from each other, but all have com-
munication with the general interior of the building. The partitions which form the sides of the main corridor and
the passages leading into the wards, as well as the sides of the "isolating wards," scullery and bath-room, are only
ten feet high, less than half the height of the ridge of the building. This partial separation affords a complete com-
munication of the wards with each other through the main central portion. The only exception to this is the water-
closets. The odor arising from these was found so offensive that it became necessary to continue the partitions
between them and the rest of the building quite to the roof and add ventilators above and below. By these means
the diificulty was entirely obviated.
The grand and general objection to the plan of these hospitals lay in the common
atmosphere which the single roof and screen partitions gave to all the rooms occupied by the
sick, including even those assigned for purposes of isolation. Although nominally built
upon the pavilion principle, they were wanting in the very point which is the leading idea
of this system.
At the Chester Hospital, Chester, Pa., the advantages of the pavilion system were
lost bv the method of aggregation of the wards. Indeed, it would be difficult to conceive
of an arrangement of fifteen wards on a given area which would so effectually interfere
with ventilation as that adopted in the construction of this establishment. Three long
wards were joined end to end, making a building so extravagantly long that an air-move-
ment in its interior in the direction of its length should have been inconceivable even had
there been open ends and no partitions. Five such buildings, placed one behind the other
at close intervals, had their ends and those of their intervals closed up by the imposition of
a continuous building at each end, used as dining-rooms and associated kitchens. The four
long and narrow intervals between the rows were then subdivided by the erection of privies
and other outbuildings, so that they became converted into twelve narrow and perfectly
closed courts into which the windows of the wards opened, excepting those in the exterior
wall of the outer series of buildings. To complete the insanitary conditions within these
courts, the privies were deep vaults constantly filled with subsoil water and exhaling odors
which had no lateral exits save through the wards of the hospital. This particularly infe-
licitous method of aggregation, for which an architect of Philadelphia appears to have been
responsible, is illustrated on the opposite page.
The Chester Hospitai, was situated on a rising ground in the outskirts of Chester, Pa. Its nucleus was a
college building, which afforded quarters and offices for the medical staff', dispensary, store-rooms, etc., with wards
on the upper floors. From this buildiug five long sheds of rough boards, roofed with tarred paper, extended parallel
with each other towards the town. Each of these was divided by two transverse partitions, with doors of communi-
cation, into three wards of 2,30, 190 and 205 feet in length respectively. On account of the slope of the ground these
wards were terraced, those nearest the college building being on a level one step higher than those continuous with
them on the farther side. These long buildings were separated laterally by intervals of fifty feet. Running at right
angles to them, and closing them in completely at the ends, were similar sheds built for dining-rooms. The outer
sheds of the series of five were prolonged at their ends beyond the dining-room connection, the extensions thus formed
being used for kitchens, laundry and (juarters of employes. The length of each of these two outer sheds was 775 feet,
of each of the three interior sheds 625 feet. The long fifty-feet intervals between the sheds were divided transversely
at each terrace-step or ward-partition by the erection of privy-houses, bath- and wash-rooms, pantries and coal-bins.
The pavilion- wards afforded 1,000 cubic feet of space to each of 867 patients. Ventilation waa by the ridge, the open-
THE GENERAL HOSPITALS.
921
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'922 THE GENERAL HOSPITALS.
inns protected tUiriug cold or stormy -n-eatUerby shutters on horizontal pivots. The water-supply was pumped from
the creek into distributins tanks. The privies were very deep vaults or pits,, which speedily became filled with liquid
and gave rise to disagreeable odors which penetrated into the wards. Pumping them out was found to be expensive
and unsatisfactory. Drains were built to discharge into a neighboring tide-water creek, but as they left the vault
eight or ten feet above the level of its bottom the evil was by no means wholly remedied.
In some of the hospitals built about this time the elementary idea of the pavilion system
was carried into practice at the expense of the organization of the hospital. Thus, at the
De Camp Hospital, David's Island, New York Harbor, two long pavilions parallel to each
other, with a space between them sufficient for a third long building, used as kitchen, dining-
room and attendants' quarters for the ward on either side of it, constituted the unit; and
the hospital was composed of an aggregation of these. Administration was difficult, and
material duplicated to an extravagant extent in an establishment of this kind.
The De Camp Hospit.^l was established on David's Island, New York Harbor, at the western entrance to Long
Island Sound, half a mile from the mainland, opposite the town of New Kochelle and about 22 miles from New York
City. The grounds, which included the whole of the island, comprised 80 acres about 30 or 40 feet above the sea level,
dotted with large shade-trees, which at one end clustered into a pleasant grove. On one side, separated from the sea
by a strip of beach, was a pond of fresh water fed by springs.
The plate facing this page represents the hospital at a late period of its history, when 20 pavilions had been
constructed, with mess-halls for the tent-wards, barracks for the guard and cottage quarters for the medical officers.
The pavilions were placed parallel to each other, but each was completely separate from its neighbor. Two adjacent
pavilions, however, were associated with each other by a shorter building in the space between them, which was used
in connection with both as a kitchen, mess-room, smoking-room and quarters for nurses and attendants. The general
diet of the patients in the tent-wards was cooked in the single large kitchen. Extra diets for all the wards were pre-
pared in special kitchens.
The pavilions were substantially built, lathed and plastered, well lighted, ventilated by the ridge and heated
by coal-stoves. They were separated from each other on one side and from their adjacent mess-buildings on the other
by an interval of 25 feet. Each was 248 X 24 x 15 feet, and divided transversely into four wards, each measuring 50
feet in length and containing 20 beds. The remainder of the length of the pavilion was occupied bj- ward conven-
iences. Bath-rooms, water-closets and lavatories were provided at the ends of each building. These were cut off
from the main portion of the pavilion by cross ventilation tlirough a hall; and between them and the wards a space
was partitioned oft' at each end for a wardmaster's room, knapsack-room and store-room. The 20 pavilion-wards
aftbrded GO square feet and 900 cubic feet of space to each of 1,600 patients. Drinking water was obtained from wells
in various parts of the grounds. The general supply was pumped by a stationary engine into sunken cisterns under
each mess-hall, from which it was raised by hand. On account of this limitation of the supply the water-closets
were not at all times free from odor; and as no provision was made for the distribution of warm water to the wards
the bath-rooms, particularly in winter, were rendered comparatively useless.
In some instances, where existing buildings had been converted to hospital purposes, the
addition of some pavilions more or less detached altered the character of the establishment by
permitting the old building to be used as offices, quarters and store-rooms. The arrange-
ment of the pavilions in such cases depended generally on peculiarities of the area available
for their erection. The plans of the Summit Hospital, Philadelphia, Pa.; may be submitted
as an illustration of this development of the extemporized hospital.
Summit House Hospital, Delaware Couxty, P-\., was situated on the west side of the Darby plank road,
about fonr miles from Market street bridge, Philadelphia, Pa. It was opened in March, 1862, in a suburban hotel, a
three-story building of 65 X 50 feet, with a two-story back building 37 X 35 feet. The first story was divided by a hall
8 feet wide into one large room and two parlors, with the dining-room and kitchen behind. The second story had
one large central chamber, with three smaller rooms on each side and four rooms in the back building. The third
story had ten rooms, each accommodating two or three beds. All were excellently ventilated by well-hung sashes
over the doors and by windows. A two-story veranda on three sides of the main building aftbrded a cool and shady
place for convalescents able to exercise in the open air. The grounds covered an area of about two acres.
When the pavilions were built the rooms of tlie hotel were given up for the use of the medical staft' and employes,
and as store-rooms, dispensary, etc. Three pavilions were erected, one on one side of the hotel, two on the other,
parallel with its sides, and connected with the back building of the hotel and with each other by a long pavilion
used as a dining-room. These wards were roughly constructed sheds with ridge ventilation. At the rear end of each
were small rooms occupied as wardmaster's room and pantry, bath-rooms and privies, the former partitioned oft' from
the end of the ward, the latter attached to its side. The privies were cisterns, emptied when necessary; they were
ventilated by underground flues connected with the chimney of a steam-engine. External to the two wards on the
left of the hotel was an irregular shed, formerly a horse-stand, which was fitted with latticed ridge towers and con-
THE GENERAL HOSPITALS.
923
verted iiitu a ward. Tlu'sr tDiUaiucd 353 liedswitli '7>0 IVi-t of air-space to each. A iiiinilierof tents were afterwards
pitched to increase the hospital accommodation. .Vlon^ the rear of the lot was a long wooden bnildinit; which con-
tained rooms variously occupied at ditVerent times as stables, store-rooms, knapsack-room, guards' barracks, gnard-
house, etc. Water was raised from a neigliborinj; stream into tanks for distribution; well-water was also used.
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At the Baxter Hospital, Burlington, Yt., the added pavilions i^rojected lengthwise
from one side of a covered corridor which had the former Marine hospital at one end as an
administration building. As the intervals between the pavilions were 48 feet wide, it is
924 THE GENERAL KOSPITALS.
evident that there was ample space at command, and that this arrangement was in no way-
constrained by local conditions, but was regarded by those who adopted it as the best that
their experience enabled them to devise. The wards were arranged in a similar manner at
the Crittenden Hospital, Louisville, Ky., where a covered corridor 8 feet wide ran along
the rear of seven pavilions, and at the Tilton Hospital, AVilmington, Del., where six
pavilions were similarly associated. The plan of the Tilton hospital is submitted on the
opposite page as an illustration of this method of arrangement. The covered corridor, orig-
inally intended as a bond of connection and means of communication between the various
parts of these pavilion hospitals, was very generally put to use as a common dining-hall.
The Baxter IIospitai., Burlington, Vt., -nas built on tlie grounds of the Marine hospital, on a terrace over-
looking Lake Champlain and about 100 feet above the level of its waters. The buildings consisted of a two-story
brick house, formerlj' the Marine hospital, which was used as qiiarters, store-rooms, offices, etc., and 21 wooden pavil-
ions, nine of which were much longer than the others and were used as wards, one as a general kitchen, one as a
mess-hall, one as a dispensary and store-room, one as a linen-room and store-room, with a finished attic for non-com-
missioned officers, one isolated as a pest-ward, four respectively as dead-house, ice-house, store-room and barn, one as
guard-house and knapsack-room, and two for the quarters and mess of the Veteran Reserve guard.
The long pavilion-wards parallel with each other and separated by intervals of 48 feet abutted on a covered
corridor which extended rearward from the administration building. Each measured 190 x 24 x 13 feet, less two rooms
9 X 10 feet, cut off at either end for use as nurses' room, water-closets, bath-rooms, etc. The remaining ward-space
was occupied by 04 beds, to each of which it gave about 65'feet of area and 850 feet of air-space. Ventilation was by
the ridge. Hospital tents were pitched for the accommodation of about 120 patients. Water was supplied to the
kitchen from a neighboring spring by a wooden conduit. The bath-rooms and water-closets in the pavilions were not
used on account of the defective character of the water-supply. The administration building contained bath-rooms
for special use. Covered sinks were provided for the use of the inmates of the pavilions.
The Crittenden Hospital, Broadway, between 14th and 15th streets, Louisville, Ky., consisted of
seven parallel pavilions projecting at right angles from one side of a covered corridor eight feet wide. The free ends
of these buildings constituted the front of the hospital. The pavilions were one-story shingle-roofed frames, lathed
and plastered to the eaves but unceiled. Each was 180 x 24 feet by 14 to the eaves and 19 to the ridge, and was
separated from its neighbors by an interval of 38 feet. The central pavilion was used for offices, etc.; it was divided
along its length by a hallway 8 feet wide, on either side of which were ten rooms used by the administration. A pro-
longation of this pavilion for 90 feet on the rearward side of the covered corridor constituted the mess-room, a wing
on one side of its farther end being used by the cooks and one on the other side by the laundresses.
The three wards on each side of the central building were each lighted by 30 windows, 15 on a side, ventilated
by the ridge in summer and by shafts 18 inches square, through which the stove-pipes made their exit, and warmed
by four stoves, each partly surrounded by a. jacket of sheet-iron with an air-box communicating with it. Each con-
tained 60 beds — 30 on a side. At one end of the ward 9 feet of its length was partitioned off, giving two rooms 9x9^
feet, used as nurses' room and store-rooms ; at the other end a similar partition gave space for bath-rooms and lavatories.
There were no water-closets connected with the wards. The privies, in rear of the hospital buildings, were three in
number, each 14 x 14 feet; each had sixteen seats arranged on the four sides of a central ventilating-shaft : the pits
were 12 X 12 and about 30 feet deep. Drainage was superficial and led into the street gutters.
The Tilton Hospital, Wilmington, Del., occupied the block of level ground, having an area of li acres,,
between Tatnail and West streets. Ninth street and Delaware avenue. It consisted of a three-story brick adminis-
tration building and six pavilion-wards, parallel to each other and projecting at right angles from a wide-covered
corridor, which ultimately became utilized as a common dining-room for all the wards. The details of the adminis-
tration building may be gathered from the plans submitted.
The wards were well and firmly built of rough boards, having an interior board lining with six inches of air-
space between the shells. The intervals between adjacent wards measured 26 feet. Each ward was 19 feet wide,
131 to the plate and 17^ to the ridge. They were 154 feet long and contained 60 beds each, excepting that nearest
to the administration building, which was 144 feet in length and contained only 56 beds. The wards were lighted by
14 or 15 windows on each side, ventilated by the open ridge and 13 slide-covered openings on each side near the floor,
and warmed each by two coal-stoves, the pipes of which passed through the ventilating shafts to facilitate the air
movement in the cold season. Bath-rooms and lavatories were provided at the free ends of each pavilion. Water-
closets were separated from the wards by a ventilated passage excepting in the case of the pavilion nearest the
administration building. A long trough under the seat of each closet was emptied and flushed two or three times a
day through pipe-sewers discharging into a deep covered well at some distance from the hospital. The water-supply
was derived from the city water-works.
A central corridor witli a double row of attached pavilions, one on each side, does not
ajipear to have met with favor after the recognized failure of attempts of that kind in the
Mount Pleasant and Judiciary Square Hospitals at Washington, D. C. The nearest approach
THE GENERAL HOSPITALS.
925
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TiLToN ilosriTAL, WILMINGTON, Ijel. — 1, WanU; 2,<.'orridor; 3, Barracks, containing officers' rooms, guanl-rooui, prisuti, smoking-rKom, water-
closet and I»atli-room ; 4, Tank-house; 5, General office; G, Surgeon in charge; 7, Officer of the day; 8, Officers' mcs«; 9, Kitchen and cunl-honw; 10,
Waicr-clo«'ts; 11, Kitclicn and coal-house; 12, Wa-sli- and ironing-room; 13, Drj-ing-rooni; 14, Store-room; 1'), Steward's Btore-room, sleeping, office and
liAth-rooni. A. B, i;round lloor of adniinistratiun Itnilding, C,Secoutl story uf A, containing rooms of eurgeou in diarge, ladies' contributing-room, hath
and water-closet. P, Wanl in second storj" of B. E, ThinI story of B, containing dormitories of officers, etc. F, Transverse section through ward-
master's room, wxsh-room and water-closets. Picket-fence marked .
926 THE GENERAL HOSPITALS.
to a double row was found in the Cuyler Hospital, Germantown, Pa., where two wards on
one side were opposed to seven on the other, but the nature of the ground appears to have
been responsible for this ward-movement to the other side of the corridor.
Cuyler HosriT.\L, Gkrmantowx, P.\., had the town-hall for its nucleus. The ground floor was used as offices
and quarters; the second floor afforded shelter for 76 patients in one ward 79 x 50 feet; three rooms on the third
floor were used for nurses and patients. To this the pavilion hospital was afterwards attached. A long corridor,
used as a dining-room for all the wards, projected backward from the town-hall building. Seven pavilions placed
parallel to each other, and at right angles to the corridor, opened into the latter on the right ; two joined it at an
obtuse angle on the left. A pavilion was also erected in rear of the main building and parallel with and to the left
of the corridor. This was used as a laundry, guard-room, knapsack-room, etc. Another, built on 'the left of the main
building and parallel with its front, gave additional acconmiodation to the administration. The irregularity in the
plan of this hospital was occasioned by the natural features of the lot ou which the pavilions were erected. The
wards were coarsely finished, ridge-ventilated sheds partitioned off at their free ends for the wardmaster and lava-
tory, but diflferiug from most of those built at the same period in having the bath-rooms and water-closets in an addi-
tion to the side of this end of the pavilion. The closets were furnished with an iron trough, which was flushed into
the sewers three times a day. The water-supply was derived from the Germantown water-works and from wells.
There appears, however, to have been no objection to parallel corridors with an elongated
space between them, constituting a hospital yard, and the pavilions attached along the outer
side of eacli corridor. This was the plan adopted at the Satterlee Hospital, West Phila-
delphia, Pa., where fourteen parallel pavilions, each 167 X 24 feet, projected from each of the
corridors at short intervals of 21 feet. This hospital was crowded on its area. The corridors
were separated by an interspace the width of which was only 70 feet; and even this was
blocked at the middle of its length by a transverse building containing the offices. This
limitation of the width of the space separating the parallel corridors was not repeated in
other hospitals. At the McDougall Hospital, Fort Schuyler, N. Y., there were seventeen
wards on each of the corridors, but the latter were sej^arated widely from each other and ran
into each other at one end in a semicircular curve. At the McClellan Hospital, Philadel-
phia, Pa., the parallel corridors curved into each other at both ends, enclosing a large unen-
cumbered central space, with the administration and executive buildings external to its sides
and the pavilion-wards radiating from its rounded ends. At the Mower Hospital, Phila-
delphia, Pa., the enclosure was enlarged laterally and contained the various accessory build-
ings, while the wards, fifty in number, radiated from the outer margin of the corridor, which
on the ground-plan formed a squarish figure with its angles rounded off". Lastly, at the
Jefferson Hospital, Jeff"ersonville, Ind., the covered corridor lost its parallelism on becoming
converted into a circular figure enclosing an area 600 feet in diameter. At this hospitixl the
corridor was 16 feet wide and 2,000 feet in length; twenty-four pavilion-wards, each 175 feet
long, and some buildings of a similar size used as store-rooms, radiated at intervals of 46 feet
from the outer aspect of the circle, while the other buildings necessary to the efficient admin-
istration of the hospital were contained in its interior.
Satterlee Hospital, West Philadelphia, Surgeon 1. 1. H.iyes, U. S. Vols., in charge, Oct. 31, 1862.— This hos-
pital was commenced May 1, 1862, and by the terms of the contract was to liave been completed in forty days. Seven
of the wards were ready for use on the 6th of June, and, as ordered, I proceeded to organize the hospital and prepare
it for the reception of patients. On the 9th the completed wards were filled with patients, and the other wards were
occupied as rapidly as finished. I was fortunate in being able to engage, as directed when the hospital was first
opened, forty Sisters of Charity, wiose labors have been unceasing and valuable. I enlisted also a sufficient number
of hospital attendants, allowing eleven to each hundred patients. Many studeuts of medicine volunteered their assist-
ance and were placed on duty as acting medical cadets. This useful body of young men, performing duty without
pay, at one time numbered as many as 41. The medical staff was enlarged as the hospital filled up, aud at preseut
there are 35 medical officers ou duty, exclusive of 18 cadets. There are now thirty-six wards in the hospital,— twenty-
eight in the house aud eight in the hospital camp. The per.sonnel of each ward comprises a surgeon, a Sister of Char-
ity, a wardmaster and three nurses. When practicable a cadet is attached to each ward, and the resident assistant
surgeons and acting assistant surgeons are so distributed as to be responsible for the wards during the absence of
the non-resident medical officers.
THE GENKRAL HOSPITALS.
927
The hosiiitiil is located at the intersection of llth anil Spnice streets, a half mile outsiile of the present city
limits, west of what is known .as West Philadelphia. It is built ui>ou au eniinenec about 200 feet above the bed
of Mill ereek and distant from it ^oO jarils. Its situation is eminently healthy. I had feared that a pool of water
known as the Mahlonville Dam, which is about 100 yards southeast from the hospital, would breed malaria, but I
am ^lad to say that the sunnuer and fall have passed without the occurrence of a single ease of disease attributable
to that cause. This dam. however, if not removed, will become a source of trouble n<'xt summer, since it receives
tlie sewage of the lio«pital from Mill creek. This hospital is surrounded with trees which all'or<l shade to the soldiers
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CrvLER IlaspiTAi., GrnMANTowN Ta.— 1. Wards, with rooms for wardmastcr, pantry. Uith-rooms and water-closets attached to each ; 2
Us-il aF ilining-rooni ; 3, Ivuni>eiack-roum ; 4. Oiianl-rooin ; 5, Prirson ; Siirpeon's office itclwcen 4 and 5 ; 0, Ironing-room ; 7, Liuen-rooni ; P,
9, Kitchi'n. t^tt^wanrs-rooni, water-cl'»sft ; U', Wonion's Itcd-rooni ; 11. llall ; 12, Siirj^'con's office, dining-room, bed-rouni, jxintrv, p"<>t-iuor(rtn ru*.
closets and bath-room; 13, 13, Guard-tiousc and watt-r-closct ; 14, Second story of town-hall, large room and attached r"'>in-' : I'>, Tliinl ^t
dorniitoiies of employes.
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928 THE GENERAL HOSPITALS.
during the heat of summer. The building was originally intended to accommodate one thousand patients. It is
huilt upon the parilion plan, and is found to be healthy and convejiient of management. The administration
building, in the centre, is 71 X 63 feet and two stories high. The lower floor has a hall running through it, on one
side of which there are three rooms; the central one is used as a surgery or cflspensary, the others as mess-rooms
for the officers. The central room on the opposite side of the hall is the reception-room: this is divided by a rail-
ing, behind which is the office of the assistant executive officer. Next to this room is the office of the surgeon-in-
charge and of the executive ojficer; on the opposite side of the reception-room is the office of the resident surgeons,
and back of that the donation-room. On the second floor of the administration building are twelve rooms, which
are used as quarters for the officers; in addition to these there are for the same purpose two one-story buildings on
the east front, each 75 X 14 feet and each containing five rooms. The administration Iiuilding stands between and
is attached to two corridors 71 feet apart, which are 14 feet wide and 13 feet high, and originally .560 feet long. These
and the wards are only one story high. The corridors run east and west and are i>arallel with each other. The wards
stand at right angles to them, and are each 167 feet long, 24 wide and 13 high; the roof has a pitch of 6 feet, and
hence the height of the ward to the peak is 19 feet ; there is no ceiling. The wards are 21 feet apart. In the original
plan there were twenty wards — ten on each side. Soon after the original building was completed four wards were
added on either side, making twenty-eight in all, and the corridors were lengthened to 740 feet. These corridors
terminate at the eastern end each in a store-house, which is two stories high ; the second story furnishes quarters for
the Sisters of Charity. At the other end the corridors terminate in smoking-rooms, 28 X 25 feet, for the patients.
Over the smoking-rooms are quarters on one side for clerks and on the other for druggists. A small wing running
ofi^ from each corridor, midway between the smoking-rooms and the administration building, furnishes on one side a
room for the chief wardraaster and on the other a mess-room for clerks and druggists. Two wings of the same dimen-
sions as the wards, and running parallel with them, at the eastern end of the corridors, are used as kitchens and
laundries, the one-half of each being appropriated to either purpose. The hospital thus consists of a central admin-
istration building, two attached corridors used as dining-rooms, and on either side fifteen wings. The sixth and sev-
enth wings from the eastern end are 71 feet apart, and in the centre of the space on the north side is a building
100 X 14 feet, the larger part.of which is used as a knapsack-room and the remainder as a post-mortem room. On the
■ south side, in the corresponding space, is a building symmetrical with the one above mentioned, which is used as
barracks for the guard and also as guard-house. The guard is composed of convalescent soldiers who are unfit to
return^o their regiments and numbers a full company. The wards are all of uniform construction. There are on
each side 15 windows, 6 feet 8 inches by 2 feet 7 inches; they are 2 feet 10 inches from the floor and 3 feet 6 inches from
the top of the wall. At the end of the ward which joins the corridor are two rooms, one on either side, 10 by 8 feet,
one of which is used for a wardmaster, the other for a female nurse (Sister of Charity). At the opposite end are
a water-closet and bath-room, the former 13 x 7, the latter 11 X 7 feet; these are separated from the ward by a hall
3 feet wide. The ward proper is thus reduced to 147 feet. The water-closet is arranged with a cast-iron receiver or
trough 12 feet 3 inches long, 1 foot 1 inch deep, 1 foot 7 inches wide at the top and 1 foot 1 inch at the bottom. It is
one-third filled with water drawn from a pipe which enters at one end, and at the other the accumulations are let off
every hour through a three-inch discharge-pipe into the general sewer by elevating a lever which is controlled by
lock and key. Each bath-room is supplied with a cast-iron receiver for washing the hands and face and a cast-iron
bath-tub with hot and cold water. Hot water is distributed to all parts of the building by means of iron pipes lead-
ing from an iron tank in each kitchen, which is heated by steam from a boiler placed in the centre of the front yard,
midway between the corridors. This same boiler furnishes heat for the greater portion of the cooking that is done in
both kitchens. The arrangements for cooking in each kitchen are a large range, two large cook-stoves and three boil-
ers each holding 60 gallons. The wards are ventilated at the ridge, twenty of them as shown in Fig. 1 and the remain-
der by the method given in Fig. 2 (see page 931). The dimensions of the former ventilator arc: Length 136 feet,
height above the roof 3 feet 6 inches and width (corresponding to the opening in the roof) 3 feet 11 inches; the
sides are closed in bad weather by a series of revolving shutters 3 feet long by 2i feet wide, which are drawn
by a cord. The ventilation of the eight last-mentioned wards is the ridge ventilation proper. These ventilators
extend the full length of the wards; the opening in the roof is li feet wide, the elevation of the ventilator above
the roof of the ward 8 inches, and the roof of the ventilator is 3 feet 6 inches in width on each side. The sewerage
of. the hospital is good. A 10-inch clay i)ipe, buried beyond the reach of frost, runs along the ends of the wards and
receives the pipes from the water-closets, bath-rooms, laundries, kitchens, etc. The two unite at the ea.st end of the
hospital and empty into a 12-inch pipe, which leads into a sink, from which the liquid drainage is carried into
Mill creek. This sink is closed over with earth and is one hundred yards from the hospital. The supply of water
has been until recently insufficient,— the original pipes were much too small. I have recently had laid a 6-inch
main leading from the street and 4-inch distributing-pipes along the ends of the wards. I have also had con-
structed two reservoirs holding 45,000 gallons. The water is supplied from the Schuylkill river by the West Phila-
delphia works, and a stand-pipe gives us mostly a good head of water. The hospital is lighted with gas from the
Philadelphia works. Early in July I put up 150 hospital tents on the grounds on the east and south sides of the
hospital. Each of these tents is 14 x 15 feet and accommodates six patients. A kitchen and dining-room were at
the same time erected for this additional number of men, and they are still in use; the kitchen is supplied with a
large range and three boilers each containing 90 gallons.
The hospital grounds are enclosed by a picket-fence 14 feet high and embrace 12A acres. The buildings form
a parallelogram 815 feet long by 433 feet wide, and in area 8.1 acres, just one-half of which is covered by hospital
floors. The capacity of the hospital for patients is as follows: There being twelve windows on either side of each
ward and two patients placed between each two windows, twenty-five are accommodated on each side, or fifty in a
THE GENERAL HOSPITALS.
929
K
Med. Hist.. Pt. 111—117
930 THE GENERAL HOSPITALS.
ward, thus allowing oue inch less than sis linear feet and a floor area of 70 square feet to each bed. By this estimate
there would be to each bed 1,128 cubic feet of air. The hospital would thus accommodate 1,400 patients. During the
summer I have frequently had 70 patients in a ward, giving 800 cftbic feet to each. Each ward now contains 60 beds
with 940 cubic feet per bed. The largest number which the building will accommodate is therefore 1,960, but this
number I consider too large for health during winter. In the hospital camp I liave had space for 900 beds. This num-
ber was reduced, by beds for nurses aud tents of administration, to 820. The largest capacity of the hospital has
thus been 2,780 beds. The largest number of jiatients actually accommodated at any one time was 2,458.
In relation to the titness of the building for hospital purposes and the advantages aud disadvantages of the
plan, I am not able to speak with the accuracy which is desirable, the hospital only having been iu use during the
summer; but thus far it has borne the test very well, arid I entertain no doubt that as a winter hospital it will prove
to be both comfortable aud healthy. The parallelism aud closeness of the wards to each other I have not found to be
practically olijectionable. The circulation of air has been good and the wards were reasonably cool during the hot
weather. The wards have been always free from odor and the air fresh. The long corridors give great facilities for
atmospheric circulation. The ventilation, however, is imperfect and must be changed for winter use. The venti-
lators of the first twenty wards are too open and too large, and of the eight other wards the ventilator roof is four
inches too high; it should, besides, project one foot farther. The plan is in most respects admirably arranged for
administration, the chief fault being in the division of the kitchens and their distance from the offices; its principal
merit is its compactness, and it is recommended by the ease with which every part of the building may be reached.
If it did not involve two kitchens I should prefer it to any other which I have seen. The disadvantages anticipated
from the parallelism of the wards is found to be trifling in practice. The building is now being plastered and will be
rendered tight and comfortable. It will be heated by means of coal-stoves, of which 200 are now being put up.
The McDouGAi.r- Hospital, Fort Schuyler, N. Y. Harbor, was built in the autumn of 1862, on the neck of
the peniusula which hts Fort Schuyler on its water-front. Its grounds covered 40 acres, iucluding the entire width
of the peninsula between the fort and the mainland. The wards, consisting of 34 pavilions, were arranged in two
lines, 17 iu each, projecting from the exterior aspects of two parallel covered corridors which enclosed a courtyard as
long as the hospital establishment and about 140 feet wide. At the western end of the courtyard the corridor of one
side was continued into that of the other in a semicircular curve. At the other end the courtyard was nearly closed in
by the erection of a two-story executive buildiug. The wards were set obli(juely along the sides of the corridor, each
forming an obtuse angle with that portion of the corridor leading to the administration building aud an acute angle
with the prolongation of the corridor beyond its own attachment. Au irregularity of the ground prevented the sym-
metry of this plan from being realized in practice; eight of the buildings abutting on the southern proug of the cor-
ridor were shorter than the others — five of them notably so. They were all too low aud narrow, and so frail iu their
constrnction that most of them had to be propped externally as a safeguard against high winds. They were roofed
with tarred paper and asphalt. They had good ridge ventilation, but the windows were too small and did not extend
close enough to the floor. Twenty-six of the wards were 147 X 174 x 8 feet ; three varied from 116 to 142 feet in length,
and five from 63 to 98 feet, averaging about 80 feet iu length. Medical officers on duty at the hospital complained,
when the building was in progress, that the plans accepted by the Quartermaster General were not carried out, — that
the width should have been 22Afeet and the height to the jilates 12 feet. Each ward of the full length was intended
for the accommodation of 50 patients; a wardmasters room was partitioned off from the free end of each, and two
small rooms iu an outhouse attached to the side of the building, at the angle of junction with the end, served as
bath-rooms and water-closets, the effluents of which discharged by pipe-sewers into the waters of the sound. The
closets were fitted with trough latrines. At tlie attached extremity of each ward 24 feet of its length was partitioned
off as a mess-room and china-closet. A tramway running along the corridor facilitated the transmission of supplies.
The executive buildiug at the free end of the hospital enclosure contained the surgeon's office, clerks' rooms,
dispensary, linen-room, knapsack-room, printing-room, reading-room, lavatory, etc. Behind this, and between it and
the glacis of the fort, was a two-story wooden building divided up into quarters for the medical officers. The ice-
house, dead-house, carpenters' shops, sutler's store, etc., were in- the Hanks of this building. At the opposite extrem-
ity of the hospital yard, connected with the convexity of the semicircular curve of the corridor, was a long two-story
building well furnished with steam-boilers for kitchen use, a bakery, swill-liotise and subsistence store-room, a steam
laundry, drying- and maugliug-room, with quarters overhead for the employes.
In the area enclosed by the pavilions was a commodious and well-arranged chapel, together with a guard-house,
operating-room and tank-house, with a steam force-pump over the main well. Three wells outside the area were also
used, but the supply was often deficient and sometimes brackish. Good drinking water was obtained from the fort,
but only in limited quantities.
The McC'LELLAN Hospital was established in February, 1863, on the Germantown turnpike, four miles from
Philadelphia, on ground which sloped gently and regularly to a neighboring creek. The pavilion buildings, 18 in
number, radiated from a closed corridor 16 feet wide, which was laid in the form of au elongated figure with parallel
sides and rounded ends. At the middle of its length, on one side, were the cjuarters of the medical officers, aud on
the other the kitchen and lauudry, subsistence and (luartermaster store-houses, engiue-hcuge and stable. The only
building within the enclosure was that used for offices; it occupied the centre, and was connected by a transverse
corridor with the main corridor on either side.
Each pavilion was 175 X 20 feet, 13 feet to the eaves and 18 to the apex of the roof. It contained 60 beds for
patients, and had a space partitioned otf at its attached end for use as dining-room and pantry and at its free end
for wardmaster's room, lavatory, bath-room and water-closet. A car-track on the corridor facilitated the distribution
THE GENERAL HOSPITALS.
931
932 THE GENERAL HOSPITALS.
of food to the wards. The wards were ventilated by the ridge, the openings of which were closed when necessary by
fallin" shutters. There were also apertures 8 inches square, oi)eued or closed by sliding frames between the windows
on the level of the floor, and channels of inflow for winter use under the floor opening near the stoves. The water-
closet at the free end of the building was cut ott" from the ward by a transverse passageway; it was fitted with a cast-
iron trou'i'h and water-supply. The closets communicated by four-inch pipes with a twelve-inch tile-pipe which sur-
rounded tlie whole of the hosjiital buildings, and received as well the discharges from the lavatories and bath-rooms.
An inner circuit of twelve-inch sewer-pipe followed the course of the main corridor and received the outflow from the
kitchen-sinks, laundry, wasli-tubs and pantries. The 12-inch main connected at one end of the oval and emptied 150
yards beyond into a cess-pool 20 feet in diameter, the liquid overflow from which passed into the neighboring creek,
while the solid accumulations were removed from time to time as recjuired. The water-service was derived from the
Germanto wn water-works on a requirement of 30 gallons a day for each inmate. Good water was also obtained, and
largely used, from wells dug within the enclosure. Tanks heated by steam furnished hot water to all parts of the
hospital. To meet danger from fire there was a 5-horse power force-pump, with 2,000 feet of 2J-inch rubber hose and
eight fire-jjlugs. Two large reserve tanks, holding 30,000 gallons, were placed over the main corridor on brick walls
for the purpose of supplying an extra quantity of water should that from the mains be insuflicient. Moreover, each
ward had 20 feet of 1-ineh hose with couplings for attachment to a small plug in the water-closet. Fire-axes and
water-buckets were kept at hand in the dining-room. A well-organized fire-guard patrolled the premises at night.
The Army Medical Museum contains a block-model of this hospital. Its plans have already been published.*
The Mower Hospital, Chestnut Hill, Pa., was opened in December, 1862. It was situated on an elevated
plateau near the village, al)out nine miles from Philadelidiia. It consisted of fifty pavilions radiating, some at right
angles and others more or less obliquely, from a corridor of a rectangular form with the angles rounded oft'. The
corridor, 10 feet wide and 2,400 feet long, enclosed a space of seven acres, having the administration building in the
centre connected with the circumference by a transverse corridor. A two-story pavilion, which projected from the
middle of the short side of the parallelogram facing the railroad station, formed tlie entrance to the hospital. It con-
tained a reception-room at its free end, with quarters for employi% in the second story; the laundry occupied its
attached extremity, and its prolongation into the enclosed area towards the administration building was the kitchen
of the establishment. A corridor by the side of this long building led from the exterior of the hospital to the admin-
istration building in the interior of the enclosed space. Within the enclosure on one side of the kitchen were the
buildings used as operating-room, butchers' shop, sutler's store and guard-house, and ou the other those used as the
general dining-room, carpenters' shop, chapel, etc. The kitchen, 110 X 30 feet, contained three large- sized hotel ranges,
three London kitcheners, eight double-jacketed steam-kettles for soup and three large-sized cooking-stoves. The
boiler-room, 29 feet square, accommodated two large boilers, a steam force-pump and fire-engine. The operating-
room, 27 X 25 feet, was fitted with seats for one hundred persons, closets for instruments and dressings, shelves for
medical works and cabinets for pathological preparations. Adjoining this room was the dead-liouse, 25 X 13 feet,
arranged for convenience in ^ioni-mortem examinations, and having a vault 8x4 feet and 12 deep, with a windlass
and dumb-waiter for the reception of bodies preparatory to burial. The chapel, 75 X 60 feet, connected with the
main corridor by a covered pas.sageway, was used as a reading-room on week-days, and contained a library of 2,400
volumes. In the angular spaces external to the pavilions, forming the rear line or posterior side of the rectangle,
were two U-shaped buildings, used as store-rooms and as barracks for the Veteran Eeserve Corps guard.
The pavilion on one side of the two-story building which formed the entrance of the hospital was used as a
knapsack-room and as quarters for the band ; that on the other side of the central pavilion was used for subsistence
stores and as quarters for the stewards. Of the 50 pavilions there remained 47 which were put to use as wards.
These were 20 feet ai)art at the corridor and 40 feet at their free ends. They were all well constructed, ventilated by
the ridge, by four shafts connected with the stove-pipe by apertures near the floor-level, and inflow channels for winter
use opening near the stoves. The water-closets at the free end were cut oft' from the ward by a passageway, att'ord-
ing cross ventilation; each had a trough 9 feet long and 12 inches wide, with five seats, a faucet for the inflow of water
and a trap for its exit when necessary.
The water-supply was drawn from the Chestnut-Hill water-works into four tanks on the second story of the
administration building and two at the junction of the transverse with the main corridor, the former having a
capacity of 18,000 gallons each, the latter of 15,000 gallons each. A terra-cotta pipe 14 inches in diameter, following
the track of tlie main corridor, carried oft' waste water from the sculleries of the wards and the buildings in the
interior of the parallelogram. A brick sewer, 30 x 20 inches, following the curves of the free ends of the pavilions,
received the discharges from the water-closets and bath-rooms, together with those from the pipe-drains. The out-
flow was into a creek about half a mile distant from the hospital. The arrangement of the buildings of this estab-
lishment is shown on the ojiposite page. The Army Medical Museum contains an excellent block-model on a scale of
30 feet to the inch.
Jefferson Hospital, Jeffersonville, Ind., Medical Inspector R. H. Coolidge, U.S. Army, Novemher, 1862.—
This hospital is situated on the north bank of the Ohio, about one mile east from the steamboat lauding at Jelferson-
ville, Ind. Its immediate locality is elevated about fifty feet above the river, and, though originally uneven, has been
graded and drained. The soil is a sandy alluvion mixed with clay.
The hospital in the general character of its construction and material resembles the Mower hospital. Chestnut
Hill, Pa., from wiiicli, however, it dift'ers in having the pavilions project from a circular instead of an ellipsoidal cor-
ridor, in having 25 instead of 50 pavilions, in having greater space between the pavilions and in many minor details.
*Piimphlet on the Representatiou of the Medical Department, U. S. Army, International Exhibition, Philadelphia, 1876.
THE GENERAL HOSPITALS.
933
COUNTY LINE ROAD
GsorxD-PLiS OF MowiE nospiTAi, Chestsxt Hill, Pa.— Scale 195 foct to tbe inch : 1, 1, 1, 1, Wards; 2, Keception-room, laundrj-, etc. In tlio
building between this and 12 13 the kitchen, etc.; 3, Enapsa<4i-roani, band quarters, etc.; 4, Store-rooms, etc.; 5, Operating-room; 0, Butcher's thop; 7,
Cuanl-house ; 8, Boilers, coal, etc.: 0, Sutler's; 10, Carpenters' shop; 11, Cbapcl; 12, Administration building; 13, Ice-house; 14, 13, Railroad depots:
16, 17, Corridors ; 18, IS, L-sha|ied buildings, used as barracks, store-rooms, etc.
All the buildings are of wood, with ridge ventilation, — the roofs of taried cloth sanded; the only exception is a
small brick building occupied by the surgeon in charge. The number and extent of its buildings may be stated as
follows: 1. -Administration building, 210 X 30 feet, two stories, divided into 0.5 rooms, — the lower story 13 feet and the
npper 10 feet high in the clear: wings on the west side, two stories, 30 X 34 feet. 2. Operating-room in wing on east
side of administration building. 30 x 34 feet. 1.5 feet high: it is lighted from the roof, supplied with hot and cold -water,
and has an ante-room and two small rooms, one on each side of the ante-room, for the reception of the dead. 3. Chapel
and reading-room, 150 x 40 and 13 feet to eaves, with, wings 24 X 16 X 10 feet. This was erected chicUy by the Sanitary
934 THE CtENeeal hospitals.
and Christiau Commissions and by private contributions. 4. Kitclien, 150 X 30 X 13feet. 5. General dining-room, 175
X 30 feet, two stories, tlie first 13, the second 10 feet higli. 6. Commissary store-room, 175 X 20 x 13 feet. 7. Knaiisacli-
room, guard-room aud prison, 175 X 20 X 13 feet ; the knapsaclc-room contains 2,240 suitable pigeon-holes and racks for
as many guns. 8. Special-diet kitchen, 160 X 35 X 13. 9. Bakery, 40 X 34 x 12. 10. Sutler's store, 100 X 20 X 13. 11.
Reservoirs, 56 X 56 feet, two stories, the first 35, the second 19 feet. 12. Laundry and engine-house, — the former
130 X 46 feet, two stories, 13 aud 11 feet respectively, divided into eight rooms above and nine below; the latter one
story, 60 X 20 X 13. 13. Barracks for guard, 172 x 24 X 10. 14. Officers' quarters, A'eteran Reserve Corps, 36 x 31
X 10. 15. Ice-house; 16, Carpenters' shop; 17, Chicken-house; 18, Stables; 19, Hog-pens; 20, Twenty-four wards.
The administration building contains the offices, disi^ensary, store-rooms for medical sujiplies, mess-hall for
officers, aud 24 small rooms for quarters for officers and non-commissioned officers. The closed corridor from which the
wards radiate is 16 feet wide and about 2,000 feet long; it has many large windows which admit of free ventilation. The
enclosed circular area measures 600 feet in diameter and contains the administration building, officers" quarters, chapel,
sutler's store.'kitchen, etc. The kitchens are more complete than those of auy hospital I have inspected. The general-
diet kitchen is furnished with three ranges made by A. Litze of Cincinnati; eight eighty-tive gallon caldrons, arranged
for both steam and hot water: one hashing-machine with six cutters and revolving block, worked by steam; six coft'ee-
boilers, copper, and six tea-caus of tin. The extra-diet kitchen has five forty-eight gallon caldrons, one range and
one furnace for boiling. The arrangements for making cofiee and tea are superior. The coffee-boilers are side by side
on a stand and above them are two pipes, one for steam, the other for boiling water. The roasted and grouud coffee is
put into a covered percolator attached to the movable top of each boiler, the boiling water is poured on the coffee
through a funnel and then steam is admitted from below; coffee for two thousand men can be made in a few minutes.
Connected with this kitchen is a small steam-engine and two large boilersAvhich supply the steam and hot water used
in the kitclien and throughout the hospital. The laundry is situated nearer the river than the hospital. It is well
furnished with washing-machines, wringers, drying-rooms for soiled aud clean linen, and for mess-room and quarters
for the laundresses and men emi^loyed. The washing-machines are worked by a small steam-engine, which also forces
water from the river to the large tank-house, from which all parts of the hospital are sujiplied with cold water by
pipes. The pavilions, arranged in radii, are 46 feet apart at the corridor and 80 feet at the distant extremities. The
buildings used as general dining-room, subsistence store-room and knapsack-room, etc., also radiate from the corridor.
Each pavilion is 175 X 20 feet, exclusive of the water-closet, bath-room and scullery, which project from the pavilion
at each end ; the height to the eaves is 13 feet and to the ridge 18 feet. Each ward is 150 feet long, the remaining 25
feet of the length of the pavilion being occupied at the end near the corridor by a room for nurses and a pantry; and
at the other end by a wardmaster's room, a lavatorj', a water-closet and a bath-room. The water-closets are cut off
from the wards by cross-ventilated passageways.
The sides of the wards are plastered. Ventilation is by the ridge in summer and by ventilating shafts in
winter. Seven of these shafts are arranged oneither side of each ward, extending from the floor to the eaves, and thence
transversely to the ridge, where the two shafts from opposite sides unite in a central vertical shaft which passes
through the ridge and is properly capped; the only opening into these shafts is near the floor. Each ward is heated
by four coal-stoves surrounded by an iron jacket. Fresh air is supplied by a transverse shaft running under the floor
aud opening near the stove. The wards are well lighted by windows on either side and by gas at night ; the win-
dows are fitted with brown linen shades. Each ward is furnished witli iron bedsteads, besides tables and chairs.
The hospital is drained by two sewers, one of terra-cotta, running along the inner circle formed by the corridor,
the other of brick, extending around the hospital on a line with the outer extremities of the wards; this system dis-
charges into the river.
In the construction of this hospital the following defects may be noted : The ridge is too high and does not
extend far enough laterally; the shutters have to be closed in rain or snow-storms. The roof has too great a pitch
for a tarred cloth and a sand and gravel covering ; shingles could have been supplied for about the same cost. The
iron jackets surround the stoves so that the men cannot warm their feet, and the lower stratum of air fails to be
heated ; the jackets should only partly surround the stoves. There is no opening in the ventilating shafts save at
the floor, so that in winter the ventilation must be imperfect unless portions of the ridge are left open. The stove-
pipes do not connect with the ventilating shafts.
This hospital was commenced in September, 1863, aud first occupied in February, 1864, though not then com-
pleted ; indeed it is not yet finished. Its cost is computed at $250,000.
The improvements made in eacli succeeding hospital erected during the war had refer-
ence to the character of the construction of the wards, their lighting and ventilation, the
attachment of their bath-rooms and water-closets and their arrangement as a whole, includ-
ing their communication one with another and with the administration and executive
departments of the hospital. Lining, lathing and plastering, flooring with close-set tongued
and grooved boards, weather-boarding externally and shingled roofs gradually supplanted
the coarsely joined and rudely finished paper-covered huts, which, at the McDouGALL Hos-
pital, required external props to prevent their prostration by the wind. The pavilions
suffered a reduction in length, as from 248 feet, with transverse partitions giving four wards
at the De Camp Hospital, or 208 feet divided into two wards at the Stanton Hospital, to
THE GENERAL HOSPITALS. 935
a clear ward length of about 150 feet in eaeli buikling. The wiiltli ami height of the ward.s
became increased from l7i and 8 feet, as at the McDol'gall Hospital to 24 or 25 and 12
or 14 feet respectively. Tiie improvement in lighting may be seen by comparing the side
elevation of the huts at Clarysville, ]\Iaryland, page 90S, with that shown on page 944.
The open ridge, which admitted driving rains and snows, received protection, and other
means of ventilation connected with the heating of the wards were introduced. Lastly,
faults of aggregation were recognized and avoided. The plans of the Chester Hospital,
which set all considerations of fresh air at naught, were not duplicated. On the contrary,
the narrow interspaces which at many hospitals besides the Satterlee were regarded as a
source of danger in case of fire, had a tendency to become enlarged until, at the Jefferson
Hospital each hut, as has been seen, radiating from a circular enclosure, was at its free end
separated from its neighbor by a space equal to four times its width and at its attachment
to the corridor by a space more than twice its width.
The closed corridor, however, continued for a long time, in every hospital plan to block
up one end of the buildings and their interspaces, although the Armory and Stanton hos-
pitals of Washington, D. C, built during the summer of 1862, showed that a covered path-
way answered all tjie purposes for which a closed corridor was intended. It was, perhaps,
the conversion of the corridor into a general dining-room at so many of the hospitals that
ultimately caused its modification into a structure insusceptible of adaptation to undesirable
uses. At all events, the covered walk, open at the sides, gradually displaced the enclosed
corridor, thus giving better ventilation between the wards and a purer air in their interior
from the side of the former corridor or mess-hall. At the Stanton and Armory hospitals
the pavilions projected from one side of the covered walk. Economy of space and central-
ization of labor were obtained at these establishments at the expense of ventilation and with
increased risks froui fire; the buildino-s were too close together, considering their great
length and inflammable material, particularly that of their roofing. At the Nelson Hos-
pital, Camp Xelson, Ky., built at a later date on a similar plan, the adjacent pavilions,
although not so long as those of the Washington hospitals, were separated by a space of
35 feet.
At the Hampton Hospital, Fort Monroe, Va., the pavilions were arranged en echelon
in the form of a V, with the administration buildings, quarters and store-rooms closing in
the triangle and the kitchen and dining-room in the enclosed space. As each pavilion in
receding from the angle was disposed lengthwise behind and external to that in front of it,
the length of the diverging series of wards was found to be an inconvenience. A similar
inconvenience was experienced at the Lovell Hospital, Portsmouth Grove, R.. I., where,
on account of the nature of the ground, the pavilions were arranged in two lines, with a
covered pathway along the middle of the wide avenue between them. At the Harewood
and Lincoln hospitals, Washington, D. C, where the V-shaped plan obtained, the distance
of each diverging line of wards from tlie administration building at the apex was reduced
by making one pavilion overlap the other. Tlie circular plan, with an open corridor, was
used in the construction of the Hammond Hospital at Point Lookout, Md.
Stastox Hospital, Washington, D. C, occupied the square bouuded by H and I, 2d and 3d streets. It con-
sisted of seven long one-story pavilions placed parallel to each other and 24 feet apart, their northern ends, on I street,
forming the front of the establishment. They were built of rough boards, lined with strong paper of a yellow color,
well lighted by numerous windows, floored with white pine smoothly planed .lud well tongued and grooved, roofed
with tarred roofing-felt, and ventilated by the ridge in summer and in winter by outlet shafts extending from near
the floor to beyond the ridge, with inlets connected with the jacketing of the stoves. The central building, longer
936
THE GENERAL HOSPITALS.
than the others, was used for administration purposes. The three pavilions on each side were each 208 X 24 feet,
witli an average height of about Hi feet. They -n-ere each divided at the middle of their length by a partition, with
comnuinioatiug doors, into two wards of 36 beds each. At the free end of each ward two spaces 10 feet square were
partitioned off, one used as a nurses' room, the other divided into bath-room and water-closets. The dining-room was
in the rear portion of the adniinistration building and had the kitchen and laundry at right angles to it jjosteriorly.
A covered w,ay surrounded the wards as a whole, extending continuously across the front and rear ends to the pavil-
ions and on either side along the outer side of the building. A similarly protected pathway connected the pavilions
in a transverse direction at the middle of their length wliere the division of each into two wards was eflectcd. Water
and gas were derived from the city mains. The water-closets were supplied with a stream of running water con-
necting with the general sewerage system.
i^TASTON Hospital, Washington, D. C. — 1, Wards; 2, Administratiou; a, Dispensary; 4, Cath-room; 5, Officers' mess; 6, Store-rooms ; 7, Diiiiug-
rooni ; 8, Kitchen; 9, Laundry; 10, Store-room; 11, Ice-house; 12, Stalile ; 13, Dead-house and knapsack-room ; 14, Coal-house ; 15, Guard-house ; IG,
Covered ways.
Armory Squ.vre HosriT.vL, Washington, D. C. , was constructed during the summer of 1862, after plans furnished
by Ass't Surgeon J. J. Woodward, U . S. Array. It was situated on Seventh street opposite the grounds of the Smith-
sonian Institution, and just beyond the canal which, at that time, as an open sewer reeking with the filth of the city,
rendered the location unwholesome. This site was selected on account of its proximity to the great thoroughfares
and its easy access from the wharves and railroad depot. The hospital consisted of eleven long pavilions jilaced
parallel to each other, with their g.ables facing the front and rear of the grounds. Adjacent pavilions were separated
Ijy a sjiace no wider than the width of one of the buildings. The central pavilion constituted the administration
building, the others, five on each side, were used as wards. The central building contained a reception room, from
which a passage continued through the centre of the length of the building, with small rooms on either side used as
the office of the surgeon in charge, the dispensary, general office, linen-room, ])Ost-otHce, store-room and officers' quar-
ters and mess-room. In rear of the central building and connected with it by a covered way was the general kitchen,.
THE GENERAL HOSPITALS.
937
105 X 25feet,aiul thelauiuhy, IT x 17 feet; al)!ikery,3G X 16feet, was a subsequent addition. On tlie iif;lit tlank,iiear
tlie stalile and knapsack-rooui, see plan, a chapel ami chaplain's ([Uarters, rooms for female nurses and a deadhonso
were afterwards constructed. In rear of the kitchen and laundry, and hetneen them and the guard-house, two harrack-
buildings wereerected, one foreontraliands. the other for the j;uard. On the left think of the hospital was the Colum-
bian Arsenal, a three-story brick building 103 X 57 feet, the rooms of which were fitted up as wards to increase tho
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capacity of the hospital. Each pavilion-ward was 1J9 x 25 feet with an average height of about 13 feet, and accom-
modated 50 beds; one on the left of the line was somewhat shorter than the others on account of the position of
neighboring buildings. A portion of the rear end of each ward was used as a dining-room; before separate quarters
were provided for the female nurses this room was so i>artitioned as to aliord them a lodging. At the other extremity
of the ward were the bath-room, water-closet and wardmaster's room. The buildings were connected by a continuous
covered-way along their rear and by transverse passages between adjacent wards near the middle of their length.
The capacity of this hospital was occasionally increased by the use of tent-wards. Ventilation was by the ridge,,
shafts and lloor-iulets, as was usual in the pavilions built at this period.
Med. Hist., Pt. Ill— 118
938
THE GENERAL HOSPITALS.
Nelson' Hospital, Camp Nelson, Ky., ^vas situated on the Lexington and Danville turnpike, near Hickman
Bridge on the Kentucky river, 20 miles south of Lexington, on a peninsula aljout a mile in diameter, formed l)y an
almost circular sweep of the river. The face of the conntry at this point is broken and hilly, often abrupt and precip-
itous. The river-bank is faced by nearly perpendicular clitfs of limestone 10 to 400 feet high. The isthmus or land-
■ward side of the peninsula was strongly fortified and mounted with siege artillery: the surrounding farms, orchards,
woodlands and commons constituted a picturesque and pleasing landscape. The grounds of the hospital eompri.sed
€} acres of the southeastern slope of the hillside. The buildings on this space, which was neatly fenced in, consisted
of seven jiaviliou-wards and others necessarily associated with them. The wards were well-constructed wooden
9
piiiil
10 u. IL 11.
jlil {■] B 11
riAMPTiix Hospital, near Fokt Moseoe, Va.— 1, Wards ; 2, Admiuistration building ; 3, Commissioned officei-s ; 4, Non-commissioned officers;
5, Kitchen and dining-rooms ; 6, Guard-bouse ; 7, Baggage-room ; 8, Deail-bouse ; 9, Stable ; 10, Siulis ; 11, Officers' sinlis.
THE GENERAL HOSPITALS. 9'?.9
fraiiu's fioiitiiif; southwest, with iiiteiveniiig avenues, 3'> feet wide, oruaniented with llowei-beils. (In account of the
sh>|iing site the liuihlings were elevated about 6 or 7 feet from tite ground at one end. Each was 120 X 2.5 x 11 feet
and contained 52 beds. Thej" were ventilated by the ridge and base, and at one end had 11 feet partitioned otf for
use as lavatory, bath-room and water-closet. In front of each building was a wide piazza. A small side building
to each ward, 18 X 12 X 10 feet, contained beds for live attendants, A two-story building, 7() X 21 X IC feet, had on
its lirst floor the ofliee of the surgeon in charge, dispensary and dining-room, wardmaster's room and store-room, and
on the .second lloor eight rooms occupied as iiuarters for chaplain, hospital stewards, sick oHicers, matrons, printlng-
oflice and lil)rary. One building. 80 X 20 X 8 feet, was u.sed as a dining-room and pantry: another, 2.5 X 25 X 10 feet, as
a full-dii't kitchen, and another, somewhat larger, for special diet ; these were well sujiplied with fixtures and furnish-
ings. Other buildings were used as knapsack and baggage-rooms and for subsistence and (juartermaster's stores. A
steam-laundry was established in a two-story building, which also aftorded ijuarters for the laundresses. About half
a mile from the hospital proper was a t«o-story frame building, 50 x 10 feet, used for cases of measles and erysipelas,
and for kitchen, dining-room and attendants' quarters. The "pest-house " for small-pox consisted of two isolated
frame buildings each 100 X 16 X 10 feet and lilted for 50 patients: tents were used as officers' kitchen, quarters, etc.
The supply of water, derived from the river, wiis pumped by steam into an elevated reservoir 100 X 100 X 11 feet, where
it was subjected to filtration and afterw.ards distributed to all parts of this hospital. Camp Nelson and the Convales-
cent camp. Hesides these buildings, tent-wards were pitched for the use of the U. S. colored troops rendezvousing
at Camp Nelson, An excellent hospital-garden and an adjoining apple-orchard added much variety to the diet of the
sick at this hospital.
The llAMPTdX HospiTAI. was situated between Hampton creek and Mill creek, two mill's from Fort Monroe,
Va.. on a nearly level plain ten feet al)ove and nearly surrounded l>y tide-water. It was opened in August, 1802, and
as originally planned and constructed consisted of 21 pavilions en rchtloii, in the form of a V; but since the sides of
the adjacent buildings did not overlap, as in the Harewood and Lincoln hospitals, the length of each line was corres-
pondingly extended and the difficulties of administration increased. Medical Inspector W. H, MrssKY, U. S. Army,
in October, 1862, objected to this hos|)ital that " the distance of the wards from the kitchen renders, under the present
system of distribution, the serving of warm food to the patients entirely impracticable — more especially will this bo
the ciiseasthe weather becomes colder. The arrangement of the buildings en eehelon in the triangular form is not the
best adapted to an ellicient administration of affairs. " Three large pavilions used as offices and officers' quarters, and
some smaller buildings, connected the ends of the diverging lines of pavilion-wards and completed a triangular figure
within which were the pavilions used as kit('hens and dining-rooms. See illustration on op]iosite page.
At a later date tlie cap.acity of this liospital was largely increased by the erection of a line of pavilions beyond
and parallel to the base of the original triangle. All these buildings were roughly constructed of boards coarsely
joined. Those used as wards were 144 x 25 feet, 10 feet to the eaves and 20 to the ridge, containing ,50 beds for
patients and two small rooms at one end for the wardmaster, bath-rooms, etc. In addition to tlie.se a four-story
brick building, formerly a young ladies' boarding-school, was used, with some attached pavilions, as an officers' hos-
pital. There were also 100 hospital-tents and 00 wall-tents, which increased the hospital accommodation to nearly
four thousand beds. The hospital was divided into forty-four wards which, for better government, were arranged
in four divisions. There were seven offices, one general dispensary and one for each division, four store-rooms, four
full-diet and four extra-diet kitchens, three knapsack-rooms, one dead-hou.se, one post-morlem room, one chapel and
one library and reading-room. A tent wiis u.sed for an operating-room. There was no laundry, as washing was done
out of the liospital by contrabands. The water-supply was raised by a steam-engine for distribution. The brick
building was provided with water-closets, but water-tight boxes requiring frequent cleaning and disinfection were
used in the sinks connected with the pavilion and barrack wards.
The LovEl.L HosriT.^L, Poktsmoutii Gkove, R. I., was built on low ground on the eastern shore of Xanagan-
sett Bay, eight miles north of Newport and twenty-three south of Providence. The grounds were bordered on the
east by the Old Colony and Newport railroad, on which was a station with a side-track for the use of the hospital.
There was a good wharf on the water-side at which vessels of 800 tons could discharge, but which could not be reached
by the large steamers generally used for the transportation of the sick. The extension of the wharf was therefore
frcciuently recommended. The grounds comprised .about twelve acres, the largest diameter north and south, parallel
with the bay. They sloped gradually from the centre, to the beach on one side and a low marsh on the other. About
the middle of their length was situated the administration building, formerly a summer hotel, with, on either side
of It, a series of fourteen pavilions, each .series constituting a division of the hospital. A main avenue, 50 feet wide,
ran north and south from the administration building, and along the sides of this avenue the pavilions were jilaced
obliiiuely like the feathers on an arrow. A covered corridor, not shown in the illustration on the next page, with slid-
iug-doors to close in winter, facilitated communication between the wards and the other buildings. The pavilions
were 160 X 25 X 11 feet, and 19 feet 11 inches to the ridge. A space 15 feet long was partitioned off as high as the
plate for bath-room, lavatory and water-closet at one end of each and for wardmaster's and iiur.ses' rooms at the other;
the remaining length of 130 feet accommodated 56 beds with about 59 feet of area and 9(X) of air-space to each. The
water-supply was from a reservoir formed by damming a spring on a level 70 feet above the hospital. A general
mess-hall, barracks for the guard, laundry . bakery, chapel, blacksmiths' shop, carpenters' shop, stables, etc., were sub-
sequently added to the establishment.
The H.VREWOOD Hospitai.. Wasiiixuto.v, D. C, was situated on what was known as the Corcoran farm on the
Seventh street road, near the .Soldiers' Home. The ground was gently rolling and diversified with woodlands and
cultivated fields. The pavilions, of unpinned boards, were arranged cii echelon in two lines, meeting at an acute angle,
940
THE GENERAL HOSPITALS.
THE GENERAL HOSPITALS.
941
with tlio iuiiuiiiistiatiou Imiklinj; phu-i'd leiifitlnvist' at tliis ]i<iiiit. The wards In their position )>o.stcii<irand external
to this hniUiini; were parallel with it. Six wore thus disposed on the vlj;ht and rear of the administration hnildini;
and nine on the other retiring line. The kitchens and dining-rooms were within the space bounded by the lines of
IIaREWOOD nOSPITAL, W.\8HINGT0>% D. C.
SoiU y^nj: 1, .\dmini3tralion building ; 2, 2, 2, Wards ; 3, Dining-room ; 4, 5, Kitchen ; G, Knapaack-room ; 7, Ice-house ; 8, Dead-house ; 3, Guard-
house; to. Laundry; It, Laundresses' quarters; 12, Engine-room; 13, Quarters for female nursis; 14, Driik building used as bakery and comnilBsary store-
house ; 15, Brick stable; the loft useil as store-house ; 10, Store-house ; 17, Born ; 18, Hospitiil tents ; 111, Old barracks ; 20, Sutler ; 21, Coal ; 22, Covered
pathway. Sinks in movable boxes placed on the tianks of the triangle.
the pavilions, and facilities were aft'orded for communication between the various buildings by means of covered
footways. Each ward, 187x24x16 feet to the eaves and 20 feet to the ridge, contained 63 beds and was divided
942
THE GENERAL HOSPITALS.
transversely into two by a median pnrtition with fnlding-doors. Ventilation was by the ridge, air-shafts, ventilating-
slides and the windows. Water was pnmiied from wells into a distributing-tank, but the supply was insufficient for
use in the w.ater-closets. Sliding-boxes, cleanse;! every twenty-four hours, were used in the closet at the end of each
ward, and special ventilators were provided to facilitate the escape of foul air. Pipe-drains carried oti" waste-water.
The situation and conveniences of the establishment are better shown by the illustration on pagePll than by a length-
ened description. At one period as many as 312 regulation hospital-tents were pitched on the grounds of this hos-
pital. They were arranged in thirteen divisions, six pavilions to a division and four tents to each pavilion, which,
as every tent accommodated six men, added 1,872 beds to the cajiacity of the establishment.
Lincoln Hospital, Washington, D. C., was opened December, 18G2, about a milo east of the Capitol, on an
undulating plain declining gently toward the Eastern Branch of the Potomac. Its pavilions were arranged in two
lines eii icheloii, forming a V, with the kitchens, etc., in the space subtended by the lines; each wing consisted of
ten pavilions. They were 187x24x16 feet to the eaves and 20 to the ridge, but, unlike those at Harewood, they
were not divided into two by a transverse partition. Ventilation was by the ridge, air-shafts and box-channels lead-
ing from floor-inlets. Each was fitted for t>2 patients. At the exterior or distal end of each ward were four rooms occu-
pying 15 feet of the length of the building and used for baths, sinks, clothing and nurses. By their opposite or
interior ends the wards were connected-with each other and the other buildings of the hospital by means of a covered
pathway bearing a railroail track 2 feet wide, which was used to convey box-cars laden with food from the main and
extra kitchens to the wards. Tent-wards were used at this hospital, four tents usually forming a pavilion. At one
time 100 tents were in use. The water-supply was raised from wells to a distributing reservoir, and waste-water car-
ried oft' by drains as at Harewood. This hospital was described and its plan figured in Circular No. 6, War Depart-
ment, Surgeon General's Office, Washington, D. C, 1865,* and again in an article published in connection with the
International Exhibition of 1876. t
The Hammond Hospital, Point Lookout, JId., was situated on a low, level and narrow peninsula, washed on
one side by the waters of Chesapeake Bay and on the other by the Potomac River. The grounds, although formerly
those of a sunurier hotel, had few shade-trees and but little verdure, so that the reflected heat from the white sandy sur-
face was freiiuently oppressive in summer notwithstanding the generally prevailing breezes from the sea. In addition,
the water-supply was not of good quality. Moreover, although Point Lookout was easy of access by water, special
and expensive arrangements had to be made with the steamers plying on the river and bay for the transportation of
its supplies, as it was not one of their regular stopping places. In fact the site possessed so few natural advantages
that Medical Inspector John Wilson, U. S. Army, in one of his reports regretted that so fine a hospital, with so good
an outfit, had been there constructed.
AVhen first established this hospital consisted of a small two-story summer hotel, its outbuildings and a num-
ber of cottages and hospital-tents. The hotel fronted Chesapeake Bay and had a series of cottages north and south
from it and disposed in lines on its flanks. Altogether there were about a hundred buildings on the point, which
afforded accommodation for 700 patients with an average of about 700 cubic feet of space for each, together with large
halls for kitchen and general dining-room, laundry, store-houses, barracks for the guard, etc. But in the summer
of 1862 it was decided to erect special buildings on the pavilion system. It was intended that there should be sixteen
frame huts radiating from a circular roofed passageway, one of these to lie used as an administration building and
fifteen as wards, and four huts in the interior of the circle to be used as kitchen, laundry, guard-house and knapsack-
room. The corridor, open at the sides, was to measure 1,001 feet along its outer circumference, with intervals of 36
feet between the attachment of adjacent buildings. The main building, to be used as dispensary, officers' quarters,
etc., was planned to be 175x50 feet, two stories high. The wards were to be 175x25 feet interior measurement, with
14 feet to the eaves and 18 to the iilate; space at the corridor end to be partitioned oft' for a dining-room and at the
free end for lavatories and water-closets; walls weather- boarded externally; the floor of planed stnft', raised from 18
to 2-t inches from the ground in every part; the roof of boards covered with felting and coal-tar well sprinkled with
white sand; the windows of two sashes, both movable, and ventilation effected by a gap 16 inches wide along the
whole length of the ridge, covered by a ridge roof 3 feet wide on each side and elevated six inches in the clear from
the main roof, and l)y well-oj)enings 8 inches in height closed or regulated by a slide on the inside and situated near
the floor-level between the windows.
ir^ir -ffr>
0=
=Q
B
u^
-^, Section of wartl ; B, Transverse section of circular covered way; C, Transverse section of straiglit covered ways crossing the circular area; D,
Side view of covered way.
The wards were finished in 1862 and were immediately occupied as dormitories, but the buildings in the interior
of the circle made very slow progress. Medical Inspector Jos. K. Bai:nes. U. S. Army, reported in May, 18(33, that
* Ittports fin the Extent and Satnre of the Mfiteritils avnilable for the preparation of a Medical and Stirgi£al History of the War of the Uehellion.
t Description of the Models of Ho^itals, Pliiladelpbia, 18TG.
TTiTO
m" U.S.CENERAL HOSPITAL
POIXT LOOIvOTTT
MARYLAND.
I
THE GENERAL HOSPITALS. 943-
tlie inoilern pan of this hospital was still incoinpletc in many of its essentials. "The kitehcn, cooking-vanges and
(lining-halls are untinishcd anil the wards have neither lavatories nor liatli-roonis, w.iter-closets nor a water-supply.
.\ capacious tank has been Imilt, but the inflow ami (listriliutin;; pipes have not been put in ami no work is being
done on them, although the steaui-eu^tine and force-pump are in order." It does not appear that the water-supply
was ever distributed to these wards; for in his report for June, ISti."), Inspector Wir.sox stated that the ])avilion-wards
were not tiuished in accordance with the original plans. They were each 180 feet long and had partitioned olf from
their attached ends a room — the original dining-room — in which the clothes of patients were stored arul their medi-
cine and diet distributed: and from their free ends two rooms — the original bath-room and water-closel — which were
used, one as iiuarters for the wardmaster and the other for the nurses.- The length of the ward-room was 150 feet,
which, with 70 beds, gave 1,028 cubic feet of space per bed. The two-story administration building on the eastern
side of the circle, running toward the bay, was 200x40 feet. A hall 8 feet wide divided it along its length on the
lower floor into offices, dispensary and store-rooms, and on the upper into quarters, mess-rooms and kitchens for the
ofliccrs and stewards.
In the centre of the circle was a water-tank, elevated on a platform over a bath-room fitted with eight tubs
and supplied with hot and cold water. This position of the bath-room was not regarded as satisfactory — patients
re(|uiriiig warm or hot baths were too much exposed in traversing the corridor; besides, the room was not well lighted,
and frequent leaking from the superimposed tank kept its floor constantly wet. A general lavatory was arranged
around the outside of the bath-room. The four buildings within the circle met at right angles at the tank. The
chajiel, 85 X 24 X 20 feet, was lathed and plastered, and titled with an elevated stage at one end and seats for an
audience of 400, The knapsack-room, 63 X 25 x 20 feet, was suitably supplied with racks and pegs; a post-office and
room for the baggage-master was partitioned off at one end of this building. The extra-diet kitchen, (i5 x 25 X 20
feet, was paved with bricks and suitably fitted; it contained a store-room and a room for the night-watchman. The
general kitchen, in use prior to the building of the pavilion-wards, continued to supply full diet for convalescents in
the cottages and other wards of the old hotel establishment. The fourth building, intended as a laundry, does not
appear to have been put to use; in some of the reports it was called a reading-room. The laundry, established in one
ol the old buildings on the point, was partitioned oil' into a wash-room, drying-room, ironing-room and engine-room.
The water-supply was from six or seven wells about 12 feet deep. These yielded a sufficient quantity, but the
water often caused irritation of the bowels in new comers. The surface drainage was impiTlect on account of the
flatness of the point. There were no sewers. Sinks were built over the Potomac river, on which the free ends of the
western pavilions abutted. The plate facing page 942 shows the arrangement of the buildings on the point.
Most of the hosjjitals that have been thus briefly described were in active service at
the close of the year ending June 30, 1864. But these were by no means all tliat had been
organized. The list appended to this chapter gives the name and locality of many others
of similar construction and arrangement that were then in use. The extensive experience
gained by the Medical Department in the administration of these hospitals led to a recog-
nition of faults and an appreciation of what was advantageous and desirable. The knowledge
thus gained was embodied in a circular published by the Secretary of War for the informa-
tion and guidance of the Quartermaster's Department, which, under the Regulations of the
Army, was charged with the dut}' of providing hospital accommodation for the troops. This
circular read as follows:
W.\R Department, Jiili/ 20, 18G4.
The following instructions are promulgated for the inforiration of officers charged with the construction of
general hospitals, and will be deviated from only in cases of imperative necessity: Buildings will not be taken or
occupied for hospital purposes nntil after full examination and approval by a medical inspector or other officer of
the Medical Corps detailed for this purpose ; and all alterations will be made in accordance with plans submitted by
him and approved by the Surgeon General,
(Signed) E, M, STANTON,
Secretary of War.
Site. — The site of the hospital should be a well-drained plain, with a subsoil of gravel, and sufficiently exten-
sive to accommodate the buildings. The situation should be elevated: as remote as possible from marshes or other
sources of malaria, and must have a convenient supply of pure water.
Plan. — (ieneral hospitals will be constructed on the principle of detached pavilions, each ward being in a sep-
arate building, with beds for sixty patients. Besides the wards there will be detached buildings for each of the fol-
lowing purposes: General administration building, dining-room and kitchen for patients, dining-room and kitchen
for officers, laundry, commissary and quartermaster's store-house, knapsack-honse, guard-house, dead-house, (juarters
lor female nurses, chapel, operating-room and stable. The wards, administration building, kitchens, dining-rooms
and chapel are to be connected by covered walks which will have floors but no sides.
No general plan for the arrangement of the buildings can be directed, as the varying character and dimensions
of sites render an uniform adherence to any one impracticable. Wards may be arranged en nhelon in two converging
lines, fonning a V — in this case the administration building should be at the apex of the V, the other buildings
•9U
THE GENERAL HOSPITALS.
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between the wings; or as radii from the periphery of a circle, ellipse or rounded oblong — in this case the administra-
tion Imikling should be one of the radii, the other buildings within the enclosure : or parallel to each other — in this
case the administration building should be in the centre of the row, the other buildings in the rear. Other plans
may be rendered necessary by the special features of the ground. In any case the important jioints to be observed
are to place the buildings far enough apart (at least thirty
feet should intervene between two parallel buildings), and
to locate them in snch a manner that no one shall inter-
fere with the ventilation of another. It is preferable to
locate the wards so that the long diameter may run north
and south or nearly so.
Each iciird will be a ridge-ventilated pavilion, one
hundred and cighty-seveu by twenty-four (187 X 24) feet.
At each extremity two small rooms, nine by eleven (9 x 11)
feet, one on each side of the passage, six (6) feet wide, will
be partitioned off. The space remaining for patients will
be one hundred and sixty-five by twenty-four (165 X 24)
feet. See figure, which gives the location of the beds and
position of the doors and windows. The small rooms ase
occupied as follows : a, chief nurse; b. closet for medicines,
etc.; c, bath-room; d, closet for close-stools.
The wards will be fourteen (14) feet high'from floor
to eaves — the pitch of the roof to vary in accordance to the
materials composing it. The floor to be elevated at least
eighteen (18) inches from the soil, with free ventilation
beneath it. A ward thus constructed will accommodate
sixty (60) patients, allowing more than one thousand
(1,000) cubic feet of air-space to each. The number of
wards will be regulated by the number of patients the
hospital is intended to accommodate. A hospital of twelve
hundred (1,200) will require twenty (20) wards.
Administration Building. — For a hospital of six to
twelve hundred (600 to 1,200) beds this will be a ridge-
ventilated building, thirty-eight by one hundred and
thirty-two (38 X 132) feet and two stories high; the first
fourteen (14) and the second twelve (12) feet high in the
clear. This building contains the general otKce, office of
surgeon in charge, linen- and store-rooms, dispensary,
chaplain's office, lodging-rooms for officers, etc.
Dining-room and Eitclicn for rntienls. — The dining-
room will be a ridge-ventilated building, large enough to
seat a number ecjual to two-thirds the number of beds.
The most convenient form is a long iiarallelogram, into
which the kitchen opens in the centre of the long side.
The kitchen will be divided into two unequal parts — the
larger for the preparation of ordinary diet, the smaller for
the extra diet — the cooking in both to be done on ranges.
Where there is an engine steam may be advantageously
used for boiling.
Dining-room and Kitchen for Officers. — A small build-
ing for this purpose will be situated near the administra-
tion building.
1117
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Laundry. — A building two stories high, with lodging
for the laundresses on the second floor. The roof should
be flat, with posts for stretching-clothes-lines.
Commissary and Quartermaster Store-room. — A small
two-story building, furnished with boxes and shelves for
the various parts of the ration — having an ice-house con-
nected with it for the preservation of meats and other per-
ishable articles, and a room for clothing. The second story
to contain lodging-rooms for the cooks.
Enajysacfi-house. — A building to receive the effects of the patients while in hospital. It will contain as many
pigeon-holes, each two (2) feet square, as there are beds in the hospital.
THE GENERAL HOSPITALS.
945
Guard-house. — A detacluHl Imildin^ to lodgo tlu' fj;iuii-<l, with u guaril-ioom for prisoners.
Dead-house. — A small buildiiif; rontainiu'; two aiiartmcnts, located ho as not to be observed Iroiii the wards, and
lighted by skylights.
Quarten for Female Xumes. — A detached building, containing lodgiug-rooms, dining-room and kilrhoii lor the
female nurses.
Chiipel. — A detached Imilding, tittod for the purpose of religious services, so arranged as to bo used as a library
and reading-room.
Operuliiiy-rooms. — Two rooms, each fifteen (!">) feet s<mare, one well lighted by skylights, the other by wiu-
<lows: the tirst for surgical operations, the secoiul for discharge-boards,' etc. It sliould be situated near the admin-
istration building.
Stable. — Kor ambulance and otiicers' horses.
li'alrr-siipplji. — Where practicable, a large tank will be erected and kept snpjilied from wells or springs by pumps
worked by a steam-engine. The engine, if possible, will bo .situated near the kitchen and laundry, in which case the
steam may be made serviceable in cooking, and the power nuiy l)e employed in working the washing- and mangling-
niachiues.
Sinks. — Where the supply of water is adeiinute water-closets nuty be constructed in one of the small rooms in
«ach ward; but where this is not the case privies will be built at a convcuiout distance from the wards, fnrnished
vith water-tight boxes, which must be emptied every night.
^^
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J II il ll LL
Venlilation. — During warm and mild weather the wards will bo ventilated by the ridge, but during winter the
lidge will be closed and ventilation by shafts substituted. Fonr stoves will be allowed to a ward, each partly snr-
Touuded by a .jacket of zinc or sheet-iron, with an air-box opening beneath it to furnish the supply of fresh air. At
eight (8) feet from the stove will be a shaft, properly capped, through which the stove-pipe will ascend. The shaft
should be eighteen (18) inches square and should not come below the tie-beams.
The influence of this order was immediately felt, as may be observed by the following
report on the Cumberl.vnd Hospital, Nashville, Tenn., by Medical Inspector H. H. CooL-
IDGE, U. S. Army. The Quartermaster's Department was about to replace the tent-wards
hitherto used at tliis hospital by wooden buildings, when the publication of this circular
caused a modification of the plans and elicited an explanation in regard to certain points
which were not in conformity with its requirements.
The CfMisEKLAND H()SPIT.\L, Nasiiville, Ten'N'., is situated on rolling ground on the Hillsboro' road, about
one and a half miles west of the Capitol. It is composed of six hundred aud fourteen tents, of which four hundred
and thirty-three are hospital, fifty-seven wall and one hundred and twenty-four bell-tents. But in addition to
these there are many shingle-roofed fr.ame buildings, as for instance: Kour division cook-houses, each containing a
kitchen, pantry and dining-hall; three lavatories: one Viatli-house: one store-house for subsistence stores, clothing
and knapsacks; one tool-house; one stable; one laundry; one special-diet kitchen; one dining-room and kitchen foi
medical ollicers; one operating-room; one dead-house and one oiTice-building. The tents aecounuodate 2.000 jiaticnts,
222 attendants. 27 medical oliicers and 3 medical cadets. Water is obtained from the city water-works anil from
■wells; the supply is insutHcient, but the quartermaster is laying a six-inch main, which will afibrd an abundance.
Med. Hist., Pt. Ill— 119
946
THE GENERAL HOSPITALS.
The superficial drainage is excellent but the sewerage is deficient. This is about to be remedied. There are no water
closets. Between the rows or streets of tents are small privies, the contents of which are drained by a sewer into a
running branch which finally empties into the Cumberland river; but these sinks are not well supplied with water
and are very objectionable. They will soon be removed.
I have not attempted an elaborate description of this hospital for the reason that it is now in a transition
state. The Quartermaster's Department, having completed its various supply depots, is now turning Its attention to
the construction of hospitals, and has commenced building on this site pavilions for 2,200 beds. A large force is at
work and three of the pavilions are nearly completed. The plans adopted were somewhat similar to those announced
by the Secretary of War July 20, 1864, and since that order was received they have been modified so as to conform
thereto as far as practicable, the principal dift'erences being that each pavilion is to be surrounded by a covered
porch, and that the width will be 22 instead of 24 feet. The quartermaster in charge informed me that he could not
get timber of sufficient length to make the wards 24 feet wide, and that if he spliced the timber it would add very
much to the cost and greatly retard the construction of the building.
Sedgwick Hospital, Greenville, La. — Scale 120 feet to the inch : 1, "Wards; 2, Administration building; 3, Guard-house, linapsack-room and
Btore-house ; 4, Dining-rooms ; .5, Kitchen ; G, Cistern ; 7, Covered ways througli which a railway runs with hand-cars for carrying food to the wards.
So many buildings had already been constructed or converted to hospital purposes in
various parts of the country that but few were afterwards erected on the plans approved in
this circular. The Sedgwick Hospital, Greenville, La., the Hicks, Baltimore, Md., and
the Sloan, Montpelier, Vt., were the most notable of these. The first was completed as a
THE GENERAL HOSPITALS.
947
hospital of 15 pavilions, radiating frona a circular coverod-way. The buildings were shorter
than those suggested by the order of the Secretary of War, giving a clear ward length of
only 115 feet, but the number of contained beds was proportionately diminished. The origi-
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©48
THE GENERAL HOSPITALS.
ual design for the second was a hospital of 36 wards, radiating from a circular covered walk;
but the signs of apjoroaching collapse on the part of the South stayed its progress to com-
pletion, leaving it a hosjjital of 18 wards attached to a pathway of a semicircular form.
The last was designed as a hospital of 12 pavilion-wards with its administrative, executive
THE GENERAL HOSPITALS. 949
and other needful buildings radiating from an octagonal enclosure, bounded by a connecting
covered-way, but the close of tlie war found it with four of its wards unbuilt and many of
its accessories incomplete.
Sedgwick Hospital, Greenville. La., seven miles above New Orleans, w.is on a llat sito on the cast liank of
the Mississippi, draining into the swamps between the river and Lake Pontchartrain. The iiroumls included about
30 acres; part was cultivated as a vcgetable-sarden for the hospital, the remainder, shaded by fine groves of live-oak,
pecans, orange-trees, craiie-niyrtles and Howering shrubs, was traversed by shell-roads and winding ])athways. The
hospital was composed of liftecn one-story pavilion-wards, 115 X 21 feet, and a two-story administration building of
the same length but U) feet wide, radiating from the periphery of a circular covered-\vr>y.
They were constructed of boards set u|)right and battened, the roofs shingled and open at the ridge for ven-
tilation. They were raised three feet from the ground on brick i)iers. Each pavilion had two small rooms parti-
tioned from its inner end for the use of nurses and two from its outer end, one of which was used for nurses and the.
other divided into two for bath-room and water-closet. The ward-space was thus reduced to 115 feet, which, witb
the two beds between each pair of windows, gave 09 feet of tloor-surlace and 1,200 cubic feet of space to each of 40'
beds. The corridor, 12 feet wide, was provided with a tramway and hand-ears to facilitate the distribution of food.
Two of the four buildings within the circle were used as dining-halls, one as kitchen and one as knapsack-
room, store-house and guard-house. The kitchen, 80 X 30 feet, is shown on page 917. It contained a patent steam-
cooking apparatus. e.\tra-diet range, carving-table, store-rooms, bedrooms, and a car-track continuous with that
of the corridor. Outside the circle, at convenient distances, were detached buildings used as laundry, gas-house,,
bake-house, chapel, dead-house, stables, etc. Water for washing was obtained from a reservoir having a capacity
of 320,000 gallons, on the river bank, whence it was distributed by pipes to the various buildings. Rain-water for
drinking pnrpo.ses was collected in a central cistern, which had a capacity of 150,000 gallons, and in small tanks
holding 10,000 gallons each at the end of each ward. To perfect the surface-drainage the ground was graded from
the centre of the circle to its periphery with a fall of one inch to every ten feet: surface-water was trapped into
brick sewers which discharged into the swamps draining into the lake. The water-closets of the hospital were fur-
nished with patent pans and discharged into brick sinks lined with cement: these sinks were connected with the
sewers, into which their liiiuids drained.
The Hicks Hospital, Baltimore, Md., was opened in June, 1865, in the western suburb of the city. The
details of its construction were supervised by Surgeon Thomas Sim, XJ. S. Vols. The original design contemplated a
circular hospital on the War Department plan, with 30 radiating wards, each accommodating tiO i)aticnts, but the close
of the war rendered its completion on this scale unnecessary; it thus became a hospital of 18 wards, projecting from
the outer margin of a covered pathway or corridor having a semicircular plan. This was generally regarded as on&
of the best hospital establishments constructed during the war on account of the substantial character of its build-
ings and the many conveniences with which it was supplied.
The front of the hospital was formed by the administration building, which faced outwards in the centre of the'
straight line bounding the semicircular area. It was 132 x 38 feet and two stories high : the first lloor contained
the otiices of the surgeon in charge, executive officer, quartermaster and commissary, the hospital library and print-
ing-office, and the second the quarters of the medical officers. On its right was a building 70 X 28 feet, which
contained the linen-room, post-office and officers' mess, and on its left a similar building containing the dispensary,
medical store-rooms, room of the discharge-board, and an operating-room lighted from above. A covered pathway in
rear of these buildings connected the ends of the semicircular corridor to which the wards were attached and closed
in the nneneumbered half circle constituting the courtyard of the hospital.
The wards were built and ventilated as required by the War Department circular. The bath-rooms and water-
closets were at the free extremity of each. The bath-room was furnished with a small stove and boiler for the supply
of hot water. The water-closets contained troughs which were emptied and flushed several times daily into well-
conditioned sewers. The water-supply was derived from the mains of the city. The wards were arranged along tho
convexity of the corridor, nine on each side of a central two-story building, which contained on its ground lloor a
dining-hall capable of seating 1,200 persons, and on its second lloor, which was accessible by stairs from the outside,
a chapel and dormitories for female nurses. In rear of this was a T-shaped building, used as kitchen and laundry^
the general kitchen, extra-diet kitchen and bakery occupied separate rooms containing suitable ranges, steam-
fixtures and bake-ovens ; the laundry had provision for drying by steam. Behind the kitchen was a tank-house
and beyond this the quarters for the guard. On the right flank of the projecting wards and at suitable distances,
were buildings used as quarters for detailed men, workshops, subsistence store-room, stable and wagon-house and
ward for contagious diseases; on the left were the knapsack and quartermaster's store-rooms, sutler's store and
some houses used as ([uarters by medical officers and stewards. The guard-room and guard-house were in front of
the line of the administration building, near the entrance to the hospital grounds. The Army .Medical Museum con-
tains an excellent model of this hospital.
The Sloan Hospital, Montpf.i.ieu, Vt., was situated about a mile from the town, on a plateau 150 feet above-
the level of the Onion river, and .surrounded by high hills, spurs of the Green Mountain range. The buildings radi-
ated from an octagonal central space, around the circumference of which was a covered platform or pathway con-
necting the whole. They were to have consisted of an executive building, four sets of officers' quarters, twelve
wards, two mess-halls, a general and an extra-diet kitchen, subsistence store-room, laundry, water-tank, operating-
room, dead-house, chapel and barracks for the Veteran Reserve Corps guard, but some of these buildings were never-
950
THE GENERAL HOSPITALS.
rrr-i
DO
0
20 □
Gbovnd plan- of Hicks Hospital, Baltimore, Md.— Scale, ISO feet to the inch: 1, 1, 1, 1, Wariis ; 2, Administration building; 3, Liuen-room;
4, Dispensary and operating-room ; 5, Dining-liall ; 6, Kitchen and laundn- ; 7, Ward for detailed men ; 8, Knapsack-room ; 0, Subsistence store-house ;
10, Quartermaster's store-house ; H, Tank ; 12, Quarters for the guard ; 13, Stable ; 14, "W'agon-honse ; 1.5, Sutler's store ; 16, Steward's quarters : 17. 18,
Officers' quarters (of which there are several not shown on the plan) ; 19, Guard-room ; 20, Guard-house near entrance-gate ; 21, Workshop ; 22, Con-
tagion-ward,— this was more distant than is represented. The wards, dining-room and administration building are connected by a covered-way.
completed. Those erected were substantially built of wood, lathed and plastered, clap-boarded, shingled and pro-
vided with double floors. Only eight of twelve wards were finished for service. They varied in length, but all
were 26 feet wide and 12 feet high, and each had 12 feet partitioned otf from the free end for subdivision into ward-
master's room and lavatory. Six had a length of 108 feet, which, with 40 beds each, gave a superficies of 62 feet and
an air-space, including the triangle of the ridge, of about 1,000 feet: the two other wards measured only 104 feet
in length. They were well lighted by windows on both sides and ventilated by the ridge and Hoor. Water was
brought through wooden pipes from a spring in the neighboring hills. A receiving-tank, with a capacity of 40,000
gallons, distributed it to the wards. A room in the laundry building was intended to be fitted up as a general bath-
room. There were no water-closets attached to the wards, but set otf from the rear of each was a small privy which
communicated directly with the drainage system of the hospital. This consi.sted of a drain 12 inches square, of three-
inch spruce plank, which surrounded all the buildings and then passed under the privies for the reception of sew-
age matter. This drain discharged into a small brook in the valley and could be flushed at will from the tank. The
method proved a failure; foul odors penetrated to the wards and caused its disuse.
Ill view of the order of the Secretary of War, submitted above, and of tlie brief account
of so many of the hospitals ah'eady given, it is needless to enlarge upon any particular scheme
of hospital construction and arrangement. The experience of the war was decidedly in favor
THE GENERAI, HOSPITALS. 951
of tlie pavilion system, each pavilion constituting a single ward isolated from adjacent build-
ings by somewhat more than its own width, and connected by a covered walk with the other
buildings of the hospital. In their aggregation this separation was eftected, without remov-
ing any of the wards to an inconvenient distance from the administrative and executive
buildings, by radiating them around some central point in a form to be determined by the
contiguration of the ground available for building.
But the plan of the pavilion-ward approved l)y the Secretary of War appears open to
adverse criticism based upon the very experience wiiich led to its adoption. Exception may
be taken to it on two points — its length and the position of its water-closets.
The length of the pavilion as usually constructed was less than that recommended by
the otHcial circular. The latter assigned a length of 165 feet for 60 beds, but the advantage
of this over 115 feet for 40 beds, as planned and carried out at the Sedgwick Hospital,
may readily be questioned. The reports of oiu- medical officers show a decided preference
for a ward containing not over 50 beds. The experience of the British in the Crimea with
similar pavilions was in favor of a ward containing only from 20 to 36 patients, as giving
better ventilation and greater comfort and economy of labor than one of larger capacity.
It will be observed that the area per bed sanctioned by the official order was less than
that allowed by the British regulations. Our long 60-bed ward gave an area of only 64 feet
to each of its occupants; the British ])avilion gave 87 feet, a ward for 20 incu having been
72iX 24X1^ feet.
All the pavilion-wards built during the war had a space partitioned off at the free end,
and generally also at the attached end, for use as a wardmaster's room, a pantry, bath-room
and water-closets. Except in those great mistakes, the Moukt Pleasant and Judiciaey
Sqcaiie hospitals, at Washington, D. C, the water-closets were always at the free end of the
building. In many of the hospitals they were attached to the lateral aspect of the pavilion
at one of the angles of its free end and cut off from the interior of the ward by a hallway
affording cross-ventilation. This was the arrangement adopted at the Ci'YLER, Summit,
McClellax, Mower, Tiltox and many other hosj^itals. It is illustrated in tlie accom-
■"■^^^■^^^^ *23anying figure, in which a is the interior of the ward; b, the
water-closet; c, the lavatory and bath-room; d, the pantry; e,
the wardmaster's room, and/ the ventilating-hall and passage-
ways. Even in some of the earliest pavilions, as in those of the
De Camp Hospital, David's Island, N. Y. Harbor, the water-
closets at each end of the four wards into which the building
was divided were separated by a passageway with cross-ventilation from the door commu-
nicating with the nearest ward, Tlio official circular did not take cognizance of this arrange-
ment, but recommended a method of direct communication between the ward and its water-
closet. The ground on which this sanction was based does not appear on the records. It
may have been argued that the cross- ventilation, obtained by placing the water-closet at the
side and cutting off the bath-room and pantry by a transverse passage, was outweighed by
the disadvantage of having one corner of the free end of the ward deprived of its window-
light and ventilation. The interests of the patient occupying the bed in that corner were
sacrificed by this method for the well-being of the majority. But these plans immediately
suggest that the cross-ventilation could readily have been effected without injury to this cor-
ner of the ward by doing away with the side additions b and c, transferring the wardmaster's
952 THE GENEKAL HOSPITALS.
room and pantry to the opposite end of the ward, and fitting up the cross-ventilated room
d as a water-closet and e as a bath-room and lavatory. Tiie arrangement would have
afforded a better protection to the inmates of the ward from water-closet exhalations than
that officially recognized. Or, to go further : The advisability of closing in the free end of
the ward by service-rooms of any kind may be seriously questioned, as their apposition
deprives that point of the building of all the advantages of exposure to sunlight and air
which its position as a free end would otlierwise confer upon it. A better site for the water-
closet and bath-room of pavilions connected by a covered walk might have been found across-
the corridor from the attached end of the ward.
In other respects the War Department circular seems to have embodied all the advan-
tages gathered by an extensive experience in the administration of large military hospitals.
Most of our pavilion-wards and their associated buildings were whitewashed externally,
but the reflected glare was a source of so much discomfort that at some hospitals, as Camf
Dennison, Ohio, and Main Street, Covington, Ky., a yellow wash was substituted.
During the first summer of their use the wooden pavilions, open at the ridge, were
conceived to fulfil all the requirements of a hospital-ward. The free communication with
the external atmosphere furnished by the open ridge seemed to guarantee a purity of the air
within, which, however, was not always found. The obvious explanation of this led imme-
diately to the introduction of counter-openings along the wall near the level of tlie floor.
These were provided with sliding-panels for closure in breezy or chilly weather, wlien the
open ridge alone sufficed to give a free ventilation. But it fref|uently happened during the
calm hot days of summer that, with all these provisions for the inlet and outflow of air, its
stagnation in the wards was ilot overcome, and hospital gangrene occasionally appeared in
pavilions crowded with wounded men. Some of the converted barrack-buildings of the
Cliffbukne Hospital, AVashington, D. C, were thus visited. Apertures do not create a-
movement; they merely permit it to take place when forces naturally or artificially directed
have called it into existence. When no aspiratory force operated as an exhaust at the ridge,
and no material difference between the external and internal temperatures developed an
inward current, the open ridge and floor apertures became for the time being valueless. In
one of the Washington hosjoitals an effort was made to work fans by hand-power over any
or all of the beds of a ward; but this was intended more for the comfort of the patients in
sultry Aveather than as a method of artificial ventilation. At such times the tent-ward was-
regarded as better suited than the frame pavilion for hospital purposes. By looping up its
sides the patients were practically moved into the open air, where diffusion and dilution took
the place of ventilation. This was so well recognized that at most of the hospitals a tent-
ward was set aside for the treatment of sloughing and gangrenous wounds.
But on the approach of winter the ridge had to be closed, as otherwise the ward became
uncomfortably cold, and driving storms of wind and snow were free to penetrate. Its closure
necessitated the introduction of special fresh-air inlets and ventilating-shafts and the utiliza-
tion of the heat of the stove and stove-pipe. The inlets were boxed channels from the side
walls opening beneath the stove, which was partially surrounded by a jacket of sheet-iron
or zinc. The air, more or less warmed in its passage into the ward, became diffused and
was ultimately drafted through a ventilating-shaft eighteen inches square, which extended
from the level of the tie-beams to beyond the ridge. The stove-pipe, before penetrating the
THK GENERAL HOSPITALS. 953
shaft, traversed the length of the ward in a horizontal direction for about eight feet from its
vertical connection with the stove.
On the whole this system of ventilation gave satisfactorj- results, although occasionally
complaint was made that the entering air, insufficiently warmed in its transit, flooded the
Hoor of the ward and chilled the feet of those who were not confined to bed. Dampers
wouhl have remedied this, but under the control of the patients they would have frequently
obstructed all ventilation. Such complaints emanated mainly from wards in which the mis-
take had been made of running the ventilating-shaft from the floor upward. The stove-pipe-
entered this shaft at a height of eight feet and created through it a strong and steady draught
which was felt as uncomfortable by all who were near its lower end. This fault at the Jef-
ferson Hospital, Jeffersonville, Ind., was aggravated by having the stove completely sur-
rounded by a jacket of sheet-metal, wliich cut the men off from much heat that would have-
otherwise been radiated.
The water-supply of the hospitals varied with their locality. Those having free con-
nection with the mains of a city-supply had usually an abundance of water e-xcept in a few-
instances of several-storied buildings or elevated sites, as at the Central Park Hospital,
Xew York City, or the City Hospital, St. Louis, Mo., where the water came only into the
lower wards, leaving the upper to be supplied by tanks and force-pumps. Many of the
larger hospitals, although freely connected with the city mains, kept on hand a reserve stock
in large elevated cisterns chiefly as a provision in case of danger from fire, — the reserve cis-
terns at the Mower Hospital contained 102,000 gallons.
Those hospitals situated at a distance from any public water system were supplied from
wells, springs, ponds and streams. When the source had a sufficient elevation the water
was led directly into a distributing tank. The large hosjiital at Portsmouth Grove, R. L,
derived all its water from a spring a quarter of a mile distant and elevated seventy feet above-
the hospital level; a reservoir was formed by damming the stream, and from this the water-
was brought to the hospital in pipes. When wells were used or water from a source having-
an insufficient elevation, steam was generally employed to raise the supply into a suitable-
distributing tank or cistern. When the local wells or springs proved insufficient, as was-
occasionally the case in some of the hospitals in the northern subui-bs of Washington, water
had to be brought in wagons from the nearest available source. Rain-water was soraetimes^
used, as in Memphis, Tenn., and New Orleans, La.
The quality of the water was seldom questioned. At Point Lookout, Md., it was-
regarded as prone to cause diarrhoea. In a few instances exception was taken to the source-
of the supply — as at Camp Dennison, Ohio, where it was pumped from a mill-race fed by
the Little Miami below the point where the drainage of the camp flowed into the river; at
Hendersonville, Ky., where the intake from the Ohio was near a bank grossly covered
with human filth; and at Germantown, Pa., where the supply was indirectly derived from
a stream which was fouled by the drainage from factories and dyeing establishments.
The satisfactory disposal of excreta from the wards of these hospitals depended princi-
pally on the water-supply. Where this was ample, as when the hospital was freely con-
nected with the mains of a city reservoir, the sewer connections were usually efficient. The
questionable position of the water-closets in some of the pavilion-wards, and even in those-
officially sanctioned by the War Dejiartment, has already been noticed. In some hospitals-
the hopper-closet was used. In those thus fitted the water-closets were seldom offensive-
Med. Hist.,Pt. Ill— 120
954 THE GENERAL HOSPITALS.
except during some teini^oraiy interference with the flow of water. The water-closets on
the up|ier floors of the hospital in Central Park, New York, were frequently from this
cause a source of complaint to the whole establishment. In others the seats were placed
over a long iron trough through which a constant stream of water carried all deposited mat-
ters immediately to the sewers. But the necessity for economizing the water-supply caused
the retention of the deposits in many of these troughs for several hours, the process of empty-
ing and flushing taking place only so many times a day. The effluvium from water-closets
of this class sometimes penetrated to the wards unless the closet itself was thoroughly ven-
tilated and separated from the body of the building by a cross-ventilated passage. In some
instances, as at Montpelier, Vt., wooden troughs in detached privies communicated with
a rude sewerage system by means of a limited water-supply. The intention was to keep these
troughs clear by occasional flushing, but the water-supplv seldom oermitted a realization of
the anticipated success.
In hospitals with a defective water-supply boxes were used, sometimes in detached
privies, sometimes even in the small rooms originally designed for a water-service. Of course
these boxes, although emptied and cleaned with the utmost regularity and care, were of neces-
sity a nuisance. Two instructive exceptions may, however, be noted, one at Turner's Lane,
the other at the Summit Hospital, Philadlephia, Pa. Medical Inspector Le Conte considered
the ventilation of the privies of the former to have been the best of any in which the box-
system was employed. Foul odors were carried off" by flues which connected with special
air-chambers heated by small stoves. "I have never," he says in one of his reports, "observed
the least unpleasant odor even when the boxes most required to be emptied." At the Sum-
mit Hospital the box-privies attached to the side of one end of the pavilions were venti-
lated successfully by underground flues connected with the chimney of the engine-house. Our
medical officers did not become familiar with the earth-closet until shortly after the war.
In some hospitals with a limited water-supply deep pits or vaults were used instead
of movable boxes. These were more or less offensive in accordance with their position and
the care taken in ventilating them and keeping them clean. Chester, Pa., furnished an
illustration of the most offensive vaults, crowded as they were into the un ventilated spaces
between the long wards. The Crittenden Hospital, Louisville, Ky., had perhaps the best
of these vaults, 30 feet deep, Avith the seats arranged on four sides of a high ventilating-shaft.
Besides the water-closets, privy-boxes or vaults attached to or in the immediate neigh-
borhood of the wards, many of the hospitals had general sinks for the use of convalescents,
guards, employes, etc. These were at some distance from the buildings. When the water-
supply was ample, a trough containing a running stream carried the deposits to the sewers ;
when the supply was limited, the contents of the trough were flushed out at stated hours.
At some hospitals favorably situated the latrines were erected over tidewater; at others
movable boxes were used; at others, again, mostly small hospitals or large hospitals tenrpo-
rarily established, deep pits were used, which, when filled, were covered over and replaced
by fresh excavations.
In cities the ultimate disposal of the excreta was effected by a communication with the
general sewerage system; in other cases the sewers of the hospital found an outlet into
some neighboring stream or tide-water; where no satisfactory outlet was obtainable the
sewer terminated in a cesspool from which liquids percolated or overflowed by a suitable
conduit into a natural incline leading from the hospital, and solids were removed from time
THE GENERAL HOSPITALS. 955
to time as they accumulated. Tiiu ifcurds of the general hospitals show but one outbreak
of disease which was reterred to faults of sewerage, — hospital gangrene and erysipelas
occurred in one of the wards of the CuYLER Hospital, Gerraantown, Pa. lu June, ISGl,
there were ten cases of the former and four of the latter disease, and in July eight of the
one and three of the other. A break in the sewer permitted extravasation into an old cess-
pool near the walls of the pavilion in question. Xo case-occurred after this defect had been
discovered and remedied.
In the early period of the history of these hospitals no efficient provision was made
against danger from fire. Even as late as December, 1862, there was no efl'ectual means
of subduing fire at David's Island, Xew York, although the hospital contained at the time
2,146 beds and was beyond the reach of any municipal assistance. The means of guanling
against this danger became a subject of special inquiry by inspectors, and in a short time
each hospital endeavored to rival the othei's in the efficiency of its fire department. Had a
tire attained any headway among pavilions covered with tarred paper and massed together
as were those of the Satterlee and many otlier hospitals, it is hardly to be supposed that
the engine and hose would have preserved the establishment; but the fire-drill and the fire-
buckets and axes in every ward, by keeping constantly before the inmates the imiuinonce
of the danger, led to such precautions and vigilance that fire was either prevented or detected
and suppressed in its incipiency. Every nurse on night duty was a guard against fire; but
in addition there was at most hospitals a special fire patrol. Full buckets and axes were
kept in each ward, which was also provided with a suitable lengtli of 1-inch rubber hose for
attachment to a plug in the water-closet. For general use 2i-inch hose, plugi5 in various
localities and steam-power were available, with a reserve supply of water in tanks in case of
accident. At large factory buildings in cities fire-escajDes were built on the outside.
Tlie personnel of these hospitals consisted of the surgeon in charge and his staff, including
stewards, clerks, attendants, cooks, laundrv-workers, etc., and guards.
The surgeon in charge was entrusted with full and complete military command over-
the persons and property connected with the hospital. He was held to a corresponding
responsibility. In exceptional instances the administration of a general hospital was dis-
turbed by the assumption of military officers temporarily in command in their neighborhood.
Thus at one period, when the wards of the De Camp Hospital, David's Island, New York
Harbor, were filled with sick and wounded Confederate soldiers, an officer of a higher rank
or grade than the surgeon in charge was sent in command of a detachment of troops to guard
the island and prevent the escape of convalescent prisoners. The duty of this officer was so
clearlv indicated that there was no occasion for interference with the management of the
general hospital; yet, by virtue of his superiority in rank, he assumed control over the
disposition of the local guard of convalescents and Veteran Reserves, taking them from their
regular assignments to relieve his own cominand and otherwise interfering with the authority
of the surgeon in charge. In fact, for the time being the general hospital became converted
into the post hospital of a military camp, subject to the orders of the commander of the camp,
although nothing in Ms orders authorized this change in the status of the general hospital.
Again, on the small peninsula which had Fort Schuyler on its water front and the McDou-
GALL Hospital across ito isthmus, there occurred at one time a conflict of authority. Origi-
nally the sentinels of the fort were placed at the foot of the glacis along the line of fence
separating it from the hospital; but at a later date they were posted across the isthmus,
956 THE GENERAL HOSPITALS.
thus including the hospital within the limits of the fort and subjecting its personnel to a
certain extent to a double system of military observances, one of which was unusual and
unnecessary at a general hosjiital, and wholly unauthorized in tlie instance in question. An
immediate appeal to higher authority was of course the proper remedy for an evil of this
character.
At small hospitals the surgeon in charge was his own executive officer, but at large
establishments an active and intelligent medical man was detailed to aid him in his super-
vision. The special duties of the executive o/^cer were those of adjutant to a commanding officer.
He had charge of the office and records, of the clerks and orderlies, supervised the prejjara-
tion of all regular reports, promulgated all orders and conducted the general correspond-
ence. He made appropriate distribution of patients received for admission, and looked
after the general well-being of the establishment as aid to his superior. Daily and weekly
reports were sent to the Medical Director of the Department; monthly reports to the Surgeon
General and Adjutant General; bimonthly muster and pay-rolls to the Adjutant General
and Paymaster; quarterly reports of property purchased with the hospital fund to the Sur-
geon General, and returns of camp and garrison equipage to the Quartermaster General-
annual returns of medicines and hospital stores to the Surgeon General, and such other
reports and papers as were from time to time required by superior authority. Among the
books kej)t in this office were records of admission, such as a hospital register of sick and
wounded, supplemented by an alphabetical register and an alphabetical register by States;
records of casualties, as of deaths, discharges and transfers; records of strength present, as
the Morning and Weekly Report Books; records of local government, as the Order-Book and
accounts of hospital fund and hospital property; and records of correspondence, including a
book of letters sent, of letters received, of letters from the Adjutant General's office, of letters
from the Surgeon General's office and an endorsement book.
The ward phi/sicians numbered on the average about one to every seventy-five patients;
but the strength of the medical staff varied with the character of the cases received for treat-
ment. Naturally convalescents and chronic cases in remote hospitals required less medical
attention than the acute cases found in those near the theatre of war.
At every hospital a ward physician, detailed from the roster, did duty for twenty-four
hours as medical officer of the day. This officer was required to be present and awake dur-
ing the period of his detail. He admitted patients in the absence of the executive officer,
and prescribed in cases of emergency in the absence of the ward surgeons. He inspected
the meals to see that they corresponded with the official diet-table and were of good quality
and well prepared. He visited each ward at 9 p. m. and again after midnight, to regulate
lights and note the vigilance of the night attendants, and he enforced discipline, at all times
exacting from patients, attendants, visitors, etc., a strict conformity to the rules prescribed
for each respectively. He was also required to make, at the conclasion of this dutv, a written
report to the surgeon in command exhibiting the true condition of the hospital, and suggest-
ing such measures of reform or imjDrovement as seemed to him advisable.
The ward jDhysician was responsible for the medical and surgical treatment of his
patients, for the police of the ward, the care of its property and the faithful discharge of their
duties by his subordinates. He was present at surgeon's call in the morning and afternoon,
and visited his ward at such other times as was needful for the proper care of individual
cases. He was required also to keep the diet and prescription book of his ward and to make
THE GENERAL HOSPITALS. 957
a record of all cases of professional interest. He sent a morning report to the executive
officer stating all changes and recommending others, such as the return to duty, furlough,
discharge or transfer to the Invalid Corps of particular individuals.
The ward, in the absence of the physician, was under the care of a ivardmasier, who
was responsible for the comfort, diet and medication of the patients, the performance of
their duty by the nurses and the cleanliness and discipline of both. He was charged with
the preservation of the ward property, the transfer and return of linen and clothing from
the laundry, the police of the sinks, lavatory, baths and water-closets, and the regulation of
the fires, lidits and ventilation.
Young men, students of medicine, under the title of medical cadets, were occasionally
employed as clerks and dressers under the immediate supervision of the ward physician.
Three or four hospital steivards wore employed at each hospital. One had charge of
the dispensary and medical property. One was frequently employed as quartermaster-ser-
geant, making issues of clothing, blankets, etc., on proper requisitions, and preserving an
official record of his transactions. Another was generally in charge of the subsistence, draw-
ing rations from the department, issuing to the kitchens and keeping the accounts of the
hospital fund. Sometimes a hospital steward -acted as chief wardmaster, thus relieving the
dispensary steward of his property responsibilities.
A chaplain was attached to most of the large hospitals. In addition to duties of a
purely spiritual character, this officer performed valuable service by keeping a record of special
patients, with the post-olfice addresses of their nearest relatives, and writing letters for those
who desired to communicate with their friends but were unable to do so on account of
wounds, sickness or other causes. The chaplain had supervision over the postal service,
the reading-room, library and cemetery.
The proportion of attendants, cooks and other employes varied exceedingly in these
hospitals. Convalescents in a ward were frequently rated as nurses until they were able to
bear the fatigues of active service. A good deal of trouble was sometimes experienced in
getting satisfactory ward attendance. When details were made by superior authority from
regiments in the neighborhood, the regimental commander generally complied with the order
by sendmg broken-down men who, but for this call to service, would probably have been
admitted to the same hospital as patients. Hired civilians were undesirable, as they often
left at a moment's notice. Details from the Veteran Re.5erve Corps, serving as guard at the
hospital, usually gave better satisfaction, as its ranks were recruited from those who had
served an apprenticeship to ward duties in the charactel* of patients.
It was the general opinion of officers in charge that one wardmaster and two able-bodied
nurses were sufficient for a pavilion of 50 beds when the cases were not of an acute char-
acter; otherwise five nurses, with help from convalescents, might be required to perform
the duties in a satisfactory manner. A hospital of 1,000 beds had therefore on its rolls 20
wardmasters and from 40 to 100 nurses. But besides these, 5 or 6 men were required in
the kitchen as cooks and 8 or 10 as assistants, usually convalescents, to peel potatoes and
turnips, pick fish, chop meat and wash dishes; the laundry required 4 or 5, with occasional
helpers, for its management; the bakery 3 or 4; the blacksmiths', painters' and carpenters'
shops and stables 10 or 15, and the dispensary, knapsack-room, quartermaster's, subsistence
and hospital store-rooms as many more; the dead-house and cemetery 3 or 4; the head-
quarter office, Including the library, about 10 men as clerks, messengers, etc.; and the quar-
958 THS GENERAL HOSPITALS.
ters and mess-rooms of the officers about 3 more, making a total of 120 to 200 employes.
With able-bodied men specially enlisted for service in the medical corps this number would
have been very materially reduced.*
Female nurses were borne on the rolls of many of the hospitals. At one time, in tlie
West's Building, Baltimore, Md., 20 of 70 nurses were women; at Stewart's Mansion 15
of 70, and at Bedloe's Island, li. Y. Harbor, 10 of 70. These were frequently Sisters of
Charity — 40 served at Satterlee, 16 at Point Lookout and 15 at Cliffburne. Accord-
ing to the testimony of all tiie medical officers who have referred to tliis point their best
service was rendered in connection wilh extra diets, the linen-room and laundry. Male
help was preferred in the wards, save in special cases of prostration and suffering where
particular care was needful in the administration of dietetic or remedial agents. Sometimes,
where no female aid was employed, female aid societies volunteered their services in super-
intending the extra diets and takintr charge of the contribution room. At Turner's Lane
and South Street Hospitals, Pliiladelphia, Pa., a lady volunteer superintended the lincn-
rooiu and extra diets. Another volunteer supervised the regular! v appointed female nurses
and had charge of the extra diets at Chester, Pa.
At first convalescents were detailed for guard and general police duties. This answered
very well at remote hospitals, which were in reality barracks for convalescents and chronic
invalids; but hospitals nearer the front could only have these duties performed by with-
holding the transfer to their regiments of men who were able for active service. Oftentimes
at this period surgeons in charge were exposed to annoyances and their hospitals to irregu-
larities which could neither be suppressed nor avoided for want of a police force. After-
wards one or more companies of the Veteran Pveserve Corps were assigned to duty at each
hospital. The senior officer of this command became responsible for the general police of
the hospital grounds and the preservation of order within the limits of the command. Suit-
able fences around the grounds of a hospital reduced guard-duty to a minimum. At Hare-
wood, Washington, D. C, there was no fence around the extensive grounds, and although
the guard was large, consisting of four companies of the Veteran Reserves, it was found
impossible to prevent convalescents and others from eluding the vigilance of the sentinels
and visiting the city, oftentimes to their great detriment. The officer .of the Veteran Reserve
Corps materially relieved the office of the surgeon in charge by supervising issues of cloth-
*Before this page passes from the bands of the compositor opportunit.v is taken to note the fact that the U. S. Army will soon be strengthened by
a body of meu such as is suggested in the text. The desirability of a trained corps of Ijospital nurses was well recognized during the war, but not until
a quarter of a century later was legislative action obtained. The Act of Congress, approved Blarch 1, 1S87, authorized the enlistment of a special corps
of men to be attached to the Medical Department, and to perform its duties under the orders and supervision of the otTicers of the department. This corps
is now well advanced in its organization by special enlistments and promotions, after examination to determine the fitness of the candidates for its higher
positions. The law provides ono hospital steward for every post, — two, if the garrison consists of six companies, and one additional for every additional
six companies ; one acting hospital steward for each post, with privates at the rate of three for each post of ono company, four for posts of two companies,
with one man additional for each additional two companies. Moreover, four men of each company are designated for instruction as litter-bearers, to
emible them to render temporary aid to the sick and wounded of their own organization, and from their ranks the privates of the hospital corps are
recruited. Each post-surgeon is provided with an ambulance and harnei-s, which must be at all times in gooil order and ready for service, and with hand-
litters, cacolets, travois, and mule-litters as may bo required. For war service the privates of the hospital corps will constitute two percent, of the aggre-
gate s.rength of the command, with an acting hospital steward to every ten privates and a steward to every thirty. They will pei-form the diities of
litter-bearf-rs, and serve with the ambulances at the primary dressing and ambulance stations and at the field hospitals of the command. For these duties
they will be organized into a company for each brigade, with their stewards and acting stewards as non-commissioned otficers, habitually camping near
the field hospital to which they are .attached. Ambulances are allowed in the proportion of ono to a regiment of infantry of less than '200 men ; two to a
regiment of from 200 to 500 men ; three to one of more than 500 men ; ono or two to a regiment of cavalry, according as it consists of less or more than
500 men, and one to a battery of artillery. The medical director exercises full control over this ambulance service. General hospitals will have six
privates to every thirty beds, with as many hospital stewards and acting hospital stewards as may be required for efficient service. This allowance is
ample, as may be s?en by comparing it with the statements in the text. A railway hospital train of twenty cars, carrying six hundred sick and wounded,
will bo manned by two stewards, six acting stewards and one hundred privates ; a hospital boat of three hundred beds will have three stewards, six acting
stewards and sixt.v-five privates, and other cars and boats will have a jiroportionatelallowance, varying, however, at the discretion of the medical director,
according to the distance to be travelled and the character of the cases to be transported.
THE GENERAL HOSPITALS. 'J.J9
ing, preparing muster and pay-rolls, witnessing payments and closing up the personal accounts
of patients on their death, disciiarge or transfer.
The hospital fund consisted of the credit on the books of tiie subsistence Departinent
foi- those parts of the ration which the sick men were unable to consume. The nioney-vahie
of these articles, amounting monthly to very considerable sums, was applied to the purchase
of delicacies for the extra-diet kitchen. Where hospital gardens were cultivated, as at Nel-
son, Ky., Dennisox, Ohio, and Madison, Wis., or where the food-supply of the hospital was
supplemented by fish caught by convalescents, as at Portsmouth Grove, R. I., the special
diets were usually excellent. At other hospitals, where milk, eggs and chickens were scarce
and correspondingly dear, the i'und was sometimes inadequate. Transfers of a portion of
the fund of a hospital in good circumstances to one not so favorably situated were occasion-
ally made by order of the Surgeon General. Ignorance and want of economy on the part
of the men detailed for duty as cooks often sapped the foundations of the hospital fund.
Under such circumstances Surgeon L. A. Edwards, U. S. Army, realized a true economy at
Portsmouth Grove in paying ^80 a month from the fund to a professional cook for super-
vising the work of the kitchen.
At hospitals in urban districts the introduction of gas was a great convenience, but as
the money-value of the ration of candles failed to pay the bills it was purchased at the
ixpense of the diet of the sick. At Chester, Pa., for instance, the gas-bill for November,
1864. was $225.54, while the value of the candle ration amounted to only $59.16.
The slush fund was derived from the sale of bones, fat, stale bread, slops, flour barrels,
straw, manure, waste paper, old newspapers, etc., and from the tax on the sutler. The
amount of this fund varied at different hospitals, but it was always considerable. At the
McClellan Hospital it averaged $200 per month ; at Harewood $250 ; at De Camp $100.
As the regulations did not take cognizance of a fund of this character, it was used for the
purchase of such articles as in the opinion of the surgeon in charge seemed desirable for the
general benefit. Most of the large hospitals provided excellent libraries for their patients
in part out of this fund. The McClellan Hospital, for instance, had 2,500 volumes besides
pamphlets, and an average of forty-five daily papers, the weekly illustrated papers and
monthly magaznies; but much of this reading- matter was composed of gratuitous contribu-
tions. A melodeon for the chapel and instruments for a militaiy band were purchased by
many of the hospitals. The incidental expenses of lectures, concerts, theatrical and other
entertainments on behalf of the patients were paid from this fund. Many hospitals supplied
themselves with a printing-press, which was of use in the current work of the establishment,
besides providing for the issue of a local paper under some appropriate title, such as the
Weekly Hepoii. But at some hospitals, where the hospital fund was inadequate to purchase
the delicacies needful for the sick, this slush-fund was applied to supplement it. Usually
the subsistence steward made the sales of the refuse matters which formed the basis of this
fund, turning the money over to the hospital treasurer, generally one of the ward physicians,
whose accounts were audited by a council of administration consisting of the three senior
otlicers, exclusive of the surgeon in charge, on duty at the hospital.
The mortality rate of a hospital was sometimes quoted by the surgeon in charge as
illustrating the healthfulness of its site and plan of construction or the efficiency of its man-
agement; but this rate depended so essentially on the character of the cases received for
treatment that the influence of other conditions could seldom be expressed satisfactorily in
960
THE GENERAL HOSPITALS.
figures. At Armory Square, Washington, D. C, tlie rate was 12.7 per cent, of the admis-
sions. This liospital was for a long time used chiefly as a receiving depot for patients sent
from the Armv of the Potomac bv tlie Alexandria, Va., railroad. All serious cases, including-
often men in artieulo mortis, were retained; those capable of sustaining a continuance of
the fatigues of travel were passed on to other hospitals. Hence the high rate of mortalitv.
At Madison, "Wis., on the other hand, the rate was only 1.94. The inmates of this estab-
lishment were generally chronic cases or convalescents who had passed the dangerous period
of their attack at some hospital near the front. These are extreme instances, but they illus-
trate the inutility of comparisons of this nature.
The extent of the hospital provision for the sick and wounded may be understood from
the following list, which shows the capacity of the general hospitals on December 17, 1864:
department of WASHINGTON.
.\rmory Square 'Washington, D. C -
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Georgetown, D.C
Near .Mexandria, Va _
Alexandria, Va
Do.
Do.
Do.
Do.
Fairfax Seminary Virginia
U.S. General | Point Loolsout, Md___
Carver .
Cninpljoll
CoIuTnliiau
Douglas
Emory
Fiuley ._-
Freedman
Harewood
.Judiciary Square,.
Kalorama
Lincoln
IMount Plea.sant _,
Kicord
Stanton
Stone
Seminary
Angnr
Claremont
L'Ouvertnre
1st Division
2d Division
.1(1 Division.
Medic.\l Officek in charge.
Surgeon D. W. Bliss, U. S. V
Surgeon 0. .\. Judson, U. S. V
Surgeon A. F. Sheldon, U. S. V
Surgeon T. K. Crosby, U.S. V
Ass't Surg. \V. F. Norris, U.S. A
Surgeon N. R. JMoseley, U. S. V
Surgeon G. L. Paitoast, U. S. A"
Act. Ass't Surg. A. R. Abbott, U.S. A
Surgeon R. B.Bontecou, U.S. V
Ass't Surg. E. Griswold, U. S. V
Act. Ass't Surg. II. I. Thomas, U. S. 'V
Ass't Surg. J. 0. McKce, U.S..^
Ass't Surg. H. Allen, U.S..\
Surgeon C. \V. Hornor, U.S.V
Surgeon B. B. 'Wilson, U. S. V
Ass't Surg. P. Gleunan, U. S. V
Surgeon H. W. Ducachet, U. S. V
Surgeon G. L. Sutton, U.S.V
\
Surgeon E. Beutley, U.S.V •!
Surgeon I>. P. Smitb, U.S.V
Surgeon A. Heger, U. S. A
Beds.
OccrpiED.
V.\C.\NT.
1,000
69(1
n6
1, 300
722
678
900
633
267
844
638
306
40O
203
197
900
045
255
1,061
755
306
72
2,000
72
1,207
793
510
311
199
434
54
380
2,575
2,012
563
1,618
898
720
1-20
107
13
420
266
154
17(1
139
31
121
13
108
068
403
265
1C4
34
130
717
61-
100
753
669
84
993
856
137
1,350
1,198
152
930
373
663
1,400
4.50
950
21,420 I
DEPARTMENT OF PENNSYLVANIA.
Xo.
N.^MK.
Locality.
Medical Officer iv charge.
Beps.
Occupied.
1
Vac,\nt.
1
2
3
4
5
G
7
8
9
10
11
Broad Street _
Citizens' Voluntary
f'ouvalescelit
.5-25
236
706
1,329
60
1, 089
3,100
3,519
288
1,204
2.S.'-,
92
878
640
723
1,369
1,600
1,000
4)1
48
690
970
15
1,089
2,311
2,464
288
845
211
20
636
380
584
776
1,003
841
84
188
176
.359
43
Do.
Surgeon K. S. Kenderdine. U. S. V
Surgeon T B Reed U S V
Do
Do.
Surgeon S. 'W. Gross, U.S.V .:
Act. Ass't Surg. J. V. Patterson, U. S. A
Surgeon L. Taylor U.S. A
Islington
Do
McClellan
Do.
Do.
780
1,055
Satterlee
Do.
Surgeon I. I Haves U S V
South Street. —
Do.
Act. Ass't Snrg. R. J. Levis, U. S. A
Sur'^eon J H Taylor U S V
Summit House
Do.
369
74
3iM
266
139
693
593
159
Do.
V>.
Officers'
Ass't Surg. S. A. Storrow, U.S. A
Surgeon T H. Bache U. S V
13
Chester
Cuyler
U.S. General
White Hall _.
Chester, Pa
14
15
16
17
IS
Ass't Surg. H. S. Schell, U.S. A
Pittsburgh, Pa
White Hall, Pa
Ass't Sur*' W H Forwood USA
York
Beverly
York, Pa
Surgeon St. John W. Mintzer, U.S.V
Ass't Surg. C. Wagner, U.S.A.
Beverlv, N. J
18,709
13,412
5,297
THK GKNERAL HOSPITALS.
DEPAUTMKNT » »K THK oHlO.
961
Ko.;
LOCAUTY.
MbuuAL Uii'uxu IX cuahge.
Brown
Clay
Crittenden _.
Eruptive
Foundry
Officers'
I'. S. General
U.S. General
Muin Slrvet .
Scminnrv
Joe Hult
V. S. General
Xelsoii .
JfUlTSOD
No. 16
L'.S. Geueial
Officers'
Louii4viIU>
lh>.
Do
III.
Do.
AslilantI, Ky
Uuwlini; Gre<'», Ky _.,
CovhiRtun, Kv
IK.
Jeffei-jionville. Ky
Lexinfiton, Ky __.»_«,
Camp Nelson, Ky
Jeffersonville, InJ
Kouxville, Tu'UU
Do.
Ky 1 Ass't Sun:. B. E. Fryer, T.S.A
„_„ , Surgeon V. Gh-hmu', I'.S.A' ™™™
Snrj;eon N. K. Marxli, V. S. V _„
.___-.. Sur;j:eon A. ('. Swuitz-vveltler, I'.S. V _.
Surgeon A. It. ri-e.-^t-olt, I'.S. V
Surgeon ('. MfDrrmmit, L*.S. V
• Act. Ass*t Surg. C. W. McMillan, U.S.A.
I .\ct. Ass*t Surg. II. G. Keefir, L*.S. A_.
Surgt'on A. M. S|»eer, I'. S. V
Surgeon H. 1*. Stenrn?*, U.S. V
Aet. Ass't Surg. K. IVter, l'.S..\
Surgeor. D. Meeker, l'. S. V ,_._.
Surgeon 31. GoMsniith, U.S. V
.\sB't Surg. J. Giininer, 24tli Ky. Vols.
Sur^ou D. BuruuDi, 25tb Mich. Vols—
::■(
Bers.
Occll'lED.
Vacant.
700
571
1-0
178
137
41
300
350
4
203
• 148
55
200
106
9t
37
18
19
275
100
l(i9
140
120
26
30(1
03
237
218
51
164
980
847
rtl
403
:152
111
7(H)
555
145
2,3!»
2,265
134
144
91
53
1,1'.")
1,106
24
42
13
27
8,535
0,970
1,565
DEPARTMENT OK TlIK EAST.
Ko.
Xamr.
LOCAMTV.
I^IfMCM, Oi-I-ICKK in ClIAiKJK.
Bel.s.
OCCITIED.
Vacant.
1
ft
4
5
l.a(lio^' Homt}
:*t. .losoph
Tninsit
Idiviil's Islaud
Ft. Coliiiiibii!*
New York Citv, X. T i..
Snrgeon A. B. Mott V, S. V
402
3-25
62
1,700
I((0
1,293
1,1m
103
482
150
200
3-25
080
300
9'>7
007
475
723
5(10
469
00
1,000
480
1,404
816
345
2-29
57
Po.
Do.
Sdr^eou B. ,\. Clenieuts, V. S. A.
Surgeon A. Jl. Iloir. V. ». V.
90
C2
Do.
Asst SnrK. W. W.l.st.r, r. S. A
Ass't Surg. r. S. C'liiiirr, U. S. A.
870
19
393
506
20
428
91
G9
231
636
219
743
510
258
415
330
421
59
705
370
713
816
830
81
900
678
83
54
Do.
Wilk-fs r(.i((l. S. Y.
Ft. Sil(((vlvr, S. Y
HeilliK'S Island, X. Y ..,
Albany, X. Y
7
.M.Il.j((gaH
Asst SurR. S. II. Orton, r. S. A
Surgeon J. Simons, l". S. A.
Ass't Snrg. M. F. Cogswell V :> V
9
in liiiffiil.)
Buffiilo, X. Y
Dr. J. Si. Brown _
Surgeon .\. Crisi>ell, l'. S. V.
Act. Ass't Surg. J. K. Stanclltield, U. S. A —
Act. Asst Snrg. A. BackiLs, I". S. A
Surgeon G. II. Hubbard U. S V
11
lii
14
1-.
ii;
17
1.-
19
20
21
22
2:1
24
25
SisU-re of Cliarity
Kliiiii^
St. Mary's
Truv ,_,
WanI
Kiiiirlit
\V.I,-I,r
Hnittli'boro'
lia.\t»r .
Sload
Do.
Elmira, X. Y
Rochester, X. Y'
Trov. X. Y
131
94
144
81
Xewark, X. J.
Xew Haven, Conn.
ABstSurg. J. T. Calhoun, I'. S. A
184
97
Slancliestcr, X. U
Brattleboro", Vt.
Burlington, Vt
Surgeon A. T. Walson, I*. S. V.
217
Surgeon E. K. Phelps, I'. S. V. -
310
Act. Ass't Surg. S. W. Thayer, jr., V. S. A—
Surgeon 11. .Tancs, V. S. V
.\ct. .\ss't Snrg. W. K. Townsend, V. S. A__
164
4S
1
295
110
751
Boston. Ma.-^
Rcadvllle. Mass _
Worcester. Mass
Portsni.inth drove, R. I
Augusta, Mc
Ib^adville
Hale
Lovpll
Couy
S((rgeou C. X. Cluunberlain, U. S. V. ^
S((rgeon Ij. A. Kdwards, l'. S. \.
Act. Ass't Surg. 0. E. Brickijtt, U. S. A
14, S'29
9, 302
5, 5-27
KORTHERN DEPARTMENT,
Name.
MEniCAL OfTiCEn in ciiaege.
i Beds.
Occupied.
( iIBc^ni'
Marine
Wa,shington Park,
West End
Seminary
Dennison
U. S. (Jeneral
I'.S. Genenil
r.S, Gonera!
I'. S. tJenenil
I'.S. General
r.S. General
Ohio ^
Ciiqts d".\friquo
Ma.lison
Destuarres
Slarino
V. S. General
I'. S. General
I'. S. General
Simons
Hari*cT
St. ilary's
Cincinnati, Ohio
Do.
Do.
Do.
Columbus, Ohio
CanipDeliiii.-ion. (>bio_.
Camp Chase, Ohio
Cleveland, Ohio
Gallipolis, (.Ihio
Evansville, Ind
Indianajiolis, Ind
Xew Albanv, Ind
Do. ■
Do.
Madison, lud
Chicago, 111
Do.
Quincy, III
Camp Butler, 111
Camp Douglas, 111
Mound Cirv. Ill
D(jtroit. llicU
Do.
Surgeon W. H. Goldbrerht, U. S. V
Surgeou X. Gav, L'. S. V _.
.\rt. As.st Snrg. .T. Ii. Smith, V. S. A
Act. Asst Surg. R. Bartholow, U. S. A
.•\ss't Surg. <;. Saal, I'. S. V.
Surgeon M'ni. Varian, W .S. A'
Surgeon S. S. Schultz, V. S. V
Asst Surg. G. M. Sternberg, U. S. A
Surgeon L. R. Stone, l". S. V
.\ct. Ass't Surg. .1. A. Jeancon, I'. S. A
Act. Ass't Surg. .1. JI. Kitchen. 1'. S. A
Surgeon Thomas W. Fry, V. S. V
-Set. Ass't Surg. .1. A. (icterlonv. I'. S. A
Act. .^ss't Surg. W. A. Clapp, 1'. S. A
Surgeon G. Grant, I'. S. V
Surgeon J. S. Uililreth. l'. S. V
Act. Ass't Surg. R. X. Wiani, V. S. A
Surgeon D. G. Ilrinton. l'. S. V
.\ct. .\5s't Surg. M'm. Sturgis, U. S. A
Surgeon J. C. Whitehill, I'. S. V
Surgeon H. AVanlner, C. S. V
Act. Ass't Surg. 1>. 0. Farrand, I'. S. -\
Act, Ass't Surg. W. II. Curmingcr, V. S. A
75
122
150
120
1,710
21 K)
3:10
350
7(12
256
860
300
146
2,430
l.iO
110
950
625
1.37
788
.178
270
5-
112
12-2
111
145
1,534
140
2.59
250
702
240
S3S
268
114
2,430 ,
129 I
99
891
525
127
788
578
270
_l_
18
10
28
9
5
182
m
n
100
32
32
1 — .]{--
' II
1
1 '"
1
1
11,421
1", 733
686
ilED. HlSl., Pt. iU— 121
962
THE GENERAL ■ HOSPITALS.
MIDDLE DEPARTMENT.
1
, No.
1
X.iME.
Locality.
Medical Officer in charge.
Beds. Occupied.
1
Vaca.\t.
i 1
.380
1, 213
400
260
,3(10
425
l,o62
600
409
290
350
302
969
303
218
213
305
1,545
482
109
273
194
78
2.54
97
12
67
120
17
lis
240
17
150
Do.
Ass't Surg. DeWitt C. Peters, U. S. A
Surgeon Z. E. Bliss, V. .«. V
1 3
4
5
National Hotel L
Newton University
McKim's Mansion
West's Buildings
Do
Do.
Surgeon 1{. W. Pease, U. S. V
Do
Surgeon L. W. Read. U. S. Y
Do
Surgeon A. Cliajiel, U. S. V
Surgeon B. A. Vanderkieft. U. S. V
Do.
Do.
Surgeon B. A. Vanderkieft, U. S. V
.\nnapolis Junction
Ass't Surg. U. Bacon, U. S. A
Surgeon E. J. Baily, U. S. A
11
1 .
0,1*9 1 4,993 i 1,190
1
DEPARTMENT OF THE NORTHWEST.
No.
Name.
Locality.
Medical Officer in charge.
Beds.
Occupied. Vacant.
1
Snr<'eon H. CuUiertsnn U. S. V
592
290
300
1,350
692
160
252
1,030
'.
Swift -- — .
Prairie dn Chien, Wis
Act. Ass't Surg. F. W. Kellv, U. S. A
Act. Ass't Surg. .1. JI. Adler, U. S. A
Surgeon M K. Taylor, U. S. V_
130
48
320
3
4
V. S. General
XJ. S. General
Davenport, Iowa
2,532
2,034
493
DEPARTMENT OF THE TENNESSEE.
No.
Name.
Locality.
BIedical Offk-eu in charoe.
Beds.
OCCI-PIED.
Vacant.
1
0
3
4
5
(1
7
8
9
10
Ass't Surg. J. C. G. Happersett, V. S. A
Surgeon F. N. Burke, U. S. A'
450
400
600
ll»
200
400
500
80
175
250
326
174
305
' 21
27
161
54
35
78
82
124
226
195
79
173
239
440
45
97
108
Do.
Adams
Otficers' . . . .
Do. 1
Ass't Surg. J. M. Study, V. S. V |
Act. Ass't Surg. G. F. Huntington, U. S. A..
Act. Ass't Surg. E. C. Strode, I". S. .\
Do. ;
Do.
Old State (Pest)
Do.
Do.
Pest
Near Vicksbnrg, Miss
Do. ^.
Do. _
Act. Ass't Surg. E. H. Buck, V. S. A
Surgeon E. F. Stratton, 11th Til. Cav
Surgeon B. S. Chase, 53d Colored Troops
V. S. General, No. 2
U. S. General, No. 3
3,055 1,263
1,792
DEPARTMENT OF KANSAS.
No.
Name.
Locality.
i
j Medical Officer in charge.
Beds.
Occupied.
Vacant.
1
2
U. S. General
C. S. General
Leavenworth. Rang
Fort Scott, Kans
1 Surgeon G. W. Hogehoom, U. S. V
300
200
160
140
140
60
500
300
200
DEPARTMENT OF THE CUMBERLAND.
No.
Name.
Locality.
Medical Officer in charge.
Beds. Occupied, j Vacant.
1
1
2
3
t
0
7
8
9
10
11
12
U. S. General, No. 1
U. S. General, No. 2
U. S. General, No. 3
U. S. General, No. 8
U. S. General, No. 11___
U. S. General, No. 14, __
U. S. General, No. 15
U. S. General, No. 10
U. S. General, No. 17
U. S. General, No. 19.—
Nashville, Teun ! .Siir-'pnii B B. Breed IT. S. V
930
880
600
540
720
775
400
289
1-20
6-29
9(X)
761
1,100
160
69
108
.«00
200
458
100
200
724
717
630
451
95
583
319
289
117
611
520
761
944
135
62
104
326
85
392
91
83
212
169
70
89
625
192
81
Do.
Do.
Surgeon J. R. Ludlow, U. S. V
Ass't Surg. ('. C. Byrne, l'. S. A
Act. Ass't Surg. G. W. Fmnce, U. S. A
Do.
Do. -
Do. - -
Do.
Do.
Do.
.\ct. Ass't Surg. J, ,7. o'Bielly, V. S. A
.\ct. .\ss't Surg. J. S. Giltner", U. S. A
Surgeon J. E. Herbst, U. S. V . .
3
18
380
Do. _
Surgeon W. H. Thorne, V. S. V
Do.
II_ S. General No. 1
Chattanooga. Tenri _.
Do.
Surgeon J. H. Phillips, l". S. V
\ss'tSnr'' R McGowan, U. S. V .
13 I U. S. General! No. 2
156
•25
7
4
474
115 ;
6i;
\)
117
14
15
U. S. General, No. 4
Do.
Do.
Gallatin. Tenn
Lookout Mouutain, Tenn
Do. do.
Act. Ass't Surg. L. S. Tesson, U. S. A
Surgeon C. H. Morton, 8th Ky. Vols
Surgeon. I. W. Brady, Stli Tenn. Cav.
Surgeon R. M. S. .Jackson, U. S. V
Surgeon L D Harlow U S. V
10
17
IS
U. S. General.
U. S. General
Officers'
19
20
21
U. S. General
TuUahonia Tenn Snr^imn s; lT;ii-f t: s' v
Field.-
Bridgeport, ,\la
\ss'tSur"' H T Le^'ler L" S V
10, 751
7,939
2,812
THE GENF.R.VL HO?PIT.\LS.
DKI'.UMMIXT I IF lllE MISSUUlil.
MEDie.\L Officer in charge.
.^liiriiio
Sinnll-pox
r. S. tJeneral
I'. S. General
r. S. Gtiieral
r. S. Geilernl
r. S. GiMienil
V. S. Gfueral
St. Louis, Mo 1 Surgeon J. K. Rogopi, V. S. V
Do. _ ' .\ct. .\i»t Surg. S. W. Adreou, U. S. .\.
Bentt)U Barracks, Mo ' Surgeou Ini Kussell, 1*. S. V
Jefferson Karnuks, Mo Surgeou .loliu !■". I{undol|>li. l'. S. A
JeffersoM City, .Mo Surgeon J. U. Ledlie, V. S. V
Kansas City, Mo Act. Ass't .-iurg. «. H,IIoi.(), V. S. \ ..
Itolla. Mo Act. Ass't Surg. It. CroweP, l\ S. A ...
SiTingfield, Mo Act. Ass't Surg. F. A. ButiLey, l". S. A.
963
BF.1IS.
1 OCCITIEU. V.\C.\.NT.
300
2^15
675.
1,700
2,30
1(12
l-.'O
200
3,462
272
66 ,
ISl
1,005 ,
189
102 j
105 '
128 ,
2,038
28
179
394
95
41
15
7'-
8'24
DEPARTMENT oF VIRGINIA AND NORTH CAKoI.INA.
Ko.
N.IME.
Locality.
Medical Officer in charge.
JhA-.
Vacant.
1
2
3
4
Ass't Surg. E. McClellan, V. S. .V .
3,497
850
002
475
300
3,003
GOO
87
330
137
434
190
135
139
103
Surgeou ,1. H. Frantz, 1". S. \
Surgeon N. P. Rice, U. S. V
Surgeon N. JIaver, loth Conn. Vols
Ass't Surg. J. C. Palmer, Sith X. Y. Vols...
Beaufort - .
Beaufort, X. C
Fost<'r
Xew Berne, N. C
MoreUead Cit.v, N. C
Mausliel.l :
■"■■■'"
4, 283
1,001
DEPARTMENT OF THE GULF.
No. . Name.
Locality.
Medical Officer is chakue.
Bed«.
Occupied. Vacant.
1 St. James
Xss'tSurg S M. Horton U S. .\
300
COO
800
928
550
050
1,500
480
9 291
218 i 382
256 1 545
133 795
187 , 3(3
10 ] 040
836 ' 005
344 136
2 Viiiversitv
Do.
Surgeon S. Kneeland, I". S. V
a Marine
Do
Do.
Do.
Do.
Surgeou J. P. G. Baxter. V. S. V
Surgeou A. McMabon, U. S. V
Vr, \. W. Smith ... . ...
'■ riiaritv
T < orps d'Afii*iue
Do.
Surgeou F. E. Piquette, 801h U. S. C. T
Surgeou C. Winue, 77th III. Vols
Baton Rou^e. La
5,808 j 1,991 1 3,817
DEPARTMENT OF THE SOUTH.
.0.
1
4
Xame.
Locality.
Medical Officer in charge.
Beds.
Oca:piED.
Vacant.
r. S. General
Beaufort, S. C
Do
Hilton Head, S. C
Surgeon .Tohn Treanor, jr., U. S. V
Surgeon ,\. I*. Dalrvnijile. L'. S. V
Ass't Surg. John T. Huber, V. S. V
Ass't Surg. James F. Weeds, V. S. A
320
20
42(1
175
202
2
208
73
58
102
r. S. General
V. S. General
St. .\ugustine, Fla
'.141
005
330
DEPARTMENT OF ARKANSAS.
So. 1 Name. Locality.
Medical Officer in charge.
Beds.
Occupied.
Vacant.
1 1 C. S. General , Little Rock, Ark "1
2 , Colored Do. I
3 1 Officers' Do. j
Surgeon E. A. Clark, t". S. V <
580
129
40
325
250
lb7
650
72
10
292
02
115
SO 1
57 il
30 j
33 ll
5 ! V. S. General. Helena, Ark
0 U. S. General .. Devalls Bluff, .\rk
188 l[
Surgeon E. A. Lee, 54th V. S. C. T
72 1!
1,317 1,101 ■ 410
DEPARTMENT OF WESTERN VIRGINIA.
No. Name. Cocality.
3tEDicAL Officer in charge.
< B»s.
OccrpiED.
VACASiT.
1 Cnmlierlaml t'uiii»»orlainl, MJ Surgeon J. B. Lewis, V. S. V
2 Fr.-.leri<.k Fmkrick. JM __ Atwt Surs. K. T. AVeir, V. S. A
1,000
1,114
342
382
200
707 293
757 357
173 109
197 183
144 1 56 ■
4 Parker-liurs; PiirkTsbnrg, M". Va
5 V. S. Ueucnil WUct-lintr, W. Va _ _
Ass't Surg. \V. A. Banks. V. S. V
Act. Ass't Surg. John Kirker, L*. S. A
1
1
3,038 1 1,978
1,060 !|
964
THE GENERAL HOSPITALS.
RECAPITULATION.
BErAETMEXTS.
Capacity.
Occupied.
Vacant.
' \V,'i'*liin"'titn - -- _ _ _
21,426
18, 709
8,635
14, 829
11,421
0,189
2,532
3,055
50O
10,751
3, 402
6,344
5,808
941
1,517
3,038
13,865
13, 412
6,970
9,302
10,735
4,993
2,034
1,263
300
7,939
2,638
4,283
1,991
605
1,101
1,978
7,561
5, 297
1,565
6,627
686
1,196
498
1,792
20O
2,812
824
1,061
3,817
336
416
1,060
Ohio _- _
Middle - . -
Northwest — - - __ - - .
Gulf ... . .
Arkansas . _ _
Total .
118, 067
83,409
34,648
.The following report by Surgeon W. C. SPENCEE, U. S. Army, describes the operations
of the Medical Purveying Bureau, on which the various hospitals, field and general, depended
for their supplies of medicines, hospital stores, instruments, dressings, books and stationery,
bedding, etc.
The medical snjiplies of the Army were derived for many years prior to 1861 almost entirely from the Purvey-
ing Depot at New York City. All the military posts in the East and many of those in the South and on the Western
frontier were supplied directly from that depot ; but, for the purpose of securing the prompt distribution of stores
to other points more dilificult of access, several subdepots had been established in the South and West. Four of
these were in existeuce in the year 1860, located respectively at New Orleans, La., San Antonio, Tex., Camp Floyd,
Utah, and Albuquerque, N. M.
By the commencement of hostilities in the spring of 1861 great responsibility was suddenly thrown upon the
Medical Bureau. The rapid organization of a large volunteer force taxed to the utmost the resources of a dexiartraent
compelled to act under circumstances of excessive embarrassment. The quautity of supplies at the principal depot
was extremely small; the manufacture of articles peculiar to the military service involved unavoidable delay, while
the funds at the command of the bureau were entirely inadequate to the emergency. Still, the urgent requirements
of the troops were met with vigor and luomptitude. The principal purveyor was directed to forward immediately
to AVashington large quantities of medicines, dressings, instruments and bedding; to cause necessary supplies to be
prepared with all possible haste and to hold them in constant readiness. Subdepots were also at once established
at Washington, D. C, St. Louis, JIo., and Cairo, 111., in charge of experienced and efficient officers.
The regiments recently formed were with few exceptions well equipped. Many procured their medical outfit
from the authorities of their respective states, many were supplied by the purveyors from the points already men-
tioned, while others proceeded to their destination with very imperfect provision for the sick and wounded, the result
almost invariably either of the inexperience of their commanding and medical officers or of the urgency of the orders
of the military authorities.
Additional purveying depots, as they became necessary, were established and liberally outfitted. Their loca-
tion was determined by proximity to the main bodies of troops, facility of railroad and water transportation and
the advantages of the market. As many as thirty of these were in active operation during the greater part of the
war period.
In addition to the stores accumulated at the depots, supplies, especially adapted to meet the emergencies occa-
sioued by severe engagements, were jjlaced in charge of a medical officer detailed as a field purveyor. It was the duty
of this officer to accompany the army upon its marches, to remain with it while iu camp, to issue the reserve supply
whenever it was needed, and to replenish it by timely requisitions upon the nearest depot.
By far the greater part of the purchases was made by the purveyors at New York and Philadelphia, and from
Ihem the supplies of the jmrveyors at the remaining points were derived either by means of re([uisitions approved
by the Surgeon General, or through orders emanating directly from him. Purchases less iu amount were made, how-
•ever, at Washington, St. Louis, Cincinnati, Chicago, Louisville and other places, when suitable articles could be
procured upon favorable terms. By means of duplicates of the bills of purchase forwarded at the date of each trans-
action the bureau was constantly informed of the state of the markets and enabled to regulate its purchases with
advantage.
Daring the summer of 1861 a revised edition of the Regulations for the Army was prepared. This was pro-
mulgated August 10, 1861, and by it the Jledical Supply Table was materially enlarged and improved. By Act of
Congress, approved April 16, 1862, still greater latitude was given iu the purchase aud issue of medical stores. Sec-
tion ."> of this act inovided:
•'That medical purveyors shall be charged, under the direction of the Surgeon General, with the selection aud
purchase of all medical supplies, including new standard preparations, aud of all books, instruments, hospital stores,
furniture aud other articles required for the sick and wounded of the army. In all cases of emergency they may
THK GENERAL HOSPITALS. 965
provide such aiUlitional accoiiuiioilatioiis I'oi' the sick and wounded of tho army, and may transpoit such medical sup-
plies as circumstances may render necessary, under such reguhitions as may hereafter bo established, and shall make
prompt and immediate issues upon all special reijuisitious made upon them under such circnmstanccs by medical
orticers; and the special requisitions shall consist simply of a list of the articles required, the ijuantity reiiuired,
dated and si<;ned by the medical oliicer requiring them."'
The bureau promptly availed itself of the authority thus conveyed. On .June 17, 18G2, a board composed of
Surgeon R. 8. S.vttkhi.kk, U. S. Army, Medical Purveyor at New York, Surgeon K. O. AliliOIT, U. S. Army, and K. IJ.
Siii'inn, >I. 1).. was convened at the city of New York for the purpose of incorporating in the existing Supply Table
such improvements as were dictated by the experience of the war.
The report of the board was uuide on July 15, 1802. On the 20th of the succeeding October a circular to med-
ical otlieers was issued by the Surgeon General containing the Revised Standard Supply Table and '• IJirections con-
cerning the manner of obtaining and accounting for Sledical and Hospital .'^upi)lies for the Army.' The followiug
extracts from these Directions are submitted:
"The standard of nu-dical and hospital supplies for the Army is the following Rupply table. It is not the design
of the Department to confine medical otlieers absolutely to that table, either in variety or (juantity , but only to establish
a standard for their guidance in making re([uisitious for supplies, leaving indiviiUial preferences to be indulged at
the discretion of the Medical Director or the Surgeon General. Xeither is it supposed that the quantities of the table
will always meet the necessities of unusual emergencies, as during epidemics or in unhealthy seasons and localities;
and n\edical ollicers who allow their supplies to bo exhausted through any such contingencies, without timely notice
of their approaching necessities, will be held to a strict accountability." * • • "Those articles of the standard
supply table which are printed in italics will be furnished only on special requisitions approved by the Surgeon
General.'' » ' • "Articles of furniture! and appliances in Class No. 2 will bo issued on 'requisitions for outfits,'
but not on ' requisitions to replenish supi>lies,' unless the medical oliicer certifies that they cannot be purchased with
the hospital fund." » • • " Carbolic acid (Bower's), sulphate of iron, nitrate of lead, chlorinated liuu! or charcoal
will be furnished as antiseptics or disinfectants, when required.'' • • * "Applications for microscopes by medi-
cal officers in charge of general hospitals will be favorably considered, provided the evidence be satisfactory that
the officer will use the instrument for the benefit of science and will report the results of his observations to the
Surgeon General."
This circular was reissued in substantially the same form on May T, 18(!3. The only alterations of importance
ihat were made in the table consisted in the omission of calonu-1 and tartar emetic, the readjustment of the contents
of the medical pannier and the substitution of medicine cases for the hospital knapsaclf.
The ([uantity and cost of the medicines, hospital stores, dressings, bedding and clothing required for the u.seof
the troops had at this time become so great that the advisability of their preparation and manufacture by the depart-
ment itself came under consideration. The advantages anticipated from the measure were: — the ability to ascertain
in every instance the comparative purity of the wines, liquors, hospital stores and crude drugs offered to the depart-
ment: the attainment of perfect purity and reliability in the medicines prepared; the securing of uniformity in the
mode of putting up the supplies for issue and the saving to the Government of a great part of the jirofit made by the
ordiijary dealers.
I laving determined upon the adoption of the proposed measure the department energetically proceeded to carry
it into eti'ect. Early in the spring of 1803 a laboratory was organized at Astoria, Long Island, in connection with the
purveying depot at New York City: another was established at Philadelphia, Pa., to co-operate with the depot at
that place. They were liberally furnished with suitable apjiaratus: well qualified medical officers were assigned to
their supervision, and the ineparation of supplies was at once commenced. A small laboratory was instituted at th©
same time at the purveying depot at St. Louis, Mo.; lint its ojierations were confined principally to the i)uttingupin
packages adajited to rei.ssne of medicines purchased in bulk and the manufacture of bedding and hospital clothing.
The results attained by these laboratories completely substantiated the correctness of the views which led to
their establishment. An elaborate "Statement of the cost-price and market value of preparations manufactured and
put up at the Army Laboratory at Philadelpliia, Pa., since its commencement in March, 1803, to Sei)tember 30, 18G.5,"
proved that the net financial gain to the Government during that period was $7136,019.32. A similar exhibit presented
by the Superintendent of the Laboratory at Astoria indicated, as a consequence of its transactions for the six months
ending November 30, 1864, savings which amounted to $279,972.04. The savings at the laboratory at St. Louis from
March 1, 1863, to July 31, 1863, were $5,451.96.
During the progress of the war arrangements were made by the Medical Bureau with various contractors Iiy
which the delivery of ice to hospitals situated in the South and Southwest was secured. These hospitals were unable
to procure the reiiuisite supply from local dealers. The number of southern localities embraced in the contracts was
materially increased in the years 1864 and 1865, and it was found advantageous to include many Northern and West-
ern points. Large quantities of ice were also forwanled for the use of armies engaged in active hostilities. Instruc-
tions were issued by the Surgeon (ieneral by which its expenditure was regulated. The per diem allowance for each
patient in hospital south of the latitude of Washington, D. C, was fixed at one pound: north of that latitudi^ at half
a pound. The ice procured in this manner during the years 1862, 1863, 1864 and 1865 .amounted in the aggregate to
48.661 tons. The vast quantities purchased from the hospital funds by the general, post and regimental hospitals
throughout the country are not included in this st:itement.
By an Act of Congress, approved July 16, 1862. an ajjpropriation of $15,(K)0 was made for jiroviding mutilated
soldiers and seamen with artificial limbs. Subsequent expenses for the same object were included in the annual esti-
mates for the Medical Department of the Army. On August 12, 1862, a Board conven6<l ia New York City, in com-
966
THE GENERAL HOSPITALS.
pliance with the instructions of the Surgeon General, to examine moiiels of artificial limljs and to select the best for
adoption. Similar lioords were convoked afterwards for the purpose of enabling the Department to avail itself of
the innivovcments made in apparatus of this character and to designate the prices that should be i)aid. Every sol-
dier entitled to an artificial limb was permitted to choose from the specimens of approved models deposited in the
office of the Medical Director at Department Headquarters the one with which he desired to be supplied. Upon
examiuationof the records it is found that there ^yere furnished to soldiers, at the expense of the United States during
the period intervening between July 16, 18G2. and May i. 1807, 49 artificial eyes. 01 hands, 2,391 arms. 4.09.J legs, 14
feet and 144 apparatus for resection.
The tabular statement which concludes this article is an exhibit of the ijuautity of certain of the supjilies pur-
chased and manufactured during the war by the Medical Department of the Army. It is presented not only on account
of its intrinsic interest and value, but also as an evidence of the faithfulness, liberality and efliciency with which the
Government provided, through its own agencies, for the welfare of the sick and wounded.
ABTICLES.
Ararijv pulvis, in ^-Ib. bottles oz-
,\i:itliiin aci:-ticuiu, in ^-!b. g. s. bottles oz.
A'-iiliim sulphuricum aroniaticum oz.
.\citlum tannicuin, in 1-oz. bottles __oz.
Acitlum tartaricum, in 8-oz. bottles oz.
./Ether fortior, in i-lb. g. s. bottles and J-lb. tins 02.
yEtiieris spiritus compositns, in ^-Ib. g. B. bottles oz.
iEtheris spiritus nitrici, inj-lb. g. s. bottles oz.
Alcohol fortius, in 32-oz. bottles bottles
Aiuinoniie, liquor, in ^Ib. g. s. bottles oz.
Argenti nitras, in 1-oz. g. s. bottles oz.
Argenti nitras fusus, in 1-oz. bottles oz.
Cauipboi*a, in 8-oz. bottles oz.
Ceratum aJipis (simple cerate), in 1-Ib. pots lbs.
Ceratum resinai, in 1-lb. pots lbs.
Chloroform oz.
Creta itreparatJi, in j-Ib. bottles oz.
E.vtractum aconiti radicis fluidum, in |-lb. bottles oz.
Extractum belladonn.'e, in 1-oz. pots oz.
Extractum buchu fluidum, in ^-Ib. bottles 02.
Extractum cinchouie iluidum {with aromatic?) 02.
Extnictum colocynthidis compositum, in S-Dz. pots oz.
Extractum conii, in 1-oz. pots s^ oz.
Extractum gentianfe fluidum, i^ ^-Ib. b^tPles oz.
Extractum hyoscyami, in 1-oz. pots oz.
Extractum ipecacuanha; tlnidum, in ^-Ib. bottles oz.
Extractum nncis voniicje, in 1-oz. pots oz.
Extractum pruni virginianie fluidum, in ^-Ib. bottles — oz.
Extractum rhei fluidum, iu s-Ib. bottles oz.
Extmctum seueg.^ fluidum, in ^-Ib. bottles oz.
Extractum Valeriana; fluidtnu, in ^-Ib. bottles oz.
Extractum zingiberis fluidum, in i-lb. bottles oz.
Ferri cbloridi tinctura, in i-lb. g. s. bottles oz.
Ferri iodidi syrupus, in i-lb. g. s. bottles oz.
Ferri et quiuiie citra*, iu 1-oz. bottles oz.
Ferri persulphiitis liquor, in 4-oz. g. e. bottles oz.
Ferri persulphatis pulvis, iu 1-oz. g. s. bottles oz.
Ferri sulphas, in 4-oz. bottles oz.
Ferri pilulfe, in S-oz. pots oz.
Hydrargyrum cum creta, in ^-Ib. bottles oz.
Ipecacuanha' pulvis, in i-lb. Ijottles oz.
Ipecacuanha; et opii pulvis, in s-lb. bottles oz.
Lini pulvis, in tins lbs.
Maguesije sulphas lbs.
]>[orphiie sulphas, iu 4-oz. bottles oz.
Oleum ricini, in 32-oz. bottles oz.
Opii piUvis, in j-lb. bottles oz.
Opii tinctura, in |-lb. bottles oz.
Opii tinctura camphorata, in ^-!b. bottles oz.
Pilnla; opii, iu g. s. bottles doz.
Potassa; bitartras, in ^-Ib. bottles oz.
Potass!? chloras, in ^-Ib. bottles oz.
Potassii iodidum, in ^-Ib. bottles oz.
Quinia; sulphas, compressed in 5-oz. tins oz.
Khei pulvis, iu 4-oz. bottles oz.
Soilla; syrupus, in 1-lb. bottles lbs.
Soda; chlorinata; liquor, in 1-lb. g. s. bottles lbs.
Soda; bicarbona.s, iu ^-Ib. bottles oz.
Soda; ct potassa; tartras, in i-lb. bottles oz.
Spiritus lavandula; compositns, in i-lb. bottles oz.
Spiritus frumenti (whiskey), in .3'3-oz. bottles bottles
Spiritus vini gallici, in 32-oz. bottles bottles
Vinum album (sherry), in 32-oz. bottles bottles
Zinci chloridi liquor, in 1-lb. g. s. bottles oz.
Zinci sulphas, in 1-oz. bottles oz.
HOSPITAL STOr.ES.
Arrow root lbs.
Beef, extract of, in 2-Ib. tins lbs.
Cocoa, or chocolate, in tins or cakes llis.
Coffee, extract of, in i-gal. tins galls.
Corn-starch, in 1-lb. papers lbs.
Farina, in 1-lb. papers lbs.
Ql'ASTITT.
869, 070
353, 477
395, 708
83, 550
399, 977
1, 002, 045
357, 372
1,610,361
483, 930
1, 237, 027
42,185
35, 818
924, 184
210, 880
51,049
1,146,982
243,048
218,326
28, 243
309, 89G
618, 957
188, 030
13, 524
347, 173
20, 534
313, 739
.11,989
307, 323
258,009
315, 633
170, 625
606, 380
616, 474
162, 614
50, 772
130, 997
153,741
544,045
277, 808
69, 278
328, 029
447, 151
415, 996
615, 828
27,200
220, 334
652, 196
828, 258
993, 311
813, 156
656, 488
568, 923
531,744
595, 644
132, 552
183, 582
167, 459
052, 913
798,553
404,117
1,907,145
682, 187
736,4.59
486, 966
02, 805
62,226
570, 980
129,596
25, 317
218, 708
251,837
ARTICLES.
Gelatine, shred, in j-lb. packages lbs.
Milk, concentrated, in 1-lb. tins lbs.
Porter, in pint bottles bottles
Tea. black, in tins or original chests lbs.
Tapioca, in tins lbs.
IXSTROIESTS.
.\mputating cases no.
Amputating and trephining cases no.
Compact field cases no.
Electro-magnetic machines no.
Exsecting cases no.
General operating cases no.
Minor operating cases no.
Personal instruments sets
Pocket cases no.
Post-mortem cases no.
Trephining cases no.
Tourniquets, field no.
Tourniquets, screw, with pad no.
Trusses, inguinal, double no.
Trusses, single no.
rUESSIKGS, Etc.
Adhesive plaster, 5 jards in a can yds.
Cotton bats no.
Otton wadding sheets
Flannel, red, all wool yds.
Gutta-percha cloth yds.
Ichthyocolla plaster, 1 yd. in case yds.
Lint, "patent, liucn or flax lbs.
Lint, picked or scraped, linen lbs.
Muslin, bleached, unsized, 1 yd. wide yds.
Oiled muslin, in 4J-yd. pieces yds.
Oiled silk, in 4^-yd. pieces yds.
Roller bandages, assorted, iu a pasteboard box doz.
BEDDING.
Bed-sacks no.
Beds, water, of India rubber no.
Blankets, white ; gray for the field no.
Counterpanes, according to pattern no.
Cushions, rubber, -with open centre no.
Cushions, rubber, for air or water, small no.
Gutta-percha bed-covers _ no.
Mattresses, hair, in two equal parts, to pack folded do.
Mattresses, of straw, moss or shucks no.
Mosquito-bars, when specially required no.
Pillows, hair _" no.
Pillow-cases, cotton, colored no.
Pillow-cases, linen, white no.
Pillow-ticks no.
Sheets, linen no.
FURXITUBE AXD APPLIANCES.
Basins, tin, wash-hand no.
Bed-pans, delf, shovel-shape no.
Bedsteads, iron no.
Close-stools no.
Lanterns, glass no.
Medicine jianniei^, furnished by the list no.
Medicine wagons no.
Mess-chests, furnished by list no.
Mugs, delf no.
Pitchers, delf, half-galloa no.
Plates, delf no.
Ranges, size as required, with fixtures complete no.
Spittoons no.
Stoves, cooking, with fixtures complete no.
Qr.\NTITY.
13,067
479,014
1,833,948
429, 696
85, 226
360
235
3,955
20
150
596
77
273
12, 656
303
213
50, 214
13, 974
0,350
43. 529
327,943
66, 727
73, 225
159, 693
100,011
224, 707
147, 135
82, 754
3,612,442
72,219
91, 702
008, 817
522,246
1,144
1, 165, 805
496, 769
6,486
11,724
39,661
75, 920
169,080
221,058
.367, 613
631, 801
418, 365
318. 815
1,638,770
92,893
38, 378
274, 701
9, 737
3'.l, 499
6, 830
251
3,954
247, 993
35,433
472, 022
204
89, 169
1,821
LIST OF MI-I)I(\VL OFFICERS CITFD OR MIiXTIOXFD.
Pago.
Abbott, A. B., Act. Ass't Surgeon 'JOO
Abbott, C'lmilisf, Surgeon 26tli Mo 64S
Abbott, R. 0.,Snrgc-on V. S. .\ 965
Ailnms, W. S., Act. Ass't Surpvon 300
Ailbr, J. 51., Aot. Ass't Snrgoon 0e2
Ailrcoii, S. W., Act. Ass't .Surgeon 903
AUUn, 0. II., Ass't Surgeon I". S. A 37, «
Alloii, C, Surgeon 1st JIo —03.".
Allen, Ilnrrisoii, Ass't Surgeon V. S. A 134,
144, 330, ,'i38, 339, 340, 345, 347, .350,
351, 35S, 379, 3S0, 381, 3S2, SS3, »S5,
380, 3S7, 388, 390, 392, 39.-., 397, 399,
4M, 405, 408, 409. 413, 432, 434, 401,
403, 07-2, 098, 732, 737, 745, 74S, 7ra,
772, 773, 770, 778, 812, 82:1, 884, 900
Allen. J. M., Surgeon 51th Pa 154, 158, 734
Anilnis, C. II., Ass't Surgeon 12Slh X. Y..395, 828
Angell, L. II., Surgeon 52il III 033
Ansell, A., Act. Ass't Surgeon 385, 808
Antis, II. T., .\ss't Surgeon 33(1 111 173
.\scli, Morris .T., Ass't Surgeon V. S. .\ 75, 303
Atkinson. AV. B., Act. Ass't Surgeon 824
Alice, Walter F., Act. Ass't Surgeon 418
lUiche, T. II.. Sui^eon V. S. V 109, 4SC, 075,
871, 900
B.ickns, A.. .Vet. Ass't Surgeon 901
Bacon, Cynis, jr., .\8s't Surgeon V. S. A 404.
709, 902
Bailey. K. K.. Act. .\ss't Snrgeon 114, 390,
842, Sfil
Bailey, .1. II., Surgeon U. S. A — 179
Riily. E. J., Surgeon V. S. A 962
Biiily. .los. C, Ass't Surgeon V. S. A 089
linker. Thus. C, Surgeon 7tli Me 272
aibhvin, L. K., Act. As.s't Surgeon.. 8'20
Banks. J. T., Surgeon 13tli Ga 589
Banks, W. A., Ass't Surgeon F. S. V 903
Barnes, Jos. K., Medical Ius|)ector Genenil
r. S. A 59, S95, 912
Barnev. Nonnan S.. .\ct. Ass't Sui^geon 883
Priirnnm. B.. Surgeon 25tli Mich 901
Barr. R. X., Surgeon 3Ctli Ohio 309, 311,
323, 327, 539
Bnrlholf, John H., Ass't Surgeon V.S. A'..73I, 881
Bartliolow, Roberts, Ass't Surgeon V. S. A._ 521,
525, 570, 001, 049, 001, 885, 899, 901
Bates. J. C Surgeon C. S. A 30
Bates. Jas. M.. Surgeon 13th Me 85, 92, 052,
717, 751
Batwell, E(lwar<l, Surgeon 11th Jlieli 319
Bii.vter, J. II.. Surgeon l". S. V 28, 481
r«ixtir, J. P. <;., Surgeon U. S. V 903
Beik, E. AV. II.. Surgeon M Inil. Cav 490, 507
IV'Uanger, J. B., Surgeon l'. S. Y 032
Benedict, M. P., Surgeon 75tli X. Y 124
Bennett. George S., Act. Ass't Surgeon 214
Bentley, Edwin. Surgeon U. S. Y 132, 343,
.347, 3.30, 384, 391, 401, 74.3, 701,
789, 7',>4, 798, 831, )j79, 88-1, 90O
R'rry. William, Surget.n 7th Ky 054
Biilwell. E, ('., Surgeon 31st Mass 122
Bigelow, J. K.j Surgeon Sth III 034
Billings, John S., Surgeon V. S. A 80, 101,
038, 089, 703, 910
Bishop, W.. Act. -Vss't Snrgeon 883
Blakeslee. Wni. R.. Surgeon lloth Pa... 841, 891
Bliss. P. W., Surgeon V. S. V 9C0
Bliss. Zel.as E., Surgeon V. S. V ?,%;, 30.3, 902
Bockee. J.. Surgi-tin V. S. V 90:1
Boisnot, J. 31.. Snrgeon l'. S. V 302
Page.
Bonine, E. J., Surgeon 2d Mich 031
Bonlecou, R. B., Surgeon l'. S. V 3S6, 653,
5,37, 9flU
Bournonville, A. C, Surgeon l'. S. V 394
Bowen, Tlionni.s, Act. As.s'1 Surgeon 137, 3,3:1,
:!83, .-Ke, 4«i! 413, "747, 808
Bowles, S. W., Act. Ass't Surgeon 5I'.5
Boyd, Geo. B., Act. Ass't Surgeon 814
Boyle, C. E., Act. Ass't Surgeon 342
Brailley, Wni. A., jr., .\ss't Surgeon U. S. A.. 20
Bradley, W. I,., Medical Cadet, I'. S. A XU
Bradt, J. G., Surgeon 2Ctli Mass 108, 892
Brady, J. W., Surgeon 8tli Tenu. Cav ^ 902
Bmineitl, T. C, As.s't Surgeon V. S. A 900
Brandies, 1!.. Act. Ass't Surgeon 280, 519
liraslieai-, IS. 1!., Surgeon ICtb Ohio 738, 739
Breed, 1!. li., Surgeon V. S. V 902
Breneman. E. PeW., Ass't Surgeon U. S. A .. 879
Brickett, G. E., .\ct. Ass't Surgeon 901
Brinton, P. G.. Snrgeon V. S. V 901
Brooke. J. E., Act. Ass't Surgeon ..412, .381,
058, 788, 794
Brown, Harvey E., Ass't Surgeon U. S. A... 109,
310, C82, 875
Brown. H. W., Surgeon 4tli Colored 095, 750
llruwn, J. M., .Vet. .Vss't Surgeon 961
Brown, Joseph B., Surgeon I'. S. .V 109
Brown, L. C, Surgeon 83th Ohio 849
Brown, Rnfus King, Surgeon U. S. V 732, 734
Brown, W. W., Surgeon 7th X. II 157, 272,
032, 651, 090, 840, 8.50
Br..wnl..w, J. II., Act. Ass't Surgeon 831
Bryan, James, Surgeon U. S. V 153, 325,
53G, 093, 900
Bryan, W., Act. Ass't Surgeon 135
Bryant, II., Snrgeon I'. S. V 339
Buck, K. II., Act. Ass't Surgeon 902
Buck, H. B., Ass't Surgeon U. S. V 740
Bucklaiul, Frank, .-Vet. Ass't Surgeon 349
Buckinan, E. D., Ass't Surgeon U. S. V 828
Burke, V. X., Surgeon U. S. V 902
Burnhani, C. .\., -Vet. .Vss't Surgeon 270
Bushey, F. .V., .Vet. Ass't Surgeon 903
Butler, J. II., Act. Ass't Surgeon 381
Byrne, B. M., Ass't Surgeon V. S. A 179
Byrne, C. C, Ass't Surgeon V. S. A 902
Byrne, John. Surgeon U. S. .V__ 179
Cady, Charles E., Ass't Surgeon 13Stli ra_.. 317
Calhoun, J. T., Ass't Surgeon V. S. A 14, 272,
317, 373, 491, 3;i9, 88,3, 901
Ciipehart, Henry, Surgeon 1st Vn. Cav 704
Carrington, W. A., Surgeon C. S. A 027, 042
Carter, Charles, Act. Ass't Surg 140, :!77, 790
Carvallo, Carlos, .Vet. Ass't Surg 353, 409, 411
Chamberlain, C. X., Snvg. 10th Mass-.1G8, 0.31, 901
Chambers, S. U., Ass't Surgeon C. S. A 889
Chambers, W. M., Surgeon I'. S. V 894
Chapel, A., Surgeon I". S. V 962
Chapman, ,ras. F., Ass't Surgeon 90th X. Y.. 078
Chase, B. S., Surgeon 53d Colored 902
Chase, Enos G., Surgeon 101th X. Y 718
Chenowith, W'. J., Surgeon 35th III — 302
Christian, R. A., Surgeon U. S. V 900
Claiborne, Jno. II., Surgeon C. S. A 887, 8{9
Clapp, W. A., Act. Ass't Surgeon... 901
Clark, Charles M., Surgeon :'.9th III 560
Clark, E. A., Surgeon V. S. V. 96:!
Clark, l5.Tac .1., Surgeon 12th Pa 30O
Clarke, A. M., Surgeon I". S. V 53
Claude, A., Act. Ass't Surgeon i 110
I-age.
CIcdR'Ut, Tho.n. It., Act. Ass't Surgeon ...700,790
Clements, B. A., Surgoou V. S. A 901
Clippingcr, Geo. W., Surgeon 14tli Ind 273
Cloak, B., Surgeon T. S. V 902
Coale, Eilward, Surgeon l*. S. X 707
Cogswell, Jl. F., Ass't Snrgeon I'. S. Y 001
Colgau, Joseph P., Surgeon 39th S. Y.„301,490,
491,717
Collins, .lames, Surgeon 3d Pa 3i'vl,37I
Combs, W. II., Act. .Vss't Surgeon 817
Coniegys, E. T., As-s't Surgeon l*. S. A 619
Conner, P. S., Ass't Surgeon V. .S. A 901
Conradj II. F., Surgeon nilh Pa 165
Cook, L. C, Act. Ass't .Surgeon 704
Cook, Thonnis M., Surgeon 101st Ohio 0.33
Coolidge, Itiehard II., Jled. Inspeet..r V. S. A. 49.
55, 101, 102, 179, 08;), 932, 945
Cooper, George E., Surgeon l'. S. A 126,153
Coover, J. II., Act. Ass't Surgeon 117
Cornick, Wm. F., Ass't Snrgeon U. S. A. .076, 078
Coues, E., Medical Cadet U. S. A 410,920
Coventry, W. B., Surgeon ifitU X. Y' 919
Cowgill, Clayton A., Surgeon U. S. V 079,082
Cox, A. L., Snrgeon V. S. Y 049
Co.'ce, L. L.. Inspector I'. S. San. Com ...894,895
Crafts, A. P., Act. Ass't Snrgeon 133,392,
396,398
Crane, Charles II., Ass't Surg. Gon. U. S. A.. IM,
078, 082
Crispell, A., Surgeon V. S. V 901
Crosby, Albert II., -Vet. Ass't Surgeon 583,
080, 001
Cro.sby, PiNi, Partmouth, X. II 084,585
Crosby, II. B., Partmouth, X. It 535
Crosby, Thos. B., Surgeon I". S. V 418,900
Crowell, R., Act. Ass't Surgeon 903
Culbertson, II., Snrgeon U. S. V 9I>2
Cunningham, T., Act. Ass't Surgeon 810
Cuylcr, J. M., Surgeon V. S. A...26,300,627,051
i Pa Costa, J. M., Act. Ass't Surgeon 320,861,
802,803,804,86.3,880
I Dade, F. T., Ass't Surgeon U. S. Y 142
I Piiggett, D. L., Act. Ass't Surgeon 809
Palrymple, A. P., Surgeon V. S. V. 903
' Palton, J. C, Surgeon l". S. Y G7S
Darraeh, B., Surgeon T. S. Y 709,867
Pavid, E., Act. -Vss't Surgeon 413
Pavies, J. M., Ass't Surgeon 9th X. J Os2
P'.Vvignon, F. J., Surgeon 96th N. Y 144, 183
Pay, PeWitt C, Act. Ass't Surgeon 605,074
Pay, J. F., jr., Ass't Surgeon 10th Mo 718
Pean, Charles A., Snrgeon 89th Colored 718
Pean, Henry M.. Act. Ass't Surgeon 117,335,
382, 383, 385, 304, 300, 403,
400,409,784,787,813,826
DeBenneville, u. S., Surgeon 11th Pa — .371
DoBruler, J. P., -Vet. A.ss't Surgeon 007
DcLeon, I). C, Surgeon U. S. A 179
Derby, Cn-orge, Surgeon 2;M Mass 109,489
Dibble, F. L., Surgeon Cth Conn 15:1,158,103
Piekerhoff, A. J., Ass't Surgeon •27tli 111. .206, 717
Dickson, John, Act. A8.s't Surgeon 747,770
Digby, J. W., Act. Ass't Surgeon 504
Ponnell, Jotham, Surgeon 13th Me C34
Porram, W. M., Ass'tSurgeon I". S. Y 903
Dorsey, Lloyd- Act. Ass't Surgeon 140,204,
346, :W7, 414, 747, 860
Doughty, J. II.. A.«'t Snrgeon U. S. Y 682
Downing, J. C. C. Ass't Snrgeon V. S. A — 851
Dmrj-, \Y. II., Act. Ass't Surgeon 813
967
968
LIST OF MEDICAL OFFICERS, ETC.
Pagr*.
Ducachet, H. \V., Surgeon V. S. V 345, i)60
Pimglison, T. B., Act. .\ss"t Surgeon 409
Punster. E. .S., Ass't Surgeon l". S. A 086,908
Dunton, W. K., Act. Ass't Surgeon C69
Dyer, .1. F.. Surgeon 19th Mass__254,309, C87,S40
Eastman. Lewis M., Ass't Surgeon U. S. A._ 908
Edgar, 'n'm. S., Surgeon Sid 111 485
Edwards, L. A., Surgeon U. S. A 959,901
Egbert, .\ngustus E., Surgeon t'. S. 'V" 750,
751,840
Elliott, Tlios. 11., -\ct. -Vss't Surgeon 410,770
Emory, A. Walsh, Act. Ass't Surgeon 701
Etheridge, , Surgeon C. S. A. 038
Evans, J. P., Surgeon U. S. V 005
Everts, F., .\ct. Ass't Surgeon 270
Everts, Orpheus, Surgeon 20th Ind 720,871
Farley, Charles C, Surgeon 2d Cal. Cav 733
Farley, Jas. 3L, Surgeon 84th X. Y 480
Farquharson. E. J., Surgeon 4tb East Tenn. 091
Farrand. D. O., Act. Ass't Surgeon 901
Faulkner, Wm., Surgeon 83d Pa . 303
Fauntleroy, A. M., Medical Director C. S. A_ 189
Faxon, W. L., Surgeon 32d Mass 412, 878
Fay, George W., Act. .\ss't Surgeon 352,746
Fee, John, Act. Ass't Surgeon 700,705
Fillmore, C. W., .^ct. Ass't Surgeon 379,790
Finfrock, J. II., Ass't Surg. 11th Ohio Cav _. 521
Fish, John, Surgeon 17th Colored 85, 095
Fisher, Paul 31., Surgeon 8th Jle 718
Fletcher, Eohcrt, Surgeon r. S. V 894
Fletcher, W. K., Act. Ass't Surgeon 778,878
Flickinger, John, Act. .\ss't Surgeon .'144
Flint, Austin, Act. Ass't Surgeon __.323, 564, 828
Flood, Patrick H., Surgeon 107th N. T 331
Flora, D. Vi'., Act. Ass't Surgeon 140,354
Foote, II. C, Surgeon 2'2d Ohio 703
Ford. Sample, .\ct. Ass't Surgeon 330,349,
393, 797
Forwood, ■«■. H., Ass't Surgeon U. S. A 900
France, G. \V., Act. Ass't Surgeon 902
Franklin, E. C, Surgeon U. S. V 903
Fi-antz, J. H., Surgeon I'. S. A 90:!
Freeman, S. D., Surgeon 13tU Pa 371
Prick, A, P., Surgeon 103rt Pa 300,088
Frink, C. S., Surgeon U. S. V 155,150,158,179
Frothingham, "W., Surgeon 44th N. T 553
Fry, Thomas ^\^., Surgeon XT. S. V 901
Fryer, B. E., Ass't Surgeon U. S. A 901
Fuller, S. E., Surgeon U. S. V 902
Fuqua, 'William 31., Surgeon 7th Fla 038,646
Furley, Charles C, Ass't Surg. 2d Cal. Cav.. 851
Gage, 31. B., Surgeon 25th 'V\'is_ -_123, 179,
272, 317, 538, 651, 719, 72S, 751, 808, 800, 841
Galloui*, Isaac F., Surgeon 17th Mass 144, 107,
179, 183, 489, 490, 710, 892
Gardner. J., .Vss't Surgeon 24th Ky 901
Gardner, W. H., Ass't Surgeon U. S. A 651
Garvin, P. E., Ass't Surgeon 40th 3Iass 749
Gates, Wm. M., Surgeon 22d 3Io 653
Gay, S., Surgeon U. S. V 901
Gibbons, Henry, jr., .\ct. Ass't Surgeon ._13G, 335
Gihon, .\lbert L., Surgeon V. S. N 095
Gilmovo, J. T., Surgeon C. S. A 028, 038, 040
Giltner. J. S., ,\ct. Ass't Surgeon 962
GiiTiu, B. 31., Act. .\ss't Surgeon 733,881
Gleason, 31. K., Act. As.s't Surgeon 335,352,
731, 732, 813, 807
Glennan, P., Ass't Surgeon U. S. "V' 960
Goldbrecht, 3V. H., Surgeon I'. S. V 901
Goldsborougb, John, .\ct. Ass't Surgeon 594
Goldsmith, 31., Surgeon V. S. V 073,901
Page.
Goodman, H. Earnest, Surgeon 2Sth Pa 25,
125,093
Gordon, "NV. A., .\ct. Ass't Surgeon 884
Gorminger, "W. H., Act. Ass't Surgeon 901
Grafton, ■fl'm. II., .\ct. Ass't Surgeon -208
Graham, Samuel, .Vet. Ass't Surgeon 749
Granger, 3V. \V., Ass't Surg. 3d Mo. Cav 179,
182,317,541,875
Grant, B. F., Act. Ass't Surgeon 806
Grant, G., Surgeon r. S. V 901
Gray, A. J., Act. Ass't Surgeon 522
Gray, A. ■«■., Surgeon -UUi Ind ._ 093
Gray, C. C, Ass't Surgeon U. S. .\ 0.35
Gray, John B., 3Ied. Insp., 3Iemphis, Tenn 895
Green, A. W., Surgeon 7th Pa 371
Greene, F., Surgeon V. S. \ 901
Greenleaf, Charles E., Surgeon U. S. A 521
Gregg, A., City Physician, 3Iemphis, Tenn__ 890
Grimes, W. H., Surgeon 13th Kans 143,635,870
Griustead, 3Vm., Surgeon U. S. V 093
Griswold, E., Surgeon I12th Pa 840,871,960
Gross, F. H., Surgeon t". S. V 901
Grcss, S. W., Surgeon U. S. V 900
Grove, John H., Surgeon U. S. V 047
Guukle, W. H., Surgeiiu 7.3d Pa 704
Habersham, S. E., Surgeon C. S. A 29, 038, 042
Hacbenberger, G. P., Ass't Surg. 28th Obio._ 703
Haight, D. L., Act. .\ss't Surgeon 407,732,
828, 882
Hale, 31., Act. .Vsis't Surgeon 770,777
Hall, A. Douglas, Act. .iss't Surg .._578, 813,872
Hamilton, F. II., 3Ied. In.spector U. S. A 632,
636,090,091,712,851
Hamlin, A. C, 3Ied. Inspector U. S. A.-_169, 730
Hammer, A., Surgeon U. S. V 637,750,751
Hammond, J. F., Surgeon TJ. S. A 080,708
Hammond, T. 11., .\ct. .\ss't Surgeon 795
Hammond, W. ,\., Surgeon General U. S. A_ 622,
899, 901, 908
Hammond, W. Leon, .\ct. .\s8't Surgeon 389,
393, 706
Hanawalt, George P., Act. Ass't Surg 340,381
Hand, D. 3V., Surgeon U. S. \ 120, 155,
179, .332, 527, 628, 033, 079
Hajipersett, J. C. G., .\ss't Surgeon V. S. A__ 902
Hard, A., Surgeon 8th 111. Cav _ ,349
Harlow, L. D., Surgeon U. S, ■\' 902
Harney, B. F., Surgeou U, S. A 179
Harney, "NV. A., .\ct. .\ss*t Surgeon 212
Harrison, B. F., Surg. lud. Bafn, X. Y 180,181
Hart, S., Surgeon U. S. V 902
Harvey, P., Surgeon 19tb Iowa 538
Ilan-ey, "U'. A., Act. .\ss't Surgeon 262
Haven, A. H., Act. Ass't Surgeon 340, 387
Haven, J. Foster, jr., Ass't Surgeon U. S. V _ 25
Haven, S. E., Surgeou U. S. V 306, 372
Hayes, I. I., Surgeon l". S. 'N' 920, 900
Hays, 3Vm., .Surgeon C. S. A 707,708
Hay ward, Nathan, Surgeon ■20th Mass 687
Haywood, E. Burke, Surgeon C. S. A 185, 687
Ilazelton, \V. J., .\ct. .\ss't Surgeon 777
llazlett, K. 3V., Surg. 5th West Va. Cav__539, 875
lleanl, Lewis, Act. Ass't Surgeon 671,704
Heazlett, J. C, Med. Beg., Memphis, Tenn.. 890
Heger, A., Surgeon U. S. A 900
Hemenway, S., Surgeon 41st Colored 695, 090
Henderson, D. W., Surgeon 9Cth Ohio ISO, 181
Hendricks, E. F., Ass't Surgeon 15th Conn.. 682
Herbst, J. E., Surgeon I". S. Y 962
Hewitt, Heury S., Surgeon U. S. 'V' 179, 183
Hildretb, J. S., Surgeon V. S. \ 901
Ilildreth, T., Surgeon 3d 3Iaine 738, 875
Hinkle, F., .\ct. Ass't Surgeon 406
Hinton, John H., Act. Ass't Surgeon 270
Ilirshfield, 11., .\ct. Ase't Surgeon 407
Page.
Hoff, Alexander H., Surgeon U. S. '\' 338, 961
Hoff, J. Vau E., Ass't Surg. U. S. A_498, 522, 525
Hoffmau, E. S., Surgeon 90th N. Y 670
Hogeboom, G. W., Surgeon V. S. V 962
Holden, .\. 3V., .\ct. .\ss't Surgeon 337, 338
Holden, E., .\ct. Ass't Surgeon 394
Holly, P. E., Act. Ass't Surgeon 214, 747
Holmes, B. S., Surgeon IT. S. A __ 083
Holsten, John G. F., Surgeon I'. S. Y 052
Hood, G. H., Act. Assi't Surgeon 963
Hopkinson, J., Surgeon TJ. S. V 960
Horn, George H., Ass't Surg. 2d Cal. Cav_.. 150,
1.37
Hornor, Caleb W., Surgeon U. S. V 783, 960
Horr, Oriu A., Ass't Surgeon 114tb Colored. 815
Horton, S. M., Ass't Surgeon I'. S. A 903
Hough, Franklin B., Surgeon 97th N. Y 655
Hovet, H., Surgeon 40tb N. Y 851
Hubbard, George H., Surgeon U. S. V.._037, 961
Hubbard, Eobert, Surgeon 17th Conn 547
Huber, John F., Ass't Surgeon U. S. V 903.
Humphreys, Lewis, 3Ied. Inspector U. S.' A__ 65,
07, 328, 047
Hunt, Sauford B., Surgeon U.S. Y 85, 312,
480, 001, 022, 633, 635, 864
Hunter, Jas. B., .Vss't Surgeon 00th Ind 155,
1.30, 175
Huntington, D. L., Surgeou r. S. A 125, 179,
024, 840
Huntiugtou, G. F., Act. Ass't Surgeon 902
Hutchinson, J. H., Act. Ass't Surgeon 384
Ingram, .\lexauder, Ass't Surgeon U. S. A_. 155,.
166, 867
Irish, Franklin, Surgeon 77th Pa 3'25, 328
Ironberger, John H., Surgeon 63d Pa 026
Irwin, B. J. D., Surgeon U. S. A 895
Isham, B. N., Surgeon U. S. V 961
Jackson, J. B., Surgeon 121st Colored 319
Jackson, E. 31. S., Surgeon 11th Pa 128, 141,
606, 608, 962.
James, , Prison Surg., Andersonville, Ga. 42
Jamison, Jno. S., Surgeou SOth X. Y' 480,
487, 710
Janes, H., Surgeon U. S. 3* 961
Jaquette, Geo. P., Ass't Surgeon U. S. A 522
Jeancon, J, A., .\ct. Ass't Surgeon 961
Jewett, Geo., Surgeon olst 3Iass 554, 5.55
Jewett, P. A., Surgeon U. S. Y 001
Johns, E. W., Ass't Surgeon U. S. A 083, 710
Johnson, G. K., Medical Inspector U. S. A 052
Jones, Joseph, Surgeon C. S. A___l, 29, 30, 31, 32,
33, 35, 30, 37, 38, 39, 42, 04, OS, 101, 103,
104, 105, 100, 108, 109, 121, 139, 149, 171,
172, 189, 190, 200, 207, 208, 501, 689, 590,
001, 028, 638, 705, 713, 720, 722, 723, 7-25
Judson, 0. A., Surgeon U. S. V 900
Karlier, T. J., Act. .\ss't Surgeon 771
Keefer, H. G., Act. Ass't Surgeon 961
Keen, 3V. "W., jr.. Act, Ass't Surgeou 733
Keeney, Charles C, 3Ied. Inspector U. S.A 49,
50, 51
Kellogg, L. D., Surgeon 17tb 111 862
Kelly, F. 'W., Act. Ass't Surgeon 902
Kempster, W., Act. Ass't Surgeou ..212, 417, 827
Kendall, H. 3V., Surgeon 5(]tb 111 053, 734
Kendall, Jas. Y., Surgeon 149tb X. Y 310, 317
Kenderline, E.S., Surgeon U. S. 3' 900
Kennedy, Stiles, Surgeon C. S. A 185, ISO, 100
Kessler, A., .\ct. .\ss't Surgeon 882
Kiernan, James L., Surgeon 6th Mo. Cav 362
King, James, Surgeon U. S. V 363, 36li ■
LIST OF MEDICAL OFFICERS, ETC.
969
ragf.
Khu,-, J. F., iUt. Ass't Surgeon 33:t
KirktT, Jolm, Act. Ass't Surgeon Ota
Kitdun, J. M., Act. Ass't SurgooTi »CI
Killiiiger, JI. S.. Snrgoon IWltli S. Y 503
Kiiipp, Joscpli, Act. Ass't Surgeon I'. S. A-. 312,
833, S4.-I
Klulier, Emilo, .\ct. Ass't Surgeon G3f.
Kneelunil, Sanniel, Surgeon 4.">th Mass__.'>.ir', 554,
j.'i7, OOC. Oil. 7-2I'.. 87S. OS)
L!inil>..I>. S^., .\cl. .\ss't Surgeon 1S4, 44U
Uue, Samuel C, Surgeon 5tli Ta 3G(i, 308
Liiniiliier, A. II., Surgeon lOOtli 111 840
Ijisliells, Tlieo. I)., Surgeon ITlst I'n C27
Lawsoii. Thunms, Surg. Gen. l*. S. .\ 170, 184
Leacli. Geo., Surgeon 57th X. Y G2fi
LeCoute, John L., 3Ied. Inspector U. S. A — 50,
Leillie, J. II., Surgeon V. S. V 003
Lee, C. C, Ass't Surgeon U. S. .\ -214, S4C
Lee, Dmight JI., Ass't Surg. 22d X. Y. Cav.. 872
Lee, E. A., Surgeon 54tli Colored 063
Lefllngwcll, If. S., Act. Ass't Surgeon 751
Legler, H. T., Ass't Surgeon T. S. V 0C2
Lehlbach, Charles F. J., Surgeon 7th X. J .. 820
Leidy, .losepb, .\ct. .\ss't Surgeon 134, 135,
137, 341, 331, 3M, 35C, 357, 358, ,T59, 380,
384, 388, 380, 305, .SOS, 390, 400, 400, 408,
418, 410, 473, G20, 720, 748, 700, 778,
780, 81-2, 814, 810, 800, 808, 881, 882
Leighton. X. W., Surgeon 173il X. Y 003
Le Roy, David, Surgeon 9th 111 025
Lettorman, Jonathan, Surgeon V. S. A 372,
088, 717, 908
Lettermau, W. II., Act. Ass't Surgcou...3o0, 363,
38-2, 383, 400, 407
Levis, H. J., .\ct. Ass't Surgeon 900
Lewis. J. B., Surgeon L'. S. Y 903
Lewis. D., Act. .\ss't Surgeon 205
Lewi.-, Francis M., .\ct. Ass't Snrgcon 815
Lidell, John A., Surgeon V. S. V 470, 580,
612, 744
Liebold, T. II., Act. Ass't Surgeon -212
Linton, J. D., Act. .\ss't Surgeon _379, 790
Little, C. F., Act. Ass't Surgeon 355
Lloyd, Frederick, Surgeon 10th Iowa 840
Loewenthal, H., Ass't Surgeon U.S. V 137,
384, 820
Logan. James T., .\ct. Ass't Surgeon ."^3
Logan, Samuel, Surgeon C. S. .V 101, 171, 172
Longwill, K. II., Act. Ass't Surgeon 035, 814
Lonl, 31. L., Surgeon 140th X. Y 392
Lownian, \V. G., Surgeon V. S. Y 369
Ludlow, J. B., Surgeon V. S. Y 902
Lute, Charles P., Act. Ass't Surgeon 633
Lyman, Geo. II., Med. Inspector U. S. .\— 50, 64,
75, 169, 294, 3.33, 30.i, 480, MO, 583, 080, Otti
Lyman, Henry M., .\ct. ^ss't Surgeon... 1.38, 312
Jladison, T. C, Surgeon V. S. A 170, 083, 7U
Magruiler, D. L., Surgeon V. S. A 083
Manfnd. Henrj-, Surgeon 22d Ky 054, 603
JLirsh. J. K,, Act. Ass't Surgeon 705, 870
JIarsli, X. F., Surgeon 4th I'n. Cav 301, 061
Martin, Ileurv- .V,, Surgeon L". S. Y 048
Martin, N. T., Act. Ass't Surgeon 813
Masi.n, J. W., Ass't Surg. VJtli Colored ..143, Ci4
Matlack, J. >!., \ct. Ass't Surgeon 730
Matthews,''\Vasliington, Act. .\ss't Surgeon.. 348,
6C6, 007, 670, 094, 714, 773, 774, 790, 814, 826
Matthews, W. H., Act. .\ss't Surgeon 139
Maltwk, E. C., .\ct. .\!«'l Surgeon 761
Maughlin, II. A., Act. .\ss't Surgeon 212
Maull. D. W.. Surgeon 1st Pel 720
May. II. C., Act. Ass't Surgeon 211,394,598
Mei>. Hist., Pt. 1X1—122
Page.
Mayer, Xallian, Surgeon ICtli Conn 682,903
JIaylert, A. P., Surgeon C. S. V 169,318,320
5IcArlhur, T. \V., Ass't Surg.-on 30tli Ohio.. 717
Mcllride, Alexander, Surgeon 40th Ohio 713
McCall, C. A., Ass't Surgeon C. S. A 738
MeClellan, K., Ass't Surgeon I'. S. .\ 063
McChm-, A. \V., Surgeon 4tli Iowa Cav 154,
055, 750, 851
McCounell, J. C, Surgeon Genenil's Ofllce^. 440
McCortuey, Jas., Act. Ass't Surgeon 069 '
JlcCorinick, Charles, Surgeon U. S. A 175,179 |
McPemiont, C, Surgeon I'. S. Y 901 i
McDennott. \V. J., Surgeon OOlh X. Y 020 i
McDonald, Wni. O., Surgeon 27th Conn..2.'iO,409 |
JIcDonnell, E., Surgeon 2d X. Y. Art 806
JIcElderry, Henry, Ass't Surgeon U. S. A... 497, '
408,506,750
McGill, George M., .\ss't Surgeon U. S. A— 131,
130, 344, 350, 356, 382, 307, 398, 309,
405, 414, 415, 417, 432, 670, 507, 748,
7(Ki, 767, 772, 774, 779, 787, 816, 884
SIcGowan, K., Ass't Surgeon V. S. Y 962
JIcGraw, Theodore A., Ass't Surgeon U. S. Y. 818 1
McKee, J. C, Ass't Surgeon U. S. A 60,541,
673,960
McKclway, A. J., Surgeon 8th X. J-.054, 087, 802
McKinuey, P., Ass't Surgeon loth Pa 308
McLaren, A. X:,Surg. V. S. A 75,309,303,305
JIcLcan, Henry, Surgeon 2d N. Y 088 '
.McMahon, A., .Surgeon T. S. Y 903 |
McMillan, C. W., Act. Ass't Surgeon 961 |
McJIurray, ^V. A., Act. Ass't Surgeon 390 I
McXulty, John, Surgeon V. S. Y 320,330
JlcParlin, A. Thomas, Surgeon C. S. A 372 i
JIcKuer, P., Surgeon U. S. V 742
Meeker, D., Su/geon V. S. Y 001
Merrill, C. L., Act. Ass't Surgeon 071. 701
Morritt, Pavid, Surgeon 55tli Pa 120,142,105,
168, 179, 180, 181, 182, 184, 302, OOC, 841, 871
Merron, J. M., Surgeon 2d X. H 6.54
Meyer, L. G., Surgeon 25th Ohio 871
Miles, B. B., Act. .\ss't Surgeon 13-2,134,389,
392,400,411,412,413,418,701,
7t'iS, 770, 790, 704, 705, 831, 877
Milhau, J. J., Ass't Surgeon U. S. A 487,034
Miller, G. McC, Act. Ass't Surgeon 778
Minis, Pavid, Surgeon 48th Pa 303,726
Minor, \V. C, Act. Ass't Surgeon 343,349,
3.M , 380, 401, 410, 454, 072, 709,
771, 775, 770, 784, 786, 786, 788
Miritzer, St. John W., Surgeon V. S. V 900
Mitchell, W. P., Surgeon 3d Ala 589
Moneypenny, John, Surgeon 12:id X. Y 329
Monroe, F. LeBaron, Surgeon 15th Miiss 012
Moroug, E. P., Surgeon -2d Md 557,502,717
Slorris, Robert, Surgeon 9th X. Y 154
Morrison, ,\. A., Act. .\ss*t Surgeon 8-25
Jlorrison, H. C, Medical Cadet I". S. A 877
Jlorrison, S. B., Surgeon 2d 3Ie 738
Jlorrison, "Walter B., Ass't Surgeon 3d Mich. 053
Morton, C. II., Surgeon 8th Ky 002
Moseley, X. R., Surgeon U. S. V .'.49,9C»
MotI, A. B., Surgeon I". S. V 749,844,901
Mower, Thos. G , Surgeon V. S. A 083
Moxley, Isaac J., Act. .\ss't Surgeon 872
Jloxley, M. King, Ass't Surgeon U. S. V..63,C47
Mulford, J. L., Surgeon 48th X. Y 125
Mullir, Alfred, Act. Ass't Surgeon 051,841
Munrix-, Thouuis. Surgeon llOtli 111 8.37
Murdwh, T. F., \ct. Ass't Surgeon 378,384
JIurphy, J. A., Act. Ass't Surgeon l:i2
3Iur]iby, John, Surgeon 9-2d Colored 718
JIurray, Robert, Medical Director I". S. A „ 320
JIursick, George .\., .\ct. .\ss't Surgeon 215,
.351,580
Slnssey, \Y. II., Medical Inspector V. S. A .. 160,
563,939
Page.
Myers, John T., Act. .\ss't Surgeon 378
Xeir, 11. K., .<urgeon stii Pa 367
Xeill, John, Surgeon U. S. Y 7.12
Xewkirk, 11. C, Act. Ass't Surgeon 348,
351, 304, 413, 581, 070, 720, 700,7«2,7i--l,
765, 71,6, 707, 772, 773, 774, 775, 812, 825
Xonlquist, Charles J., Surgeon 83d X. Y 155
Xorris, Basil. Surgeon V. S. A 089,833
Xorris, William F., Ass't Surg. U. S. A ..732,900
Norton, J. C, Surgeon U. S. Y 700
O'Connell, 1". \., Surgeon 28th Ma.s».. 844
Octerloney, J. A., .\ct. Ass't Surgeon 901
Olden, S. M., Act. Ass't Surgeon.. 709,789,
791,794,795,798
Oliver, George H., Surgeon V. S. V 908
Oliver, J. L., Act. Ass't Surgeon 809
O'Meagher, Wni., Surgeon 37th X. Y 373
O'Reilly, T. J., .Vt. Ass't Surgeon 902
Orion, S. II,, Ass't Surgeon V. S. A. 901
Osborne, C. 11., .\ct. Ass't Surgeon 744
Otis, George A., Surgeon 27th Mass .373, .'.20,
0118, 624
Otterson, W. C, Surgeon V. S. V 411,0.37
Ould, E. R., Act. Ass't Surgeiui 072,771
Owens, D. C, Act. Ass't Surgeon 114
Packanl, John II., Act. Ass't Snrgcon - 800
Page, Calvin G., Act. Ass't Surgeon 583,597,
001,010, 01'2, 718
Page, Charles, Jledical Director U. S. A..872, 919
Page, J. W., Inspector San. Com .107, 082
Palmer, B. R., Act. Ass't Surgeon 054
Palmer, G. S., Surgeon U. S. Y 750,002
Palmer, J. C, Ass't Surgeon S5th X. Y 903
Palmer, AVm. H., Surgeon 3d X. Y. Cav C54
Pancoast, G. L., Surgeon U. .S. Y 9C0
Parr, W. P., Act. Ass't Surgeon 747
Pattee, A. F., Act. .\ss't .Surgeon 840
Patterson, J. V., Act. Ass't Surgeon 9C0
Pntzki, .1. H., Ass't Surgeon I". S. A .Kl
Patillin, George 31., Act. Ass't Surgeon 740
Peabody, 0., Ass't Surgeon 23d Iowa .WS
Pease, C. G., Surgeon 2d "Wis. Cav 055
Pease, E. 31., Surgeon 0th X. Y. Cav 215
Pea.se, R. \Y., Surgeon lOtli X. Y. Cav...487,46«,
7f>0, 902
Peck, A. F., Surg. 1st X. 31. 3Iountcd Yol8-_121,
1-24, 179, 181, 032, 752, 841, 802
Peckham, F. 11., Surgeon 3d K. 1 718
Peer, p. W., Act. Ass't Surgeon 415
Perin, Glover, Surgeon U. S. .\ 001
Perley, Thos, F., Surgeon V. S. V 901
Pern-. Ira, .\ss't Surgeon 9th Colored 701,702.
Persons, H. T., Surgeon Ist Wis Cav 705
Peter. H., Act. Ass't Surgeon -. 901
Petei-s, DcWitt C, .\ss't Surgeon T. S. A 391,
491,902
Peters, J. A., Ass't Surgeon 21st X. Y 020
Phelps, Ed. E., Surgeon V. .S. V 504,901
PhilliiJS, C.^V., Surgeon 7.5th 111 1-25
Phillips, J. .\., .Surgeon Olh Pa 300
Phillips, J. H., Surgeon V. S. Y .J 902
Picot, JI. II., Act. Ass't Snrgcon ._ - 213
Pierce, II., Ass't Surgeon lolllh X. Y 131,381
Pilott, , Prison Surg., .\ndersonville, Ga. 42
Pineo, Peter, 5Ie<lical InsiK'ctor U. S. A..32.'>,320
Piquette, F. E., Surgeon 80th Colored 903
Porter, G. E., Act. Ass't Surgeon 400
Porter, Isaac G., Act. A«s't Surgeon 749
Pi Iter, J. B., Surgeon 30tli Ohio 318
Powers, Cyrus. Ass't Surgeon T5tli X. Y 850
Prentiss, P. W., Act. Ass't Surgeon 6C1
970
LIST OK MEDICAL OFFICERS, ETC.
Page.
Prfsrott, A. B., Surgeoii U. S. V 'M^
Prici-, J. H., Act. Ass't Surgeon SSO
Prince, David, Surgeon V. S. V 362
r>iultliire, S. .1., Act. Ass't Surgeon 44,110,
700, 701, S87, 880
Rain-iiy. Frank A., Surgeon C. S. A G38, G4:J
Rauisa.v, <-n-o. M., Surgeon Ootli N. Y 550
lianilall, Burton, Surgeon U. S. A 179
Kanilall, P. W., Ass't Surgeon 1st Cal 802
Bauiloliili, John F., Surgeon U. S. A 1. 0C3
liaiiluiel, ir., Act. Ass't Surgeon 700,882
Kawsun, Charles II., Surgeon 5th Iowa 404,
405, 080, 703
Koad, Ezra. Surgeon 21st Inrt 180,541,54",
033, 051, 720, 802
Kead, L. Vr., Surgeon 1st Pa 308,002
Kebcr, Charles T., Act. Ass't Surg.._213, 701, 702
Kecil, T. B., Surgeon U. S. V 900
Eeese, JIadison, Surgeon 118th 111 654,885
Keeves, , Prison Surg., Andersonville, Ga. 42
Eeul, Eobort K., Surgeon Sil Cav 718
Ecyhurn, Robert, Surgeon U. S. V. —85,405
Ee.vnoltls, 0. K., Act. Asst. Surgeon 325,328
Eice, A. E., Ass't Surgeon IstMass Cav C90
Rice, .1. M., Surgeon 25th Mass ■_373, 840
Eice, Kathan P., Surgeon V. S. V 730, 903
Eice. P. B., .Surgeon 1.32d N. Y 082
Eolierts, 0. W.,.Act. Ass't Surgeon 384,385,
302, VSO, 704, 795, 700
Eohertson, James, Act. Asa't Surgeon 378
Eobinsou, P. Gervais, Surgeon C. S. A 588
Eobinson, W. T., Surgeon 104tli Pa 503
Eodinau, Lewis 11., Bledical Cadet U. S. A 740
Eoehrig, Otto, Act. Ass't Surgeon. 262
Sogers, J. K., Surgeon V. S. V 003
Eogers, J. Murray, Surgeon C. S. A 027
Eogers, 31. Ct., Act. Ass't Surgeon 702
Eohrer, E., Surgeon 10th Pa 318, 536
Eoss, J. Smith, U. S. N 584
Eossiter, .1. P., Act. Ass't Surgeon 213
Eowzie, , Prison Surgeon, Andersonville,
Ga 42
Eoyal, W. W., Act. Ass't Surgeon 412
Euge, J. A., Act. Ass't Surgeon 037
Euggles, A. D., Act. Ass't Surgeon 770
Bush, D. G., Surgeon 101st Pa 120
Eussell, n. n.. Act. Ass't Surg._394, 701, 705, 775
Enssell, Ira, Surgeon V. S. V 577,578,579,
580, COS, 009, Oil, 030, 048, 758, 759. 903
Saal, G., .\ss't Surgeon U. S. V 901
Sabine, Samuel A., Surgeon 9th N. Y. .\rt 142
Salter, F., Surgeon V. S. V 092,790,797,817
Sample, K. .1., Act. Ass't Surgeon 777, 789
Sanborn, J. E., Surg. 27th Iowa— 718, 757, 809, 845
Sanders, , Prison Surgeon Andersonville,
Ga 42
Sanger, Eugene F., Surgeon U. S. V 320, 331
Satterlee, E. S., Surgeon V. S. A 179,184,905
Saville, .Tno. I., Surgeon 2d Colo. Cav 841
Schell, Henry S., Ass't Surgeon U. S. A 272,
301, 000
Schultz, S. S., Surgeon U. S. Y 901
Schu^sler, Charles, Surgeon 6th lud 328
Scott, Jno. Vt'., Surgeon loth Kansas ISO, CSO
Seavens,- Joel, .\ct. Ass't Surgeon 734,737
Semple, J. E., Ass't Surgeon U. S. A 915
Shafhiit, A. J., IIosp. Steward, V. S. A 447
Shaler, A. B., Act. Ass't Surgeon 053
Shaner, David, Ass't Surg. Cth West Va— 707, 812
Sheetz, J. U., Ass't Surgeon 47th Pa 124
Sheldon, A. F., Surgeon I". S. V OOO
Sherman, S. N., Surgeon 34th if. Y"_.155, 300, 063
Shippcn, Edward, Surgeon U. S. V 332
Page.
.Shittler, Otto, Act. Ass't Surgeon 784
Silliman, H. E., Ass't Surgeon l". S. A 58
.Sim, Thomas, Surgeon U. S. V 049,902
Simons, J., Surgeon V. S. A 901
Simjison C. T., Act. Ass't Surgeon 390
Simpson, E. F., Surgeon U. S. A 179
Sisson, N. B., Ass't Surgeon 92d Ohio 091, 002
Sloanaker, L. M., Surgeon 19th Iowa 054,720
Sniart, Charles, Ass't Surgeon V. S. A— .100,101,
103, 020, 089, 708, 855, 872, 880, 887
Smiley, Thos. T., Act. Ass't Surgeon 530, 678,
840, 80-2, 808
Smith, A. K., Surgeon V. S. A — 087
Smith, A. Vi., Act. Ass't Surgeon 903
Smith, D. P., Surgeon U. S. V 900
Smith, George 0., Ass't Surgeon 53d 111 637
Smith, G. M., Act. .\ss't Surgeon 114
Sniilh, J. B., Act. Ass't Surgeon 130,901
Smith, J. D., .\ct. Ass't Surgeon 214
Smith, J. E., Act. Ass't Surgeon 341, 3.'i4, 398
Smith, J. Pasral, Surgeon OOlh JT. Y 718
Smith, Joseph E., Surgeon V. S. \ 215,313.
030, 800
Smith, J. v. C, Act. Ass't Surgeon 208
Smith, S., Act. Ass't Surgeon 214,881
Smith, S. Compton, Ass't Surgeon 4th ^Vis.
Cav 301, 053'
Smith, W. M., Surgeon 85tli N. Y' 143, 718
Smith, W. E., Act. Ass't Surgeon 708
Smythe, D. Porte, Surgeon 19th Tex C08,7,"i8
Snow, .\. B., Surgeon N. Y'. Engineers 302
Southworth, Charles T., Surgeonl8th Mich— COO
Speer, Alexander JSr., Surg, 7th Pa. Cav..302,901
Spencer, V>\ C, Surgeon V. S. A 004
Spies, George A., Surgeon 47th Ohio 052
Sprague, E. H., Surgeon 14th Vt 057
Sprague, H. M., Ass't Surgeon U. S. A— .273, 051
Stanchfield, J. K., Act. .\ss't Surgeon 001
Stanton, D., Surgeon 1st Pa. Cav 370
Stearns, C. 'W., Surgeon 3a N. Y' 530
Stearns, H. P., Surgeon U. S. V 901
Steele, Henry K., Surgeon Sth Ohio 338
Stemmerman, Wm., .\ct. Ass't Surgeon. ._789, 815
Sternberg, G. M., Surgeon U. S. A 104, 670,
888, 901
Stevenson, B. F., Surgeon 22d Ky___ _ 089
Stiebeling, Goo. C, Surgeon 52d N. Y 020
Stille, Alfred, Act. Ass't Surgeon 8O0
Stillwell, T. H., Act. Ass't Surgeon 585
Stipp, Geo. W., Bledical Inspector V. S. A___ 020
St. John, J. T., .\ct. Ass't Surgeon 747
Stocker, .\. E., Surgeon V. S. V 370
Stoddard, F., Act. Ass't Surgeon 132
Stone, L. E., Surgeon V. S. A' 961
Storrow, S. A., Ass't Surgeon U. S. A 900
Stovell, M., Act. Ass't Surgeon , 810
Stratton, Eohert F., Ass't Surgeon 11th 111.
Cav 801,962
Strode, E. C, Act. Ass't Surgeon 062
Strong, H. P., Surgeon 11th 'Wis 703,870
Strothotte, A., Surgeon 23d Ky 810
Studley, AV. H., Act. Ass't Surgeon 732
i^fudy, J. M., Ass't Surgeon V. S. V 902
Sturgis, AVm., Act. Ass't Surgeon 901
Snckley, George, Surgeon V. S. V 20,704
Summers, John E., Medical Inspector U. S. A. 035
Sutton, G. L., Surgeon U. S. T 960
Swartzwelder, A. C, Surgeon t'. S. T 061
Swasey, C. E., Surgeon U. S. T 903
Sweet, 0. P., .\ct. Ass't Surgeon 203,344,
388,404,407,41.5,832
Swift, E.. Surgeon r. S. A 109, 352, 701
Taylor, J. H., Surgeon l". S. V 310, 311, 478, 900
Taylor, John X., Surgeon 3d Mo. Cav 885
Taylor, L., Surgeon r. S. A 9C0
Page.
Tay'.ov, M. K., Surgeon U. S. V..804, 806, 807, 002
Teats, S., .\ct. Ass't Surgeon 214,341
Teed, J. L., Surgeon U. S. V 902
Tesson, li. S., Act. Ass't Surgeon 902
Thayer, S. W.,,jr., Act. Ass'tSurgeon 601
Thayer, V. n.. Surgeon 14th N. H.__530, 052, 742
Thonuis, E. I., Act. Ass't Surgeon 6.33, 9C0
Thompson, , Prison .Surgeon, Auder^on-
ville, Ga 42
Thompson, E. A., Ass'tSurgeon 12t)i Me 108
Thompson, Jas. H., Surgeon U. S. T 50,153,740
Thomson, W., Ass't Surgeon U. S. A 380
Thornburn, , Prison Sui'geou, Anderson-
ville, Ga 42
Thorno, J., Act. Ass't Surgeon fiO.'j
Thorne, W. H., Surgeon 12th Pa 363,309,962
Thorp, Abner, Medical Cadet, I". S. A 391
Thrall, William E., Surgeon 27th Ohio 2.i
Thurston, A. H., Surgeon U. S. V 001
Tolman, W. L., Ass't Surgeon 10th Mo. Cav. 750
Tompkins, E. A., Ass't Surgeon 4th Cal 803
Towie, S. K., Surgeon 30th Mass 119,122,
123, 120, 153, 179, 182, 313, 637, 850
Towu, F. L., Surgeon V. S. A 518,522
Townsend, V,'. E., Art. Ass't Surgeon 961
Towusheud, N. S., Bledical Inspector U. S.
A .52,85,035
Tozier, L. L., .\ct. Ass't Surgeon 269, 776
Trader, John AV., Surgeon IstBIo. Cav 851
Trantman, C. T., Act. Ass't Surgeon 398,41'i
Treadwell, J. B., Ass't Surgeon 45th Blass 404
Treanor, .John, jr.. Surgeon U. S. T 903
Tripler, Charles S., U. S. A 25, 155, 105, 100,
109, 020, 047, 683, 686, 687, 688, 708, 807
Turner, Henry E., Act. Ass't Surgeon 718
Turner, T., Act. .\ss't Surg 212,338,308
Turney, S. D., Surgeon U. S. V ,_ 962
Tutt. Charles P., Act. Ass't Surgeon 34:i
Twining, S. D.. Act. Ass't Surgeou..761, 70S, 770
I'pham, J. Baxter. .Vet. .\ss"t Surgeon 5.55, .557.
604, 009
I'pson, S., .\ct. .\ss*t Surgeon 378
Urban, II., Act. .\ss't Surgeon 760
Vanderkieft, B. A., Surgeon U. S. Y 002
Yanderpoel, S. Oakley, Surgeon General N.
Y. .State 020
Yan Derveer, H. F., Surgeon oth N. J— .055, 687
Yan Duyn, A. C., Surgeon T. S. Y 962
Yan Slyck, DeT\'itt C, Surgeon 35th N. Y„. 31s
Yariaur "Wm., Surgeon I'. S. Y 901
YoUum, E. P., Medical Inspector U. S. A_— 57.
103,104,109,553,054,871
\Yagner, C, .\ss't Surgeon V. S. A 900
M"ainwright, D. AVadsworth, Surgeon 4th N.
Y 361
"Wall. .Vndrew, Ass't Surgeon 77th Ohio.
Wallace, T. C, Ass't Surgeon 93d X. Y..
Wallack, J. BI.. Act. Ass't Surgeon
"Walton, Claibourne J., Surgeon 21st Ky
310, 530,
Wa'Jton, George E., Act. Ass't Surgeon..
Walton, L. A., Act. Ass't Surgeon.. .412,
Ward, S. B., Act. Ass't Surgeon
Wardner, II., Surgeon I'. S. Y
Ware, E., Surgeon 44thBIa3s ^.556,
Warner, J. T., .\ct. Ass't Svu-gco:i
Warren, J. 11., Surgeon V. f. Y..325,320,
Wairen, .1. X., Ass't Surgeon 25th S. C.
Waters. Edmond C... Act. Ass'tSurgeon.
Waters. W. E., Surgeon I'. S. Y
..51,52,
07, 047
. 032
.... 215
ISl,
54),65-J
. 3-.;
417, 77' I
. 41ti
.... 001
009, 010
. 381
372, 480
.171.170
700
086
LIST OV MEDICAL OFFICERS, ETC.
971
Pag.-.
Wiitkins, , PrUon Surgeon, Audcrson-
Watson, Alex. T., Surgeon V. S. V..,'.T7, SCS, OCl
Watson, Louis, Surgeon ICth 111 li52,TlT,7a4
WeMi, J. T., Surgeon 23(1 (^Ulio 2flO
Webster, Wartx'n, Ass't Surgeon T. S. A 32G,
329,330,S92,9Gl
Weetls, .Tiinies K., Ass't Surgeon V. S. A itiy
Weir, U. K., Ass't Surgeon V. S. A.."31,"45,9(a
Wells, \V. L., Act. As,t Surgeon Xi5,33C
West, S. B., Act. Ass't Surgeon 342,353,
378,392,3113,412
White, C. B., Surg. V. S. A..515,519,525,n3.i,S79
White, Isaiah II., Surgeon C. S. A 40,42
White, .1. F., Act. Ass't Surgeon 390
Wliite, S. v., .\ct. Ass't Surgeon 4U
White, W. II., Surgeon 22(1 Ion a C73
Whiteheail, W. E., Ass't Surgeon I'. S. A... 889
Whitehill, J. C, Surg. r. S. v.. 1.13, 179, 81 1,901
Wliitniire, .Tas. S., Surgeon 50th 111 - 8-11
VVhiltinghani, K.lwanl T., Act. Ass't Surg.. 302
Page. [
Wicsel, II. J., Act. Ass't Surgeon 330,381,382
Wilcox, C. H., Surgeon 21st K. Y 0'20 ]
Wilcoxson, l. D., Act. Ass't Surgeon 800
Williauis, , Prison Surgeon, .\nderson-
ville,«a 42
Williams, .\. I'., .Vet. Ass't Surgeon 34.>, 807 |
Williams, T. II., Surgeon C. S. A 32,102,103
Willson, Geo. B., Sui-geon M Miell 183
Wilson, 11. It., Surgeon T. S. V i. VOO
Wilson, Beigumin, .Vet. Ass't Surgeon 212
Wilson, John, ^litlical Ius|>ei-tor U. S. .\ 108,
089, 942, '.ms
Wilson, W". ,1., Ass't Surgeon 13th OhioCav. 734
Winch, Geo. P., Surgeon 42a Wis 550, .551
Winne, C, Surgeon 77th 111 0C3
Wirth, 1!., Act. Ass't Surgeon 577,578
Witherwax, J. M., Act. Ass't Surg 348,812,880
Wolf, .1. A., Surgeon 29th Pal 710
Wood, C. S., Ass't Surg. GCth N. Y...G88,"64,S4l
■Wood, B. C, Surgeon r. S. A 179,184,710,895
Wooilhriilge, T., Surgeon 12Sth Ohio 54
Woodhull, Alfred A., .\53't Surgeon I'. S. A.IO-;.
171, 487, 488, 090, 701, 8.13
Woodhull, A. W., Surgeon 9th X. J 154,105
Woods, W. S., Surgeon 02d Pa fii'vl
Woodwanl, B., Act. Ass't Surgeon 073
WoiHlward, Joseph ,1., Surgeon I*. S. A_ 2, 3,
44, 75, 70, 77, 120, IM, 104, lOS, 170, 17.'>.
215, 273, 274, 300, 31 1 , 334, :'.;9, 31'/), 372,
373, 377, 441, 442, 455, 4.M!, 407, 408, 409,
473,484,4S5,509,.51O,.Ml,5'21,C10, fil)",
020, 0-22, 741, 819, !i;H, 8,35, 830, 874, 930
Woostcr, David, Surgeon 5lh Cal 084,892
Wright, A. W., .Surgeon .'.Sth Pa.. 125
Wright, John. Surgeon 107lh III IM
Wright, J. J. B., Surgeon l". S. A 179
York, Shuhal, Surgeon .54th 111 CG5,C72
Young, J. B., Act. .\ss't Surgeon... 133, ;H8
Y'oung, S. C, Surgeon C. S. A 6S8
LIST OF MEDICAL AUTHORS AND OTHERS CITED OR MENTIONED
Pago.
Alibott, S. W 1C7
Aitkfii, W_ _ 121, 47G, S24
Alibc-rt. J. L loT
Alis.iu. W. P - 'i
Anilviil, G — Ki
Andrews, E . ^^-^
Annesley, Sir Jas IT"
Armstrong, W. S 595, «12
Aslnirst. John, jr CG9
Atkinson. T. P 85
Audou.ird, F. M 150
Baikie, W. B 107
Bailly, E. M - 148
Baker. H. B 502,518
Balcli. G. B 625
Balfour, Francis 1C5
Ball.v, V-___ 184
Baltzell, W. H — (504
Bamberger, 11 -__ 4G2
Bardsley, J. L 1S4
Biirker, F 477
Barrows, A. W 101
Bartholow, Eoberts 172, 175, oil, 517, 504
Bartlett, Elisha 72, 73, 121, 285,
288, 290, 291, 292, 295, 296, 480, 510
Baudens, 51 085
Biiumler, Christian 296
Becquerel, A 298
Bchier, J 548
Bell, Joseph 294
Bennett, H. X 606
Bennett, J. Hughes 73, 74, 534, 535, 824
Berenger-Feraud, L. J. B 127, 173, 174, 175
Beyer, H. G 740,741
Blane, G. P. J— — 147
vBlane, Gilbert 707, 709
Boliug, Wm. M _. 121
Bolton, James 628,0:38, 645, 646
Boudin, J. Ch. M 159,513,604,822,823
Bowditch, Uenry I 72
Boyle, James 158
Bracken. J. King 477
Bramblett, W. H..: 490
Brera, V. L 151
Bretonneau, Pierre 72, 294, 452
Bright. K 72, 149
Bristowe, J. S 452, 824
Bronsou, H 101
Brown, Bedford 490
Brown, Joseph 99
Brown, T. F ._5S5, 580
Brown-Seqnard, C. E 548
Bryson, .\lexander 167, 173, 714
Buchanan, G 604
Buck, Gurdon 477
Page.
Budd, Wm 73,74,402,
493, 490, 499, 500, 504
Buhl, L 502,503
Bush, L. P 735
Butler, L. C SS9
Buzzard, 714
_49G, 497, 501, 548, 757
,..512,519,
,708,
Cabell, Jas. I,
Caldwell, C
Cameron, John F
Campbell, H. F
Carstens, J. H
Caulkins, J. S
Cayley, "NVm
Celli, A
Chalvet,
Chauffard, P. E
Chenu, J. C
Cbesney, J. P
Chevers, Norman 304,
Cheyne, J
Chomel, A. F 184, 285,
288, 294, 295, 298, 452, 474,
Claiborne, J. H 502
Clark, Alonzo 271,474,511
Clark, Sir Andrew
Clark, John _._ 176, 177,
Clark, D. C
Cleland, M. T
Cohadon, V. A
Cohn, Ferdinand
Colby, M. F
Colin, Leon 159, 173, 325. 482, 505,
Collin, E 99, 146, 147,
Condie, D. Francis 74.
Coonley, E. D 101
Copland, Jas 99, 121,
Cormack, Sir J. Rose
Cornish, W. It
Corre, A
Courty, Am6dee
Cullen, Wm
Cumming?, J. C
Cutter, Ephraim
157
683
73
525
611
494
104
714
008
685
614
365
477
286,
482
,510
,003
804
527
585
817
151
448
1S5
513
148
121
162
824
824
705
514
648
74
127
634
Page,
Ditterich, L 54'.>
Doniphan, I). A 121
Dorr, Wm. G 485-
Dougall, Joseph 184
Drake, Daniel 101
Draper, D. W 604
Draper, W. H 802
Dreschficld, Julius 104
Du Chaillu, lOT
Dnnglison, R 824
Dussourt, M 325
Dutroulau, A. F 127.140,147.148,1.51,172, 610-
.M17
Eastman, J. C
Easton, J. A
Eberle, John
Eberth, C. J
Edwards, L. B
Eichwald, Ed. von
Eisenmann, G
Emmerich, Rudolf
Engel, Ernst
Estlander, J. A 477,
Eve, Paul F 1C7,02S,648,
Ewing, W. T
585
172
824
492.
490
l.VJ
150-
801
7
478
700
521
DaCosta, J. M 292,299,615
Daly, Francis 165
Davaine, C 801-
Davidson, H. M 42
Davy, Robert 517
Dawson, Henry B 31
DeLisle, Frederick In-ing 715
Delmege, A. G 175
De Saussure, H. W 167
Dickson, Samuel Henry 72, 296, 501, .510, 807
Faget, J. C 127
Farnsworth, P. J 888
Farqnharson, E. J 490
Fayre, Sir Joseph 129,498
Fclder, W. L — 510-
Feuner, E. D 101
Ferguson, Wm 85,158-
Flint, Austin 107,179,269,
280, 283, 284, 285, 287, 288, 291, 293, 297,
298, 299, 325, 511, 614, 802, 824, 850, SOT
Fontaine, R. A 185
Forbes, F 527
Forget, C. P 452.
Formad, H. F 740,741,742
Forry, Samuel 101, 102, 165, 683, 714
Jorwood, W. S 688
Fothergill, J. Milner 474
Frerichs, Fried. T 146,147,149,150,151,401
Friedel, C 172
Friedliinder, Carl 801. 804
Gatfky, G — 492
Gaillard, E. S 610
Gaines. E. P 123,101
Gairdner, W. T..-_ 289,298
Garrod, Alfred B_. 709,714
Gay, G. H 1 109
Crtiger, A "50'
972
LIST OF AUTHORS CITED.
973
PaKC.
tk-ndrin, A. S 147, V-l
OfrLanland IViiiiock T'J
Gorliarxlt, C T-W
Client, H. U 120
Ciiltfuii. J. P 11.7
f.iitl. Fniiii X. Ton 4'.0
IJill. H. Z 10.7
i.irnuil. II lt>j
(Jittermaiiu, J. W : 184
O...Itfi. Cwniillo 1(>*
Conlon, C. A 49S, KU
Goro. AllKTt A 17:i, 17.i
Gra'fi', A. vou i'.4S
Gravi-s. R. J 175, 2tl4, 401, 40i
Gn^t-'iu', .Iiitnofi A -104, 30.1
Ureom-. Will. A 127, OSS, 045
Grii'singcr, W 299, 452, 404
Gross, S. D - "2
Guillaiwc, 534
Guillcniin, I. F... — 530
GutlnTlet, M. J 477
GUterKH-k, P 470
Hal... En«li 284,285,287,293,290,
Hall. ,<ir .lohii 1C7,
Hall. T. G. 527,
Hamilton, J. Butlfr 172,
Huniiiiond, Win. .\ 149,
Itaii.l. P. W
liar.'. K - _
Harlcy. .lulin 444,
033,
Han
, Gli$lif
narris. J. C
Harris, T. II_ 895,
Hart ..home, Henrj- 8G2,
ll.isiel. .\ug - 147,
Hay.'iii, Georges 400,
Ilavn.-, L. J
Heller, J. F.--
Heiulriekson, Thomas
Herrick, S. S 172,
]|..rt7, Henry - 99,
ilesohl, Eioliard
Heuhiier. 0 — 740,
llensti!.. J. W.__
Hicks, Robert J 7ll7,
Hildenhran.l. J. Val. de
llilliar.1, W
Hii^h, A - JOl, 610,
Hods
. II. M.
298
175
528
174
100
510
178
459
(^iO
101
890
803
401
475
107
COS
51
174
172
149
741
ini
708
72
517
802
109
lloHpiann, C. E. E_
297, 29S,
434. 4:i.% 445, 452, 459, 404
Hollister, J. H 8O0, 810
Holmes, Oliver Wendell 101
Holmes, K. S 101
Homans, C. D 109
Home, Sir .\ntliony D 173, 175
Hopkins, T. S 047
Hoppe-Seyler, F 127
Horton, J. A. B 121, 178
Human, C. 0 _. •299
Hunter, Cliarles ,i47, 548
Hunter, Jolin 170, 178
Hutehtnson, Jas. II 149
Hutchinson, T. J 107
Page.
Jarnugin, W. C 512
Jenner, Wui 73, 74, 280, 287, 289,
290, 292, 294, 290, 452, 474, 49:1
Jilek, A. R. Ton 17A 173. 174
Johnson, James 177
Johnston, W. W 449
Joynes, I,. S 127, 128
Jucrgcnsen, T COS, SO^i, 805
Karanietxas, G 175
Keen, W. W •>97, 2;iS, 470, 478, MS
Kelsih, A 15(1, 1.'.2, 15:i, 104
Kcliilrick, JuhnG. M 409
Kelilu-dT, H 294
Kirk, John 173
Klebs, E 104,492
Klein, E 445, 440,447, 448, 4.W, 40*1, 492
Kueh, U 492
Kollock, P. M 101
Klihlie, W 127
I-wnnec, H. T. 11 807,825
Lancisi, J. M 159
Lnnzi and Terrigi 1.V2, 104
Lavemii, \ 104, .101
Laeeran, Louis 144, 147, 148
Lebert, H 452, 529
Lehmnnu, C. G 474
Leminun, 11. T 5(>2
Lonte, FriHl. P 557
Leonanlund Foley 149
Letierich, Luilwig L 492
LcTick, J. J 312,3-25,375,510
Liebemieister, Karl 279, 282, 283, 284, 2SS, 2'.H),
292, 294, 290, 297, 41H, 482, 493, 500.503, 504
Lind, James 105, 170, 177, 178,527, 70S, 709
Lister, Joseph 405
Livingston, Charles 173
Livingston, Pavid 173
Loolnis, A. L 512, 513, 629, 802, 824, 850
Louis, P. Ch. A 7-2, 270, 280, 282, 28.3, 285, 280,
287, 288, '290, 291, 292, 293, 294, 29.%
296, -297, 298, 301, 401, 403, 420, 422,
420, 4:)0, 431, 432, 434, 4.35, 442, 452,
4.15, 458, 401, 402, 475, 480, 482, 005
Low, H. lirure 498
Lucas, Leonard 173
Lyman, Francis R 087,704
Lyon, IrTing W 313
Lvous, Rolwrt D 325
Immemiann. II.
Irvine. J. P
Jackson, James
Jackson. J. E
,lac.in..t. K.-lix
282,290,291,
292,294,290,298,299
.148. 324, 530
Maceulloch, John 159
Mackintosh, John 177
Maclagan, T. J .270,299
Macon, W. H 490
Magendie, F 184
Maillot, F. C 99, 145, 140, 147, 148, 150, 178
Mallet, J. W 102
JIalonc, G. B 128, 175
Manson, O. F 123
JIarchiafaTa, E 164
Mariani, T... 184
Martin, G 184
Martin. Sir J. K 121,105,178,270
Maury. K. II 515
McDaniel. E. D 127, 1-28, 175
McGirr, John E 033
McLean, W. C 850
McLeil, James 493
McWilliain, J. 0 — 167
Meckel, H 140
Meigs, J. Forsyth 146, 402
Jlericourt. I.eR..yde 175
Merritt, J. King 172
Page.
Metcalf, P. Herbert 498
Michel, R. F 120,1-27
Milligan, F. II 167
MiJliroe, .\lex. LeB 170
Montanll, J. J. 11 4.'>2
Miwr.., W 105
Morehead, Tharlce 105, 173, 270, 5-27
Mosns G. A _ 587
Motel, M. 289
Moiiat, F. J 107
Murchison, Charle»..-.270, 275, 279, 282, -283, 2J4,
285, 286, 287, 288, 289, 290, 291, 2il2,
293, 294, -295, 296, '298, 299, Sltl, 311,
434, 4,52, 403, 404, 473, 477, 478, 480,
482, 493, 495, 490, 498, SOI, 504, 00(
Nasse, I 151
Nolct, A. F .. 151
Kopple, M '. 147, 161
Xiemeycr, F. von 127,498
Nivet, P. F 161
Norconi, A. B 127, 128
Nothnagcl, H 311
Nott, J. C 18.5
Oatnian, .1. E 521
Obermeier, Otto 801
Oilevaino, F. 185
Oertel, M. J 741
Oldham, C. F 158
Opixilzer, J 548
Osborn, J. D 120, 127, 1-28
Osborn, T. C 122,126
Paget, Sir 3avt.j» 476
Parent-Puchatelet - 102
Parkes, E. A 159,298
Pai-sons, Franklin 493
Pasteur, L 801
Patton, A 810
Payne, Allian S 497
Payne, B. S 501
Peabody, George L 6
Peacock, Thomas B 287,291
PeplHr, Wm — 184
Perriue, Henry 178, 179
Petit, M. A 72
Pcttenkofcr, Max Ton ..502,50:1
Pezcrat, P 151
Phares, D. L 888
Pincoffs, Peter -622, 023
Piorrj-, P. A 147, 1.".0, 151, 461
Planer, Julius. ...149, 150
Playfair, Geo - 409, 470
Plunkett, F. C 811
Pontic, E 128
Porter, A 707
Porter, J. A - 516
Posey, J. F.. — 101
Potior, A. J — 184
Powell, T. K .: 617
Pringle, J -- 527
Prost, P. A "I
Pusey, H. K 514
Putnam, S 502
Quaiu, Richard 807
Ralfc, Charles H "15
Rasori, G 807
Rea.le. H. C 1G7
ReeoRl*. B. F 888
974
LIST OF AUTHORS CITED.
Page.
Beeves, J»s. E_ 73, 260, 285, 287, 290, 295, 298
Reynolds, J. E 824
Eicluird, George W CIO
Itich:irds, Chauuiiig 895
Rindfleisch, Ed 440
Robinson, A. H ^^^
Rogers, Stephen 172, 175
Rokitauski, C. von 147, 443, 458, 402, 822
Rookor, J. J M8
Rnelile, Hugo 824
Rnppaner, .\ - 547
Russell, E. G 102,511
Salisbury, James 11 052
Scanzoni, F. W 548
Scrive, G 325
See, G 801
Seguin, E 279, 299
Serres, E. R. A 72
Sliarkey, Seymour J 493
Shattuck, G. C_ 72
_^ Skoda and Oppolzer 289
" Sinn, W. S 186
Smart, Cliark-s 495
Smart, Wm. R. E __ 107
Smiley, TUos. T 179
Smitl], A 107
Smitli, Nalhan 294
Smitli, T. B 889
Smitli, W. F 511
SpaMiug, Geo 893, 804
Sijuibb, E. R 005
Stazevich, F 708
Stewardson, T 140, 150
Stewart, A. P 287
Stille, Alfred 172, 175, 184, C09, G12, 824, 802
Page.
Stokes, William 401, 8U7
Stout. S. n ..038, 045
Sullivan, John 99
Sydenham, Thomas 71, 170
Talamou, C 801
Tanner, T. H 824
Taylor, J. E 8.-.G
Tebault, A. G 85
Tebault, C. H 645
Tomaselli, Salvatore 175
Tommasi-Crudeli, C'_.. -.159, 104
Torti, F 179
Thomson, Jas 173
Thomson, Pinckney 490
Thorn, S. S 179
Thrall, S. B 107
Triplett, \V. II 817
Trousseau, Armaud 287,294, 822, 824
Turner, A. Paul. 184
Twining, W 177
Tyree, J. J 888
I'pbam, J. Baxter 404
Valleix. F. L, I 72
Vallin, E 148, 149, 400
Van Buren, W. H 100, 172, 173
Van Eman, J. II 514
Veatch, ^V. H 510
Virchow, Rudolf.. 127,474, 475, 502, 824
Virmontois, M. J 286
A'ivenot, Rudolf E. von 172, 173
Yogel, A — 298
Page.
Volkmann, R 477
"Waggoner, F. Rice 521
Waldeyer, 475
Walsbc, W. H 807
Ward, L. H 822
Waters, Ed 4,52
Watsou, Irving A 271
Watson, Thomas 73, 121, 292, 402, 634, 535, 824.
Webber, S. G C04
Wells, J. C 184
Wells, W. C 822,823
White, C. B 101
Wilks, Samuel 404
Willes, W. S 107
Williams. Jeff. D 617
Wilson, H. B 888
Wilson, James C 285, 287, 291, 295, 404, 499
Wiuder, Jno. H 42
Wise, Alfred 521
Wood, Alexander 547
Wood, E. A 889
Wood, George B 72, 73, 74, 121, 167, 271, 28.5,
288, 291, 292, 290, 534, 535, 544, 807
Wood, H. C 172, 740, 741, 742
Woolfryes, J. A 174
Worthington, Henry 512, 519, 525
Wnnderlich, C. A 279,295
Wutzer, C. W. 184
Yager, E. T 554, 009
Zenker, F. A 475
Ziemssen, H. von 008, 802
i:n^dex.
Pago.
AlKlomiiml nain in nmlarinl fevere V22
Abtluuiiiiiil jiaiii, trentuu-nt of, iu tUo contiuiicd fevers 648
AMumiual tfiuU-nu'ss in tyi'liuh! fever 205
AlKlominal t:.'ii(lurin'S3 in typho- malarial lever .......... 274, 307
AlHluminal visrem, comlition of, in the continued fevers 434
Abscess uf PitU'i'n in malarious subjects..— _— . 147
Alkscesse'', heiatic _... 877
Abscesses, pulmonary, in ratnrrlinl pneumontn 798
Al*scess*'s, pulmonary, in Iob;ir pneumonia . _ 770
Al>stracts uf journal articles on the symptomatology uf the continued
fevers _ 312
Acclimitiou iu malarious regions ICO
Accoutrements, morbid conditions attributed to the weight of 8G9
Acetate of ammonia in (lie continuetl fevers _„. — .. . 541
Acetate of potassa in the continued fevers , , 641
Acids, vegetable, their use in scur^'y 713
Aconite in cardiac diseases .-....»... 863
Aconite in t'.ic continued fevers .,__. Ml
Aconite in tho treatment of pucumonia — ._ 807
Adynamia in remittents, frequency of 119
Adynamic chumcters of non-specific fevers 271
Adynamic remittents caused by malarious waters . ,. IGl
Age of jKilients in continued fevers 481
Ages, relative number of soldiers of different, ___.._._... — . 481
Agminatwl glands, condition of, in continued fevers .422, 436
Agminated glands, condition of, iu intestinal catarrh — . 456
Air-sivice, allowance of, to Confederate prisoners and U. S. guards at
Camp Chase, Ohio . .. 55, 66
Air-space jier prisoner ftt Ft. Delaware prison-depot GG
Air-si«ce. limitation of, not ri'sponsible for mortality among rebel
prisoners i.>f war . GG
Alga niiasnmtica of Lanzi and Terrigi 152, 1G4
Algid pernicious fevers 12G
Alimentarj- tract, condition of, in tho continued fevers 434
Alton, 111., prison-dejKit, description of 50
Alton, 111., prison-depot, general statistics of 4G
Alton, III., prison-depot, prevalence of typho-malarial fever at 210
Analysis of the post-mortem appeanmces in cases of continued fever. 41i)
Analysis of the post-mortem appearances in 300 cases of lobar pneu-
monia 770
Analysis of the post-mortem appearances in 135 cases of secondary
pneumonia 798
Analysis of tho post-mortem appearances in scurvy 702
Analysis of tho symptoms in a series of cases of malarial fever 120
Analysis of tho Fyniptoms in a series of cases of modified typhoid fever 300
Analysis of the symptoms in a serii>s of cases of typhoid fever 279
Analysis of typhoid fever cases in which turpentine was used 543
AndersouviUe, Ga., condition of prisoners at 39
Andersonville, Ga,, description of tho i>rison-hospital 42
Andersonville, Ga-, description of the stockaded enclosure 38
Andersonville, Ga., deficient medical attendance at 36, 42
Andersonville, Ga., diarrhtea and dysentery at 37
Andersonville, Ga., exposure of prisioners at 36
Andersonville, Ga., .malarial fevers at 38, 108
\iidersonville, Ga., rations of prisoners at 40
Andersonville, Ga., recommendations of surgeon in charge 42
Atulersonville, Ga., scurvy at 37
Andersonville, Ga., sickness and mortality among prisoners ^t 35
Andersonville, Ga., small-pox at 628
Anuereonville, Ga., typhoid fever at 37, 208, 491
Aneurism 868
Aaeurism, conservative changes in, due to debilitating camp diseases. 860
Annapolis, 3Id., spott<-d fever at 141
Anorexia in typhoid fever 291
Antimonials in cerebro-spinal fever __„. 612
Aphonia in continued fevers 4G4
Api<etite, condition of, in malarial fevers .. 122
Armory Square Hospital, Washington, D. C, description and plans.. 906
Pago.
Army Iliwpital^Coriis V'lS
Anny itch _ ^'SO
Army itch not Rrabies « 888
Army itch, reports of medical ofllcers and others on 888
Army medical oflker, functions of 531
Army of tho Potomac, cause of tlie severity of malarial fevers In 158
Army of tho Potomac, scurvy In 686
Army of tho Potomac, sunstroke among thn troops of tho_. ...... — - 854
Aromatic sulpliuric acid in thu continued fevers 548
Aromatic tiulpburic acid in remittents 183
Arsenious acid iii typhoid fever ......... ..— — 049
As^ciation of diurrhiL>a and dysentery with malarial fevers 144
Association of neumlgiii with malarial fevers 120
Association of remittent and typhoid fevers 119
Asthma ... 729
Attendants, number and duties of, at goueral hospitals 957
Bacilli of typhoid fever 402
Itacillus malaria' of Klebs and Tommasi -Crude li 104
Bacterium luctis ..__ -. 495
Bandolier style of carrying blanket, sheUe:-tL'nt, etc 870
Bands, military, at general hospitals 959
BaiTack-buildings, their conversion into hospitals — 908
Baths, warm, in cerebro-spimil fever - 612
Baxter Hospital, Burlington, Vt., description of 924
Beds, number of, in tho various general hospitals in active service tu
December, 1864 960
Bed-sores in the continue 1 fevers 432, 476
Bed-sores in typhoid f.-v<>r 27)*, 288, 298
Beil-sores in typho-malarial fever -......-.. 304
Bed-sores, treatment of, in tho continue<l fevers 548
Beef, fresh, issued, when practicable, as often as requiix'd by tho
trooi^i, on the order of a commanding officer 712
Belladonna in functional heart disease , 8G3
Benton Barracks, Mo., censbro-spinal meningitis at 586
Benton lljirracks, Mo., pneumonia at . — .-— .. 758
Benton Baniickr:, Mo., anomalous results of attempted vaccination at. 63G
Bisulphito of soda in cerebro-meniugitis ..— 612
Blisters in c-'rebro-spinal fever 613
Blisters in the continued fevers 541, 518
Blisters in ri'mittents ... 183
Blood, condition of, in cerebro-spinal fever , GOl
Blooil, condition of, in the continued fevers 432, 471
Blood, condition of, in malarial diseases 129, 149, 152
Blood, conditioii of, iu scurvy 708
Blood, degeneration of, in continued fevers, due to the operation of
the fever*caus? 473
Blood, deterioration of, in fever, duo to the retention of metabolic
products . . 474
Blood-letting in cerebro-spinal fever 612
Blood-letting in pneumonia 808
Blooil-lL-tting in remittents 177
Blood-letting in suni^troke 857
Blood in the urine in malarial ffvers -. 477
Blue-nose iu continued fevei"s 477
Bone, disease of, foUowiug continued feVL-rs 476
Bovine crusts, evil results from the use of, in vaccination 648
Bovine vims, advantages of. for anny use 648
Brain, condition of, in malarial fevers . 148
Brain, condition of, in scurvy T02
Brain and its membranes, condition of, in the continued fevers.. .431, 478
Brain and its membranes, condition of, in catarrhal pneumonia 8*H)
Brain and its membranes, condition of, in lobar pneumonia 783
Brattleboro, At., cerebro-spinal f.ver among recniitsat 5G4
Breath, character of, in typhcnmalarial fever _ 306
Broad and Cherry -streets n^>spital, Philadelphia, Pa., description and
plans of__ ..... 003
Bromide of potassium in cerebro-oplnal fever -. — 612
975
976
INDEX OF SUBJECTS.
Bromine vapor as preveutirc of tlio spread of t*rysipelas
Bronchial glands, condition of, in catarrhal pnenmonia
Bronchial tubes, condition of, in the continned fevers 430,
Bronchial tnbes, condition of, in catirrhal pneumonia
Bronchial tubes, condition of, in lobar pneumonia
Bronchitis, acute
Bronchitis, acute, clinical records of
Bronchitis, acute, statistics of
Bronchitis, chronic -
Bronchitis, plastic, case of
Bronchitis in typhoid fever
Broncho-pneumonia, clinical records of 1
Bunks, double-tiered, in V. S. burracks
073
7t)0
4B4
799
780
7-26
727
71'.)
T-J8
■-■.!7
7ti3
GG
Calomel in cerebrn-spinal fever
Campl'eH Hospital. Wjishin;ston, D. ('.. description and plans of__909,
Camp Butler, 111., prison-camp, description of
Camp Chase, Ohio, prisou-camp, description of
Camp Chase. Oliio, prison-camp, statistics of sickness at
Camp Dennison, Ohio, general hospital at _ 909,
Camp Douglas, 111., prison-camp, description of
Camp Bouglas, 111., prison-camp, hospitals of
Camp Douglas, III., prisou-camp, statistics of sickness at
Cami>-fever, abstracts of journal articles on
Camp-fever, no typical cases of
Camp-fevei-s, board of investigation into their nature — 18G1
Camp Jlorton, Ind., prison-camp, description of
Camp Morton, lud., prison-camp, statistics of sickness at 4G,
Camp typhoid and civil-life typhoid, post-mortem differences between
Capsicum in the treatment of intermittents '.
CarI)onate of ammonia in remittents
Carbonate of ammonia in pneumonia
Cardiac diseases
Cardiac diseases as a sequel of Chickahominy fever
Cardiac diseases, functional, causation of
Cardiac diseases, organic, nature and causes of
Cardiac diseases, reports of medical officers on 1
Cardiac diseases, treatment of
Cardiac muscular exhaustion
Cartridge-boxes, hernia attributed to the weiglit of
Cartridge-boxes, lumbar pains attributed to
Cartridge-boxes, renal congestion said to be caused by
Carver Hospital, Washington, D. C, description and plans of 910,
Cases of aneurism
Cases of asthma
Cases of bronchitis, acute
Cases of bronchitis, chronic
Cases of bronchitis, plastic
Cases of cerebro-spinal fever, clinical and post-mortem records
Cases of cerebro-spinal fever at the Alexandria hospitals
Cases of cerebro-spinal fever among recruits at Concord, N. H
Cases of cerebro-spinal fever among the Confederate troops
Cases of cerebro-spinal fever in the field hospitals
Cases of cerebro-spinal fever at the National Ilospital, Baltimore, Md-
Cases of cerebro-spinal fever at New Berne, N. C
Cases of cerebro-spinal fever at various general hospitals
Cases of cerebro-spinal fever in the 24th Army Corps
Cases of congestive chills
Cases of consumption complicated with malarial symptoms
Cases of consumption returned to duty
Cases of death from undiscovered causes
Cases of-diphtheritic inflammation of the fauces and air-passages
Cases of diphtheria with post-mortem observations
Cases of erysipelas
Cases of empyema
Cases of fever:
Common continued
From the records of the 27th Conn
From the records of the 19th 3Iass
"SViih sequent dian-hoea
With intercurrent erysipelas
Cases illustrating morbid conditions consequent on fever
Cases of internal hemorrhage in fever
Cases of perforation uf the intestine in f(.-ver
Cases of fever with pulmonary complications
Cases of malarial tl-vw, clinical record.^
612
913
60
54
46
910
48
49
4G
312
75
75
53
54
484
182
183
810
8G0
321
8C2
8G1
8G1
863
862
871
914
8118
729
727
729
727
558
574
583
5S7
5G9
570
558
576
566
137
820
820
8G8
742
745
666
817
211
250
254
260
259
260
259
259
259
112
Page.
Cases of remittent fever at the Seminary Hospital, D, C 229
Cases of unmodified typhoid from the Seminary Hospital records 216
Cases of typhoid fever from various records 257
Cases of typho-malarial fever, clinical records 212
Cases of typho-malarial fever from tlie Seminar}' Ilospital records 230
Cases from the, post-mortem records of the continued fevers : -
Diagnosis typhoid, more or less sustained by the clinical history__ 335
Diagnosis typho-malarial, with or without a record of symptoms
to substantiate it ^ 345
Diagnosis typhoid, but the clinical history suggestive of mahirial
complications 351
Diagnosis typhoid, the clinical history insufficient or absent 377
Diagnosis variously reported 403
Illustrative of complications and seqnela; 410
Diagnosis typhus 41S
Cases of gangrene of the lung 795
Cases of haemoptysis independent of pulmonary consumption 869
Cases of hernia, strangulated 872
Cases of intermittent fever treated by turpentine externally ISG
Cases of intermittent fever treated by tincture of opium and solution
of ammonia '. 186
Cases of irritable heart 1 865
Cases of kidney disease 882
Cases of laryngitis 731
Cases of malarial poisoning, acute 823
Cases of measles, clinical records 655
Cases of measle.s. post-mortem records G5S
Cases of ophthalmia 852
Cases of paralysis from exposure to cold and damp 846
Cases of pericarditis, idiopathic 806
Cases of periostitis and deep-seated suppurations from exix>snre to cold
and damp S42
Cases of peritonitis, idiopathic : 879
Cases of pleurisy 811
Casesof pleurisy consecutive to measles 817
Cases of pneunuinia, catarrhal 783
Cases of pneumonia scfpient to measles 788
Cases of pneumonia from the clinical records 752
Cases of pneumonia with typhoid symptoms 767
Cases of pneumonia, relapse in 764
Cases of pneumonia from the post-mortem records 760
Cases of pneumonia complicated wiih erysipelas 795
Cases of poisoning by opium 890
Cases of rheumatism, acute 829
Cases of rheumatism, chronic 837
Cases of rheumatic nuUingering 836
Cases of rheumatic ojihthalmia 841
Cases of rupture of the heart - 867
Cases of scarlet fever 662
Cases of scurvy, clinical records 696
Cases of scurvy, post-mortem observations 700
Cases of small-pox, clinical 629
Cases of small-pox, post-mortem C32
Cases of spurious vaccination at the Chimborazo Hospital, Richmond,
Va 039
Cases of congestion and inflammation of the spinal membranes 846
Cases of sunstroke 857
Cases of tonsillitis 733
Cases of tonsillitis assuming a diphtheritic aspect 737
Cases of tubercle, pulmonary 825
Cases of tuberculosis, acute, general >. 827
Catarrh — 725
Catarrh, association of, with measles 722
Catarrh, comparative frequency of, among the troops of the several
departments and regions 724
Catarrh, statistics of, among white and colored troops 719
Catarrh, epidemic 725
Cathartics in intermittents ISl
Cathartics in remittent fever 183
Cathartics in the continued fevers 540
Catheterization in cerebro-spinal fever 013
Catheterization in the continued fevers 548
Causation of common continued fever 485
Causation of cerebro-spinal fever 608
Causation of malarial diseases 153
Causation of typhoid fever 480
Causation of typho-malarial fever 508
INDEX OF SUBJECTS.
CausatioQ of typhus r>20
Cause of tlwitli in (ho ciniliniietl fevers 4S3
(_'ausi-s of mortality ainon^ tlie Rebel iiri.-ioiie s 43
Cerebml fiioctioiii di^turbod iu ccntiniied fever?, without Aiicoplmlie
lesiuus : 4T".>, -ISO
Cerebral lesions iu coutinued fevers without rcconled cervbr.il synii>-
toiiid „. 479
Cerebral intmbranes, coiiditiou of, iu the continued fcvor* 431, 47S
Cerebral syini>touis of typhoid fever ,„_, - 270, 288
Cerebnd symptoms in typhoid sometimes due to the primary imi>n.-^
on thebU>o<l 4S0
Cerebml symptoms iu typho- mala rial fever „__ 304
Cerebro-spiual fever ....»_ 652
Cerebro-spinul fi-ver, cases uf mean or average duration 591
Cerebro-*pinaI fever, rapid cases 5'.13
Cerebiw-^pinal fever, protracted cases 506
Cerebro spinal fever at Beutou Rirrack*. Mo oSO
Cerebro-spiual fever antong recruits at Krattleboro', Vt 6r.l
Cerebro-spinal fever at Cliillicothe, Mo 654
Cerebro-s|;inr.l fever among the colored troops 5S6
Cerebro-spinal fever among the recruits at Concord, X. H ._ 583
Cerebro-spiual fever among the Confederate troops 587
Cerebi-o-spinal fever at Fredericksburg, Va 5SS
Certbro-spinal fever at Galloupe's Islaud, Boston Harbor 5S3
Cerebro-epinal fever at various geueral lioi^pitals 576
Cerebro-spinal fever at ilrenada. Miss 538
Cerebro-spinal fever at Kansiis City, Mo 565
Cerebro-spinal fever at Ft. Monroe, Ya 553
Cerebro-spinal fever at Mobile, Ala 587
Cerebro-spinal fever at the National Hospital, Baltimore, Md 570
Cerebro-spinal fever at New Berne, K. C 551
Cerebro-spinal fever among the prisoners 500
Cerebro-spinal fever iu the lllh Maine and l04th Pa 562
Cerebro-8piuaI fever in the 24th Army Corps 566
Cerebro-spinal fevcrat Washington, D. C 553
Cerebro-spinal fever, associations of, with epidemic catarrh 60S
Cerebro-spinal fever, aii^ociations of, with malarial fever 60G
Cerebro-spinal fever, associations of, with measles 603
Cerebro-spinal fever, associations of, with pneumonia 608
Cerebrt>-spiual fever, associations of, with typhoid fevor 005
Cerebro-spinal fever, associations of, with typhus 598, 603
Cerebro-si;inal fever not a cerebro-spinal nieuiugitis GOl
Cerebro-spinal fever a complicatiou of tho eruptive, malarial and
typhoid fevers 596
Cerebro-spinal fever due to any miasm which destroys the integrity
of the IiKkhJ 610
Cerebro-spinal fever after continued fever 266, 311
Cerebro-spinal fever, etiology of 603
Cerebro-spinal fever, fatality of 554
Cervbro-spinal fever with no lesion of the brain or spinal cord 594
Cerebro-spinal fever, jiathological anatomy of 590
Cervbro-spinal fever, jiathology of 601
Cerebro-spinal fever and pernicious malarial fever, diflBculty of dis-
criminating between 594
Cerebro-spinal fever with no iM>st-mortem evidence of meniugitis.59!', 601
Cerebro-spinal fever, jireventiou of 610
Cervbro-spinal fever, prophylaxis of, by quinine 611
Cerebro-ppinal fever, ivconciliatiou of the different statements with
regani tu the climatic and other conditions associated with its prev-
alence 609
Cerebro-spinal fever, recoveriee from ,„__ __„ . 698
Cerebro-spinal fever and remittent fever, difficulty of discriminating
bet^veen 597
Cerebro-spinal fever, seasonal variations in the prevalence of 607
Cerebro-spinal fever simulated by pneumouia____ 758
Cerebro-spinal fever, summary of the post-mortem appearances of 590
Cerebro-spinal fever, symptomatology of — 590
Cerebro-spinal fever, temporary improvement in cases of 596
Cerebro-spinal fex'er, treatment of 611
Cess-pool fever 271
Chaplains at general hosjiitals, duties of__„. 957
Chest complications of typho-malarial fever -___„ 307
Chester, Pa., description and plans of hospital at 920
Chickahoniiny fever , 75
Cliills in cerebro-spinal fever 591
Chills and 3[>1enic enlargement, connection between 150
Cliills in typhoid fever 275
Med. Hist..Pt. Ill— 123
Page.
Chills in typho-uialarial (over . 301
Chimborazo IKkspital, Itichmond, Va., coses of opurious vaccination at. 639
Chimborazo IKtspital, Itichnioud, Va., fatality of the coutinue«l fevero
at _ 207
Chimbora/u Hospital, Bichmond, Va., medical tttatistics of 2.i
Chimbom/o IK>spilal, Itichmond, Va., report on typhoid fev»T ot .___
CUinihonizo Iliiepita', Bichmond, Aa., treatment of intennittents iu
the ___
riiiniborazo llw])ilal, Bichmoud,Va., treatmeutof rheunmtism in the.
Chlonite of potash in diphtheria .
Chlorate t..f i>ol;u<li in adynamic fevers
Chluniti' of potash in sniall-pox ,
Cholera not pres'-nt dnring the war i>eriod._
Choleraic variety of congestive fever
Chronic bronchitis_„_„„„.„ , ,
Chronic bronchitis, statistics of ,_„ .
Chronic malarial poisoning, fatal cases with iu>st-mortem reconi;*
Chronic malarial poisoning, 8l:*tistics of a.—.
Chronic malarial poisoning, symptomatology of _._._.__._.
Chronic malarial poisoning, treatment of__, _...._„_ .
Cinchona as an antiilote in malarial fevei^s .
Cinchonia, sulphate of, in malarial fevers „ .—„.„.-.„_
Civilians as nurses at geuenil hospitals „_
Clark's u-so of cinchona iu malarial fevers
Clarysville, Md., general hospital at ,„
<'liffburne Hospital, AVashiugton, I>. C, description of ._.— .
Clinical reconls of disease generally fragmentary and imiwrfcct „.
i.'luthing, insufficient supply of, at Ft. l>elaware prison-depot
Clothing, insulTicient supply of, at IChiiini, N. Y., prison-camp
Clothing, supply of, at Pt. Lookout, Sid., prison-camp
Clothing-bag as a substitute for tho kuajisack
Coffee as a specific iu typhoid fever ™..
Cold to the head iu the continued fevers-»__-.
Cold sponging for reducing tho febrile heat in tho continued fevers
CoMai)se, treatment of, iu the continued fevers -
Coma, iu continued fevers, due to abnormal liquidity of tho blood
Coma in cerebro-spinal fever
Coma-vigil in tyi)hoid fever -_™. -
Command of general hospitals vested in the surgeon iu charge
Common continued fever, clinical recoi-ds of .
Common continued fever, disposition of cases of, after June, 1802
Common coutinued fever, etiology of ._
Common continued fever, probable nature of tho reported caites
Common continued fever an abortive typhoid
Common coutinued fever a distinct clinical entity
Common continued fever, frequency and fatality of
Common continued fever aaajwrcentago of the total of tho continued
fevers 192,
Company funds for varying the diet of the soldier ..
Comparison of the medical 6tati^tic3 of the war with those of other
bodies of men of the military age
ComjHirison of the annual rates of sickness and mortalitj-from various
diseases among the white and the colored troops
Comparison of the prevalence and fatality of disease in the Vnion and
Bebel armies
Comparison of the mortality from disease among tho Rebel prisoners,
the Federal prisoners and the U. S. troojw, white aud colored
Comimrison of the prevalence of disease and tho mortality thereby oc-
casioned among the U. S. prisoners at Anderson ville, Ga., the V. S.
troops iu the field, the Bebel forces and other bodies of men
Comparison of tho prevalence of disease among Confederate trooiw in
the field and the V. i:^. prisons
Comi>ariM)u of the mortality from disease among the Bebel i)risoner3
and the Southern troops in the field
Comi>ari3on of the sick-rates from st>ecified diseases in the Union and
Rebel armies .._. —
Comparison of the frequency of continued fevers at certain ages, with
the relative number of men of lh<jse ages in the ranks of the army.
Concord, X. U., cases of cerebro-spiual fever among recruits at _
Confederate armies, medical statistics of
Confederate Army of the Potomac, medical statistics of 29,
Confederate States Sledical Journal :
Articles on cercbro-s|)inol fever ._«_..-..
Articles on the external application of tho oil of turpentine as a
substitute for quinine iu intennitleuts
Conge-stive chills, anomalous symptoms iu
Congestive chills, fatal cases with i«ost-mortem records
319
189
844
7Ji)
647
63;i
67.'>
126
723
719
M;t
81
129
183
176
181
957
176
908
910
210
53
56
60
871
534
643
541
541
480
592
289
955
212
75
485
271
73
74
ICl
203
712
IG
13
31
4S
35
45
47
32
482
583
29
, 32
180
120
137
978
INDEX OF SUBJECTS.
Page.
Congestive chills, mortality from ^^
Congestive chills, prevalence of '^
Congestive chills, rate of fatality of *'■*
Congestive chills, relative frequency of "S» 9^
Congestive chills, reports of medical officers on 141
Congestive chills, Bymptomatology of - 12.>
Congestive chills, treatment of 183
Constipation, causation of difftrences in the rej-orted prevalence of __ ST4
Constipation, its connection with headache statistically considered.^ 874
Constipation, its relations to diarrhcea S73
Consiimptiun among the colored troops 819
Consumption and malarial fever, the doctrine of, antagonism between 822
Consumption due to the exposures of active service 818
Consumption in the subjects of malarial disease HO, 820
Consumptiou, lines indicating monthly variations in the prevalence of 828
Consumption, post-mortem records of 825
Consumption, prevalence of, largely due to carelessness of recruiting
officers ^^8
Consumption, statistics of 818
Consumption, synopsis of clinical records of 812
Consumption, treatment of 828
Contagion as an element in the propagation of cerebro-spinal fever __ CIO
Contagion as an element in the propagation of diphtheria 742
Contagion as au element in the propagation of erysipelas 6G3
Contagion as an element in the propagation of typhoid fever 490
Continued fevers, cause of death in the 4S3
Continued fevers, clinical reconls of 210
Continued fevers, death-rate from, among the Confederate troojis 207
Continued fevers, frequency and fatality of the reported forms of 192
Continued fevers, frequency and fatality of, among white troops 191
Continued fevers, frequency and fatality of, among colored troops — 191
Continued fevers, relative frequency and fatality among the white
and the colored troops 195
Continued fevers, non-s]>ecific varieties of 27u
Continued fevei-s, relative frequency uf, and mortality caused by, the
various formsduring the several years of the war 193
Continued fevers, percentages of fatality of the various forms of 194
Continued fevers, greater prevalence of, among the Rebel troops 205
Continued fevers, pathological anatomy of 410
Continued fevers, prevalence of, in the various departments 203
Continued fevers, prevalence as related to season and locality 196
Continued fevers, principle on which their systematic treatment was
based 530
Continued fevei-s, statistics of the 190
Continued fevers, statistics of, in the Confederate armies 2U5
Continued fevers, statistics of, in certain of the Confederate general
hospitals 208
Continued fevers, treatment of 531
Continued malarial fever 512
Continued malarial fever, etiology of 508
Continued malarial fever, post-mortem characteristics of 484
Contraction of the pupil in typho-malarial fever 30J
Convalescence, period of, in typhoid fever 276, 270
Convalescents as nurses, etc., in general hospitals 957
Convulsions in congestive fever . 126, 130, 138
Cornea, sloughing of, after continued fever 2C;J, 311
Cornea, ulceration of, in the continued fevers 432
Cornus florida, use of, by Confederate surgeons, in malarial fevers 190
Cough in typbnid fever 297
Cough in tyitbo-malarial fever 307
Counter-irritants in cerebro-spinal fever 611
Counter-irritants in congestive fever 183
Crittenden Hospital, Louisville, Ky., description of 924
Cumberland Hospital, Nashville, Teun., description of 945
Cupping in cerebro-spinal fever 611
Cutaneous hypertesthesia in cerebro-spinal fever 591
Cuyler Hospital, Germantown, Pa., description and plans of 926
T>anville, Va., records of prison-hospital at 44
Danville, Va., small-pox at 628
David's Island, N. Y. Harbor, typhus f<;Vfr at 333
Deafness in typhoid fever 288
Deafness in tyjiho-malarial fever 304
Death, immediate cause of, in the continued fevers 483
Death, pericnl of, in typhoid fever 277
Death-rates from malarial disease among the white and colored popu-
lation of certain cities and sections of the V. S 7S
rage.
Death-rates from malarial disease in the States and Territories of the
TT S
10->
eatb-
rates from
typhoid fever in a
r
S. urban
population of
eight
,,o
e Camp Hospital
, David's Island, X
Y.
Harbor, d
escription and
plans
of
^•2.?.
Delirium in cerebro-spinal fever 501
Delirium in malarial fevers 122
Delirium in secondary pneumonia 801
Delirium in typhoid fever 288
Delirium in typho-malarial fever . 304
Delirium tremens - 890
De novo origin of typhoid fever 495
Diaphoretics in cerebro-spinal fever 612
IHarrhoea and dysentery at AndersonviUe, Ga 37
Diarrlueaarid dysentery, association of, with malarial fevers 144
Diarrhwa and dysentery, their relations with the malarial fevers, as
shown by the mortality statistics of the Tenth Census 616
Diarrhiea aud dysentery'as concomitants of remittent fever 122
Diarrho?a and dysentery, their association with the continued and i>ar-
oxysmal fevers 615
Diarrhoea and dysentery, cases of, with typhoid symptoms 619
Diarrhcea, cases of, with implication of the patches of Peyer 620
Diarrhtea, asymptoui or associate of incipient scurvy 705
Diarrhcea, treatment of, in intemiittents 182
Diarrhcea in typhoid fever 270, 292
Diarrhcea in typhoid fever, treatment of 540
Diarrha-a in typho-malarial fever 274, 306
Diet in the treatment of the continued fevers 551
Diet, extra, superintendence of, at general hospitals 958
Diet of the soldier improved and varied by the use of the comjjany
fund "12
Digestive system, condition of, in typho-malarial fever 3U5
Digestive system, condition of, in typhoid fever 291
Digitalis in the continued fevers 541
Digitalis in heart affections 8<i3
Digitalis in pneumonia 807
Digitalis in remittents 183
Dilatation of the pupil in typhoid fever 280
Diphtheria "^^
Diphtheria, cases of "42
Diphtheria, cases of, from the medical journals 74'.t
Diphtheria, causation of "-'O
Diphtheria, clinical records of "42
Diphtheria, comparative insusceptibility of negroes to "35
Diphtheria, contagion as an element of causation In 7-12
Diphtheria, laryngotomy in 744
Diphtheria, post-mortem reconls of 745
Diphtheria, prevalence of 73.'»
Diphtheria a putrid sore throat 742
Diphtheria not reported during the first fourteen months of the war. 735
Diphtheria, sequelie of 749
Diphtheria aud tonsillitis, associafion of '.IS
Diphtheria, treatment of "49
Disability from disease, discharges on account of 24
Disability existing prior to enlistment 25
Disability caused by malarial fevers "0
Discharges on account of disability from disease 24
Discharges on account of chronic rheumatism 832
Discharges on account of consumption 818
Discharges on account of disease of the heart 860, 864
Discharges on account of disease, infrequency of, among the colored
troops 28
Discharges on account of specified diseases 27
Discipline, enforcement of, in the grounds of general hospitals 958
Discipline, enforcement of, in the wards of general hospitals 9.^6
Diseases which caused the chief part of the mortality during the war. 14
Diseases allied to or associated with the paroxysmal and continued
fevers ^^'
Diseases attributed to non-miasmatic exposures 715
Diseases attribute*! to non-miasmatic exposures, seasonal prevalence of 721
Diseases attributed to non-miasmatic exi>osures among the prisoners
of war — '""^
Diseases of the respiratory organs "1^
Diseases of the respiratory ot^ns, distribution of, by departments and
723
regions '
DiEziness in typhoid fever 283
INDEX OF SUBJECTS.
979
Pago.
Dizziness in typhu-nml;iriul fever 304
Itogwoul, UK* i>r, by Coiiftdfrato surgeons in iitalariul fevers 100
r»uKwood as ti propbylaflic in nialiiriiil fcvera 175
pMtbii'nfiiteriti- „_-—- 72
Pmighis Hospital, Wushiugton, P. C 008
Iitiver's pow(U-r in tlu- fontiuucil ft-vers -.—...-_. — — ™„ 641
Pover's puwiler in rt-mittents . 182
Prowziiifsd in typhuid fever ... 288
Drowzinoss in typluf-nialarial fever 304
I>utHienuni, conilitioii uf, in the contiaucd fevers 421, 435
Pnplication of case's in Confederate hospital rocard«_,_. .. 30
I\vsent(*ry ca«se<l by malaria „ GIG
Dysentery, lesions of, in malarial affections 144
Dyjiphagia in the continneil fevers . 464
Pysuria and braiu symptoms, relation between, in contiuned fevers,
208. 308. 4G3
Kar, suppurative iiillammntion of, in the eontinued levers ,
Ecebymoses of internal organs and uf skin, want of cuiucideuce be-
tween, in the cuutinued fevers _„
Ecchyniotic blotches in typhoid fever .. .„„
Eechymotic blotches in typho-nmlarial fever , ..._275,
Klmira, X. Y., prison-camp, description of .....
Elmira, X. Y., prisou-camp, insalubrity of
Ktmim, X. Y., prison-camp, moilical statistics of .._._.
Klmira, X. Y., prlsou-camp, small-pox at .._. -
Kjnbolism a cause of gangrene of the feet after fever ,
Emetics in typhoid fever
Emetics in interniitteuts - . .
Emory Hospital, Wasbingtou, D. C, description and plans of
Emphysema bepatis„.._. .. .__..
Emphysema of the neck iu the continued fevers
Empyema, cjisos of ,
Ktid<.>canlium, condition of, in lobar pneumonia .
Enteric discbarges infective
Enteric lesion, absence of, in certain cases of continued fever having
typhoid pymptunis
Ephemeral fever ...
Epidemic catarrh
Epidemic catarrh, statistics of
Epidemic cerebn.>-spinal meningitis
Epidemic constitution as affecting the chamcter of febrile cases
Epidemics of typhoid fever local or regimental merely, not goncral__
Epigastric pain iu typho-malarial fever 274,
Epistaxis in malarial fevers
Epistaxis in typhoiil fever 282,
Kpistaxis in typhn-malariat fever
Erosion of the intestinal lining in tlio continued fevers
Eruptive fevers „ .___
Eruptive fevers among the Confederate troops
Erysipelas, cases of
Erysipelas among the Confederate troops
Erysif>elas among the Confederate prisoners
Erysipelas among the Confederate prisoners at Alton, III
Erysipelas during the Jlexican war .
Erysipelas, contagious nature of
Erysipelas, post-mortem records of
Erysipelas, prevalence and fatality of .
Erysipelas, reports of medical officers on
En.sii>elas, special wards for
Erysipehis, statistics of ,
Er>'sipelas, symptoms, progress and sequela} of
Erysi|K'las in typbo-nialarial fever
Erysipelas comiMiratively seldom connected with traumatism
Erj'sijieliia, treatment of ,-.-■■■ .-.
Etiology of common continued fever
Etiology of continued malarial fever
Etiology of cerebro-spinal fever
Etiology of typhoid fever
Etiology of typho-malarial fever___ ._._
Etiology of typhus fever
Executive oITicers of general hospitals, duties, etc., of _„
Exhalations from certain soils the cause of malarial disease
Expectant treatment of pneumonia
Expectorants in chronic pneumonia
Extravasations of blood in the continued fevers.,. .432,
471
287
304
56
03
4G
57
478
540
182
015
4G1
4G4
817
781
493
401
271
725
719
COl
71
505
307
122
283
302
450
C24
67
6CG
fiC3
029
51
G65
6C3
GOG
GC2
072
6(14
624
6G4
304
663
673
485
508
608
486
508
526
956
155
806
809
476
Page.
Famino-fevcr of Ireland, 1818-19 477
Famine not essential to the origiualiou of tyi>lnm „ 528
Fans t<t cH'atti an air-movement in hospital wards 952
Fatality of disease at Amlerponville, iia . .____—._. 34
Fatality of disease among U. S. prisoners at Danville, Va,„.., 44
Fatality of typho-malarial fever 308
Fatality-rotes among Rebel prisoners ...-.._... Cl
Fatality-iates of spi-clfleil diM>as<L-s among Rebel pristmers 47
Fatality-rotes of specitied dis(>ascs in the Union and Rebel armies. 31
Fatality-nites Incorrect .„ 4
Falatity-niles, factor to lessen error of ... 5
Febricula, idioimtbic .__ 74
Female nurses in general hospitals. ___. . j__ 958
Fences, utility of, around the grounds of general liospitals . 958
Fever, cerebro-spinal .«„. . 652
Fever, cess-iwol : _.„ . .._._._ 271
Fever, common continued 211, 270, 485
Fever complications, or seqneloi of ......... 41G
Fever, continued malarial 508
Fever, intestinal _. . . .„..„_.._.___. 73
Fever, irritative , . .. 271
Fever, malarial 77, 111, 119, 129, 153, 105, 170
Fovor, melanuric 127
Fever, mountain . ,...—_ 51'J
Fever, paroxysmal .... 77
Fever, pneumonic, in its relations to typhoid . G13
Fever, i>ythogenic „ . 495
Fever, remittent pneumonic 12.'J
Fever, rheumatic . ..-.-. -.-..-_.-.. 829
Fever, scarlet . ,. 662
Fever, typhoid „ 212, 273, 335, 377, 403, 48C
Fever, typho-ntalarial 212, 300, 345, 508
Fever, typho-malarial, since the war 608
Fever, typhus 208, 526
Fever, yellow G75
Fever-cases, common continued 211
Fever^<aises, malarial 112
Fever-cases, typhoid, from various records.—... ..... 257
Fever-cases, typho-malarial . .. 212
Fever-cases in regimental hospitals ...... 24d
Fever-cases of the Seminarj- Hospital, used to distinguish typho-mala-
rial fever from pure typhoid ._„ . 274
Fevers, continued 190
Fevers, diseases allied to or associated with the paroxysmal and con-
tinued ; 551
Fevers, eniptivo .__. 624
Fevers, history of the segregation of typhoid from typhus 71
Fevers, opposition to the identification of typhoid as distinct from
typhus 72
Fevers, methoil of reporting, at the beginning of the war 71
Fibrinous heart-clots, of ante-mortem formation . 468
Filth unnecessary to the development of typhus fever . 504
Filtration of water-supplies a preventive of malarial fevers 162
Fire, provision at general hospitals against danger from 955
Food, in?pecti<;ai of, in the service of general hospitals 95G
Ft. Delaware, Del., prison-depot, description of 57
Ft. Delaware, Del., prison-depot, medical statistics of 4<J
Ft. Jefferson, Fla., yellow fever at .... 678
Fowler's solution in the treatment of iutermittents...... 182
Functional disease of the heart, meaning of the term in army practice 864
Funds, company .._ 68
Funds, hospital _ _ - .68, 959
Funds, prison _- 08
Funds, slush, at general hospitals 959
Gall-bladder, condition of. in the continued fevers 427, 40.1
Galbbladder, condition of, in cerebro-spinal fever GOD
Gallipolis, Ohio, general hospital at _-..-- — — 908
Gangrene following fever 263
Gangrene of the feet following continued fevers 310,432, 477
Gangrene of the nose and face following continued fever __.... 477
Gangiene of the lung in ratarrhal pneumonia .... 799
Gangrene of the lung in lobar j>neumonia .._«. 780
Gangrene in typho-malarial fever . _— — _ 308
Gangrene, its occurrence in ridge-ventilated pavilions 952
Gangrenous spots on blistered surfaces in the continued fevers ...432, 47()
980
IKDKX OF SUBJECTS.
Page.
Gas-lighting of general hospitals, expense of 'Jo9
Gastric irritability, treatment of, in iutermittents 1S2
Gastric irritability iu typhoid fever 291
Gastric irritability iu typho-malarial fever -74, 305
Germ theory of disease iu relation to malaria 164
Germ theory of disease in relation to typhoid fever __ 492
Germ theory of disease in relation to typhus outbreaks 529
Georgia bark, use of, by Confederate surgeons in unilarial f^vL-rs 1S9
Gieshoro' Point, Md., epidemic of fever at 587
Glycerine, use of, in typhoid fever 547
Good Saiuaritan Hospital, St. Louis, 3Io., du'scripliouaud plans of 905
Gross on the typhus of the U. S. prior to 1828 ■. 72
Guard duty at general hospitals 958
Gurgling, intestinal, in typhoid fever 295
Gnrgliug, iutestinal, in typho-malarial fever 307
Hjvmatuvia, malarial
H;vmaturia, malarial, treatment of__.-
IIa>moptysis, phthisical, iron in the treatment of
Ha-moptysis unconnected with jmlmonary tubercle
Hammond Hospital, Pt. Lookout, Bid., description and plans of
Hamilton Hospital, near Ft. Monroe, Ya., description and plans of-.__
Harewood Hospital, Washington, D. C, description and plans of
Hart's Island, N. Y., condition of prisouere of iiar at
Headache in cerebro-spinal fever
Headache in malarial fevers
Headache in typhoid fever
Headache in typho-malarial fever
Headache, its relation to constipation
Heart, condition of, in continued fevers 420,
Heart, condition of, in cerebro-spinal fever
Heart, condition of, in malarial fevers
Heart, condition of, iu catarrhal pneumonia
Heart, condition of, in lobar pneumonia
Heart, condition of, in scurvy
Heart, contents of, in continued fevers 429,
Heart, dilatation and thinning of
Heart, discharges on account of disease of
Heart, muscular exhaustion of
Heart, rupture of
Heart, sudden death in the continued fevers attributed to the condi-
tion of the
Heart-clot in broncho-pneumonia
Heart-clot in continued fever, an ante-mortem formation
Heart-clot in continued fever, exciting cause of
Heart -clot and degeneration of the cardiac fibres, connection between,
in continued fevers _.
Heart-clot and deterioration of the blood, connection between, iu the
Heart -clot and pulmonary congestion, connection between, in the con-
tinued fevers
Heart -clot, malarial cases of
Heart-clot, typhoid fever cases of 396, 415,
Heart-failure iu malarial disease
Hemiplegia after continued fever 265,
Hemorrhage from the intestines in congestive fevers
Hemorrhage from the intestines in the continued fevers
Hemorrhage from the intestines iu the continued fevers, treatment of_
Hemorrhage from the intestines in ty])hoid fever „
Hemorrhage from the intestines in typho-malarial fever
Hemorrhagic malarial fever
Hepatic disorder in malarial fevei-s
Hepatic tenderness in typho-malarial fever
Hepatitis, suppurative
Hernia attributed to the pressure and weight of the waist-belts and
cartridge-boxes 1
Hernia, reports of medical officei-s on the causation of
Herpes labialis in typhoid fever _„-.
Herpetic eruptions in typho-malarial fever
Hicks Hospital, Baltimore, Md,, description and plans of
Hilton Head, S. C, hospital at
Hilton Head, S. C, yellow fever at
Hospital construction, circular from the A\*ar Department concerning
Hospital fund, constitution and management of
Hospital stewards, employment of, at general hospitals . .
126
128
824
869
942
939
939
65
591
122
288
304
874
466
599
148
800
781
702
467
864
864
862
867
468
471
470
470
138
416
129
311
126
450
548
294
307
126
123
274
877
871
871
288
303
949
915
678
943
959
957
Page.
Hospitals, extemporized 897
Hospitals, extemporized, iu Alexandria, Ya 8'.'7
Hospitals, extemporized, iu Maryland Sli7
Hospitals, extemporized, in Philadelphia, Pa SUS
Hospitals, extemporized, in northern cities SifS
Hospitals, extemporized, in 'Washington, D. C 897
Hospitals, extemporized, south of Washiugton, P. C 898
Hospitals, extemporized, in western cities 1 898
Hospitals, extemporized, descriptions and pluus of 899
Hospitals, general 890
Hospitals, general, conversion of barrack-buildings into 000
Hospitals, general, at New Orleans, La 80S
Hospitals, general, list of those in active service iu December, 1864 9G0
Hospitals, general, disposal of excreta at 953
Hospitals, general, domestic economy of 0'>9
Hospitals, general, funds of 050
Hospitals, general, guard and police duties at O.iS
Hospitals, general, personnel of 955
Hospitals, geueral, proportion of atteudautsat 957
Hospitals, general, provision against danger from fire at 955
Hospitals, general, water-supi>ly of 953
Hospitals, regimental, unwholesome conditions in, as regards the
spread of infectious diseases 400
Hutchinson's microscopic examination of malarial blood 14o
Hydrastis, infusion of, with chlorate of potash in dijihtheria 750
Hydrochloric acid, treatment of tyi>hoid fever by 551
Hyperemia iu fevei-s derives its importance from its site 615
Hypodermatic medication not in general use during the war 547
Ice in diiihtheria
Ice, supply of, to hospitals in the south and southwest
Ice, treatment of bedsores by
Ileum, condition of, in catarrhal pneumonia
Ileum, condition of, in lobar pneumonia
Ileum, hyijcrwmia of, iu continued malarial fever
Ileum, hyperemia of, in the continued fevere 422, 438,
Indigenous remedies used by Confederate surgeons iu malarial fevers.
Inebriety
Infarctions in lobar pneumonia
Influenza, the association of, with cerebro-spinai fever
Inhalations in pneumonia
Inoculation of variolous matter at 3Iacon, Ga
Intermittent fever, clinical characteristics of
Intermittent fever, cases with post-mortem records
Intermittent fever, fatality-rates of
Intermittent fever, knowledge of our medical officers concerning, at
the beginning of the war
Intermittent fever, mortality from
Intermittent fever, its percentage of the total of malarial fevers
Intermittent fever, prevalence ofl .. ^ .
Intermittent fever, relative frequency of types of 78
Intermittent fever and remittent fevers, identity of the cause of
Intermittent fever, seasonal waves of prevalence
Intermittent fever, symptomatology of
Intermittent fever, treatment of ,
Intermittent fever, treatment of, at the Cbimborazo Hospital, Eich-
mond, Ya —
Intermittent fever treated by tincture of opium and solution of am-
monia
Intermittent fever treated by the external application of turpentine.
Intestines, condition of, in malarial diseases
Intestines, condition of, in scurvy
Intestinal fever —
Intussusception of the small intestine in continued fevers 421,
Iodide of potassium in cerebro-spinal fever
Iodide of potassium in malarial cachexia
Irritable heart
Irritable heart, cases of _
Irritative fever
Iritis
Iron in chronic malarial poisoning
Iron, persulphate of, iu remittents „_
Iron in the treatment of consumption
Isolation in small-pox
Itch
965
548
800
782
440
440
189
890
780
608"
SIO
645
122
131
79
74
78
98
77
,98
119
92
119
181
189
186
186
144
702
73
435
612
183
862
865
271
840
183
182
824
627
886
IXDEX OF .SUBJECTS.
981
Jactitatiou iu cert-bro-epinal ft-ver
Jaundice
Page.
691
874
87«
870
877
875
250
120
870
JaniiiUco, fauil ca^5 of —___...„_.
Jauiidico, frequfiicy of, iu malarious locaIities__„„
JauiKlic^' ami iHHamuialion of llio liver, relation between
Jaundice, itB occurrence in local epidemics .
Jaundice, its occurreuco in couuectiou with tyiihoid fever _.
Jnundice in t>ernii-ious malarial fevers .
Jaundice. I'ri-valence of
Jaundice in rtiiiitteut fever, tn-ntmeut of „ „. 183
Jaundice, reports of medical oftifers on ,™ __. 875
Jnundice iu lypho-nialarial fever., __« 305
Jaundice, nnccrlainty of the iwthology of the cases of 870
Jefferson Uo^'pital, Jeffersonville, lud., de^ription of 'XVI
Jejunum, condition of, in the couCinucd fevers ____. , 421, 4;i,*»
Jointsi, disease of, following continued fevers_.-_ 470
Johnson's Island, Ohio, prison-camp, description of 'v4
Johujion's Island, Ohio, prison-t-j»riip. niwljcal statistics of ..,„___ 4>>
Johnson's IsUtnd. Ohio. prison<nnip, sitlubrity of 03
Jone«, on uialariat Moot! _. „.« 149
Judiciary* Stiuaix* Uospital. Washington. D. C, description and plans of. 917
Kansas City, 3Io., cerebro-^pinal fever at 665
Key West, epidemics of yellow fever at 076, 679
Kidnej-s^ condition of, in cerebro-spinal fever GdO
Kidneys, condition of, in continue^l fevers _.„ __42S, 46;t
Kidneys; condition of, in malarial fevers . 148
Kidneys, condition of, in catarrhal pneumouia , 8(X>
Kidneys, condition of, in lobar pneumonia . . 782
Kidneys, condition of, in scurvy 702
Kidneys, congestion of, attributed to the weight of the cartridge-box. 872
Kiilueys, diseases of . 881
Kidneys, inflammation of .._-__^ ..__ 882
Knai>sack. weight of, a cause of digcaso 870
Lancisi's nerial miasm as a cause of malarial fevers
Lauzi and Terrigi's alga miasmatica __.. 102,
Large intestine, condition of, In cerebro-spinal ft-ver
Large intestine, condition of, in the continued fevers 423,
l<arge intestine, condition of, in the malarial fevers
Large intestine, condition of, in catarrhal pneumonia
Large intestine, condition of, in lobar pneumonia
Lavrran on the parasitic nature of niahirial diseases „
Laryngeal inflammation in typhoid fever «,„
Laryngeal complications in typho-malarial fever
Larv'Ugitis-. _, ,,„■■ -___
Laryngitis, cases of
Laryngitis associated with catarrhal pneumonia
Laryngitis associated with lobar pneumonia ._
Laryngitis, statistics of
Laryngitis, tracheotomy in .. ..„
Laryngotomy in diphtheria .
I*arynx, gangrene of ,
Larynx and trachea, condition of, in the continued fevers 429,
Libraries of general hospitals __..
Limbs, artiflcial, for maimed soldiers and seamen
Lime, use of in diphtheria
Lime-juice as representative of a fresh vegetable diet in scurvy
Lincoln Hospital. Washington, P.C., description of
Liver, condition of, in cerebro-spinal fever .
Liver, condition of, in the continued fevers 427,
Liver, condition of, in malarial fevers
Liver, condition of, in catarrhal pneumonia
Liver, condition of, in lobar pneumonia
Liver, condition of, in scurvy .
Liver, emphysema of
Liver, inflammation of
Locality, influence of, on the prevalence of disease not accurately de-
termined by the statistics
Lovell Uuspital, P«.'rtsmouth Grove, R. I., description and plans of
LumUir pains attritmtctl to the weight of the cartridge-l>ox
Lumbricoid worms in cerebro-spinal fever
Lnmbricoid worms in the continued fevers 422,
Lungs, condition of, in cerebro-spinal fever .„_
150
104
60<)
441
144
800
783
104
297
30G
730
731
799
780
719
730
744
732
403
959
965
750
710
942
000
40<(
140
800
782
702
461
877
17
939
872
591
436
803
599
•^ Page.
Lungs condition of, in the continued fevers « 43tt, 404
Lungs, condition of, iu lualuriul f.-vers 148
Lungs, coudttiou of, in catarrhal pneumouia _. 798
Lungii, condition of, iu IoImf pneumoniu ...... ...- - 779
Lungs, condition of, in M-urvy. J 702
Lung», Weight of, in primary pneumonic cases 780
Malaria,a caui*e of dysentery ,...™™ . 010
Malaria, chill theory of, disproved , . . 158
Malaria due !<% n want of ridation ttetween (he nutritive elemenl4 of
a Soil and its living vef^etation . . , 158
Malaria, genu theory of ... _.. ... ___. 1»'4
Malaria from ganlen mould iu flower-|R>ts .„_ -_—.„._. 159
Malaria not an unstable organic gas 104
Malaria in pnow and rain-water .._.._ 16:1
Malaria, transmission of, by \vater*suppltes ... . 1.V.I
Malarial cases regarde*l as spottiil fever , 14<)
Malarial complieaiions of typhoid, recognition of, Ix^fore the wjir..„ 510
Malarial diseases, b4.-lief of uur medical ofllcers iu the id«'Utity of their
origin „__-. __-_ 155
Malarial disi'ase, causation of__«.„ __„ .,,_. 151
3Ialarial disease, clinical reconls of ... —___ _™. 111
Malarial disease, indications of it^ presence aa a complication of ty-
jdioid fever ,„■, . . 274
Malarial disease, pathological nuatomy of _„„ ... 144
Malarial disease, pathology of ._._„_. 150
Malarial disease, jirevenlion of — _— ™_ . 105
Malarial disease, symptomatology of ™._ 119
Malarial disease, treatment of _-^-. 170
Malarial fever-cases subn»itte<l as diarrhiea and ilyscntery .„_ 420
Blalarial fever and consuniplutn, the doctrine of antagonism between. 822
Malarial fever, fulminant, simulating tyjjhus . 325
Malarial fever and typhoid poisons or miasms, conditions of their evo-
lution - 501
Malarial fever and typhoid poisons or miasms, differences in their ac-
tion on Iho iut«-stinal canal _—_.—_- . 145
5Ialarial fi-vers among the I*. S. forces 77
Malarial fevers among the Confederate forces 102
Malarial fevers among the i)risonei's of warheld by the l". S. 109
Malarial fevers among tho prisoners of war held by the Rebel anther-
Malarial fevers, absence of details iu the records of .... . 111
Malarial fevers at Andersonville, Ga 38
Malarial fevers, the as.-^ociation of, with cerebri>-spinal fever.. 000
Malarial fevers mistaken for cerebm-spinal meningitis 120
Malarial fevers, assumption of infectious clmracters by .„, 527
Malarial fevers, cause of their severity in the Army of the Potomac.. 159
Malarial fevers, predisposing causes or conditions of „„ 158
Malarial fevers, comparison of prevalence anil mortality among white
an»l colored troops 80, 84
Malarial fevers and diarrhrcal diseases, their relations an shown by the
mortality statistics of the Tenth Census 010
Malarial fevers, disability cans^^-d by.. — „. . 79
JIalarial fevers due to a morbid condition of the blood 152
3Ialarial fevers and eulargwl splceu, connection between 147
31ularial fevers, mortality from 78
3[alarial fevers, mortality from, annual variations in 83
Malarial fevers, mortality fmm, seasonal variations in 04
Malarial fevers, prevalence of 77
Malarial fevers, prevalence of, among the Confeilerate troops 1(2
Malarial fevers, prevalence of, relative, among the white and the
colored troops _ -». -™ 86
Malarial fevers, prevalence of, in mixed garrisons of white and colored
troops since the war. ._ ...... — —....», . 83
Malarial fevers, prevalence of, annual variations in 82
Malarial fevers, prevalence of, regionic variations in 89,94
Malarial fevers, prevalence of, seasonal variations in 89
Malarial fevers, prevalence of, influence of rtr<-urrences on 92
Malarial ft-vers, prevalence of, influence of temjiemturc on 90
Malarial fevers, relapses in 1*J4
Malarial fevers, reports of medical officers on gjmptoms and tnat-
Malarial fevers, statistics of "7
Malarial group of typho-malarial fevers, tnie nature of 450
31alarial ha'maturia 120
Ma^al manifestations in the apparent absence of organic decompo-
sition in the soil "^^"^
98:
INDEX OF SUBJECTS.
Page.
513
cteJ with cousumptiou, 823
1S3
Sliilarial miasm a cause of tyi.boid fever ___
Malarial Diiasm, deaths from, in patients a
Malarial ueui-algia, tieatineut of
JIalarial i)igmentatiou —
flialarial piieuraouia
Malarial rheumatism ^34
Malarious exhalations from rich soils in the absence of living vegeta-
tiou
Malarious regions, accliniatiou in.
146
123
157
166
Malarious waters at l*'t. Bridger, Wyo. Ty., and Camp Douglas, Utah, 160
Malignancy of acute diseases in overcrowded quarters 531
Malignant congestive fever popularly called yellow fever 126
Malingering, as related to chronic rlieumatism 836
Marine Hospital, St. Louis, Mo., description and plans of 907
Mason Hospital, Boston, Mass., description of i'US
McClellan Hospital, near Philadelphia, Pa., description of 930
McDougall Hospital, Ft. Schuyler, N. Y., description of 930
McKim's Hospital, Baltimore, Md., description and plans of — 909
Jleau strength of the Confederate forces, difficulty of obtaining ac-
curate representations of, for the calculation of sick and mortality-
rates 31
Measles, association of, with cerebro-spinal fever., 603
Measles, clinical records of 655
Measles, intentional infection under medical supervision as a means
of exhausting the suscejitibility to 059
Measles, prevalence and fatality of C49
Measles, post-mortem records of G5S
Measles, reports of medical officers on 051
Measles, seasonal variations in the prevalence of VM
Measles, seqnelfe of 050, 655
Measles, statistics of 624, 655
Measles, treatment of the individvial case 601
Measles, treatment of a command infected with 000
Medical cadets at general hospitals 020, 957
Medical and hospital supplies, etc., quantity of, issued by the Medical
Purveying Bureau during the war 9G6
3Iedicf\l Purveying Bureau, report of its operations 9G4
Medical statistics of the l". S. troops 13
Medical statistics of the Confederate armies 29
Medical statistics of the Franco-Prussian war, 1870-71 7
Medical statibtics of the U. S. military prisons 40
Medicated whiskey of the C. S. A. as protective against malarial at-
tacks .
Melanuric fever 127
Memphis, Tenn., licensed i-rostitution at 895
Meningitis, spinal, and rheumatism, association of , 833
lllercurials in cerebro-spiaal fever . 595, 612
Mercurials in the continued fevers 641
Mercurials in pneumonia 807
Mercurials in remittents 177
Mesenteric glands, condition of, in cerebro-spinal fever COO
Mesenteric glands, condition of, in the continued fevers 426,458
Mesenteric glands, condition of, iu scurvy 703
Miasmatic contagious diseases .. 500
Miasmatic origin of typhoid, cases illustrative of 490, 522
Miasmatic t.vpboid fever 510
Miasme hiimain us a cause of typhoid fever j 505
Micrococci in diphtheritic pseudoniembrane 741
Military operations, influence of, on the prevalence of disease, not
accurately determined by the statistics 17
Milk-supply and typhoid fever propagation 495
Missouri mange 887
Moon, influence of, on malarious subjects 165
Mortality among U. S. troops during the war 1
Mortality, difference between the actual and the reported 2
3Iortality, causes of the monthly fluctuations of 23
Mortality influenced by season, locality and military operations 17
Jlortality from disease in the Confederate armies , 30
Mortality from malarial fevers among the Confedei-ate troops 100, 108
Mortality-rates trustworthy when calculated from the tabulated sta-
tistics 3
Mortality-rates of an army, standards of comparison for the 7
Mortality-rates of general hospitals, cause of variations in the 959
Mortality-rates, general, annual movement__.__ . 0
Mortality-rates, general, annual fluctuations of, in thevarious dei)art-
ments __. is, 19
Mortality-rates, general, aaunal fluctuations of, in the various regions^ 18
Page.
Mortality-rates, general, monthly fluctuations of, in the several regions 22
Mortality-rates among U. S. and C. S. prisoners and U. S. troops in the
field compared 43
Mortality-rates, U. S. Army, 1840-59 _. 8
Mortality-rates, U. S. Army, 1867-83 9
Mortality-rates, V. S. Army, causes of their recent diminution 10
Mortality-rates, U. S. Army, from various diseases for eighteen years
before the war 10
Moriality-rates, U. S. Army, from various diseases during the war— 11, 16
Mortality -rates, V. S. Army, from various diseases for ten years after
the war 16
Mortality-rates from various diseases, V. S. male population of the
military age 16
Mortality-rates, U. S. white troops, as compared with those of other
bodies of men of the military ago 14
Mortality-ratesfrom various diseases, annual, white and colored troops. 13
Slortality-ratesfrom various diseases among the Cuufederate troops 33
Mortality-rates from various diseases among the Confederate prison-
ers 47. 61
Mortality-rates of the British troojjs in the Crimea 7
Mortality-rates of the German army, campaign of 1870-71 7
Mortality-rates of the German army in times of peace 8
Mortality- rates from various diseases, French army, 1875-78 10
Mortality-rates from various diseases, German army, 1875-78 16
Mound City Hospital, 111., description of 905
Mountain fever 100, 519
Mountain fever essentially a malarial fever 524
Mountain fever of the Western territories identical with the camp
fevers of the war 52G
Mount Pleasant Hospital, "Washington, D. C, description and plans of_ 917
Mower Hospital, Chestnut Hill, Pa., description and plans of 932
Mumps r ^^~^
Muscles, condition of, in the continued fevers 432, 470
Muster-rolls of the Confederate Army for 1862-63-64 31
Myalgia ^ 836
Nashville, Tenn., licensed prostitution at 893
National Hospital, Baltimore, Md., cases of cerebro-spinal fevtr at___ 570
National Hospital, Baltimore, Md., description of_ 899
Nausea in typho-malarial fever 305
Nausea and vomiting in cerebro-spinal fever 591
Negro, his alleged insusceptibility to malarious influences 85
Nelson Hospital, Camp Nelson, Ky., descrii)tion of 938
Nervous system, injury to, following fever 265
Neuralgia 874
Neuralgia, its association with malarial fevers doubtful 120
New Albany, Ind., typhus fever at 328
New Berne, N. C, yellow fever at 679
New Berne, N. C, cerebro-spinal fever at 554
Newkirk, A'a., general hospital at 908
New Orleans, La., freedom of, from yellow fever during the war 075
New Orleans, La., typhus fever at 331
Nitrate of potash in the coutinuetl fevers 541
Nitrate of potash in scurvy 714
Nostalgia SS-l
Nostalgia, reports of medical officers on 884
Nostalgia, suggestions for the treatment uf 884
Nursing, value of, iu the continued fevers 533
Nutrition of the body in fatal cases of the continued fevers 483
Nyctalopia as a symptom or associate of scurvy 706
Nyctalopia independent of scurvy 707
Nyctalopia iu the Southern army 707
Ochletic miasms, intensification of typhoid phenomena by 5(J7
Odor from the typhoid feverpatient 288
Odor from the body in typho-malarial cases 304
Oedema in the continued fevers 432
Oedema glottidis in continued fevers 404
Officer of the day, duties of, at general hospitals 956
Oldham's theory of malaria disproved . 158
Old Hallowell House, Alexandria, Va., description and plans of 901
Ophthalmia ascribed to the scorbutic taint 851
Ophthalmia, causation of 850
Ophthalmia, rheumatic 841
Ophthalmia, statistics of 849
IXPEX OF SL'BJKCTS.
983
Tuge.
Oplitbalmopcopic detection of pi^nu-nt in the brain of nm!arioug«u)>-
jtrts _ - - HO
Opium auil iininionia usctl by Conrcdcrnte etirgt'oiiit a» a »iil»tituti> fur
r|uinint' in the IrL-atinont of inlennittents :.,..„.
Opium in ct'rebm-spiniil fever., . — , „
Opium in the ooutinned fcvvrs
Opium in pnenmoniii ......
Orchitis aft<r iM>ntiuntHl fever
Organic tlecompo^ition itt the soil trithout a))i>ixreu( umluriul niuuifi«<
tat ions _
Orpuiic tlisease <>f tho heart ..——._—_.___- .„
Otorrhua in typhoi*! fever 260,
OveriTi'Wtling, it^&^ociation with cvrebro-spinal fever
Overvrowding, ita connection with typhoitl fever jiropaKation
Overerowdinp, its connection with the ilevebipnient of typhus among
prisoners of war at Salisbury, X. <'
Overcrowiliui; in tents and htits „_„
Oveivrowdiu^ in V. S. niilitaiy prisons..™.
ISO
GI2
647
80G
3U
150
SGtt
278
CCkO
507
529
71 fi
G5
Pain in the feot foHowing fever.. 262,
Pain in the feetaml U-jts iu typhoiJ fever
Tain in the joints and mu:icle5 in typho-malarial fever .
Palmer-brnce. the
Pancreas, condition of, in cen-bro-spinal fever
Pancreas, condition of, in continued fevers 428,
Pancn'as, condition of, in h>bar pneumonia
Pancreas, condition of. in pcurvy
Pamlysis agitans after continued fever 2CG,
Paralysis a!M:ril»ed to the wind of parsing shot or shell
Paralysis from injury cause.! by involuntary muscular action
Paralysis, statistics of
Pamplegia after continued fever gC5,
Parkersburg, Va., general lutspital at
Parotid glands, condition of, in malarial fevers
Parotid glands, inflammation of, in lobar pneumonia
Parotid swellings following fever 204, 278, 298, 308, 311, 420,
Paroxysmal fever?, the _
Paroxysmal tyjK' of typho-malarial fever
Patches of Peyer. conilition of, in ceivbro-spiual fever
Patches of Peyer, condition of, iu the continued fevers :
Healthy condition of 422, 436,
Pathological changes in
Perforation of
Reparation of
Shaven-beanl ap]H'arunce of
Sloughing of
Tumefaction of
Ulceration of
Patches of Peyer, tumefaction and ulceration of, in nou-specific diar-
rho-al cases.-.
Pathological anatomy of cerebro-spinal fever
Patliologiral anatomy of malarial diseases
Pathological anatomy and jwithology of the continued fevers
Pathology of cen^bro-spinal fever
Pathology of jaundice
Pathology of malarial diseases
Pathology of ecur>-y
Patterson Park Hospital, Baltimore, Md., description and plans of
Pavilion hospitals fii^t constructed iu West Virginia
Pavilion ho,«iiita!^, mistakes made in those first constructed
Pavilion lo'.'-pitals, faiilty systems of aggregation
Pavili<in In-spitals, the elementary idea carried into effect at the ex-
pense of convenience of administration
Pavilion hospitals, i>rogi'ese of improvement in the construction of
Pavilion hospitals, official instructions to officers charged with their
construction
Pavilion hospitals constructed in accordance with the requircuieuts
of official or^Iers ___-
Pavilion hospitals, advantages of yellow- instead of white-washing
externally
Pavilion wards, adverse criticism on the requirements of official onJers
Concerning the construction of
Pavilion wards attached to some central extemporized hospital bnild-
309
2l>8
308
871
600
4l»
782
702
311
846
840
845
311
908
149
7S3
434
77
274
600
439
448
451
453
455
438
43G
437
456
5i)U
144
419
601
876
150
709
912
908
919
920
ing_
Pavilion wards attached to corridors enclosing a central oblong ur cir-
cular sjiace . ,
922
934
943
946
052
051
922
920
Page.
ParilioQ wards, disposition of, en echelon 935
Pavilion wards, provision for their ventilation in winter 952
Pavilion wards, the wanning of .......... 952
Perfonition of the intestine in the continued foveni 425, 450
Pericanlitis, idiojknthie . , _...,...—_ 8t>6
Pericarditis an association of pleurisy .-._....-..__ 810
Pericanlitis an association of cerebro-spinal fevor...... ........ GM
]*ericanlitis in loKir iineumonia.... 759, 768, 781, 805
Pericardium, condition of, in the continued fevers .......428, 465
Pericanlium, condition of, in malarial fevers _..___,..-. -.— 148
Pericardium, condition of, in catarrhal pneumuniu .....1.... 790
Pericaiilium, condition of, in si-urvy „......_. .___—— 702
Periodic feven* and inflammation of the spleen.,.. .... 151
PeriiMlicity of malarial fevers and sol-lunar influeuco.. ...___. 165
Periostitis from exinwuro to cold and wet . 842
Periostitis following continued fevers ... 476
Peritoneum, condition of, in cerebro-spinal fever. GOtJ
Peritoneum, condition of, in catarrhal pneumonia ....... =- 8(M)
Peritoneum, condition of, in bibar pneumonia . 783
Peritononm, condition of, in scurvy ... -_...._.-._ 703
Peritonitis in continued fevers. .... . —277, 426, 450
Peritonitis, idiojMithic . — 879
Pernicious malarial fever, symptomatology of....... _ 125
Pernicious malarial fever and cerebro-spinal fever, difficulty of dis-
criminating bet ween, ,..„._ . _. — .- 694
Perspiration in typhoid fever 283, 295
Perspiration in typho-malarial fever 274, 301
Perspiration, treatment of, in the continued fevers 648
Petechia* and internal eccliymoses, want of coincidence between, in
continued fevers 472
Peti.>chia} in the continued fevers 432
Petechias in malarial fevei-a 126
Peteehiro in typhoid fever 279, 287
Petechiie in typho-malarial fever 275, 304
Pettigrew Hospital, Raleigh, N. C, special treatment for ague at 186
Pharynx and tesophagus, condition of, in the continued fevers.. .420, 434
Pigment deposits in the intestines in continued fevers 426, 455
Pigment deposits in the intestines, cause of their infrequency in acute
malarial fevers 458
Pigment deposits iu the intestines, cause of their infrequency in ty-
phoid fever 458
Pigment in malarial blood .— 149
Pigment in the brain in malarial fevei-s _ 149
Pigment in the liver, spleen, etc., in malarial fevers 146
Pink spots in cerebro-spinal fever 592
Piuckne;-a pubens, use of, by Confederate surgeons, in malarial fevers 189
Pleura, condition of, in cerebro-spinal fever 699
Pleura, condition of, in the continued fevers 430, 465
Pleurisy, association of, with catarrhal pneumonia 790
Pleurisy, association of, with lobar pneumonia 780
Pleurisy, clinical records of 810
Pleurisy, complication of, by pericarditis 810
Pleurisy consecutive to measles 817
Pleurisy, ]>ost-mortem records of 810
Pleurisy, statistics of 710
Pleuro-pneuniouia, frequency of, in the continued fevers affecting the
colored troops 465
Pneumonia a cause of organic disease of the heart 861, 864
Pneumonia among colored trooi>s 758
Pneumonia an acute specific disease 801
Pneumonia, analysis of the symptoms of, in 130 rases 755
Pneumonia, analysis of the post-mortem apiwarancee in 135 catarrhal
cases "^8
Pneumonia, analysis of the post-mortem appearances in 300 lobar
cases 770
Pneumonia, as a camp disease, invariably attributed to exposure to
cold and wet ^^2
Pneumonia, association of, with cerebro-sidnal fever 008
Pneumonia, association of, with tyidioid fever ... — _ .._...— 804
Pneumonia at Benton Barracks, Mo 758
Pneumonia, carl»onate of annnouia in the treatment of. 810
Pneumonia, catarrhal cases following measles, clinical reconls 754
Pneumonia, catarrhal cases following measles, post-mortem records — 788
Pneumonia, chronic ...... — — 758
Pneumonia, chronic, as distinguished from consumption . 757
Pneumonia, chronic, treatment of ... — — 809
Pneumonia, clinical records of.._.. — — 752
9S4
INDEX OF SUBJECTS.
Pneumonia, contajriun tlevelopod in ca?os of
PneuiiioniH, distribution of, l.y departments iind regions
Piieiiinonia due to a depmvaliou of the blood produced by specific
fflirile inia^^iiis
Pueninonia in the continued fevers, treatment of
Pneumonia due to epidemic influences
Pneumonia, expectant treatment of
Pneumonia, general depletion in
Pneumonia, inhalations in the treatment of
Pneumonia, mercurials in the treatment of
Pneumonia, micrococcus of
Pneumonia, parallelism of its line of prevalence with those, of diseases
due to climatic and meteorological exposures
Pneumonia, pathology of
Pneumonia not a pneumonitis
Pneumonia, post-mortem records of
Pneumonia, rates of prevalence and fatality among; tJie Southern
troo])s
Pneumonia in remittent fever
Pneumonia simulating cerebro-si>inaI fcTcr
Pneumonia, statistics of
Pneumonia, tartar emetic in
Pneumonia in typhoid fever 277,
Pneumonia in typho-malarial fever 275,
Pneumonia, treatment of
Pneumonic exudation, constituents of
Pneumonic fever
Pneumonic fever, its associations with continued and paroxysmal
fevers
Pneumonic fever, its relation to other continued fevers not intimate
Pneumonitis, the pathological essentials of
Point Lookout, Bid., prison-camp, description of
Point Lookout, Bid., prison-camp, medical statistics of
Poisoning by deadly drugs
Poisoning by rhus toxicodendron
Police duties at general hospitals
Post-mortem appearances of the cerehro-spinal axis iu cerebro-spinal
SOo
54S
758
SOG
808
810
807
801
722
801
803
759
123
75S
710
807
297
307
805
804
803
C13
G15
803
59
46
890
890
958
fever_
Post-mortem records of aneurism
Post-mortem records of cerebro-spiual fever
Post-mortem-records of the continued fevei-s
Post-mortem records of consumption
Post-mortem records of diphtheria
Post-mortem records of erysipelas
Post-mortem records of liernia
Post-mortem records of laryngitis
Post-mortem records of malarial diseases
Post-mortem records of measles
Post-mortem records of pericarditis, idiopathic [?]
Post-mortem records of peritonitis (idiopathic?)
Post-mortem I'ecords of pneumonia, catarrhal
Post-mortem records of pneumonia, lobar
Pttst-mortem records of rheumatism, acute
Pust-mortem records of ruptured heart
Post-mortem records of scurvy
Pust -mortem records of small-jtox
Post-mortem records of sunstroke
Potash salts, use of, iu scur\y
Potatoes to be issued to the troops three times a week whenever prac-
ticable
Practice of medicine, works on, supplied to its officers by the Medical
Department, U. S. A
Prairie dig
Prevalence of disease, influence of season on the, accurately deter-
mined by the statistics
Prevalence of disease, influence of locality on the, not accurately
determined by the statistics
Prevalence of disease, influence of military operations on the, not
accurately determined by the statistics
Prevention of cerehro-spinal fever..
Prevention of malarial diseases
Preventive measures in the continued fevere
Prisoners, Kehel, their condition at the time of their capture
Prisoners, Rebel, their condition at the time of their commitment
Prisoners, Rebel, efforts to improve the condition of
Prisoners, Rebel, condition of, at Hart's Island, N. Y
Prisoners, Rebel, prevalence of disease among ,
592
8CS
558
334
825
715
('C9
872
731
129
CSS
sr,G
879
7S3
759
831
SG7
700
632
SCO
713
73
8S7
17
GIO
,165
531
63
C4
Go
05
45
Page.
Prisoners, Vnion, condition of, when received at Annapolis, Md., after
parole 43
Prisoneis, Vnion, fatal cases of disease among, without medical treat-
ment 39
Prisoners, Union, food and medicine for, in the Andersonville prison-
hospital ^__ 42
Prisonei's, Union, rations provided for liy the Confederate Congress— 39
Prisons, Rebel, prevalence of disease among U. S. troops in XJ
Prisons, U. S., commitments to C3
Prison-fund, U. S., sources and dispositinn GS
Prison-pen at Salisbury, N. C 527
Prison-records of Andersonville, Ga . 34
Prison -re CO x'ds of Cahawba, Ala 33
Prison-records of the hospital at Bauville, Va 44
Prison-records of hospital Xo. 13, Richmond, Vu 33
Prison-records of hosjiital Xo. 21, Riclimond, \a. 33
Privy-boxes at general hospitals 954
Privy-vaults at general hospitals 954
Prophylactic use of quinine IGG
Prophylactic use of willow bark, dogwuod, etc 175
Prostitution, licensed, at 3Iemphis, Teun 895
Prostitution, licensed, at Xasliville, Teun 803
Prostration in the continued fevers, causes of 475
Prostration in typhoid fever 2S2
Prostration in typho-malarial fever S05
PsoPG muscles, disorganization of, in malarial fever 149
Pseudo-rheumatic affections, Dr. AVooilward's description of the 834
Ptyalism in cerebro-siiinal fever 595, G12
Pulmonary congestion in the continued fevers due to enfeebled circu-
lation and deteriorated blood C14
Pulmonary congestion and degeneration of the heart, relation be-
tween, in continued fevers 4G7
Pulmonary congestion and heart-clot, connection between, in con-
tinued, fevers 470
Pulse in cerebro-spinal fever 591
Pulse in malarial fever 120
Pulse in typhoid fever 281
Pulse in typho-malarial fever 301
Pupils in cerebro-spinal fever 591
Pupils in typhoid fever 289
Pupils in typho-malarial fever 3o5
Purgatives in cerebro-spinal fever Gil
Purgatives in typhoid fever 540
Purpuric spots in cerebro-spinal fever 592
Purulent infiltrations and deposits in continued fevers 432, 47G
Purveying Bureau, Medical, ropi.rt of its operations 9G4
Pya-mic developments in the continued fevers 47G
Pythogenic fever 495
Quarantine in yellow fever 682
Quartans, their percentage of the total of the iutermittents 98
Quinine, administration of, iu large doses 178
Quinine, its alleged loss of remedial power after continued use 17.>
Quinine, alleged untoward effects from its prophylactic use 174
Quinine, cause of the unnecestsary pei-sistence in the use of, iu con-
tinued fevers 538
Quinine in cerebro-spinal fever 611
Quinine in congestive fever 183
Quinine, death caused by 184
Quinine, inefficacy of, in chronic malarial poisoning 183
Quinine in the prevention of relapses in ague 182
Quinine as a preventive tf cerel.ro-sivinal fever 607
Quinine as a preventive of malarial attacks 166, 171
Quinine in the treatment of the continued fevers 535
Quinine in the treatment of iutermittents 181
Quinine in the treatment of remittents 182
Quinine, untoward efTects iu its use in suppressing fevers 183
Quinoidine rs. quinine as preventive of malarial fevei-s 174
Quotidians, their nercentage of the total of the iutermittents 78, 98
Ratio of men of certain ages per hundred of the total in service 481
Ration of the U. S. Army prior to the Rebellion 711
Ration of the U. S. Army during the Rebellion 69, 711
Ration, Confederate ,\rmy Regulations C7
Ration allowed to Rebel prisoners 6^
I^'DEX OF srnjECTs.
985
nation of r. S. troors held in Confederftto pristms 39
Kfcoiiinieuiliitious fur iiu|truviug the couditiuii uf RoWl itri»uiu-niat
Alton, III ._ _ 51
i;*-oi>mineii<latiuns for iiupruviug the condUiou uf 1U>Ik>1 pritioiiorsnt
Ft. Di'Inwaro. Pol J, iS
R<ri:in)m<*iidiitioiis for improving the cuwlitiou uf Rrlfl priM)i)iT!i iit
Etiiiim. N. Y..,- . __- .'(G
KfComiiK'iiiliilion!* fur improving t!ie couditiun of Rebel prisoners at
rt. I.ookoiit. Md 59
R^-cords, clinioil, cause of the imiK-rfectiuns of ___„ ™__ 634
ReconK etc., k^pt Ity the ninnngeineiit of general ho«ipital8 956
Recrudescence of typlioid fever . _. „„ 2^8
Rt'Iai>?« '" continued fever „ _ :iI2
Re!«i*^' in nmliiriul fever ._»_.__ ._— lt'4
Ki-lapsf in typhoid fever 2frfi, 279, 2'.»S
Rfhi|»>«' in typho-mahirial fever 3(1S
Ki-niittent fever, cases with iHi?t-niortein records..™ l:!2
Remittent fever, clinical characteristics of 122
Remitteitt fever, clinical records of, at the Seminary IIosi>ital, D. <'__ 2I.">
Remittent ffver and cerehro-*i>inal fever, diftlculty of discriminating
hetweeu ._--. .i»......... 5ti7
Remittent fever, knowledge of onr medical officers concerning, nt tho
lieginning of the war . 74
Remittent fever, mortality from 78
Remittent fever in non-malarious regions . lf-0
Remittent fever as a pon-entage of tho total of the malarial fevers 98
Remittent fever, percentage of, among the cases reiK«rted as typho-
malarial „_ ,._ ..... 375
Remittent fever, prevalence of 78
Remittent fever, rate of fatalitj-uf ■ -..-_« 79
Remittent fever reconle^i as typho-malartal 330
ICemtttent fever. r\-lativo infre»iuency of, in malarious districts 97, 98
Remittent fever relatively oioro frequent among the Union than
among the Confe<Icmle troops . , 107
R'-niittent fever, seasonal variations in prevalence.. 92
Remittent fever, sj-mptomatology of_.,..___ 119
Remittent fever, treatment of „. 182
Remittent fever an<l typhoid fever, aflilintion existing between..«..„ 513
Remittent pneumonic fever „_ 123
Reumvitl fn.im the malarious locality ueedful to the cure of chronic
malarial ]H*isoning_..... 183
Renal congestion attrihuta.'d to the pressure of the cartridge-belt . 872
Reparation cf intestinal ulcerations in fever 453
Report of a h»^>anl convened December,- ISGl, to-jqnireiutothe nature
and character of the fevers prevailing in the Army of the Potomac, 3C5
Report of a K>ard of enquiry into the causes of an epidemic disease
affecting the 11th Army Corps 5C3
Report of a board pronouncing on the syphilitic character of certain
so-called v.iccination sores C37
Report on ccrehro-spinal fever among recruits at Concord, X. 11 583
Report on the occurrence of cerebral cases in an epidemic of typhoid
R"IK>rt on pJingrene of the fift in the 3d Anny Corps . 310
Report on the anomalous n-su1ts of attempts at vaccination at the
Camp Poufilas prison-<lep<;>t G47
Report on discharges on account of functional disease of the heart 6G4
Report on tlie operations of the Medical Purveying Bureau 904
RpI>orts and retnms called for from the management of general hos-
Rejwrts of meiUatl officers on :
Adyaniic fevers of the early periotl of the war 3G0
Army itch 888
Bloodletting in pneumonia 608
Cardiac diseases 8Cl
Cartri<lge-lM>Its, the injurious effects of •_ 872
Cerehro-spinal fever at Brattlehoro' Vt CtCA
Cerehro-sjiinal fever at Chillicothe, Mo 554
Cerebro-spinal fever among the colored troops 580
Ccrehro-spinal fever among the Confederate trooi>s 587
Cerebro-spinal fever at Concord, X. H „ 583
Cerehnvspinal fever at Ft. Monroe, Va.__ .— ._ 553
Cerebro-spinal fever at Galloupe's Island, Boston Harbor 58:J
Cerebro-si.inal fever at Kansas City, 3Io 505
Cervhrc^-spinal fever at Slobile, Ala „__ 595
Cerebro-stinal fever at New Berne, N, C 555
Cerebro-spinal fever in the 44th N. Y 553
Cerebro-spinal fever in the 24th Army Corps 506
Med. 1Iist.,Pt. Ill— 121
Reports of medical officers on :— [Continued.]
Common continued fever
Cong^'stive fevers___.
Conliuue<l feverpi, syinptonuitology of _.„
Coutinuetl fevens treatment of
I>iphtheriu, treatment of .__.. _-__.„.-
I>i<4ibilities existing prior to enlistment . .
I>is<.<nse^ attribut^Hl to non-miaKnuitic expot^ures.
Kpidemic catarrh-... . .__._
Krys)|ielas ,
Page.
141
312
538. 547-550
751
716
, 720
. C72
Ileruiiv, causation of 871
Intermittent and remittent fevers, symptoms and lrL-atnienlof_123,17d
.Taundiix* ..„_......-. ._- 675
Malarial disease, causation "f . .. 153
Chronic malarial poisoning ... ._. 114
Pernicious malarial fevers , _-_„-__..__.._. .... 141
Measles , _. C."»l
Xostalgia _. SS4
(iphthulmia, causation of ..... 850-
Pneumonia, treatment of ... „ . « 808
. Pneumonia, the typhoid tendencies of._„_ 750
Prostitution, Iicense»l ..„ .„_ 804
Quinine, the prophylactic use of, in malarial fevers .._.___ 108
Rheumatic affections —._... . 840
al!-p.
032
Spinal meningitis . 845.
Spotted fe\'er in camp near Auna|)oIis, Mil 141
Sunstroke ^'>ry
Tonsillitis, the prevalence of ._. . 734
Typhoid fever, etiology of 48G-401
Typhoid fever, the de novo origin "f , ,„■■■ . .____ - 497
Typhoid fever, its malarial complications .___ 3C3
373
332
320
801
Typlio-malarial, value attached to the term.
Typhus fever
Typhus, suspected
Yenercal diseases . ......
Bespiratioh in typho-malarial fever . 308
Rest, essential in functional disease of the heart . 803
Rhemuatism, lines indicating the ptvvaleuce of— facing_„_„ 828
Rhematism, acute, causes of death in 830
Rhenmatisin, acute, clinical and post-mortem records of_—_. 829
Rheumatism, acute, statistics of . 820
Rheumatism, chronic, character of the cases of._ 832
Rheuhiatism, chronic, clinical records of - 837
Rheumatism, chronic, i>ost-mortem records of ._ 840
Rheumatism, chronic, statistics of .. 832
Rheumatism, chronic, trottmeiit of . ._ 843
Rheumatism, chronic, treatment of, in Confederate hospitals 844
Rhus toxicodendron, poisoning by .. . , SW
River-water and typhoid epidemics __. 494
Rock Island, 111., prison -barracks, description of 52
Rock Island, III., prison-barracks, medical st^ttistics of . 40
Rock Island, 111., prison-barracks, small-pox at 53
Rose-colored spots in tj-phoid fever 277, 2S4, 285
Rose-colored siwts in typho-malarial fever. 34i3
Salisbury, N. C, prison-pen at ., _- — 527
Salisbury, N. C, prison-pen, fatal cases of disease among tho prisoners
at, without medical treatment 30
Salisbury*, N. C, prkon-pen, typhus fever at . 520
Salivary glands, affection of, in continued fevers 420, 4iH
Sarracenia purpurea, in sniall-pox ..... C33
Sattcrlee Hospital, West Philadelphia, Pa., description and I'laris of__ 920,
9-28, 931
Scabies B8T
Scarlet fever C02
Scarlet fever, statistics of — ~ '"'24
Scorbutic rheumatism 834
Scorbutic ulcers —.--.-. 700
Scurvy at Audersonville, Ga ..— .— — — — 37
Scnrvy in the Army of the Potomac 080
Scur\y in the t*. S. Army l»efore the war 0S3
Scurvy among the colored trwjis -.— 004
Scuri"y among the Confederate trwj* .. — 01,07
Scnrvy in tho English and French armies in the Crimea comi«ared i* ith
its prevalence during our war — 683
986
INDEX OF SUBJECTS.
Pago.
Scurvy among Rtbel prisoners of war ^7
Scurvy iu its a^ociatiou with the coutinued fevers 0^2
Scui'vy, causation of — '"^
Scurvy, cliuical lecords of 'j-'^
Scurvy as a complication of the contiuuod fevers 470, 48ci
Scurvy, complication of other diseases by "03
Scurvy, condition of the blood iu 708
Scurvv in connection with spurious vaccination in the South G46
Scurvy, general freedom of our armies from 703
Scurvy, influence of the mouotony of camp life on the production of _ 710
Scuri-j-, an instructive lesson furnished by its history in our armies.., 713
Scurvy, not mistaken for rheumatism 833
Scurvy, morbid anatomy of 708
Scurvy officially announced as the cause of many cases of so-called
chronic rheumatism 704
Scurvy, pathology of 7U9
Scurvy, post-mortem records of 700
Scurvy, prevalence of 083
Scurvy, reports of medical officers on the prevalence of ^ 089
Scurv}', symptoms of 704
Scun-y, treatment of 709
Season, influence of, on the prevalence of disease accurately determined
by the statistics 17
Sedgwick Hospital, Greenville, La., plans and description of 946
Seminary PTospital, Georgetown, D. C, plans and description of „__ 899
Seminary Hospital, Georgetown, D. C, fever records of 215
Sequela' of typhoid fever 279
Sequehe of the continued fevei-s 309
Sewage in water-supplies a cause of the spread of typhoid fever 494
St-weraire, defective, at general hospitals, disease attributed to 955
Shaven-beard appearance of the intestine iu fever cases 455
Sickness, cases of, absoUite and reported 3
Sickness, cause of the fluctuations of the rate of 23
Sickness in the Confederate armies 30
Sickness influenced by season, locality and military operations 17
Sickness and mortality among the U. S. forces 1
Sickness in U. S. prisons, causes of 70
Sick-rates from various diseases in the U. S. Army before, during and
after the war __11, 13, 16
Sick-rates, V. S. troops, as compared with those of other bodies of men
of the military age 14
Sick-rates, annual, from specified diseases in the Union and Kcbel
aiTuies 32
Sick-rates among the U. S. prisoners at Andersonville, Ga 35
Sick-rates from specified diseases among the Confederate troops 32
Sick-rates among Rebel prisoners 47, 61
Sick-rates, difficulty of comparing those of different armies 15
Sick-rates of an army, standards of comparison for 7
Sick-rates, trustworthiuess of those derived from the tabulated statistics 4
Sick-rates, general, annual movement of 0
Sick -rates, general, annual fluctuations of, in the various regions , 18
Sick-rates, general, monthly fluctuations of, in the several regions 21
Simple continued fever 211, 2T1
Sinapisms iu remittents 1S3
Sinks at general hospitals 954
Sisters of Charity at general hospitals 958
Skin, condition of, in malarial fevers ... 120
Skin, condition of, in typhoid fever 283
Skin, condition of, in typlio-malarial fever 302
Skin diseases ggtj
Sloan Hospital, Montpolior, Tt., description of 049
Slush funds of general hospitals, constitution and management of 959
Small intestine, condition of, in cerebro-spinal fever 600
Small intestine, condition of, in the continued fevei-s 421,435
Small intestine, condition of, in pneumonia, catarrhal 800
Small intestine, condition of, in pneumonia, lobar 782
Small-pox among U. S. troops 624
Small-pox. among Confederate troops 07
Small-pox in the Confederate Army of the Potomac 627
Small-pox among the prisoners of war confined at Northern depots._07, 029
Small-pox among the prisoners of war confined at Elmira, N. Y 57
Small-pox among the prisoners of war confined at Hock Island, 111 53
Small-pox in the Southern prisons 628
Small-pox, absence of contagion in the early period of 633
Small-pox, clinical records of 629
Small-pox, death from second attacks G27
Small-pox, post-mortem records of G29
Sniall-pox, prevalence of
Sraal!-pox, stsitistics of
Small-pox, susceptibility of our troops to
Small-pox, treatment of
Soil, a certain dryness of, essential to the evolution of the typhoid miasm
Soil, vegetation and malarial diseases, connection between
Solitary glands, affection of, in catarrhal diarrha-a
Solitary glands, condition of, in cerebro-spinal fever
Solitarj' glands, condition of, in the continued fevers 424,
Solitary glands, condition of, in pneumonia, catarrhal
Solitary glands, condition of, in pneumonia, lobar
Solitary glands, pathological changes in
Solitary glands, tumefaction of
Solitary glands, ulceration of
Sol-lunar influence on malarious exhalations
Sordes in tyjihoid fever
Sordes iu typlio-malarial fever „„.
Spasms in cerebro-spinal fever
Spinal meningitis after continued fever 266,
Spinal meningitis, traumatic, symptoms of
Spleen, condition of, in cerebro-spinal fever
Spleen, condition of, in the continued fevers 426,
Spleen, condition of, in malarial diseases
Spleen, condition of, in pneumonia, catarrhal
Spleen, condition of, in pneumonia, lobar
Spleen, condition of, in scurvy
Spleen not concerned in the disorganization of the blood in malarious
subjects L
Splenic enlargement and chill, connection between
Splenic enlargement in chronic malarial poisoning
Splenic enlargement iu typhoid fever
Splenic enlargement in typho-maldrial fever
Splenic lesions, absence of, in pernicious fevers
Spontaneous generation not involved in the de novo origin of typhoid
625
624
026
633
501
156
442
600
442
8IHJ
783
444
443
443
165
292
306
591
311
6112
600
459
146
800
152
150
120
296
307
148
fever-
Spotted fever .
Spotted fever with no lesion of the brain or its membranes
Spotted fever, malarial cases regarded as
Spring-water and tj-phoid epidemics
Stanton Hospital, Washington, D. C, description and plana of
Statistics, medical, of U. S. troops
Statistics, medical, of C. S. troops
Statistics, medical, of U. S. military prisons
Statistics, medical, of C. S. military prisons
Statistics, medical, of cardiac diseases
Statistics, medical, constipation, headache and neuralgia
Statistics, medical, of consumption _
Statistics, medical, of the continued fevers among the U. S. troops
Statistics, medical, of the continued fevers among the C. S. troops
Statistics, medical, of the continued fevers among Union soldiers,
prisoners of war
Statistics, medical, of the continued fevers among Rebel soldiers,
prisoners of war „
Statistics, medical, of diseases of the respiratory organs
StJitistics, medical, of erysipelas.- 624,
Statistics, medical, of hepatitis _
Statistics, medical, of jaundice
Statistics, medical, of malarial fevers among the U. S. troops
Statistics, medical, of malarial fevers among the C. S. troops
Statistics, medical, of malarial fevers at the U. S. prison-depots
Statistics, medical, of malarial fevers at the C. S. prison-depots
Statistics, medical, of measles 624,
Statistics, medical, of nostalgia
Statistics, medical, of ophthalmia
Statistics, medical, of rheumatism, acute
Statistics, medical, of rheumatism, chronic
Statistics, medical, of scarlet fever
Statistics, medical, of scurvy
Statistics, medical, of small-pox 624,
Statistics, medical, of sunstroke .
Statistics, medical, of venereal diseases
Sthenic remittents, rare
Sthenic remittents, treatment of
Stimulants in cerebro-spinal fever
Stimulants in congestive fevers
Stimulants iu the continued fevers .
Stimulants in pneumonitic attacks™ ...... —
499
601
595
140
494
935
1
29
46
33
860
873
818
190
205
209
719
062
877
875
77
102
109
108
655
884
849
829
832
624
6S3
625
853
891
119
1S3
613
183
546
609
INDEX OF SUBJECTS.
987
Pape.
Stiniulantct in reniiltouta — — — . — .—.„.■ 183
Slonmcli, cuuJitioii nf, iu cercbro-spiiml fevvr.— _._ _. 000
Stoniaili, condition of, iu cuntiinit'tl fovers 421, 435
Stoniacli, coutlilion of, in nmluriul diswi«'j< . 144
Stonmcli, couiUtiuu of, iu inu-unionia, catarrhal . 800
Stomaoli, coniUtioii of, in jincuniouia, lobar 782
Stomach, comlitiou of, iu scurvy 702
Stomach, hcrniiil i»riitru!sii>u of, into thorax ..... 872
Stone Hospital, \V;i>hiuglon, D. C — iH>8
Strautrulatcd hernia 871
Stnvliuia iu ccrebro-siHual fever 012
StrycliuiH in iiiternntli-uts — 182
Stuj-or iu typhoid ffver 288
Stup'ir iu typho-malarial ft-vor 304
Submaxillary ghtndr:, swelling of, after coutiuucd fi-vi?r 3U
Sul'jit'il watLT-U-vel, its connection with the evolution of the typhoid
mia^MU - 502
28i>
284
304
022
857
857
Tnicheotomy in laryngitis __
Page.
.._ 7:tO
28
Sul»sultus toudiuum in typhoid fever
Sutlaniiua in typhoid fcver
Sudaniina iu typho-malarial fever — 303,
Snuimit Hospital, Philadelphiat Pa., description and plans of
Snustroki*, cii^e.-i of -_
Snu^trok*', cerebnil form of
Sunjilroke, its high rato of fatality in civil life as compared with mili-
tary experience . . .....
Sunt-troke, lis occurrence chietly during marches —
Sunstroke, pathology of
Sunstroke, prevalence of, iu the Army of the Potomac
Sunstroke, post-mortem records of
Suu>tn'ke, statistics of
Suustrukf >yncopic form of
Snujlroke, treatment of
Supplies, medical aud hospital, deficiency of, at Ft. Delaware prison-
depot, Dei —
Supplie:-, medical and hospital, deficiency of, at Elmira prison-camp,
Suppuration, intermuscular, from exposure to cold aud wet
Supnin.-nal capsules, condition of, in cerebro-spinal fever
Suprarenal caiitsules, couditiou of, in the continued fevers
Suprarenal cajif^ulf!*. condition of, in scurvy
Surface-water, ass^tciation of malarial fevere with the use of
feurgeuns in charge of general hospitals, duties, etc., of
Symptomatology of cerebro-spinal fever
Symptomatology of common continued fever
Symptomatology of tv^phoid fever ._.
Symptomatology of modified typhoid fever
Synco|M- in typhoid fever
Syphilis, doubtful infection of vaccine vims by
Sy)ihilitir inoculation by the vaccination operation officially asserted,
Sweet spirit of nitre iu the continued fevers _„
857
854
854
854
860
853
8.5-1
85G
58
56
812
GCO
428
702
162
955
590
270
273
300
278
646
638
641
Tarha hlm'itres in typhoid fever 287
Tartar emetic in the treatment of pneumonia 807
Temperature in typhoid fever 279
Temperature charts! of mountain fever . 523, 524
Temi»erature charts of typho-malarial fever 518, 520
Temperatures, mean, of the hot months of the years of the war 854
Teut-hofipitals, advantages of, in the treatment of sloughing and gan-
grenous wounds .___. 952
Tents, difficulties attending the heating of 716
Tenfct used to increase the accommodations of general hospitals 908
Tertians, their percentage of the total of intermittents 78, 08
Thirst in typhoid fever _ 201
Thyroid body, condition of, in the continued fevers , 4.30
Tilton Hospital, 'Wilmington, Pel., description and plan of 924
Tinnitus aurium in typhoid fever ._ 288
Tinnitus aunum in typho-malarial fever 304
Tongiie, condition of, in cerebro-spinal fever 591
Tongue, condition of, iu malarial fevers 121
Tongue, condition of, iu typhoid fever 291
Tongue, condition of, in typho-malarial fever 275, 300
Tonsillitis, caj^es of 734
Tonsillitis and diplitheria, assocfatiuD of 738
Tonstillitis in scorbutic cases 730
Trachea, condition of, in pneumonia, catarrhal . 799
Trachea, condition of, in pneumonia, lobar 780
Transfers to the Veteran Reserve Cor| !«......_..-_. „
Tnin8|M)rti(liou of sick soldiers from the front, sutTering and danger
attending the .. -_-..„.-.-.. .— .„- KU
Treatment of lutthnm 729
Treatment of bronchitis, acute . 728
Treatment of bronchitis, chronic 728
Treatment of caniiac disooM'S 803
Treatment of cerebro*spinal fevor_.™-.-„. ......__„ Oil
Treatment of congestive fuvonj 183
Tr^mtment of consumption ._. „_.______ „.._._.,. 828
Tn>atment of the continued fevers .... 531
Treatment of <liphtheria I -.—- 748
Treatment of ery!^i[>eiiis..„„. __... G73
Treatment of intermittent fevor___„. .. . ..„_.__ 181
Treatment of laryngitis -..„_...........__.______..._... 730
Treatment of malarial diseases generally considered . 170
Treatment of malarial coukplications of typhoid fever „ 5:15
Tri'atnient of malarial iwisoning, chronic .-„ 183
Treatment of measles.. „._.„..„_.. _... ......._ C59
Treatment of ophthalmia __..—..-..-..—....._..-.—.__ 851
Treatnu-nt of pneumouia„_ — — ■,..,-■■ ...—.. 806
Treatment of rtMuiltent fever. __; .„ 182
Treatment of rheumatism .„_. . 843
Treatment of scurvy .— ... 709
Treatment of small-pox 6.'13
Treatment of spinal uieuiugitis-™. -__— — . - 846
Treatment of sunstroke _.... -_ 850
Treatment of tonsillitis .__.._.__.- 734
Tubercular deposits in catarrhal pneumonic cases.... 799
Tubercular deposits in primary pneumonic cases ___. ™™. _. . 780
Tubercular disease of the abdominal viscera......--. ....... 827
Tubercular disease of the brain and its membranes 827
Tuberculosis, acute, general, cases of ._ 827
Turpentine, external use of, by Confederate surgeons, in iutermittents, 185
Turpentine in the continued fevei-s _„ „.......- — 641
Turpentine in remittents . .... — — — 182
TyiniKinites in typhoid fever 295
Tympanites iu typho-malarial fever _...„ ....... 307
Typhoid character assumed by malarial fevers .—_ 119
Typhoid fever at Andersonville, tia _ 37, 208, 491
Typhoid fever, association of, with cerebro-*!pinal fever 605
Typhoid fever, average annual curve of prevalence of 200
Typhoid fever, baccilH of 492
Typhoid fever, cases of, erroneously reported as dlarrho?a 618
Typhoid fever case.*, differences between those of the war and those of
civil life 300
Typhoid fever, cause of the absence of special reports on itsorigindur-
ing the war ^^
Typhoid fever, causes of, in military camps 505
Typhoid fever, cause of its increased prevalence in the armies 15
Typhoid fever, clinical features of 275
Typhoid fever, clinical records of --. 212
Typhoid fever, clinical records of, at the Semiuarj- Hospital, D. C 215
Typhoid fever and continued malarial fever, post-mortem difTereuces
Typhoid fever, curve of prevalence of, among the urban population of
the I'. S. .
200
Typhoid fever, date of onset obscure in modified cases 303
Typhoid fever, defervescence of 270, 280, 284
Typhoid fever, de novo origin of 495
Typhoid fever, direct contagion of 490, 493
Typhoid fever due to a specific cause 491
Typhoid fever, duration of the attack 280
Typhoid fever an enteritis
Typhoid fever, epidemics duo to infected camps
Typhoid fever, epidemics due to individual susceptibilities
Typhoid fever, etiology of
Typhoid fever, freedom from, of cities which exclude sewage from their
1
489
507
486
water-supply
Typhoid fever, frequency and fatality of
495
191
Tvwhoid fever, fulminant, simulating typhus fever 325
Typhoid fever germ ^*^*
Typhoid fever, immunity from, due to exhausted susceptibility — 489, 491
Typhoid fever, impossibility of ascertaining the true rate of fatality of. 195
Tyidioid fever, indirect infection of 4.3
Typhoid fever, influence of aggregation on the prevalence of 199
\
988
INDEX OF SUBJECTS.
Page.
Typhoid fovor an internal exanthem . 72
Typlioiil fever, irregularities in the line of prevalence of 108
Typhoid fever, knowledge of our medical officers concerning, at the
beginning of the war 73
Typhoid fever miasm, conditions of its evolution 501
Typhoid fever a miasmatic contagious disease 500
Typhoid fever, nature of the cases reported as 377
Typhoid fever, onset of 27G
Typhoid fever, parallelism of the lines of prevalence of, in the various
regions 202
Typhoid fever, want of parallelism in its lines of prevalence and mor-
tality 1 200
Typhoid fever as a percentage of the total of the continued fevers.192, 203
Typhoid fever poison . _ 492
Typhoid fever, prevalence of, in rural districts of the V. S. 73
Tyi'hoid fever, prevalence of, in the various departments 203
Typhoid fever, the previous case of, not always discoverable 498
Tyjihoid fever and remittent fever, affiliation existing between . 513
Typhoid fever in the Rocky Mountain region 525
Typhoid fever, second attacks of 2G7, 312
Typhoid fever sequent to malarial attacks, fatal cases with post-mor-
tem records . 136
Typhoid fever a specific enteritis , 72
Typhoid fever, susceptibility of country levies to , 491
Typhoid fever, treatment of 538
Typhoid and malarial poisons, differences in the actions of, on the in-
testinal canal 145
Typhoid pneumonia . 277
Typhoid pneumonia, use of the term . 613
Typhoid eymiitoms in continued febrile cases without typhoid lesions- 401
Typhoid symptoms and malarial fever, recognition of the association
of, before the war _,»,»„ ,_„ 510
Typhoid symptoms in pneumonia ._,. 756
Typhoid symptoms in pneumonia, treatment of — _- 810
Typho-malaria of telluric origin 514
Typho-malarial fever, fii*st official announcement of the meaning of
the term « 76
Typho-malarial fever, acceptance of the term by army medical officers. 372
Typho-malarial fever, ambiguity of the terra „ 76
Typho-malarial fever, application of the term by army medical officers. 374
Typho-malarial fever, cases of, submitted as diarrhoea and dysentery. 420
Typho-malarial fever, classification of the fevers aggregated under the
term 526
Typho-malarial fever, clinical records of . 212
Tji^ho-malarial fever and common continued fever, relative frequency
of _ 205
Typho-malarial fever a continued fever ^ . 190
Typho-malarial fever, enteric fever not present in all the reported
cases of . ._« 191
Typho-malarial fever, erroneous views of pathologists regarding its
prevalence , „ 374
Typho-malarial fever, etiology of.»_ 508
Typho-malarial fever evoked by the association of the malarial miasm
with a septic poison . 512
Typho-malarial fever, fatality-rates of 70, 191, 193
Typho-malarial fever a fever sui-generis 511
Typho-malarial fever, frequency of the occurrence of 376
Typho-malarial fever a generic title for mountain fever 521
Typho-malarial fever, histoiy of the introduction of the term 75
Typho-malarial fevera hybrid 511
Typho-malarial fever, illustrations of, from civil life since the war... 514
Typho-malarial fever with the malarial element predominant found to
be a continued malarial fever with no specific typhoid element 484
Typho-malarial fever, mortality from 78, 105
Typho-malarial fever, nature of the fevers reported as 77, 374
Typho-malarial fever, obscurities of the term 509
Typho-malai'ial fever, onset of 301
Typho-malarial fever as a percentage of the total of the continued
fevers 192^ 203
Typho-malarial fever asa percentage of the total of the malarial fevers 98
Typho-malarial fever, practical results of the continuance or disuse of
the term ^__ 5-26
Typho-malarial fever, prevalence of 78, 191
Typho-malarial fever, prevalence of, seasonal variations in the 92, 196
Typho-malarial fever, symptomatology of 300
Typho-malarial fever, symptoms of, in the absence of typhoid lesions. 357
Typho-malarial fever and typhoid fever, clinical differences between . 309
Page.
T3iiho -malarial fever, undesirable results following the introduction
of the term 376
Typho-malarial fever, variations in the prevalence of, unconnected
with variations in the prevalence of the continued fevei"s 2'^5
Typhus fever in the canii)s at M'ashington, D. C 32*1
Typhus fever at David's Island, N. Y 3:'.:'.
Typhus fever at New Albany, Ind 328
Typhus fever at New Orleans, La 331
Typhus fever at Salisbury prison, N. C 526
Typhus fever at Wilmington, X. C 332, 526
Typhus fever in the llth Army Corps 330
Typhus fever in the 12th Army Corps 320
Typhus fever in the 15th U. S. Infantry _ 328
Typhus fever in the 3Gth Ohio 327
Typhus fever in the 77th Pa 328
Typhus fever caused by a concentration of human miasms 530
Typhus fever, association of, with cerebro-spinal fever G03
Typhus fever, clinical records of__, . 268
Typhus fever, etiology of 520
Typhus fever, frequency and fatality of the reported cases of 101
Typhus fever, knowledge of our medical officers concerning, at the be-
ginning of the war 73
Typhus fever, non-existence of, among troops in the field 324
Typhus fever as a percentage of the total of the continued fevers _102, 203
Tj-phus fever, spontaneous origin of „ 529
Typhus fever, suspected cases of 325
Typhus fever, symptomatology of 323
Ulceration of the cornea in the continued fevers 4:12
Ulcei-ation of the intestines in fever cases 43t>
Urinary bladder, condition of, in cerebro-spinal fever i;(iri
Urinary bladder, condition of, in the continued fevers 428
Urine, condition of, in malarial fevers 123
Urine, condition of, in typhoid fever . 297, 550
Urine, condition of, in typho-malarial fever . 308
Urine, retention of, in cerebro-spinal fever 591
Taccination at the camps of organization of the N. T. State troops
Vaccination in U. S. prisons
Vaccination, untoward results of attempts at
Vaccination in the Army of Northern Virginia
Vaccination at Camp Douglas, 111
Vaccination at the Chimborazo Hosi>itaI, Richmond, Va
Vaccination in the Department of Arkansas-.
Vaccination in the Department of the Cumberland
Vaccination at St. Louis, Mo
Vaccination in the Western Departments
Vaccination in the 1st Ark .
Vaccination in the 17th Army Corps
Vaccination in the 18th Ind _
Vaccination, failure of the successful operation to protect from small-
pox
Vaccination, an unusual method proposed
A'accine crusts from the calf, method of cultivation
Vaccine farm, report on the inspection of
Vaccine lymph from spontaneous vaccinia
Vaccine virus, efforts to determine the relative value of humanized
crusts and those cultivated on the calf
Vegetable matter a congenial soil for the increase of the typhoid cause
Vegetation and malarial diseases, connection between _
Veins, occlusion of, in lobar pneumonia
Venereal diseases, preventive nwasures at 3Iemphis, Tenn
Venereal diseases, preventive measures at Nashville, Tenn
Venereal diseases, records of
Venereal diseases, reports of medical officers on
Venereal diseases, statistics of
Venereal diseases, treatment of
Venesection in cerebro-spinal fever
Venesection in pneumonia
Venesection in remittents
Ventilation of pavilion-wards as specified by War Department orders.
Ventilation of pavilion-wards in winter, provision for
Ventilation of privies
Ventilation of ridge-ventilated pavilions insufficient in close, sultry
weather ......._.-.-»...-..... — - — — — — — — —
626
67
634
638
i;47
G30
G36
G3G
636
G;i5
|>J7
637
637
631
G33
634
634
634
635
504
156
783
895
803
sol
SOI
SOI
801
612
177
945
052
954
INDEX OF SUBJECTS,
989
Pago.
Veteran Kescrve Corpis meuibon of, useful as wanl attcixlaut:* iu gen-
eral ho^iiitaU ._— . ....—. 'X>7
Vftvnin lleservo l'or|is. H-ansfers to . ,-_-™-.™ 2$
Vi-tiT,iU Kfserve l'or|« (lie police fuive of genenil hospitals O^S
VtitTaii trooiis, ini|M,-iliuieiitu caniiil l»y, when on active wrvice 870
Yfintnini viritU* in cerel>ro-spiiml fevt-r ._._ G12
A'eratruMi viriile in tlie cuntiniuti fevers 5-11
Ver.itruni viriile in heart affections ,_„ 863
Vemirinii viri<le in jmennionia . 806
Vil.ices in niahiriul fevei"s . 126
Yibices in typho-nialaria' fevi-r 2T'>, 304
Voniiliii;: iu reniiltents. treatment of 1S2
Vomiting in typho-muturial fever .-._..__„ „ 305
Walking fever _ 319
Wakefnhu-ss in typho-niahirial fever __.__ 3l>4
^^'a^l General Hospital, Newark, K. J., description of ...... 003
Witrilinasters, duties of, at general liospitalti . 957
Wiiiil-pliysicians of general hospitals, duties of » , 956
Wanning of ridge-ventilated jutvilious in winter 052
\\'atfr. necessity of, in the treatment of sunstroke. — _„ 856
Vater-supply of general hospitals . 953
Walt-r supplies and the propagation of typhoid fever .... 404
Water supplies, transmission of malaria by means of _, . 159
Page.
Water-closets of pavilion-wards iujudicioubly placed 951
AVtt(er*closet service of general hospitals. ... 053
Wellft, connci'tion between typhoid prevalence and high and low
water in . 503
Well-waters and tyidioid epidemics . . ..... 404
Well-waters, their freedom from malaria .... IG2
Western itch 887
West's buildings, Baltimore, Md., description of 901
Whiskey ration^ doubtful value of ......... . ....... 171
AVilli>w bark as a prophylactic in malarial fevers 175
Wilmington, X. C, typhus fever nt 332
WocKlward's clan^itication of the continued fevers of the war 484
Woodward's classification of the camp fevei-s . 273
Yelhiwfvverot Fort Jeffei-son. Fla__ 1 678
Yellow fever at Hiitmi IKad. :*. c 678
Yellow fever at Key Wtst, Kla 670, 070
Yellow fever at New Berne, N. C 679
Yellow fever, freedom of New Orleans from.. ..._..„„ 675
Yellow fever, inelTicieney ofa quarantine of detention 682
Yellow fever, rentoval from the epidemic focusof value as a protective
measure .„_ 682
Yellow fever, sanitary supervision and disinfection as protective against 682
Yellow fever suggested by the jaundice of malarial fevers .. 123
END OF THE MEDICAL VOLUME.
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